An inductive content analysis of behavioural sleep information in Canadian online infant sleep resources

Abstract

Objectives

To conduct an inductive content analysis of publicly available online resources to describe existing content provided by Canadian government and social service health organizations for parents of infants.

Methods

Online resources were obtained as part of a larger environmental scan on Canadian infant sleep information. Inclusion criteria required that English or French written resources focused on sleep in infants under 2 years, be created by a Canadian governmental or health service organization and include behavioural infant sleep information. Resources were independently coded by two research assistants using inductive content analysis.

Results

A total of 51 resources were identified, with most being in English (n = 45, 88.24%). Most resources contained information on developing a bedtime routine (n = 41, 80.39%), feeding (n = 44, 86.27%), and infant sleep patterns and needs (n = 48, 94.12%). Information on sleep patterns and needs mainly focused on age-specific sleep considerations. Information on individual and family considerations and the causes of sleep difficulties and disruptions were less common.

Conclusions

This content analysis demonstrated that the majority of content on infant sleep from Canadian government and social service organizations is related to age-specific sleep patterns and/or infant feeding. Less information is available on how parents can influence infant sleep (particularly when experiencing difficulties with infant sleep), individual and family considerations (especially on cultural considerations and family well-being), and causes of sleep difficulties. Future research and resource development could address potential knowledge gaps by using community co-design and collaboration.

Graphical Abstract

Graphical Abstract.

Introduction

Parental concerns about infant sleep and specific sleep difficulties are common (1,2). Especially in the first two years, infant sleep supports infant mental health (3), growth and development (4). Infants who experience poor and short sleep may be at an increased risk for more sleep problems (5), and poor socioemotional, behavioural, and cognitive development (3,6,7). Disrupted infant sleep can negatively impact the family system, contributing to poor parental sleep (8), fatigue (9), and mental health issues (2,10). Given the impact of infant sleep on infants and their family, sleep health is an important public health priority.

Parental knowledge about infant sleep, specifically sleep needs, routines, and sleep problems, is limited (11). Previous literature has focused on parental knowledge about safe sleep practices (12), rather than broader infant sleep health (13). While information on safe sleep practices is important, knowledge and informed expectations (14) about other aspects of sleep, such as routines and infant sleep variability (15), is essential for promoting family well-being (16) and sleep health (17). Parents value advice that is grounded in experience, appreciative of diversity, and helps manage their expectations about infant sleep (13), which may vary widely between parents (14).

Many parents use the internet to find parenting information (18,19), with some using it at least daily (20), and others using informal information sources rather than formal medical support (21), which could lead to being confused or overwhelmed by conflicting information (22,23). Only about two-thirds of parents’ report assessing the reliability of online information and even fewer report understanding the information (19). In Canada, many health and social service organizations provide online credible and evidence-based parenting and child health information (e.g., Perinatal Services BC) to meet parents' information needs.

Given the importance of infant sleep and parents’ frequent use of online information, it is important to understand what infant sleep information is available to parents. Thus, the aim of this study was to describe online behavioural infant sleep information provided by credible Canadian health and social service organizations. With sleep resources serving as a first support for parents and sleep being linked to mental health, the findings contribute to the development of inclusive and culturally informed resources. Understanding the current landscape of information provided to Canadian parents can help identify information gaps and inform future resource development.

Methods

We conducted an inductive content analysis of publicly available resources provided by credible Canadian social service and health organizations to describe what behavioural infant sleep information is provided to parents and identify information gaps.

Search strategy

Resources were obtained as part of a larger environmental scan on infant sleep resources (Keys et al., unpublished manuscript) using a grey literature search methodology informed by Godin (24) and Carson et al. (25). Between May-June 2023, searches were completed using customized Google search engines from Ontario Public Health Libraries Association (OPHLA; https://www.ophla.ca/p/customsearchcanada.html) for provinces, territories, and Canada-wide resources and additional search engines for British Columbia, Alberta, Manitoba, and Canada-wide to include relevant websites not included in the OPHLA search. Since English and French are both official languages in Canada, searches were conducted using English search terms “(infant OR baby) AND sleep” and French search terms “(bébé OR nourrisson) AND (sommeil OR “faire ses nuits”)” for regions that provide French-speaking services (i.e., Quebec and New Brunswick). No publication date limits were set.

