Do psychosocial sleep interventions improve infant sleep or maternal mood in the postnatal period? A systematic review and meta-analysis of randomised controlled trials

Pre-emptive Intervention for Autism Spectrum Disorder: Theoretical Foundations and Clinical Translation

Autism spectrum disorders (ASD) are an emergent public health problem, placing significant burden upon the individual, family and health system. ASD are polygenetic spectrum disorders of neural connectome development, in which one or more feedback loops amplify small genetic, structural, or functional variations in the very early development of motor and sensory-motor pathways. These perturbations trigger a 'butterfly effect' of unpredictable cascades of structural and functional imbalances in the global neuronal workspace, resulting in atypical behaviors, social communication, and cognition long-term. The first 100 days post-term are critically neuroplastic and comprise an injury-sensitive developmental window, characterized by a neural biomarker, the persistence of the cortical subplate, and a behavioral biomarker, the crying diathesis. By the time potential diagnostic signs are identified, from 6 months of age, ASD neuropathy is already entrenched. The International Society for Autism Research Special Interest Group has called for pre-emptive intervention, based upon rigorous theoretical frames, and real world translation and evaluation. This paper responds to that call. It synthesizes heterogenous evidence concerning ASD etiologies from both psychosocial and biological research literatures with complexity science and evolutionary biology, to propose a theoretical framework for pre-emptive intervention. This paper hypothesizes that environmental factors resulting from a mismatch between environment of evolutionary adaptedness and culture initiate or perpetuate early motor and sensory-motor lesions, triggering a butterfly effect of multi-directional cascades of atypical developmental in the complex adaptive system of the parent and ASD-susceptible infant. Chronic sympathetic nervous system/hypothalamic-pituitary-adrenal axis hyperarousal and disrupted parent-infant biobehavioral synchrony are the key biologic and behavioral mechanisms perpetuating these atypical developmental cascades. A clinical translation of this evidence is proposed, for application antenatally and in the first 6 months of life, as pre-emptive intervention for ASD.

Profiles and characteristics of clinical subtypes of perinatal depressive symptoms: A latent class analysis

AIMS

To investigate clinically relevant subtypes of perinatal depressive symptoms.

DESIGN

Cross-sectional study.

METHODS

A sample of 2,783 women at different prenatal and postnatal periods was recruited between August 2015 - August 2017. The Patient Health Questionnaire-9 (PHQ-9) was used to assess depressive symptoms. Data analyses consisted of latent class analysis (LCA), analysis of variance and multinomial logistic regression.

RESULTS

(a) Five latent subtypes (Classes 5/4/3/1/2) were identified: 'no symptoms', 'mild physio-somatic symptoms', 'severe physio-somatic symptoms and moderate anhedonia', 'moderate-to-severe symptoms' and 'severe symptoms'; (b) Postpartum women were more likely to belong to the severe depressive symptoms group, whereas pregnant women were likely to report severe physio-somatic symptoms; and (c) History of abortion and perinatal complications increased the likelihood of belonging to all moderate-to-severe classes. Lower levels of education increased the probability of belonging to Class 2. Younger women were more likely to be categorized into Classes 1 and 2.

CONCLUSIONS

This is the first study to examine heterogeneity of perinatal depressive symptoms and delineate the characteristics of subtypes at different prenatal and postnatal periods via the PHQ-9, using LCA in a Chinese general population.

IMPACT

This research details the heterogeneity of perinatal depressive symptoms and delineates the characteristics of subtypes at different prenatal and postnatal periods in a Chinese general population.

Consistent use of bedtime parenting strategies mediates the effects of sleep education on child sleep: secondary findings from an early-life randomized controlled trial

OBJECTIVE

Using data from a randomized controlled trial, this study investigated whether parent's consistent use of recommended bedtime strategies with infants was a mediating mechanism for improved child sleep.

