Environmental Scan of Sleep Health in Early Childhood Programs

Abstract

Objective:

To ascertain how sleep health knowledge is translated to early care and education (ECE) programs, using a multi-component environmental scan.

Methods:

A website scan identified organizations’ sleep content re: recommended practices, developmental effects, and “actionable” ratings (0–2). ECE staff surveys assessed preparedness, practices, and beliefs about addressing sleep health and sleep problems in ECE programs. Semi-structured interviews with stakeholders from the ECE, pediatric and sleep communities assessed awareness, priorities, and practices at their organizations.

Results:

Of 15 websites scanned, half lacked sleep content on links to development, optimal duration, or scientific background. ECE staff (n=31) were comfortable speaking to parents about healthy sleep, and with incorporating sleep education and guidance into ECE. Stakeholders (n=15) rated healthy sleep as a high relevance, but lower priority issue. Within ECE settings stakeholders reported that knowledge about specific links to health and development were poor, and that sleep health was often obscured by ‘safe sleep’ issues. Their recommendations included: linking sleep health to ‘hot topics’ such as obesity or preschool suspensions and expulsions, integrating it with the teaching of routines, and raising public awareness.

Conclusion:

Despite understanding that healthy sleep promotes school readiness, there is insufficient specific, actionable information in ECE training, programs, or policies. Findings suggest a need for an awareness campaign with clear, actionable messaging, dissemination of turnkey materials, and integration with policy and professional training systems.

Trial Registration-

ClinicalTrials.Gov: NCT03556462

Background

The foundations of life-long health are built in early childhood. Healthy sleep sets the stage for optimal social, cognitive, and physical development. Chronic lack of sufficient, quality sleep may result in impaired brain development, neuronal damage, and loss of developmental potential (Jan et al., 2010). Early childhood is a critical window, when routines are established and interventions more practicable (Koulouglioti et al., 2014). Parents can more easily regulate the sleep routines (e.g., bedtime, waketime), of younger children, compared to school- or teen-aged children. Circadian rhythms are synchronized by exposure to light as well as by daily routines, such as dinnertime or hearing an alarm clock. In this way, routines, which are easier for parents of younger children to implement may help synchronize sleep and wake cycles with circadian rhythms (Bathory & Tomopoulos, 2017). Healthy sleep practices-- an early and consistent bedtime routine, screen time limits, and falling asleep alone-- improve sleep length and quality (Yu, Sadeh, Lam, Mindell, & Li, 2017).

The most common, modifiable, and consequential sleep problems in young children are insufficient sleep, behavioral sleep problems (BSPs), and sleep disordered breathing (SDB). BSPs, problems falling or staying asleep (American Academy of Sleep Medicine, 2014), occur in ≈25% of preschool-aged (3–5 years) children.(Owens & Jones, 2011) SDB, which ranges from snoring to obstructive sleep apnea, occurs in 1–20% of preschoolers (KA. Bonuck et al., 2011). While children of this age should sleep 10–13 hours per day (including naps) (Paruthi et al., 2016), 25%- 50% do not (National Sleep Foundation, 2004). Despite differing etiologies, short sleep duration, BSPs, and SDB in early childhood all adversely impact social-emotional (Sivertsen et al., 2015), cognitive (Beebe, 2011), and educational functioning (Galland et al., 2015), and increase the risk of obesity (K. Bonuck, Chervin, & Howe, 2015).

Parents and providers lack knowledge about pediatric sleep health; both score about 50% on surveys of knowledge (Honaker & Meltzer, 2015) (McDowall, Galland, Campbell, & Elder, 2017). Parents under-estimate their child’s sleep needs, lack awareness of optimal sleep hygiene, and don’t recognize either BSPs or snoring as indicators of sleep problems. Less parental knowledge is associated with less than optimal sleep practices (McDowall et al., 2017). While sleep is among the leading parental concerns during pediatric visits, rates of screening and management by pediatric primary care providers are low (Honaker & Meltzer, 2015). Finally, racial, ethnic, and economic factors contribute to sleep health disparities. Cultural values influence sleep practices (McLaughlin Crabtree et al., 2005; Milan, Snow, & Belay, 2007), including racial/ethnic differences in sleep duration and hygiene (McDonald, Wardle, Llewellyn, van Jaarsveld, & Fisher, 2014; Mindell & Williamson, 2018), and co-sleeping. (Williamson, Rubens, Patrick, Moore, & Mindell, 2017) Environmental factors, e.g., noise and air pollution are linked to BSPs and sleep duration (Johnson, Billings, & Hale, 2018), while SDB, rates are high in minority and low-income children, who are under-treated (Boss, Niparko, Gaskin, & Levinson, 2011).

