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Integrative literature review: sleep patterns in infants attending nurseries

Revisión integradora de la literatura: sueño en lactantes que frecuentan guarderías

ABSTRACT

Objective:

To identify evidence available in the literature about sleep patterns of infants attending nurseries.

Method:

An integrative review of studies published in Portuguese, English or Spanish available in full text on LILACS, CINAHL, and PubMed databases. The following descriptors sono, lactente and creches or berçários (in Portuguese) and sleep, infant and childcare or nurseries were used for LILACS, CINAHL and Pubmed, respectively. Nine studies were selected and analyzed.

Results:

The main component explored in the studies about sleep pattern is the sleep position of the infants, due to its association with sudden infant death syndrome. The results pointed to the need to promote and develop written guidelines regarding behavioral practices to reduce the risk of this phenomenon.

Conclusion:

Evidence has identified sleep issues, mainly regarding the sleep position of the infant and the environment where the infant sleeps, showing that it is critical to set routines and interventions to improve the quality of sleep care of infants attending nurseries.

Descriptors:
Nursing; Sleep; Infant; Nurseries; Child Health

RESUMEN

Objetivo:

Identificar evidencias disponibles en la literatura sobre el sueño del lactante que frecuenta guarderías.

Método:

Revisión integradora de artículos publicados en portugués, inglés o español, disponibles en su totalidad en las bases LILACS, CINAHL y PubMed. Fueron utilizados los descriptores "sueño", "lactante" y "guarderías" o "cuarto de niños" y "sleep", "infant" y "childcare" o "nurseries" para LILACS y para CINAHL y Pubmed, respectivamente, siendo seleccionados y analizados nueve estudios.

Resultados:

El principal componente explorado en los artículos acerca del comportamiento del sueño es la posición en que el niño duerme, en vista a su asociación con el síndrome de la muerte súbita infantil. Los resultados resaltaron la necesidad de promoción y desarrollo de normas escritas cuanto a las prácticas comportamentales para reducción de riesgo de ese fenómeno.

Conclusión:

Las evidencias identificaron problemas relacionados al sueño, principalmente con relación al posicionamiento del niño y al ambiente en que duerme, siendo fundamental el establecimiento de rutinas e intervenciones, visando mejorar la calidad del cuidado con el sueño de los lactantes que frecuentan guarderías.

Descriptores:
Enfermería; Sueño; Lactante; Guarderías; Salud de los Niños

RESUMO

Objetivo:

Identificar evidências disponíveis na literatura sobre o sono do lactente que frequenta creche.

Método:

Revisão integrativa de artigos publicados em português, inglês ou espanhol, disponíveis na íntegra nas bases LILACS, CINAHL e PubMed. Foram utilizados os descritores "sono", "lactente" e "creches" ou "berçários e "sleep", "infant" e "childcare" ou "nurseries" para LILACS e para CINAHL e Pubmed, respectivamente, sendo selecionados e analisados nove estudos.

Resultados:

O principal componente explorado nos artigos acerca do comportamento do sono é a posição em que a criança dorme, haja vista sua associação com a síndrome da morte súbita infantil. Os resultados ressaltaram a necessidade de promoção e desenvolvimento de normas escritas quanto às práticas comportamentais para redução de risco desse fenômeno.

Conclusão:

As evidências identificaram problemas relacionados ao sono, principalmente em relação ao posicionamento da criança e ao ambiente em que dorme, sendo fundamental o estabelecimento de rotinas e intervenções, visando melhorar a qualidade do cuidado com o sono dos lactentes que frequentam creches.

Descritores:
Enfermagem; Sono; Lactente; Creches; Saúde da Criança

INTRODUCTION

Early childhood is considered a crucial period for parents to start a sleep routine for infants and/or children, as sleeping well contributes to proper growth and development and provides security and confidence to the environment where the child lives. For infants, it is a phase of adaptation and learning about the world around them. Therefore, routine ensures that the provision of child care, especially when the child starts to attend a nursery.

