Evaluation And Management Of Sleep Disorders In Infants

Discuss About The Evaluation Of Sleep Disorders In Infants?

One of the common and significant issues faced by the parents are the not sleeping behaviour throughout the night and thereby restricting from going to sleep by their children (Sivertsen et al., 2015).  The persistence of the sleep disruptions with crying episodes led to negative impacts on the parents such as distress, fatigue and decrease in the tolerance towards the night time problems (O’Neill & Gilea, 2017). The other part of concern was that some of the parents who faced the issues regarding episodes of crying in night by infants did not consult any professionals to solve the problem (Bell, 2014). The difficulties faced in the bedtime sleep led to child abuse, maternal ambivalence and maternal depression towards their child (Weinraub et al., 2012). Keeping this issue into consideration, professional support played major role in solving the spontaneous awakening and crying phases in night further preventing the conflict of parent-child (Mindell & Owens, 2015).

In this review, different databases were considered such as MEDLINE, SCOPUS, EMBASE, CINAHL and Cochrane Library. The search terms were “child,” “toddler,” “infant,”  “sleep,” “settling,” “wake,” “treatment,” “medication,” “therapy,” and “intervention”. The searching pattern was supplemented through tracking all the articles and cited reviews, bibliography, books as well as hand searching the journals based on the topic for the last 5 years. 

The studies that were included in this review were centred within young children aged 5 or younger, who represented nocturnal awakening at night time, with established sleep problems and crying episodes. Settling these infants to bed was generally followed by tantrums and was recognized as problematic by their respective parents. Non-randomized control trials were selected. The review includes journals that focus on study of specific outcome measures, which included settling time, night time awakening episodes and relationship with emotional availability of mothers. The journals considered were all peer reviewed and published in English language. The journals with publication date not prior to 2012 were selected. The exclusion criteria comprised the articles that were non- English journals, published abstracts, dissertations and those with publication date before 2012.

Prenatal factors that influenced the frequent awakening and crying in the night-time in a regular basis by the infants included breastfeeding, temperament, parental attention, family distress, colic and physical illness followed by poor sleep (St James-Roberts, 2013).  Though suggestions regarding managing the issue had been evaluated but 2126 randomized interventional controlled trials were not conducted for the crying episodes and night-time awakening in the infants. The different suggestive ideas regarding reducing the problem included modification in diet, sedation with gradual ignoring of the crying episodes (Richardson & Friedman, 2016). With this respect, only few procedures among which included a new technique known as scheduled awakenings had been examined which resulted effectively causing the infant to preclude frequent nocturnal awakening and episodes of crying (Young, 2016). 

Inclusion and exclusion criteria

It was found that scheduled awakening and systemic ignoring effectively reduced the nocturnal awakening and crying phases in infants. The systemic ignoring causing the infants “cry it out” was recommended to be very effective by the pediatrician showing the fastest improvement.  The control group children showed general decreased awakening but some were still showing the spontaneous night awakening (Weissbluth, 2015). These proved that some infants recover over time. It was found that out of 11 infants 4 showed no awakening after 8 weeks and after the last follow-up only half of them recorded to be awakened once a week. Age played no role in the process both all the groups. Some of the parents related that they ignored the crying and waited for their child to stop crying. This strategy of lengthening the time of crying was found similar to the studies of Ferber (Kuhn, 2014).  Of the 11 infants in control, 7 infants that showed reduced nocturnal awakenings with significant results of time effects which could be measured by videotaping.

Due to lack of significant difference in between systemic ignoring and scheduled awakening except at 3 week both were encouraged, although the second one being reported to be slower. This resulted for a suggestion of an alternative effective process other than ignoring (GUIDE, 2014). Although some parents feared to wake their infants in scheduled process, all 11 went back to sleep after some time precluding the spontaneous awakening in night. As the parents found it more affective in precluding the spontaneous awakening, they made no complains in implementing the scheduled awakening strategy (Schnoes, 2016). But one of the limitations of the present study restricted the evaluation of a better treatment protocol of standard awakenings as in most of the studies it was just an educated guess of the awakening length (Turner, 2012). 

At the initial stage 50 children were assigned randomly to one out of three conditions that scheduled awakenings, systematic ignoring or control. 17 infants were excluded for different reasons as given in appendix A (Moore, 2012).

Thus, only some of the investigators had successfully evaluated the techniques but none of them were systematically studied through a randomized study of clinical control. No hypothetical view was considered regarding the efficacy of one treatment with respect to the other one (Bolten, 2013).

The trials of the studies are assessed in an independent way and in a non blinded manner. The critical appraisal tool assesses 4 similar kinds of studies that illustrated the effectiveness of intervention methods on sleep disturbances and nocturnal wakening among infants. The tool analyses the focus of study, follow-up strategies, outcome measures, equal treatment for all patients, significance and precision of the treatments and their applicability in local population.

Prenatal Factors Contributing to Sleep Disturbances in Infants

• Appendix B – The average count of night time awakenings through the three conditions are provided which showed that the systemic ignoring technique showed more efficacy in reducing the awakening in the infants through 8 weeks of treatment.
• Appendix C- The points at which the three groups differed in the treatment were evaluated through a range of analysing 8 variances that were conducted for each treatment week.
• Appendix D- The scatter plot analysis is provided to represent the count of awakening and crying episodes through the treatment weeks with respect to 33 children. Each point represented a child and the data indicated a wide variable among the control and the documented developmental trends.
• Appendix E- Demonstrates a broader literature search and key findings.

Conclusion

Thus, from the above review it can be concluded that systemic ignoring plays an effective role in reducing the night time awakening and crying phases in the infants. It reduced the spontaneous awakenings frequency rapidly but the awakenings duration was found to rise initially which became unacceptable to some parents. Alternative technique, scheduled awakenings were found to be more viable to some of the parents. But as this technique was slower, the efficacy stayed unclear. Other factors such as change in sleep cycle, shaping and controlling stimulus successfully eliminated the awakenings in the night time during the use of scheduled awakenings. But before delivering scheduled awakenings technique more studies should be conducted to make understand the other non expert professionals. Apart from this, it could be said that both the systemic ignoring and the scheduled awakenings showed more effective results rather than to see the child outgrow the problematic behaviour. Lastly both the treatment strategies must be compared with modified diet, medication and delayed progression in the parents attention to retain relative efficacy. To successfully implement the strategies to reduce the spontaneous night time awakenings followed by reduced crying phases in the children, proper funding should be provided in order to conduct the interventions properly and effectively as it involves different stages of treatment with follow-ups after the treatments.

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