Despite knowledge about the adverse effects of sleep problems in children, there has been limited research on effective strategies to promote sleep as a healthy behavior overall, (Perry GS, Patil SP, & Presley-Cantrell LR, 2013) or on how to integrate them in Early Care and Education (ECE) specifically. Nearly 4.5 million preschool- aged (3–5 years) children attend ECE programs in the United States. ECE programs have untapped potential to promote healthy sleep (Hale & Bonuck, 2016) and identify children with sleep health concerns. Early childhood sleep problems are associated with health and developmental risks. Yet, screening tools used to identify developmental delays/disorders fail to adequately assess either BSPs or SDB (Bonuck KA et al., 2011). ECE professionals connect with families to teach children healthy routines and practices that support health and development. ECE programs could serve as key venues for translating knowledge from sleep science into practice, by implementing healthy sleep curricula, and integrating screening tools identify sleep problems.

Our National Institute of Health (NIH) study includes multi-component interventions to promote healthy sleep in ECE alongside “knowledge-translation” strategies to translate evidence-based knowledge into practice.(National Collaborating Centre for Methods and Tools, 2011 (Updated 12 September 2017)) There is a “know-do” gap between knowledge in sleep science and its translation to implementation of preventive interventions. This gap was highlighted in a 2015 joint NIH and Sleep Research Society meeting where, to bridge this gap, participants recommended educational interventions to promote awareness of the adverse health, functional outcomes, and costs associated with sleep problems. While the meeting did not address issues related to preschool aged children, its recommendations for adolescent sleep emphasized the need for multi-level (individual, family, community) interventions (Parthasarathy et al., 2016).

To guide our NIH study’s knowledge translation strategies, we conducted a multi-pronged environmental scan with the goals of assessing ECE and related communities’: a) knowledge about links between sleep health and child development, b) perceived salience and application of this knowledge, and c) opportunities for facilitating knowledge translation of sleep health to ECE program and policy. Environmental scans use mixed methods to collect and analyze information on public health issues and practices (Wilburn, Vanderpool, & Knight, 2016). First, we scanned organizational websites for pediatric sleep-related content. Second, we surveyed staff from New York State Head Start agencies participating in our NIH research to promote sleep health. Head Start is a federally-funded ECE program providing comprehensive education, health, and social services to low-income families (see Methods for further details). Third, we conducted semi-structured stakeholder interviews to assess organizations’ awareness, priorities, and practices regarding childhood sleep.

Methods

Website Scan:

We selected 26 organizations for the scan based upon criteria of: a) child health and/or child care mission, b) engaged in training, information dissemination, policy and/or services, and c) national scope. Using Python 3.5, we searched organizational websites from May-August 2016 for permutations of: ‘sleep,’ ‘rest,’ ‘nap’ and ‘bedtime.’ We extracted each webpage’s title, url, and content keywords. Natural language processing summarized content into semantically central sentences. If a search term appeared in the webpage, its context was reprinted for analysis. When the Python output yielded a PDF that could not be ‘parsed,’ the URL for the PDF was searched for the terms “sleep” and “nap.” If that search yielded a “page not found” we searched within the website (when possible) for “sleep” and “nap” and took the first 10 hits. If the site did not have an internal search option, we searched in Google itself for “organization name” + “sleep” or “nap.”

Authors used an abstracting tool and codebook to evaluate websites according to: a) Sleep Links- content about effects of sleep on physical health and behavior/cognition, b) Sleep Background or Tips- content on sleep duration, sleep hygiene, ‘science’ of sleep, c) Target Audience- whether this appeared to be geared towards parents, teenagers, school-aged children, or ECE staff, and; d) Literacy Rating- as a measure of applied knowledge, the extent to which information is accurate, accessible, and actionable (U.S. Department of Health and Human Services, 2010). Content and target audience were classified as “Yes/No.” Applied Knowledge was rated from 0 – 2 per a health literacy rating scale (Doak CC, Doak LG, & Root JH, 1996). Two of us independently abstracted website output, after co-coding of the first five organizations reached 80% reliability. Content for analyzable output was summarized.

