This article offers practical ways to incorporate healthy sleep education into pediatric practice and discusses key questions, barriers, and strategies associated with such efforts. The rationale for incorporating healthy sleep education in pediatric practice settings is presented, and desirable features of sleep education programs that may be implemented in pediatric practice are identified. Potential barriers are reviewed and strategies offered to overcome these barriers, such as developing resources applicable to healthy sleep education and practical information for pediatricians. Key factors regarding effectiveness of such interventional programs and key points relevant to successful healthy sleep education in pediatric practice are highlighted.
A substantial body of evidence demonstrates that an appropriate level of sleep is necessary for a healthy and productive lifestyle, academic success, and emotional well-being; these are 3 key elements associated with successful development. While a considerable proportion of adolescents obtain less sleep than they need, and are thus chronically sleep deprived, declines in sleep time and increasingly delayed bedtimes suggest the emergence of sleep restriction in preadolescents and even younger children. Adolescents have shown a gradual decrease in weeknight sleep time of about 1 h, with correspondingly later weeknight bedtimes and longer sleep times on weekends.
The significance of chronic sleep insufficiency is underrecognized in the context of youth health. Whereas sufficient sleep is associated with normal metabolism and appropriate physiologic functioning, sleep deprivation has been empirically linked to obesity, diabetes, hypertension, metabolic syndrome, and cardiovascular problems. In addition, poor sleep has been shown to impair academic performance, learning, memory, and neurobehavioral functioning, especially in the context of activities essential for academic success; these include attention/response inhibition, memory, verbal creativity, problem solving, and general cognitive abilities as reflected by IQ test scores. Finally, poor sleep has been linked to an increase in accidental injuries in younger children and is directly related to an increased risk of motor vehicle accidents, a topic of increasing relevance to adolescents of driving age. Collectively, therefore, the multiple negative impacts of sleep deprivation emphasize the need to provide children and their parents with education on healthy sleep and tools that assist in achieving such sleep.
The goal of this article is to offer practical ways to incorporate healthy sleep education into pediatric practice and to discuss key questions, barriers, and strategies associated with such efforts. The authors begin by presenting the rationale for incorporating healthy sleep education in pediatric practice settings. The desirable features of sleep education programs that may be implemented in pediatric practice are then identified. Next, the authors review potential barriers to implementation and offer strategies to overcome these barriers, including development of a pool of resources applicable to healthy sleep education, and practical information that may be of use to primary health care pediatricians. Key factors that increase the effectiveness of such interventional programs are highlighted. The article ends by identifying the key points relevant to successful healthy sleep education in pediatric practice.
Rationale for incorporation of healthy sleep education in pediatric settings
Despite the wealth and strength of evidence demonstrating the critical importance of sleep, and the adverse impacts of sleep deprivation, such knowledge is not widely available to children and families. The existence of problems that are potentially avoidable on application of healthy sleep education, and the difficulties currently experienced in addressing such problems, represent a “translation gap.” Given the critical nature of the domains that are adversely affected by sleep restriction, it has been suggested that the appropriate use and dissemination of knowledge on the importance of sleep, and of tools that allow environmental factors or habits related to sleep to be changed, may have significant positive impacts on the health, quality of life, and academic performance of youth. Sleep education within the community or the consulting rooms of primary care pediatricians therefore offers a unique opportunity to close the gap associated with sleep education and, in so doing, to significantly improve youth health and well-being and reduce the preventable burden of disease caused by sleep deprivation.
The desirable features of sleep education programs in pediatric practice
Healthy sleep education can be conducted at 3 complementary levels: primary, secondary, and tertiary prevention. Primary prevention encompasses interventions aimed at preventing the development of sleep deprivation by providing age-appropriate knowledge on sleep, and strategies that both ensure healthy sleep and prevent the onset of sleep disorders. To achieve this goal, the focus is typically on the provision of parental education on how sleep deprivation may affect children, information on normative developmental milestones, and how to use age-appropriate strategies to optimize sleep. Such education targets child developmental physiology and sleep needs. Secondary prevention strategies used by health care providers usually attempt to diagnose and treat existing sleep disorders at early stages, thus before significant morbidity occurs, or feature targeted interventions aimed at children at risk for sleep disorders (eg, pre-adolescents with significantly delayed bedtimes). Finally, tertiary prevention seeks to reduce the negative impact of sleep disorders using intensive individualized clinical interventions targeted to children or adolescents with serious or chronic sleep problems. This article focuses on primary prevention. The goal is to offer useful background material and to explain strategies that will help to minimize sleep deprivation, thus promoting good sleep.
