Clinical reviewDo psychosocial sleep interventions improve infant sleep or maternal mood in the postnatal period? A systematic review and meta-analysis of randomised controlled trials
Introduction
Sleep complaints are common amongst mothers of infants and insufficient, inefficient or fragmented sleep is associated with postnatal depression (PND) [1], [2], [3], [4]. During pregnancy, most women wake multiple times during the night and especially towards the end of their pregnancy [5]. More than half of all pregnant women report poor sleep quality and symptoms of insomnia, with approximately 25% sleeping less than 7 h per night [6]. In the third trimester, it is estimated that 90% of women have some sleep complaints including increased wake after sleep onset, reduced sleep efficiency and shorter sleep duration [7]. Sleep disturbance during pregnancy is associated with increased depressive symptoms [8], although the direction of causality is unclear.
Even women who do not have marked sleep disturbance during pregnancy will experience a change in their sleep pattern following childbirth [9], predominantly due to the natural shortened sleep-wake patterns of most infants. On average, adults sleep 8.5 h at night [10], whilst the longest expected sleep period of a healthy newborn is generally only 4–5 h. The mother will usually need to feed and re-settle her newborn in between these sleeps leading to shorter overall sleep duration and more fragmented sleep. This has similar detrimental effects on cognition and mood to chronic short sleep [11]. Clearly these problems can be further complicated when infants have feeding problems, which are commonly associated with reports of infant sleep problems [12]. It has been estimated that women experience approximately 1.5 h less sleep duration in the early postnatal period. For some women, there is a slight improvement in sleep duration and consolidation by 6 wk postpartum [13]. However, for many, sleep disruption continues throughout the postnatal period with 60% reporting poor sleep quality at 2 mo [1] and frequent night waking remaining common for up to 12 mo postnatal [14].
There is a strong correlation between poor sleep efficiency, sleep maintenance, fragmented sleep and maternal reports of infant sleep duration in the postnatal period and PND [1], [2], [3], [4]. Postnatal depression affects up to 12.9% of mothers in the first 12 mo after the baby's birth [15]. There is a growing literature that PND has an adverse effect on mother-infant interaction throughout the postnatal period [16] and has consistent adverse outcomes in children well beyond their first year of life with poorer cognitive and emotional development than those of healthy mothers [17]. Therefore, there has been considerable interest in developing interventions that improve PND.
Treating PND is challenging. While antidepressants are largely accepted as being safe during breastfeeding, many women are reluctant to use them [18]. A range of interventions has been developed specifically to treat PND and a recent meta-analysis demonstrated that interventions are effective in improving depressive symptoms compared to control conditions, with the best evidence supporting interpersonal psychotherapy [19]. However, these treatment interventions require highly trained professionals and multiple sessions (e.g., 6–12 sessions) and consequently are often less accessible or cost effective. Preventative approaches have also been explored. A systematic review has shown short term preventative success and highlighted the need for more robust studies in this area [20].
Given that sleep disturbance is a risk factor for PND [4], [21], it is possible that targeting sleep directly during the perinatal period may reduce depressive symptoms. While there have been studies that have attempted to improve postnatal mood through treating sleep disturbance, there has not been a quantitative meta-analysis of this literature to determine whether targeting sleep is an effective strategy for improving maternal mood.
There have been three previous reviews on similar topics. A 2010 Cochrane review, examined the efficacy of postnatal educational interventions on infant growth and development, crying, sleeping and preventative care. Within this review, four randomised controlled trials (RCTs) investigating sleep education programs were included. This study presented multiple analyses, however, due to the specificity of the selected sleep outcomes, a maximum of two papers were included in each analysis. We have broadened our criteria to all behavioural sleep-focused interventions so that more papers could be incorporated. We have also explored maternal mood [22].
The other two reviews were narrative systematic reviews which examined the efficacy of psychosocial sleep-based programs administered to women in the first six mo postnatal and from 6 mo to 2 y, respectively *[12], [23]. The authors concluded that before 6 mo, behavioural interventions were not efficacious on infant sleep or maternal mood. However, this review included non-RCTs and hence the conclusion was based on overall poorer quality studies. In contrast, the final review examined psychosocial sleep-based interventions in children aged 6 mo to 2 y. Although evidence of improvement was found, the studies focused specifically on children with sleep disorders and therefore the generalisability of the results is unclear [23].
The current review aims to systematically evaluate RCTs that have investigated psychosocial interventions implemented in the pre or postnatal period (i.e., up to 12 mo postnatal) designed to improve sleep in infants. The primary outcomes are maternal reports of infant nocturnal total sleep time and night wakes. The secondary outcome is maternal mood.
We will address the following questions:
- 1)
are psychosocial sleep-focused treatments effective in improving maternal reports of infant nocturnal total sleep time and or reducing the number of night wakes?
- 2)
are treatments that target infant sleep effective on the secondary outcome of improving maternal mood?
Section snippets
Literature search
A literature search of PubMed, PsycInfo, EMBASE and CINAHL was conducted on November 28th, 2014 using the following combination of keywords in the title or abstract: stress OR depression OR depressive disorder OR dysthymia OR affect OR rumination OR mood AND sleep OR insomnia OR night waking OR unsettle OR settle AND pregnancy OR prenatal OR postnatal OR postpartum OR perinatal OR antenatal OR puerperium AND infant OR baby OR newborn. Articles were limited to peer-reviewed journals written in
Risk of bias and quality assessment
A risk of bias analysis was conducted for each study based on the ‘The Cochrane collaboration's tool for assessing risk of bias' [39]. This analysis can be found in Appendix A: Risk of bias assessment. Two study authors (LK and CBM) scored these independently with an inter-rater reliability score of 0.62 based on Cohen's Kappa coefficient. Participant blinding could not be guaranteed within each of these studies as the interventions are psychosocial, therefore this item was not assessed. The
Discussion
In this review, we analysed whether infant sleep and maternal mood can in fact be improved using a psychosocial sleep-focused intervention. It was hypothesised that improvements would be found across all measures, namely maternal reported infant nocturnal total sleep time, night waking and maternal mood. This hypothesis was met for one of the two primary outcome measures. That is, there was evidence of a small to medium and statistically significant effect of sleep interventions on infant
Conclusions & implications
Lack of sleep, fragmented sleep and poor sleep efficiency are common problems for many new mothers, with accompanying consequences [43], [44]. A number of interventions exist with the intention of improving infant sleep; however, there is little consistency in the content and delivery of these interventions. Our review has indicated that sleep interventions conducted in infants under 12 mo of age has a small to moderate effect on improving maternal reports of total nocturnal sleep time in
Conflicts of interest
There are no conflicts of interest to declare.
Acknowledgements
This research was supported by the The BUPA Health Foundation, Australia.
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