Head Start Staff Surveys:

Staff from seven New York state Head Start programs in urban, suburban, and rural settings completed surveys during initial site visits for the NIH study in Fall 2015. Head Start is a federally-funded ECE program in the US serving nearly 1 million low-income birth-to-five year olds and their families. Compared to the US population, participating families are generally more ethnically and linguistically diverse. Unlike traditional ECE programs, it incorporates health and family well-being services, in addition to promoting school readiness through early learning activities. In fact, Head Start Program Performance Standards mandate the provision of developmental (e.g., motor, cognitive) and health screening, as well as support for children’s health, mental health, oral hygiene, and nutrition. Despite this holistic focus, the Head Start Program Performance Standards only mention sleep in the context of safe sleep positioning, and the requirement that full-day (≥ 6 hours) preschool children be encouraged- but not required to rest or nap (Head Start Early Knowledge and Learning Center).

Researchers consented staff and administered surveys prior to presenting the study’s rationale and logistics, The survey, used in our prior study, (K. A. Bonuck, Schwartz, & Schechter, 2016) includes items on Preparedness, Beliefs, and Practices. Preparedness items (n=4) assessed how comfortable staff were in educating parents about sleep and whether this fit within their scope of work. Responses were classified as “Not at all,” “Somewhat,” or “Very.” Beliefs items (n=6) assessed staff perceptions of sleep health education place within the mission of Head Start, and sleep impacts on teaching and learning. Responses were categorized as “Agree,” “Neither,” or “Disagree.” Practices items (n=6) ascertained frequency of staff having discussions about their child’s sleep with parents, or with other staff. Response categories were “Never,” “Rarely,” “Sometimes,” or “Often.”

Stakeholder Interviews: Stakeholder interviews focused on: 1) awareness of the associations between early childhood sleep, health, and development, 2) the relative priority of young children’s sleep health within their organization; 3) current or planned programmatic or policy initiatives related to sleep in general, and to its associations with child health and development in particular. One author (AS), an ECE consultant, selected interviewees representing governmental, research, advocacy, and professional organizations. Governmental leaders include those from the US Department of Education, Office of Early Learning and the US Department of Health and Human Services, Office of Head Start and Office of Child Care. The national research and advocacy organizations serve as information clearinghouses, disseminate research, and aim to inform policy. Child health, sleep health, and professional development organizations comprised the remaining stakeholders. Interviewees were not speaking on behalf of their organizations. There was some overlap between organizations selected for the website scan and stakeholder interviews.

Stakeholders received an email invitation to participate, followed by a two-page background brief if they expressed interest. A semi-structured interview guide (Supplementary file) explored: whether and in what context sleep issues (except Sudden Infant Death Syndrome) ‘percolate’ up to them; any organizational policies or programs that might impact children’s sleep; conversely, how young children’s sleep might impact their organization, and; current or planned initiatives related to sleep. Closed-end items included: familiarity- both their own and that of colleagues at their organization – and with links between child sleep, health, and development (‘1’ Not Very – ‘4’ Very); relevance of sleep health of young children in ECE to organization (‘1’ Not Currently – ‘5’ Very High), and; priority of sleep health in young children for the organization (‘1’ Not Currently – ‘5’ Very High).

Following an informed consent process, stakeholders were interviewed by telephone in 2016. Fifteen (15) audiotaped interviews were transcribed (one was discarded due to technical difficulties). Members of the initial analysis team read through the transcripts and generated preliminary codes. This list was applied to an excerpt of the data and then refined using an iterative process, until it was judged to be sufficiently specific and comprehensive, and to ensure agreement on the code definitions. Next, data were uploaded into Dedoose, a qualitative data analysis program, and members of the team coded the entire data set. The team reviewed the data and codes in order to develop underlying themes. An expert in qualitative data analysis (AK) reviewed and affirmed the validity of the codes and themes. Several interviewees did not consent to their names and/or organizations being identified or to being cited for attribution. When permissible and useful for context, quotes are attributed to the stakeholder’s organizations. The NIH parent study, approved by Einstein’s Institutional Review Board, is described in detail elsewhere.(S. C. Bonuck K, Schwartz B, 2016)

Results:

Website Scan:

From an initial list of 26 organizations, 11 were excluded from analysis because they did not yield output. The n=15 organizations with analyzable output (Table 1) engage in training, research, and policy; two are direct child care providers. Parents are the most common audience (n=11), followed by ECE staff (n=8), school-aged children (n=2), and teens (n=1). Nemours KidsHealth is notable for targeting teens, school age-children, and parents. The scan had assessed the websites for: five sleep domains: sleep impact on health, sleep impact on behavior/cognitive functioning; sleep duration, sleep hygiene, and sleep science. Six organizations carried content for most or all of these domains: American Academy of Pediatrics (AAP), Bright Futures, Child Trends, Nemours Foundation, National Resource Center for Health and Safety in Child Care and Early Education (NRC), and the National Head Start Association (NHSA). Of these, Bright Futures, Nemours KidsHealth, and the NRC also received the highest literacy rating (2). Content about the impact of sleep on health (n=8 organizations) and behavior/cognition (n=7 organizations) referenced obesity, emotional and mental health, and behavior. Most websites had content about sleep hygiene (n=11 organizations); tips spanned infancy though college-aged. Just under half included content on sleep duration (n=7) or the science of sleep (n=7).