The desirable features of sleep education programs in pediatric practice
Healthy sleep education can be conducted at 3 complementary levels: primary, secondary, and tertiary prevention. Primary prevention encompasses interventions aimed at preventing the development of sleep deprivation by providing age-appropriate knowledge on sleep, and strategies that both ensure healthy sleep and prevent the onset of sleep disorders. To achieve this goal, the focus is typically on the provision of parental education on how sleep deprivation may affect children, information on normative developmental milestones, and how to use age-appropriate strategies to optimize sleep. Such education targets child developmental physiology and sleep needs. Secondary prevention strategies used by health care providers usually attempt to diagnose and treat existing sleep disorders at early stages, thus before significant morbidity occurs, or feature targeted interventions aimed at children at risk for sleep disorders (eg, pre-adolescents with significantly delayed bedtimes). Finally, tertiary prevention seeks to reduce the negative impact of sleep disorders using intensive individualized clinical interventions targeted to children or adolescents with serious or chronic sleep problems. This article focuses on primary prevention. The goal is to offer useful background material and to explain strategies that will help to minimize sleep deprivation, thus promoting good sleep.
The essential components of healthy sleep education programs
Sleep education programs should provide the primary health care pediatrician with information needed to discuss with parents all aspects pertaining to healthy sleep in children. This information includes: (1) the importance of sleep and its impact on health, cognitive functions, and emotional regulation; (2) signs of child sleep deprivation; (3) the development of basic sleep processes and sleep regulation; (4) environmental factors that affect sleep and information; and (5) specific strategies to facilitate healthy sleep.
Desirable attributes of health care providers that contribute effectively to healthy sleep education
Primary health care pediatricians are ideally positioned to significantly contribute to sleep education efforts because they have ample opportunities to interact with families on an ongoing basis, possess a good understanding of the condition of any specific child and his or her family, and are perceived to be authorities on issues associated with health (thus parents are likely to follow their recommendations). Despite the importance of sleep to the mental and physical health of children, and the likelihood that primary health care pediatricians can effectively transfer sleep information to parents and children, a large gap in clinical practice may be discerned. This factor is problematic because until sleep information is widely disseminated, an important opportunity to significantly improve youth health will be lost.
Two key barriers to the incorporation of healthy sleep education into pediatric settings may be identified. First, pediatric providers are busy, and often lack the time and resources to actively engage in sleep health education. Primary prevention strategies are often not only time-consuming but are also less likely to be reimbursed. Second, most pediatricians have not been adequately trained regarding the importance of sleep and the impact of insufficient sleep, the recognition and evaluation of sleep disturbances, and appropriate interventions. The authors first describe these barriers in detail, and next seek to develop approaches that might lower the barriers, thereby contributing to a narrowing of the translation gap.
Barrier #1. Competing Demands for Increasingly Smaller Amounts of Time
Time pressure represents a significant barrier to the ability of the primary care pediatrician to engage in dissemination of preventative information pertaining to healthy sleep. Studies have shown that time pressure clearly affects the tolerance of providers toward added tasks or the use of new tools even when these benefit both patients and health care providers. Hence, a busy primary care pediatrician may simply not have adequate opportunity to acquire novel relevant information, to prepare self-help tools for patients, or to deliver that information in the context of the clinical encounter.
Barrier #2. Lack of Awareness and/or Knowledge
Primary care pediatricians may lack both awareness and knowledge of the impact of sleep on several critical domains of development, and do not appreciate the need to help children and families to make healthy sleep a part of daily life. Such knowledge gaps have been reported by Papp and colleagues, who found that the overall mean sleep knowledge test score of primary care physicians was 34%, and by Owens, who found that primary care pediatricians correctly answered only 60% of questions testing sleep knowledge, with almost 25% of pediatricians scoring less than 50%. Such lack of knowledge may be the result of insufficient training in sleep medicine. Several studies have found that the amount and quality of sleep education included in medical student and resident training is very limited. This lack of basic training is consistent with the minimal knowledge of sleep and sleep disorders shown by practicing physicians and pediatricians. Although the National Institutes of Health established a program to increase the sleep education component of medical training in 20 medical schools, a gap between training and practice is still apparent in most schools.