Resource selection

Resources were included if they: (1) targeted parents of children under 2 years of age, (2) included behavioural infant sleep information, (3) were created by a credible Canadian social service or health organizations rather than social media influencer or content creators, and (4) were in French or English. Webpages and online downloadable documents were included. Exclusion criteria included: (1) no extractable behavioural sleep information (i.e., only included safe sleep information), (2) not original content (e.g., referred parents to another resource in a different province), (3) targeted healthcare providers, or (4) video-based resource materials. Research assistants reviewed the first 10 pages (100 results) of each search, recording the URL, search date, and whether to include the resource in an Excel file. All search results were archived as PDFs. Two research assistants (TM, NS, RS, KJ, MH, AV, EW, ML) independently screened each resource. After resolving disagreements through discussion, remaining disagreements were resolved by consultation with a senior researcher (EK, MHP).

Data extraction and analysis

Resource characteristics (e.g., title, author/website, province/territory) were extracted to an Excel file and verified by a second research assistant. Disagreements were resolved through consultation with a senior researcher. PDFs were uploaded to NVivo 14 and text and images were coded using an inductive content analysis approach (26), where codes are developed based on the data rather than being predetermined (26). Preliminary codes were developed by TM and RI and refined with EK prior to independent coding. Two research assistants independently coded the English (TM, SK) and French resources (AV, KV) in their original language. The research team met to ensure the codes were translated appropriately and retained meaning across languages. A high percent agreement was established between coders for the extraction of English (86%) and French resources (87%). Most disagreements were resolved through discussions between the original coders; remaining disagreements (<2%) were resolved by consulting a senior researcher (EK, MHP). The research team brought assumptions informed by lived experience with parenting and/or young children (MH, MHP, EK), professional backgrounds in nursing and public health (SK, RI, NS, EK), midwifery (SK), and training in psychology (TM, AV, MH, ML, MHP). Code counts reflect the number of resources containing that code.

Results

Search results

Our search yielded 1910 resources. After initial screening, 1762 resources were excluded. Of the remaining 148 resources, 97 were excluded based on the exclusion criteria, resulting in 51 resources in the final analysis. We conducted a broad search with a wider definition of infants from ages 0 to 2 years to capture more resources, but over half (n = 32, 62.75%) focused only on 0 to 12-month-old infants. See Figure 1 for more information. See Table 1 for resource characteristics.

Figure 1.

PRISMA flow chart of resource identification and screening (from 27).

Table 1.

Characteristics of included resources (N = 51).

Characteristic	Count (%)
Resource language
English	45 (88.24%)
French	6 (11.76%)
Resource organizational level
Provincial	51 (100.00%)
Resources by province
Alberta	3 (5.88%)
British Columbia	6 (11.76%)
Manitoba	2 (3.92%)
New Brunswick	4 (7.84%)
Newfoundland and Labrador	1 (1.96%
Nova Scotia	2 (3.92%)
Ontario	20 (39.22%)
Quebec	5 (9.80%)
Saskatchewan	8 (15.69%)
Resource only focused on infants 0 to 12 months	32 (62.75%)
Resource only focused on sleep	26 (50.98%)

Count is the number of resources that contained the resource characteristic.

Content coding

In total, 5 categories with 14 subcategories were developed to describe resource content (Figure 2). Results are presented by code frequency. See Table 2 for code descriptions and quotes.

Figure 2.

Results of content analysis that assessed the behavioural sleep information in online resources.

Table 2.

Codebook for online behavioural sleep information resources.