METHODS

Expectant mothers were allocated to 4 groups: usual care (Control); additional support regarding Food, (physical) Activity, and Breastfeeding (FAB); advice on infant sleep through 1 group educational session during the antenatal period and 1 home visit when the child was 3 weeks of age (Sleep), or both FAB and Sleep interventions (Combination). An index relating to parent's consistent use of strategies to encourage infant sleep self-settling was developed from data collected when infants were 4 and 6 months of age. Child sleep self-control was measured at 3.5 years of age through a behavior rating scale. Child overnight sleep duration was measured using accelerometers at 1, 2, 3.5, and 5 years of age. Analyses examined whether any association between intervention group and child sleep self-control or sleep duration was mediated by consistent use of bedtime strategies at 4 and 6 months.

RESULTS

Compared to Controls, Sleep group parents had significantly higher odds of using more intervention strategies consistently (1.63; 95% confidence interval [CI] 1.14-2.33), as did Combination group parents (1.45; 95% CI 1.01-2.07). Consistent strategy use was significantly associated with a decrease in child bedtime behavioral difficulties (0.97; 95% CI 0.95-0.98) and increased sleep duration (0.152; SE = 0.017). Sleep group assignment reduced child sleep self-control difficulties and improved sleep duration indirectly via parent's consistent use of bedtime strategies.

DISCUSSION

Consistent use of appropriate bedtime strategies in infancy is an important factor that influences child sleep self-control in later development.

Postpartum Depression: Pathophysiology, Treatment, and Emerging Therapeutics

Postpartum depression (PPD) is common, disabling, and treatable. The strongest risk factor is a history of mood or anxiety disorder, especially having active symptoms during pregnancy. As PPD is one of the most common complications of childbirth, it is vital to identify best treatments for optimal maternal, infant, and family outcomes. New understanding of PPD pathophysiology and emerging therapeutics offer the potential for new ways to add to current medications, somatic treatments, and evidence-based psychotherapy. The benefits and potential harms of treatment, including during breastfeeding, are presented.

Trajectories of sleep quality from late pregnancy to 36 months postpartum and association with maternal mood disturbances: a longitudinal and prospective cohort study

Study Objectives

To examine trajectories of poor sleep quality from late pregnancy to 36 months postpartum, baseline indicators, and association with prospective maternal mood disturbances.

Methods

A cohort of 262 nonclinical women was followed at late pregnancy, 42 days, 3, 6, 9, 12, 18, 24, and 36 months postpartum. Sleep quality was measured with the Pittsburgh Sleep Quality Index at all time points, and mood disturbances were assessed at late pregnancy and 36 months postpartum.

Results

The rate of poor sleep quality followed an inverted U-shaped curve. Women reporting poor sleep quality at late pregnancy held a consistently higher risk of poor sleep quality at postpartum points. Three sleep trajectories were distinguished, namely, the stable-low (29.4%), the decreasing-mild (56.5%), and the stable-high (14.1%). Poor sleep quality, depression, and anxiety at baseline were linked to trajectory groups with poorer sleep quality. Adjusting for covariates, the trajectory of the poorer sleep quality group demonstrated increased mood disturbances at 36 months postpartum. Replicating the analyses in women without baseline symptoms of depression and anxiety above clinical cutoffs obtained similar results.

Conclusions

Women are vulnerable to poor sleep quality from late pregnancy to postpartum years, but follow distinct trajectories. Poor sleep quality, depression, and anxiety at late pregnancy help us to anticipate the sleep trajectories. Trajectories of poor sleep quality indicate increased mood disturbances at 36 months postpartum. A flexible suite of interventions targeting both poor sleep quality and mood disturbances should be implemented and tailored to women in the prenatal and postpartum periods.

The Possums Infant Sleep Program: parents' perspectives on a novel parent-infant sleep intervention in Australia

AIM

To evaluate parental perspectives on the acceptability and usefulness of a 'cued-care' approach to infant sleep implemented in an Australian primary care setting. The Possums Infant Sleep Program aims to empower parents to better understand their infant's sleep and their responses to it, and optimize healthy function of the infant's biological sleep regulators to protect against excessive night-waking.