Sleep is important during all stages of the life of children, since it has a regulatory role in their bodies. It is a basic biological need, and it is considered a mechanism of body protection(11 Orengo FFLopes RBM, Wojcieszyn WSN, Melo TC, Barros RA, Santos Jr DF, et al. Prevalência de distúrbios do sono em crianças de 5 a 10 anos. ConScientiae Saúde [Internet]. 2012 [cited 2015 Jul 15];11(2):320-5. Available from: http://www.redalyc.org/articulo.oa?id=92923674016
http://www.redalyc.org/articulo.oa?id=92...
). Changes in the sleep pattern of a child have direct effects on the child development, especially in the early stages of childhood, whose chronological age is based on developmental milestones. In addition, sleep disorders during the first years of a child's life are more severe and intractable(22 Owens JA. Behavioral sleep problems in children [Internet]. 2013[cited 2016 mar 13]. Available from: http://www.uptodate.com/contents/topic.do?topicKey=PEDS/6353
http://www.uptodate.com/contents/topic.d...
).

In the nursery stage, children aged 0 to 3 years stay between 4 and 12 hours a day in nursery institutions, presenting 1.2 to 3.1 naps throughout the day and considerable maturation vulnerability; therefore, an environment that can ensure the biological and social conditions for a healthy survival of these children is required(33 Galland BC, Taylor BJ, Elder DE, Herbison P. Normal sleep patterns in infants and children: A systematic review of observational studies. Sleep Med Rev[Internet]. 2012 [cited 2016 Mar 20];16:213-22. Available from: http://www.sciencedirect.com/science/article/pii/S1087079211000682
http://www.sciencedirect.com/science/art...
), including sleep pattern, emphasized in all stages.

In child education, Nursing can contribute to child care in nurseries, providing guidance to family members and educators, and specific health control interventions to support the development of a framework that allows full-time child care(44 Esteves MR, Carrijo GK, Andrade MBT, Santos LES, Ferriani MGC. Influências das relações intrafamiliares no comportamento de crianças que frequentam creches públicas de Alfenas. Rev Gaúcha Enferm [Internet]. 2012 [cited 2016 Mar 20];33(3):97-103. Available from: http://www.scielo.br/pdf/rgenf/v33n3/13.pdf
http://www.scielo.br/pdf/rgenf/v33n3/13....
). In this perspective, nurses are constantly seeking new scientific knowledge to provide improved care to patients in different care scenarios.

Nursing is art and science, whose essence and specificity are focused on providing care to human beings, involving their families and communities(55 Pott FS, Stahlhoefer T, Felix JVC, Meier MJ. Medidas de conforto e comunicação nas ações de cuidado de enfermagem ao paciente crítico. Rev Bras Enferm [Internet]. 2013 [cited 2016 Mar 20];66(2):174-9. Available from: http://www.scielo.br/pdf/reben/v66n2/04.pdf
http://www.scielo.br/pdf/reben/v66n2/04....
). Then, nursing professionals are constantly in contact with the health/disease process of the population, acting on the protection, promotion, rehabilitation of human beings and disease prevention in an autonomous, full, holistic, and interdisciplinary way.

Based on the discussions promoted by the authors on the sleep theme and the importance of an integrative review for the development of knowledge in the field of Nursing, they decided to investigate, in relevant and updated literature, sleep patterns of infants attending nurseries to develop a consistent and understandable scenario seeking to acquire knowledge that may be incorporated into the nursing practice.

Evidence-based practice is an important tool because it combines studies of different methodologies that show results without affecting the epistemological connection of empirical studies included(66 Soares CB, Hoga LAK, Peduzzi M, Sangaleti C, Yonekura T, Silva DRAD. Integrative review: concepts and methods used in nursing. Rev Esc Enferm USP [Internet]. 2014 [cited 2016 Mar 20];48(2):335-45. Available from: http://www.scielo.br/pdf/reeusp/v48n2/0080-6234-reeusp-48-02-335.pdf
http://www.scielo.br/pdf/reeusp/v48n2/00...
). The knowledge produced in the area favors the clinical practice of nurses and reflects the development of future studies. In addition, it optimizes resources and ensures a safe, patient-focused care based on interpersonal relationships that involve nursing, patient, family and community.