Although no easy means of removing the aforementioned barriers is apparent, several strategies may increase awareness of the importance of sleep and the use of available evidence-based tools promoting healthy sleep by primary care pediatricians, enhancing integration of relevant research findings into pediatric settings with minimal impact on the workload of the pediatric primary health care provider.
Overcoming Barrier #1. Reducing the Time Demand Associated with Preparation and Dissemination of Healthy Sleep Information
First, the use of available material (brochures, pamphlets, DVDs, online resources) could save preparation time and facilitate information dissemination. For example, the information included in this article and the findings of evidence-based programs aimed at healthy sleep education have been reported in peer-reviewed journals. Most interventions have targeted the parents of infants. A summary of results from these studies is given in Table 1 . Second, nurses attending during regular check-ups can provide useful information, and can conduct telephone follow-up after office visits, effectively helping parents and children to develop healthy sleep education principles and to sustain good sleep behavior. This approach minimizes time demands without compromising the quality or effectiveness of care. Third, a pediatrician or nurse could employ a group education format; both parenting programs and community maternity classes are effective in this regard. Finally, screening tools such as the BEARS (B = Bedtime issues, E = Excessive daytime sleepiness, A = night Awakenings, R = Regularity and duration of sleep, S = Snoring) allow for a quick assessment of sleep problems while at the same time educating parents about the importance of sleep and consequences of poor sleep habits.
| Author/Organization, Country | Program Title | Age Group | Age Range | No. of Participants (Experimental/Control) | Intervention Techniques | Mode of Delivery | Target Audience | Findings |
|---|---|---|---|---|---|---|---|---|
| Stremler et al, 2006, Canada | n/a | Infants | 6 wk | 15/15 | Information provision, cognitive restructuring, behavioral exercises | Informational booklet, face-to-face consultations with nurse, telephone follow-up | Parents | Fewer nighttime awakenings [7.9 vs 12.3, difference 4.4 (95% CI: 1.4–7.6), 2 P = .006], and sleep durations that were 46 min longer than the control group [217 vs 171 (95% CI: 5–88), 2 P = .03]. No effects for length of nocturnal sleep, daytime sleep |
| St James-Roberts et al, 2001, UK | n/a | Infants | 0–3 mo | 202/203 | Information provision, behavioral exercises | Informational booklet and face-to-face consultations with study personnel | Parents | 14% reported seeking less help for problems involving infant crying or sleeping problems (χ 2 = 6.01, P = .049) as compared with educational (24%) and control (21%) groups. At 12 wk, sleeping bout of >5 h was 2.61 times higher (95% CI 1.02–6.69) |
| Kerr et al, 1996, Scotland | n/a | Infants | 3 mo | 86/83 | Information provision | Informational booklet and face-to-face consultations with study personnel | Parents | Fewer settling difficulties (χ 2 = 4.88, P = .03), less night wakings ( P = .02), and higher overall sleep score ( P = .03) as compared with control group |
| Pinilla and Birch, 1993, USA | n/a | Infants | Prenatal | 13/13 | Information provision, behavioral exercises | Face-to-face consultations with sleep specialists | Parents | Increased total sleep F (1,24) = 16.82, P <.01, average duration of sleep F (1,24) = 22.45, P <.01, and longest sleep episode F (1,24) = 24.29, P <.01 as compared with control group. 100% slept through the night by week 8, as compared with 23% in control condition |
| Wolfson et al, 1992, USA | n/a | Infants | 0–9 wk | 29/31 | Information provision, cognitive restructuring, behavioral exercises | Informational booklet, question periods, group discussion, and problem-solving strategies | Parents | Increased number of sleep episodes, F (1,46) = 7.17, P <.01, amount that infant sleeps for more than 300 min consecutively, F (1,46) = 9.29, P <.01, and longest sleeping episode, F (1,46) = 8.56, P <.01 as compared with control group. Increased parental self-efficacy |