METHODS

The evaluation was undertaken by an independent infant sleep researcher, with no previous involvement in the Possums program. Parents' experiences of the sleep intervention were captured using a mixed methods approach involving (a) group discussions of sleep issues between parents and clinic staff, (b) discussions with parents who volunteered to provide face-to-face feedback, and (c) an online survey designed in light of the information gained from a and b. A one-year audit of clinic registrations provided contextual data.

RESULTS

Sixty-four clinic clients fully (45) or partially (19) provided answers to survey questions. Respondents were primarily mothers, mean age 34, with a postgraduate qualification and high family income. Their term infants were predominantly breastfed and attended the clinic for feeding and/or sleeping difficulties across the first year of life. Almost all embraced the Possums approach, describing it as challenging and life changing. Audit data confirmed the survey sample reflected the general clinic population.

CONCLUSIONS

The Possums Infant Sleep Program was acceptable to parents, and highly valued. Recipients reported reduced stress, less concern about perceived sleep problems (frequent night-waking, short-day-time naps, delayed sleep onset), and better quality of life.

Perinatal maternal depression, antidepressant use and infant sleep outcomes: Exploring cross-lagged associations in a pregnancy cohort study

BACKGROUND

Both perinatal depression and infant sleep problems are common concerns in many communities, with these problems often coinciding. Findings in this area conflict and much of the research relies on poor measures of sleep and/or depression. Adding to this complexity is the rise in antidepressant treatment for perinatal maternal depression and no previous study has examined the relationship between such exposure and infant sleep.

METHODS

This study draws on four waves of data (early pregnancy and third trimester, and six and 12 months postpartum) from 264 women in the Mercy Pregnancy and Emotional Wellbeing Study, a prospective pregnancy cohort study of women recruited in early pregnancy in Melbourne, Australia. Cross-lagged regression models were used to examine reciprocity of longitudinal effects between depressive symptoms and infant sleep.

RESULTS

Maternal antepartum depression and antidepressant use were not significant predictors of infant sleep problems. Likewise, infant sleep problems were not significant predictors of postpartum maternal depression. However, maternal cognitions about infant sleep, characterised by maternal expectations to immediately attend to their crying child, did demonstrate positive reciprocal effects with infant nocturnal waking between six and 12 months postpartum.

LIMITATIONS

Infant sleep outcomes were reported by the mother and the sample were predominantly Anglophone, restricting generalizability of the models to other cultures.

CONCLUSIONS

Maternal depression and antidepressant use were not found to be significant factors in infant sleep problems and, likewise, infant sleep problems were not associated with maternal depression. However, postpartum maternal cognitions around six months postpartum regarding limit-setting at night may predict increases in later nocturnal infant signaling.

Non-pharmacological interventions for improving postpartum maternal sleep: A systematic review and meta-analysis

Evidence suggests that poor postpartum sleep quality is a risk factor for the development of postpartum depression. As such, non-pharmacological interventions have been developed to help improve sleep in the postpartum period. The primary aims of this systematic review and meta-analysis were to determine if non-pharmacological interventions improved maternal sleep and to compare the effectiveness of different intervention types. Secondary aims included examining effects on maternal mood and infant sleep. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and Web of Science from their inceptions to September 2017 and found 15 eligible studies. Non-pharmacological sleep interventions were found to improve subjective reports of maternal sleep (Cohen's d = -0.54, 95%CI = -0.88 to -0.19). Massage (Cohen's d = -1.07 95%CI = -1.34 to -0.79) and exercise (Cohen's d = -0.82 95%CI = -1.28 to -0.37) interventions had the largest impact on maternal sleep quality. Positive effects on nocturnal infant sleep were found for interventions overall (Cohen's d = -0.27 95%CI = -0.52 to -0.02) but not for maternal depression (Cohen's d = -0.08 95%CI = -0.28 to 0.12). Despite evidence suggesting improvements in subjective maternal sleep, more research must be conducted on the durability of effects of non-pharmacological interventions using objective measures of sleep quality.