In the context of child assisted in nurseries, especially in terms of the sociocultural influence that this institution has in the children's sleep routine, this study aimed to identify evidence available in the literature regarding the sleep patterns of infants attending nurseries.

METHOD

This is an integrative review, whose study design is an important tool, as it allows the analysis of facts in the literature in a broad and systematic way and reveals scientific data produced by other authors(77 Ramalho Neto JM, Marques DKA, Fernandes MGM, Nóbrega MML. Meleis' Nursing Theories Evaluation: integrative review. Rev Bras Enferm [Internet]. 2016 [cited 2016 Mar 20];69(1):162-8. Available from: http://www.scielo.br/pdf/reben/v69n1/en_0034-7167-reben-69-01-0174.pdf
http://www.scielo.br/pdf/reben/v69n1/en_...
). It requires the same standards of rigor, clarity and replication used in primary studies(88 Caetano EA, Panobianco MS, Grandim CVC. Análise da produção científica nacional sobre a utilização de grupos na reabilitação de mastectomizadas. Rev Eletr Enf[Internet]. 2012 [cited 2016 Mar 20];14(4):965-73. Available from: https://projetos.extras.ufg.br/fen_revista/v14/n4/pdf/v14n4a26.pdf
https://projetos.extras.ufg.br/fen_revis...
), and it is the most comprehensive methodological approach for literature reviews.

An integrative review comprises the following steps: definition of study theme and question; definition of eligibility criteria; selection of studies from scientific databases; evaluation of selected studies and critical analysis; categorization of studies; evaluation and interpretation of results; and data presentation using the integrative review structure(99 Botelho LLR, Cunha CCA, Macedo M. The integrative review method in organizational studies. Rev Eletr Gestão Soc[Internet]. 2011[cited 2016 Jan 18];5(11):121-36. Available form: https://www.gestaoesociedade.org/gestaoesociedade/article/view/1220/906
https://www.gestaoesociedade.org/gestaoe...
). Therefore, the following study question was defined: What is the scientific evidence of sleep patterns in infants who attend nurseries?

This study started by searching Health Sciences Descriptors (DeCS) through the Virtual Health Library (VHL); and the Medical Subject Headings (MeSH) of the National Library, to learn about the universal descriptors. Then, the following controlled descriptors were used, in Portuguese and English: "sono/sleep," "lactente/infant," and "creches or berçários/childcare or nurseries."

The following inclusion criteria were defined: studies published in full text, electronically available in Portuguese, English and/or Spanish, whose results were related to aspects of sleep patterns of infants attending nurseries or other units with the same purpose, such as family homes for child care. Editorials, letters to the editor, dissertations, theses, reports of experience, and reflective studies were excluded. It should be noted that no limit was defined for years of publication to cover as many studies as possible.

In June-July 2014, the bibliographic review was orderly conducted on three databases: Latin Literatura Latino-Americana em Ciências de Saúde (LILACS), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PubMed portal.

The six studies selected from PubMed were excluded because they were repeated on the CINAHL database, leading to nine studies that comprised the sample.

Data were collected in two stages. The first consisted of an advanced search on the databases, with details of study quantities: LILACS, 4; CINAHL, 85; PubMed, 1,410; totaling 1,499 studies. After the study selection and identification process according to the inclusion criteria, previous reading of all titles and abstracts, 15 studies were selected, as follows: LILACS, 2; CINAHL, 7; and PubMed, 6. In the second stage, full text reading was conducted, and six studies were excluded, as they were repeated on one of the databases. Therefore, duplicate studies were computed only once, resulting in a sample of nine studies.

After reading each study again, an instrument was filled out with the following information: title, authors, journal, country, language, year of publication, objectives, methodology, and study results, highlighting the methods of sleep evaluation, which are summarized in Chart 1 and 2.

Chart 1
Distribution of references included in the integrative review, according to LILACS, CINAHL and PubMed databases, organized according to the publication year, 2016
Chart 2
Distribution of main results from selected studies, 2016

RESULTS

Charts 1 and 2 show an overview of all nine studies selected, highlighting their characterization, methodologies and results.

Of the nine studies selected, eight were from foreign journals and one from a national journal. None of the articles were from nursing journals; however, one of the studies had a nurse as its author. Seven articles were available in English; one in Spanish; and one in Portuguese.