Code name	Description	Quotes
Sleep patterns and needs
Age-specific sleep considerations	Includes how long sleep and waking patterns are related to different age groups.	“During a baby's first few months, maturing of the brain allows the baby gradually to sleep for longer periods. By age 3 months, most babies sleep for their longest period (up to 7 to 8 h) during the night and develop set nap times.” (Resource 8)
Naps	Daytime naps, naptime routines	“Most babies are napping 3 times per day by the age of 4 months, morning afternoon and early evening. Between 6 to 12 months old, babies usually transition from 3 naps down to 2 longer naps.” (Resource 28)
Feeding	Anything to do with feeding (e.g., at night, breast feeding, waking to feed, etc.).	“Feed your infant whenever he shows feeding cues. Most newborn babies feed at least 8 times in 24 h. Some babies feed regularly and establish a routine quickly; others like to have short feeds very often, especially in the evening or at night. Cluster feeding (frequent short feeds) is very common in the first few weeks.” (Resource 21)
How parents can influence sleep
Developing a bedtime routine	Sleep habits to perform repeatedly, including interventions to perform while getting the baby to sleep (e.g., bath time before bed, keeping the room dim and quiet).	“Establish a brief routine before bedtime and nap time. Your infant will learn to associate the bedtime and nap routine with going to sleep. Choose a couple of activities like breastfeeding, bathing, telling a story, singing or massaging, etc. The routine should be enjoyable to all.” (Resource 21)
Daytime activities to help with sleep	Things parents can do during the daytime, rather than at nighttime, to help with sleep.	“Physical activity during the day promotes sleep. If your baby is not yet mobile, they need at least thirty minutes of tummy time spread throughout the day, while they are awake.” (Resource 35)
Night wakings back to sleep	Things to do to get baby back to sleep. How to teach baby to put themselves back to sleep. Things to do it if they do not fall back to sleep after waking.	“Your baby will sleep better at night if you teach her that she can go into her crib awake and fall asleep on her own. This will also allow her to get herself back to sleep in the middle of the night when she wakes up.” (Resource 3)
Self-soothing and independent sleep	Teaching baby to self-soothe. Things babies do when they self soothe.	“Allow your baby to try to settle herself by moving, wiggling, talking and maybe even fussing for short periods of time. Babies don't have to cry it out to learn how to sleep, but a few minutes of fussing at bedtime may give your baby a chance to settle herself. When she learns that she can go to sleep without you being present, she will be on her way to independent sleep.” (Resource 3)
Sleep cues	Signs to know when to put baby down. Signs of fatigue or overtiredness.	“You can help your baby sleep by recognizing signs that your baby is getting sleepy. These signs include: Rubbing eyes, pulling on ears or twirling their hair, yawning, looking away or zoning out, cranky and irritable. Learning your baby's cues will help identify when it is time for naptime or bedtime.” (Resource 20)
Soothing strategies by parents	Interventions parents can do to soothe the baby (e.g., therapeutic touch to soothe the infant).	“Some babies fall asleep easily with just a little help, while others can be harder to settle. Feeding, rocking, singing, shushing, and patting may be soothing to your baby.” (Resource 30)
“Sleep training”	What is sleep training? Examples of methods.	““Sleep Training” is a common term for a method of letting baby fall asleep on their own. Some training methods involve leaving baby to cry without being comforted. Some unintended effects on mother and baby could include: • Increased crying • Early weaning from breastfeeding • Increased anxiety for mom • Increased risk of SIDS” (Resource 19)
Individual and family considerations
Individual differences for infants and families	Talks about how families are not all the same and how infants are different (e.g., personality and temperament) and have different needs than others.	“Babies with an intense or spirited personality often have more trouble learning how to sleep independently. They need warmth and structure from their parents and lots of patience! Things that work with other babies may not work with these babies.” (Resource 3) “Tous les bébés sont différents. Certains dorment plus que d’autres. Certains dorment moins. Certains s’endorment rapidement et ne se réveillent pas, alors que d’autres s’endorment moins facilement et se réveillent au moindre bruit. Vous ne pouvez rien y faire: votre bébé est comme il est, c’est tout.” [All babies are different. Some sleep more than others. Some sleep less. Some fall asleep more quickly and don't wake up, while others fall asleep less easily and wake up to the slightest noise. There is nothing you can do about it: your baby is the way they are, that's all.] (Resource 15)
Cultural consideration	Discusses culturally related considerations. Includes images of diverse families.	“Lullabies have been used for centuries in many cultures to help babies sleep.” (Resource 1)
Family well-being	Discusses how babies sleep and its impact on the rest of the family.	“Every baby can learn healthy sleep; it just takes time and the right approach for your baby and your family. No matter what you choose, you need to feel comfortable that it's right for all of you. Sleep is an important contributor to the health of babies, parents, and families. Call Health Link at 811 or talk with your health care provider about any concerns you have and how sleep may be affecting your family's health and well-being.” (Resource 1)
Causes of sleep difficulties and disruptions	Why a sleep problem may be occurring. Example—teething, sickness, etc.	“Many infants continue to wake at night. Some reasons for waking include: Hunger, Teething, Being hot or cold, Growth spurts (developmental stage), Illness, Loneliness (attachment)” (Resource 29)

Sleep patterns and needs

Information about sleep patterns and needs was found in the majority of resources (n = 48, 94.12%). This information was discussed in terms of age-specific sleep considerations in nearly all the resources (n = 47, 92.16%) and provided parents with information about how long infants sleep based on their age group. Just over half of resources (n = 30, 58.82%) contained information on naps, including content on naptime routines and age-specific considerations.