Parent-Infant Room Sharing During the First Months of Life: Longitudinal Links With Behavior During Middle Childhood

Current recommendations encourage parent–infant room sharing for the first 6 months of life. This longitudinal study (N = 193) is the first to examine long‐term relations of early room sharing with three domains of child behavior: sleep, behavior problems, and prosocial behavior. Information on room sharing was collected daily for infants’ first 6 months. At ages 6, 7, and 8 years, outcomes were assessed with maternal and teacher questionnaires and behavioral observations. Early room sharing was not related to sleep problems or behavior problems. Additionally, more weeks of room sharing were positively related to higher maternal ratings of child sleep quality and more prosocial behavior. In conclusion, early room sharing appears to be related to positive, but not negative, behavior outcomes in middle childhood.

Real-World Implementation of Infant Behavioral Sleep Interventions: Results of a Parental Survey

OBJECTIVE

To describe parental practices implementing behavioral sleep intervention (BSI) outside a clinical setting.

STUDY DESIGN

Parents (n = 652), recruited through a Facebook group designed as a peer support group for parents using BSI, completed an online survey about their experience using BSI with their infant or toddler.

RESULTS

On average, parents implemented BSI when their infant was 5.6 (±2.77) months. Parents most often used modified (49.5%) or unmodified extinction (34.9%), with fewer using a parental presence approach (15.6%). Regardless of BSI type, more parents endorsed "a great deal of stress" during the first night (42.2%) than 1 week later (5.2%). The duration of infant crying was typically greatest the first night (reported by 45%; M = 43 minutes) and was significantly reduced after 1 week (M = 8.54 minutes). Successful implementation of BSI on the first attempt was reported by 83%, with a median and mode of 7 days until completion (79% by 2 weeks). Regardless of BSI type, after intervention parents reported their infant had less difficulty falling asleep, fewer night awakenings, and were more likely to sleep in their room and/or in their own crib/bed.

CONCLUSIONS

The majority of parents report successfully implementing BSI, with significantly reduced infant crying by the end of 1 week and success within 2 weeks. Few differences were found between behavioral approaches.

A Proposed Nursing Theory: Infant Sleep and Development

Although well positioned to work with families of young children, nurses do not yet have a theory that guides practice and research by relating infant sleep to child and family development. The authors of this paper describe a proposed theory that combines Bronfenbrenner's bioecological theory of human development with the Barnard model of parent-child interaction to inform nursing practice and research related to infant sleep and optimizing child and family development. The theory focuses on sustainability of change in family processes and infant sleep, with a goal of optimizing family wellness as the proximal environment for child development.

Clinically Oriented Subtyping of Chronic Insomnia of Childhood

OBJECTIVES

To identify different profiles of pediatric insomnia, based on the most frequent clinical presentations (nocturnal awakenings, difficulty in falling asleep, nocturnal restlessness, early morning awakenings).

STUDY DESIGN

A structured parent interview was conducted in 338 children (mean age 21.29 months, SD 10.56) referred by pediatricians because of insomnia resistant to behavioral approaches and common drug treatments. The aim was to assess the characteristics of insomnia in children, together with family sleep-related history. A latent class analysis was run to identify profiles of insomnia. ANOVA and the χ² test were used to examine differences between profiles.

RESULTS

A 3-class model was built by latent class analysis: 17% (n = 58) of children constituted the first class, characterized by difficulties in falling asleep, with restlessness, nocturnal restlessness, and awakenings during the night; the second class, characterized by early morning awakenings, comprised 21% (n = 71) of children; 62% (n = 209) of children fell within the third class because of their high frequency of nocturnal awakenings and difficulties in falling asleep. The first class reported longer sleep latency and the presence of restless legs syndrome and anemia in the family history; depression and/or mood disorders were more frequent in class 2 and allergies and/or food intolerance were more frequent in class 3.

CONCLUSIONS

Our study suggests the existence of 3 different phenotypes of insomnia in children, based on clinical, personal, and familial data. The identification of these different phenotypes might help to optimize the assessment and treatment of insomnia in young children.