Although no temporal restriction had been defined to study search and inclusion, the topic in question is a recent discussion in the literature, from 1997 to 2011. In addition, the interest in this field of research is concentrated in the United States, as six studies were from this country, and the others were from Chile, Brazil, and Canada.

Regarding the study design, most of them (six studies) were cross-sectional studies; in addition, two were interventional and one was descriptive, and they were classified by levels of evidence according to the Oxford Centre for Evidence-based Medicine - Levels of Evidence(1919 OCEBM Levels of Evidence Working Group. The Oxford Levels of Evidence 2[Internet]. Oxford Centre for Evidence-Based Medicine. 2011 [cited 2016 Mar 20]. Available from: http://www.cebm.net/ocebm-levels-of-evidence/
http://www.cebm.net/ocebm-levels-of-evid...
), as levels 2, 2 and 5, respectively.

The nursery population ranged from one(1414 Melchior LE, Biasoli-Alves ZMM. Comportamento de bebês na rotina diária da creche. Rev Bras Cresc Desenv Hum [Internet]. 2002 [cited 2014 Jul 15];12(2):42-51. Available from: http://www.revistas.usp.br/jhgd/article/viewFile/39693/42552
http://www.revistas.usp.br/jhgd/article/...
) to 190(1717 Moon RY, Calabrese T, Aird L. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: lessons learned from a demonstration project. Pediatrics [Internet]. 2008 [cited 2014 Jul 15];122(4):788-98. Available from: http://pediatrics.aappublications.org/content/122/4/788
http://pediatrics.aappublications.org/co...
) children. Two studies included(1313 Dayie RA, Aronson SS, Jansen-McWilliams L, Kelleher KJ. Use of a statewide system to improve health and safety in child care facilities. Ambul Pediatr [Internet]. 2001 [cited 2014 Jul 15];1(2):73-8. Available from: http://www.sciencedirect.com/science/article/pii/S1530156705600214
http://www.sciencedirect.com/science/art...
,1717 Moon RY, Calabrese T, Aird L. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: lessons learned from a demonstration project. Pediatrics [Internet]. 2008 [cited 2014 Jul 15];122(4):788-98. Available from: http://pediatrics.aappublications.org/content/122/4/788
http://pediatrics.aappublications.org/co...
), besides the nurseries, family homes for child care, which was considered an environment for child care provided at home. These, in turn, when compared to nurseries, typically involve lower costs, more personalized care and more flexible times, often including the option night and weekend care. However, night and weekend care is also offered by nurseries. In this review, one study was conducted in 110 night nurseries.

In relation to children, they aged 0 to 36 months, since one of the articles evaluated children aged 12 to 36 months. Of the studies, three analyzed children younger than 6 months only; and one study evaluated children aged 0 to 3 years. Regarding study nº 9(1818 Hall WA, Scher A, Zaidman-Zait A, Espezel H, Warnock F. A community-based study of sleep and behaviour problems in 12- to 36-month-old Children. Child Care Health Develop[Internet]. 2011 [cited 2014 Jul 15];38(3):379-89. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2214.2011.01252.x/epdf
http://onlinelibrary.wiley.com/doi/10.11...
), it was not excluded because the infant, in the Brazilian context (0 to 2 years old), was included in the toddler age group (0-36 months of age).

The subjects interviewed in almost all studies (eight) were the nursery directors/caregivers. In only one study, the parents, directors, and caregivers were investigated.

Regarding the results of the studies, most (eight studies) of the institutions knew or adopted some written recommendations for infant sleep; however, the prone position was still used in nurseries or family care units. Another study focused on the prevalence of sleep problems in the children investigated (38%) and their association with parental interventions during child sleep.