Feeding

Most resources (n = 44, 86.27%) contained information on feeding and sleeping, including content on breastfeeding, formula feeding, nighttime feeding, and/or waking to feed at night. Information on night feedings described how infants wake due to growth spurts and their small stomachs and reassured parents that infant night wakings to feed are expected. Feeding content was often described in combination with age-related differences in feeding, bedtime routines, and independent sleep.

How parents can influence sleep

Ways parents could influence infant sleep were coded in 43 (84.31%) resources. Nearly all (n = 41, 80.39%) discussed developing bedtime routines, including information on nap and night routines, the importance of routines, and activities such as keeping the room dim. Under half of the resources (n = 23, 45.10%) described daytime activities parents could do to promote sleep, such as natural light exposure and physical activity. Strategies for managing night wakings and helping infants get back to sleep were coded in 23 (45.10%) resources and included reasons for night wakings and activities parents can do to soothe during wakings. Information on infants learning to self-sooth and sleep independently appeared in 22 (43.14%) resources, describing how infants might try to settle themselves. Content on infant sleep cues (n = 21; 41.18%) encouraged parents to watch for their infant's cues and examples of overtired cues. Some resources (n = 20, 39.22%) discussed soothing strategies that parents could use to help settle their baby and help them fall (back) asleep, such as singing lullabies or therapeutic touch. Few resources (n = 3, 5.88%) specifically mentioned “sleep training”. Such content included defining the term sleep training, examples of sleep training, and potential effects of sleep training, such as infant crying and maternal anxiety.

Individual and family considerations

Information on individual and family considerations appeared in over half of the resources (n = 28, 54.90%). This code was used when resources described how individual differences for infants, such as infant personality and temperament, were related to sleep (n = 22, 43.14%). Cultural considerations were coded in 12 (23.53%) resources, with nearly all (n = 11, 91.67%) of the content in this category consisting of images of families or infants of diverse ethnicities. Only 1 resource (8.33%) explicitly mentioned culture, although the content lacked detail. Three (5.88%) resources addressed family well-being. This included content on how sleep impacts the rest of the family and recommended parents access further resources if they had concerns about their family's well-being.

Causes of sleep difficulties and disruptions

Less than half of the resources (n = 23, 45.10%) included content on the causes of sleep difficulties and disruptions, including information explaining why night wakings or sleep difficulties may be occurring, such as an infant being overtired or hungry.

Discussion

This study described the content of 51 online infant sleep resources from Canadian health and social service organizations. Overall, these resources addressed infant sleep patterns and needs, sleep and feeding, and how developing routines could promote infant sleep. There were notable gaps in providing information on the underlying causes of and strategies to manage infant sleep difficulties and individual family considerations related to infant sleep, including family well-being and cultural considerations.

Information on sleep patterns and needs, and individual differences between infants, is likely beneficial to include in resources, since parents may have inconsistent and varying expectations about their infant's sleep (14,28). Moreover, while information about “normative” infant sleep may help reassure parents, it is also important to acknowledge intra-individual sleep variability. For example, night-to-night fluctuations in the same infant are normal (15) but could be perceived as unusual and problematic if this variability is not described explicitly and normalized. Thus, while highlighting typical trends in infant sleep and differences between infants is important, acknowledging infant intra-individual sleep variability is also valuable.

Content related to infant feeding included breastfeeding, formula feeding, and nighttime feeding. The inclusion of feeding-related content with information on infant sleep is well-justified, given the well-established evidence that feeding practices are associated with infant sleep (29,30). Similarly, the inclusion of information on bedtime routines is well-justified given research showing that bedtime routines can reduce sleep onset latency and the number of night wakings, as well as increase sleep duration (16,17).