Effectiveness of a psycho-educational intervention to prevent postpartum parental distress and enhance infant well-being: study protocol of a randomized controlled trial

Background

The first months after birth can be challenging for parents, leading to parental distress and decreased well-being. Parents with high levels of distress are found to respond less adequately and sensitively to their infant, which in turn affects infant well-being and health. The goal of this study is to examine the effectiveness of a psycho-educational intervention to prevent postpartum parental distress and enhance the quality of caregiving and infant well-being. In contrast to other interventions, this intervention will be (1) offered already before birth, (2) offered to all parents-to-be, regardless of their risk of postpartum distress, and (3) include fathers. The proposed study examines the effectiveness of this intervention on (1) parenting distress, (2) quality of caregiving, and (3) the infant’s well-being.

Methods/design

In this randomized controlled trial, 128 pregnant women and their partners will be recruited through midwifery practices and general media. Women with a complicated pregnancy, current psychopathology, insufficient Dutch language proficiency and without Internet access will be excluded. Parents will be randomized to either the intervention or a waitlist control group. The intervention consists of a booklet and video (offered prenatally), a home visit at 34–36 weeks of pregnancy and a telephone call 4 weeks after birth. Information and practical tools are provided on (1) sensitive responding and making contact with the baby, (2) crying, (3) feeding, and (4) sleeping. Assessments will take place at baseline (26–34 weeks of pregnancy), during the home visit (34–36 weeks of pregnancy), and 2, 6, and 10 weeks after birth. The control group will be offered the intervention after the end of the study. The primary outcome is maternal parenting stress. Secondary outcomes are: paternal parenting stress, parental well-being, quality of caregiving, and infant well-being and health.

Discussion

The goal of this study is to test the effects of a psycho-educational prenatal parenting intervention to prevent postpartum parental distress and to enhance well-being in both parents and infants. When the intervention appears effective it can be implemented broadly because of its low costs. It will make support available for a large number of parents and their children.

Trial registration

Netherlands National Trial Register, ID: NTR6065. Registered on 15 September 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-017-2348-y) contains supplementary material, which is available to authorized users.

Insomnia, postpartum depression and estradiol in women after delivery

After childbirth, women may develop symptoms of depression with the associated sleep disturbances. This study assessed the relationship between insomnia and both depression symptoms and blood estradiol levels in women during the early postpartum period. 84 patients were assessed 24-48 h after labor. The main assessment methods were the following psychometric scales: Beck Depression Inventory (BDI), Edinburgh Postnatal Depression Scale (EPDS) and Athens Insomnia Scale (AIS). Serum estradiol levels were measured using ELISA assay. Women who developed postpartum insomnia significantly more often reported insomnia during pregnancy (P = 0.001), were more likely to have suffered from depression in the past (P = 0.007) and had significantly higher BDI (P = 0.002) and EPDS (P = 0.048) scores. Our study demonstrated no significant association between Restless Legs Syndrome (RLS) during pregnancy and postpartum insomnia. The groups of women with and without postpartum RLS showed no significant differences in the incidence of postpartum insomnia. No significant differences in estradiol levels were observed in women with and without postpartum insomnia. The study showed the following factors to play a major role in development of postpartum insomnia: an increase in Beck Depression Inventory score, a history of depression and a history of insomnia during pregnancy.

Anticipatory guidance to prevent infant sleep problems within a randomised controlled trial: infant, maternal and partner outcomes at 6 months of age

OBJECTIVE

To evaluate the effectiveness of sleep education delivered antenatally and at 3 weeks postpartum to prevent infant sleep problems at 6 months of age.

DESIGN

Sleep intervention within a randomised controlled trial for the Prevention of Overweight in Infancy (POI) study.

PARTICIPANTS

802 families were randomly allocated to one of four groups: usual care (control), sleep intervention (sleep), food, activity and breastfeeding intervention (FAB), and combined group receiving both interventions (combination).

INTERVENTIONS

All groups received standard Well Child care. The sleep intervention groups (sleep and combination) received an antenatal group education session (all mothers and most partners) emphasising infant self-settling and safe sleeping, and a home visit at 3 weeks reinforcing the antenatal sleep education. FAB and combination groups received four contacts providing education and support on breast feeding, food and activity up to 4 months postpartum.