DISCUSSION

The theme of child sleep in nurseries related to the issue of environment safety and the relationship with sudden infant death syndrome was frequently identified in the selected literature. This fact is justified by the high prevalence of the phenomenon in child care settings, as indicated in the study(2020 Moon RY, Biliter WM, Croskell SE. Examination of state regulations regarding infants and sleep in licensed child care centers and family child care settings. Pediatrics [Internet]. 2001 [cited 2016 Mar 20];107(5):1029-36. Available from: http://pediatrics.aappublications.org/content/107/5/1029.long
http://pediatrics.aappublications.org/co...
), which reports 20% of sudden infant death syndrome during sleep in child care settings. A study conducted in the United States, investigating 1,916 cases of sudden infant death syndrome, found that 20.4% of these deaths occurred in child care settings(2121 Moon RY, Patel KM, Shaefer MD. Sudden Infant Death Syndrome in Child Care Settings. Pediatrics [Internet]. 2000 [cited 2016 Mar 20];106(2):295-300. Available from: http://pediatrics.aappublications.org/content/106/2/295.long
http://pediatrics.aappublications.org/co...
). Therefore, the risk of sudden infant death syndrome is extremely high during sleep in daycare settings(2222 Kiechl-Kohlendorfer U, Moon RY. Sudden infant death syndrome (SIDS) and child care centres (CCC). Acta Pædiatrica [Internet]. 2008 [cited 2016 Mar 20];97:844-5. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1651-2227.2008.00850.x/epdf
http://onlinelibrary.wiley.com/doi/10.11...
).

Consistently, the child position during sleep is considered the main variable in question, discussed by seven of the nine studies evaluated. Concerning the environment and the context of infant sleep, the following practices were pointed out as unsafe: exposure to smoke; prone position during sleep; sleep on surfaces that are not firm; use of pillows, blankets and toys near the child. This is justified by sleep habits, and the ventral position is the main risk factor for sudden infant death syndrome(2323 Bezerra MAL, Carvalho KM, Bezerra JLO, Novaes LFG, Moura THM, Leal LP, et al. Fatores associados aos conhecimentos das mães sobre a Síndrome da Morte Súbita do Lactente. Esc Anna Nery Rev Enferm[Internet]. 2015 [cited 2016 Mar 20];19(2):303-9. Available from: http://www.scielo.br/pdf/ean/v19n2/1414-8145-ean-19-02-0303.pdf
http://www.scielo.br/pdf/ean/v19n2/1414-...
).

For some authors, infant death related to sleep remains a serious public health problem; however, a number of interventions have been implemented to increase adherence to safe recommendations(2424 Ward TCS, Balfour GM. Infant Safe Sleep Interventions, 1990-2015: a review. J Community Health [Internet]. 2016 [cited 2016 Mar 20];41(1):180-96. Available from: http://link.springer.com/article/10.1007%2Fs10900-015-0060-y
http://link.springer.com/article/10.1007...
). The study recommends the dorsal decubitus position up to one year of age to reduce the risk of sudden infant death syndrome, and states that it does not increase the risk of asphyxia and aspiration in children, not even in those with gastroesophageal reflux, provided the child has no upper airway disorder that prevents the effective action of natural airway protection mechanisms(2525 American Academy of Pediatrics - AAP. SIDS and Other Sleep-Related Infant Deaths: expansion of recommendations for a Safe Infant Sleeping Environment. Pediatrics [Internet]. 2011 [cited 2016 Mar 20]:128(5):p.1-27. Available from: http://pediatrics.aappublications.org/content/early/2011/10/12/peds.2011-2284
http://pediatrics.aappublications.org/co...
).

In a study conducted in Portugal with 94 children under one year of age and their caregivers, 58.4% of the interviewed mothers preferred to place the child in the lateral decubitus position at sleep time, and the main reasons was that parents considered it safe or had been advised by a health professional. Only 38.2% of the interviewees place the child in the supine position after receiving professional guidance. In addition, the practice of sleeping in the same room, co-sleeping, and the presence of objects near the child at sleep time were also frequently mentioned (89.9%, 56.2%, and 67.4%, respectively)(2626 Azevedo L, Mota L, Machado AI. Ambiente de sono seguro no primeiro ano de vida. Nascer Crescer [Internet]. 2015 [cited 2017 Mar 24];24(1):18-23. Available from: http://revistas.rcaap.pt/nascercrescer/article/viewFile/8573/6131
http://revistas.rcaap.pt/nascercrescer/a...
).