Up to 80% of families may encounter infant sleep difficulties in the first year (2), yet clear guidance for managing these difficulties was limited. Some resources included basic strategies (e.g., routines, self-soothing strategies), yet few explicitly included terms that parents may associate with sleep management strategies (i.e., “sleep training”), possibly due to varying definitions or conflicting views about how to support families when managing infant sleep difficulties. However, parents have reported difficulties in understanding online information (19) and have limited knowledge of children's sleep needs and sleep problems (11), highlighting a need for resources to provide clear guidance about how individual infant factors may be related to sleep difficulties (e.g., temperament) and what parents can do if they are experiencing infant sleep difficulties. Without appropriate and credible guidance, parents may turn to less credible, costly, or overwhelming sources, which may lead to increased stress, isolation, and limited improvements in infant sleep (31,32).

Surprisingly, content on sleep and family considerations was limited despite associations between infant sleep and parent mental health and wellbeing (2,10). Mothers have expressed feelings that their care may not emphasize their own maternal health (23), and fathers report limited knowledge of parental mental health (33). As such, resources could include more content about how infant sleep relates to parental sleep and mental health. Using a family-centred approach would position the child within their family context, respect diversity in both culture and care preferences (34), acknowledge how parenting practices (35), family structure (36), and parental knowledge (37) affect infant sleep, and acknowledge the reciprocal relationship between a child's sleep and overall family functioning (38,39).

Cultural considerations were underrepresented in resources despite varying definitions of sleep problems (40) and sleep-related parenting practices (41,42) across cultures, such as higher bedsharing rates among Turkish, Moroccan, and Caribbean mothers (42), and lower rates among Western cultures (41). However, bedsharing did not appear in the coded content, likely due to the study's emphasis on topics other than sleep safety. Still, given the known cultural variations in sleep practices (41,42), and the diverse nature of Canadian families (43), sleep information could be tailored to better support diverse families and promote culturally safe care. Developing resources with communities supports the sharing of lived experiences, respect for cultural diversity (44), and ensures that parents have access to culturally relevant information that supports family well-being and improves understanding of online sleep information.

Strengths of this study include the comprehensive search for online infant sleep resources, having two independent research assistants verify inclusion criteria, and independent coding. Despite challenges of multilingual qualitative research (45), our multilingual team enabled the search to be conducted in English and French and allowed coding resources to be coded in their original language, enabling French resources to retain meaning. Limitations include our focus on text-based resources, which may have resulted in missed information from video-based components. Parents may increasingly prefer digital and visual formats and access information via social media (46), therefore future research could examine sources created by online influencers and content creators. Our search was conducted from May to June 2023, so some content may have since changed, though our findings likely still describe major trends that could be considered in future resource development. Finally, we only assessed information content, not quality, although resources came from credible sources, so it is reasonable to assume that the content had undergone expert review. Still, future research could evaluate accuracy, quality, and parental acceptability to ensure alignment with families’ needs and preferences.

This content analysis described the information in existing Canadian infant sleep resources and showed that common topics included sleep patterns and needs, sleep and feeding, and how developing routines could promote sleep. However, opportunities remain to adopt a family-centred approach by acknowledging links between infant sleep and family wellbeing, considering diverse cultural contexts, and providing specific guidance for managing sleep difficulties. These findings align with Canadian recommendations that many sleep problems can be addressed through behavioural strategies that consider diversity, family context, and parental needs (47). Integrating these elements into resource development and care could support health care providers and researchers in providing tailored guidance for navigating sleep challenges and developing resources that better align with families’ needs.

Funding

This research did not receive any specific funding. Keys is supported by a Michael Smith Health Research BC [SCH-2023-3177].

Potential conflict of interest

Although this project did not receive any direct funding, AV reports other funding from Social Sciences and Humanities Research Council and Centre intégré universitaire de santé et de services sociaux du Nord-de-l’Île-de-Montréal. MH reports other funding from Canada Graduate Scholarships—Social Sciences and Humanities Research Council (Doctoral Program). ML reports other funding from Daniel Monica Gold Centre Student Stipend Award, Les Petits Trésors—CIUSSS du Nord-de -l’île-de-Montréal, and Canada Graduate Scholarships—Social Science and Humanities Research Council (Master Program). MHP reports other grants from Canada Research Chair in Pediatric sleep, outside of the submitted work. EK reports other grants from Social Sciences and Humanities Research Council, Michael Smith Health Research BC, and the Canadian Institutes of Health Research. EK reports honoria for a keynote address at McGill University and webinar talk at McMaster University.

Data availability

The data underlying this article will be shared on reasonable request to the corresponding author.