| Adair et al, 1992, USA | n/a | Infants | 4 mo | 164/172 | Information provision, behavioral exercises | Informational booklet, face-to-face consultations with pediatrician, and sleep charts | Parents | At 9 mo of age, less night waking (M = 2.5) as compared with control condition (M = 3.9); P = .02 |
| Reid, ongoing, Canada | Parenting Matters: Helping Parents With Young Children | Children | 2–5 y | n/a | Information provision, cognitive restructuring | Informational booklet and telephone support | Parents | n/a |
| Gruber et al, ongoing, Canada | Sleep for Success | Children | 6–12 y | n/a | Information provision, cognitive restructuring, behavioral exercises | Interactive educational sessions, question periods, group discussion, and problem-solving strategies | Children, parents, educators, administrators | n/a |
| Blunden, 2007,Australia | ACES junior sleep education package; ACES high school sleep education package | Children, adolescents | 4–6, 10–12 y | n/a | Information provision | Powerpoint presentations, workbooks, teaching manuals | Educators | n/a |
| Bakotič et al, 2009, Croatia | n/a | Adolescents | 15–18 y | 625/575 | Information provision | Informational booklet | Adolescents | Increased knowledge for ages 15, F (1,1168) = 28.46, P <.001, 16, F (1,1168) = 5.74, P = .017, and 17, F (1,1168) = 17.17, P <.001, but not 18, P = .467. Females showed higher knowledge retention than males ( F = 95.95, P <.01) |
| Moseley and Gradisar, 2009, Australia | Improving Adolescent Well-Being: Day and Night | Adolescents | 15 y | 41/40 | Infromation provision, cognitive restructuring, motivational interviewing, behavioral exercises | Educational sessions | Educators, adolescents | Increased total number of correct answers on sleep-related questions from preprogram (M = 7.21, SD = 1.80) to postprogram (M = 8.52, SD = 1.60), t = 3.45, P = .001. No effects on target sleep variables |
| De Sousa et al, 2007, Brazil | n/a | Adolescents | 12–18 y | 58, no control | Information provision | Educational sessions | Educators, adolescents | Reduction in the index of sleep irregularity ( t = 2.18; P <.05), a decrease in sleep latency ( t = 3.17; P <.01) and an advanced nap schedule ( t = 1.57; P <.05). No effects on sleepiness and sleep quality |
| Cortesi et al, 2004, Italy | Crash in Bed Instead | Adolescents | 17–19 y | 225/200 | Information provision | Powerpoint presentations and group discussion | Adolescents | Gain in correct answers F (2.44) = 879.32 P <.001 to sleep questions from baseline (M = 4.2) to immediately after the course (M = 8.6) and at follow-up periods (M = 6.7) |
| Rossi et al, 2002, USA | Young adolescent sleep-smart pacesetter program | Adolescents | 12–18 y | n/a | Information provision, cognitive restructuring, behavioral exercises | n/a | Educators, adolescents | n/a |
| Unpublished dissemination initiatives | ||||||||
| Editorial review board, Sick Kids Hospital, Canada | Aboutkidshealth | Infants, children, adolescents | 0–18 y | No quantitative data reported | Information provision | Web site | Parents | No quantitative data reported |
| American Academy of Sleep Medicine, USA | Sleepeducation | Infants, children, adolescents | 0–18 y | No quantitative data reported | Information provision | Web site | Parents, adolescents | No quantitative data reported |
| National Sleep Foundation, USA | Pillow Talk | Infants, adolescents | 0–5, 12–18 y | No quantitative data reported | Information provision | Blogging Web site | Parents, adolescents | No quantitative data reported |
| National Sleep Foundation, USA | Sleep for Kids | Children | 5–12 y | No quantitative data reported | Information provision | Web site | Children, parents, educators | No quantitative data reported |
| Children’s Hospital of Colorado, USA | Kids health library | Children | 5–12 y | No quantitative data reported | Information provision | Interactive online Web site | Children | No quantitative data reported |
| The Morehouse School of Medicine, USA | Sleep and Space | Children | 5–12 y | No quantitative data reported | Information provision | Television | Children | No quantitative data reported |
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