OUTCOME MEASURES

Here we report secondary sleep outcomes from the POI study: the prevalence of parent-reported infant sleep problems and night waking, and differences in sleep duration. Additional outcomes reported include differences in infant self-settling, safe sleep practices, and maternal and partner reports of their own sleep, fatigue and depression symptoms.

RESULTS

Linear or mixed linear regression models found no significant intervention effects on sleep outcomes, with 19.1% of mothers and 16.6% of partners reporting their infant's sleep a problem at 6 months. Actigraphy estimated the number of night wakings to be significantly reduced (8%) and the duration of daytime sleep increased (6 min) in those groups receiving the sleep intervention compared with those who did not. However, these small differences were not clinically significant and not observed in 24 hours infant sleep diary data. No other differences were observed.

CONCLUSION

A strategy delivering infant sleep education antenatally and at 3 weeks postpartum was not effective in preventing the development of parent-reported infant sleep problems.

How Postpartum Women With Depressive Symptoms Manage Sleep Disruption and Fatigue

Postpartum sleep and fatigue have bidirectional relationships with depressive symptoms and challenge women's everyday functioning. The everyday process of managing postpartum sleep and fatigue in the context of depressive symptoms remains unexplored. We conducted a grounded theory study with a sample of 19 women who screened positive on the Postpartum Depression Screening Scale (PDSS™) Short Form at 3 weeks postpartum. Women completed semi-structured in-home interviews and the full PDSS and Modified Fatigue Symptoms Checklist at 1, 3, and 6 months postpartum. The sample was on average 27 years old, with 2.8 children, and 63% were African-American. They described a basic social process of Finding a Routine Together, during which women's experiences with their infants progressed from Retreating at month 1 toward Finding a New Normal at month 6. In their work to Find a Routine Together, mothers' patterns of change over time were continuous, gradual, or prolonged. Their progress was influenced by depressive symptoms, social support, work and daycare, stability in social circumstances, and underlying stressors. This study's findings suggest the need to allocate resources and tailor interventions to meet the needs of women who are most vulnerable to the health effects of ongoing persistent severe fatigue, disordered sleep, and sub-clinical and clinical levels of depressive symptoms. © 2017 Wiley Periodicals, Inc.

Dietary Prebiotics and Bioactive Milk Fractions Improve NREM Sleep, Enhance REM Sleep Rebound and Attenuate the Stress-Induced Decrease in Diurnal Temperature and Gut Microbial Alpha Diversity

Severe, repeated or chronic stress produces negative health outcomes including disruptions of the sleep/wake cycle and gut microbial dysbiosis. Diets rich in prebiotics and glycoproteins impact the gut microbiota and may increase gut microbial species that reduce the impact of stress. This experiment tested the hypothesis that consumption of dietary prebiotics, lactoferrin (Lf) and milk fat globule membrane (MFGM) will reduce the negative physiological impacts of stress. Male F344 rats, postnatal day (PND) 24, received a diet with prebiotics, Lf and MFGM (test) or a calorically matched control diet. Fecal samples were collected on PND 35/70/91 for 16S rRNA sequencing to examine microbial composition and, in a subset of rats; Lactobacillus rhamnosus was measured using selective culture. On PND 59, biotelemetry devices were implanted to record sleep/wake electroencephalographic (EEG). Rats were exposed to an acute stressor (100, 1.5 mA, tail shocks) on PND 87 and recordings continued until PND 94. Test diet, compared to control diet, increased fecal Lactobacillus rhamnosus colony forming units (CFU), facilitated non-rapid eye movement (NREM) sleep consolidation (PND 71/72) and enhanced rapid eye movement (REM) sleep rebound after stressor exposure (PND 87). Rats fed control diet had stress-induced reductions in alpha diversity and diurnal amplitude of temperature, which were attenuated by the test diet (PND 91). Stepwise multiple regression analysis revealed a significant linear relationship between early-life Deferribacteres (PND 35) and longer NREM sleep episodes (PND 71/72). A diet containing prebiotics, Lf and MFGM enhanced sleep quality, which was related to changes in gut bacteria and modulated the impact of stress on sleep, diurnal rhythms and the gut microbiota.