Seven studies evaluated the existence of written guidelines on the sleep position and showed low percentages of nurseries with those guidelines in place(1010 Gershon NB, Moon RY. Infant Sleep Position in Licensed Child Care Centers. Pediatrics [Internet]. 1997 [cited 2014 Jul 15];100(1):75-8. Available from: http://www.sids.org.ar/ar4.htm
http://www.sids.org.ar/ar4.htm...
-1111 Moon RY, Biliter WM. Infant sleep position policies in licensed child care centers after back to sleep campaign. Pediatrics [Internet]. 2000 [cited 2014 Jul 15];106(3):576-80. Available from: http://pediatrics.aappublications.org/content/106/3/576
http://pediatrics.aappublications.org/co...
,1313 Dayie RA, Aronson SS, Jansen-McWilliams L, Kelleher KJ. Use of a statewide system to improve health and safety in child care facilities. Ambul Pediatr [Internet]. 2001 [cited 2014 Jul 15];1(2):73-8. Available from: http://www.sciencedirect.com/science/article/pii/S1530156705600214
http://www.sciencedirect.com/science/art...
,1515 Moon RY, Weese-Mayer DE, Silvestri JM. Nighttime child care: inadequate sudden infant death syndrome risk factor knowledge, practice, and policies. Pediatrics [Internet]. 2003 [cited 2014 Jul 15];111(4):795-9. Available from: http://pediatrics.aappublications.org/content/111/4/795.long
http://pediatrics.aappublications.org/co...

16 Moon RY, Oden RP. Back to sleep: can we influence child care providers? Pediatrics [Internet]. 2003 [cited 2014 Jul 15];112(4):878-82. Available from: http://pediatrics.aappublications.org/content/112/4/878.long
http://pediatrics.aappublications.org/co...

17 Moon RY, Calabrese T, Aird L. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: lessons learned from a demonstration project. Pediatrics [Internet]. 2008 [cited 2014 Jul 15];122(4):788-98. Available from: http://pediatrics.aappublications.org/content/122/4/788
http://pediatrics.aappublications.org/co...
-1818 Hall WA, Scher A, Zaidman-Zait A, Espezel H, Warnock F. A community-based study of sleep and behaviour problems in 12- to 36-month-old Children. Child Care Health Develop[Internet]. 2011 [cited 2014 Jul 15];38(3):379-89. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2214.2011.01252.x/epdf
http://onlinelibrary.wiley.com/doi/10.11...
). Regardless of the existence of such guidelines, it is important to explain about the sudden infant death syndrome and highlight the preventive measures that are considered important by the caregivers of children, favoring the dorsal decubitus as the ideal position during infant sleep. This premise is possible considering the evidence of two interventional studies that showed the positive effect of implementing educational programs for child care providers about improvements in the sleep environment(1616 Moon RY, Oden RP. Back to sleep: can we influence child care providers? Pediatrics [Internet]. 2003 [cited 2014 Jul 15];112(4):878-82. Available from: http://pediatrics.aappublications.org/content/112/4/878.long
http://pediatrics.aappublications.org/co...
-1717 Moon RY, Calabrese T, Aird L. Reducing the risk of sudden infant death syndrome in child care and changing provider practices: lessons learned from a demonstration project. Pediatrics [Internet]. 2008 [cited 2014 Jul 15];122(4):788-98. Available from: http://pediatrics.aappublications.org/content/122/4/788
http://pediatrics.aappublications.org/co...
).

Nevertheless, three other studies(1010 Gershon NB, Moon RY. Infant Sleep Position in Licensed Child Care Centers. Pediatrics [Internet]. 1997 [cited 2014 Jul 15];100(1):75-8. Available from: http://www.sids.org.ar/ar4.htm
http://www.sids.org.ar/ar4.htm...
-1111 Moon RY, Biliter WM. Infant sleep position policies in licensed child care centers after back to sleep campaign. Pediatrics [Internet]. 2000 [cited 2014 Jul 15];106(3):576-80. Available from: http://pediatrics.aappublications.org/content/106/3/576
http://pediatrics.aappublications.org/co...
,1515 Moon RY, Weese-Mayer DE, Silvestri JM. Nighttime child care: inadequate sudden infant death syndrome risk factor knowledge, practice, and policies. Pediatrics [Internet]. 2003 [cited 2014 Jul 15];111(4):795-9. Available from: http://pediatrics.aappublications.org/content/111/4/795.long
http://pediatrics.aappublications.org/co...
) highlight the fact that caregivers say they place the children in the prone position because their parents request that, which reinforces the need to invest in health education process and programs to parents, caregivers and family members about the risk factors for sudden infant death and prevention measures, especially regarding the proper child sleep position.

Of the studies analyzed in this review, only one addressed the prevalence of changes in infant sleep pattern, using specific instruments, including the Infant Sleep Questionnaire (ISQ). The authors evaluated the child sleep problem according to the maternal perception and with a set of items that determine, by means of a score, possible changes in the sleep pattern of the evaluated children(1818 Hall WA, Scher A, Zaidman-Zait A, Espezel H, Warnock F. A community-based study of sleep and behaviour problems in 12- to 36-month-old Children. Child Care Health Develop[Internet]. 2011 [cited 2014 Jul 15];38(3):379-89. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2214.2011.01252.x/epdf
http://onlinelibrary.wiley.com/doi/10.11...
).

Regarding sleep evaluation instruments, a study conducted in Portugal with 107 preschool children and 122 school children using the Portuguese Children's Sleep Habits Questionnaire identified a global prevalence of sleep problems in 75.7% of the evaluated children, and an average score for the instrument of 47.05 points. Comparatively, sleep problems identified among preschool children were higher than in school children; the main ones were: bedtime resistance, difficulty falling asleep alone, needing a parent in the room and starting sleep in their bed, and the presence of nocturnal awakenings and the frequency with which they occur(2727 Lopes S, Almeida F, Jacob S, Figueiredo M, Vieira C, Carvalho F. Diz-me como dormes: hábitos e problemas de sono em crianças portuguesas em idade pré-escolar e escolar. Nascer Crescer [Internet] 2016 [cited 2017 Mar 24];25(4):211-6. Available from: http://repositorio.chporto.pt/bitstream/10400.16/2033/1/04_ArtigosOriginais-2_25-4.pdf
http://repositorio.chporto.pt/bitstream/...
).

Study limitations

The study limitations refer to the sample, as only freely available online studies were included.

Contributions to the field of Nursing, public health or policies

Considering sleep essential for child health, the interventions should be performed by institutional caregivers, family members and health professionals, particularly the nurses working in childcare, given this professional is one of the main links between the patient and the health institution, regarding health promotion actions to clarify and provide proper practices for the full development of child sleep and prevent future sleep disorders or even early deaths.

The evidence and information that have been identified in this review support the planning of public health policies that address sleep needs of infants in nurseries, which are crucial for reducing changes in child health.

FINAL CONSIDERATIONS

When discussing sleep issues of infants attending nurseries, the focus is on recommendations regarding measures and positions for a safe sleep environment aiming to reduce infant sudden death syndrome, and on the sleep position. Although child care institutions know about sleep recommendations, those that adopt these directions or have some type of written guideline for professionals are still very limited, leading to inadequate practices due to the requests of parents.

However, it is important to perform the evaluation of characteristics related to sleep patterns of children attending nurseries, since, in the first years of life, these factors can strongly influence sleep, that is: the family context in which the child is inserted; sleep habits adopted at home and at school by caregivers; the sleep duration required by each child, considering the diversity of the child needs; and the knowledge related to the rhythm of each child, considering the range of factors that can influence sleep in the infant and that are interconnected to the process of temporal and structural organization of sleep in two different environments: the home and the nursery.

In addition, other relevant aspects related to the sleep environment in which the child is inserted are: the quantity of objects placed next to the child at the moment of sleep; the place where the child sleeps; the presence of smokers; and the organization of the place where the child sleeps. All these, associated with intrinsic and other behavioral factors, such as sleep position, can directly influence the quality of infant sleep.

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Publication Dates

  • Publication in this collection
    Mar-Apr 2018

History

  • Received
    08 Oct 2016
  • Accepted
    19 Apr 2017
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