Table 1:

Website Scan: Organizational Description and Target Audience (N=15)

Organization Name	Organization Description	Sleep Links to: (✖=Yes, ✔= No)		Sleep Background or Tips: (✖=Yes, ✔= No)			Target Audience	Literacy Rating*
		Physical Health	Behavior/Cognitive	Sleep Duration	Sleep Hygiene	Sleep Science	Parent, Teen, School Age, ECE Staff, Pediatrics, Special Education	0–2
American Academy of Pediatrics (AAP)	Professional member organization; produces clinical guidelines and policies	✔	✔	✔	✔	✔	Parent Pediatrics	1
Brazelton Touchpoints Center	Offers development for professionals working with young children	✖	✖	✖	✖	✔	ECE Staff Pediatrics	0
Bright Futures:	Led by the AAP; national health promotion and prevention initiative,	✔	✔	✔	✔	✖	Parent ECE Staff Pediatrics	2
Center on the Developing Child	Based at Harvard; evidence-based research and policy	✔	✖	✖	✖	✖	Other: Academic	0
Child Care Aware	Offers child care information for families and providers	✔	✖	✖	✔	✔	Parent ECE Staff	2
Child Trends	Non-profit; research and communication to improve public policy	✔	✔	✔	✔	✔	Parent ECE Staff	1
Council for Exceptional Children (CEC)	Advocacy, standards and professional development for educators	✖	✖	✖	✖	✖	Special Education	0
Early Childhood Technical Assistance Center	Funded by US Dept. of Education; early intervention and early childhood special education TA	✖	✔	✖	✖	✖	ECE Staff Special Education	0
Nemours Foundation (Kids Health website)	Health, and development information re: for 0–18 year olds	✔	✔	✔	✔	✔	Parent Teen School-Age	2
Kindercare	For-profit provider of ECE and child care; large network, 100% accredited	✖	✖	✖	✔	✖	Parent ECE Staff	2
National Association for the Education of Young Children	Professional membership organization; ECE practice, policy and research	✖	✖	✖	✔	✖	Parent ECE Staff	1
National Head Start Association	Non-profit; advocacy and professional development on behalf of Head Start	✔	✔	✔	✔	✔	Parent ECE Staff	1
National Resource Ctr. for Health and Safety in Child Care and Early Education	Non-profit; AAP affiliated; maintains compendium of health and safety standards for ECE programs in the US	✔	✖	✔	✔	✔	ECE Staff Pediatrics	2
Ounce of Prevention Fund	Non-profit; focus on 0–5 year olds living in poverty; Educare partner; professional development, research, and advocacy	✖	✔	✔	✔	✖	Parent ECE Staff	1
Zero-to-Three (0–3)	Non-profit; 0–3 years focus; professional development, technical assistance & parent info	✖	✖	✖	✔	✖	Parent ECE Staff	1
	Total	8	7	7	11	7

^*Literacy rating- global rating of sleep website contents’ accuracy, accessibility, and how actionable it is

Head Start Staff Interviews:

Regarding Preparedness, staff were most comfortable guiding parents on bedtime routines (60%= Very) and need for sleep (55%= Very), but less comfortable with methods for helping children sleep (43%= Very) and cultural sleep practices (39%= Very). (See Table 2.) Regarding Beliefs, all agreed that sleep problems interfere with learning, and that staff training should include educating parents about healthy sleep. Most also agreed that staff should be trained to counsel parents about sleep problems (90%), though not quite as many endorsed Head Start screening for sleep problems (69%). Regarding Practices, staff ‘sometimes’ or ‘often’ told parents about a child’s sleepiness (68%), asked about the child’s sleep patterns (61%), talked to parents about healthy sleep, or were asked to keep a child awake at naptime (40%). Of note, 30% [sometimes/often] told parents about a child’s breathing problem during sleep.

Table 2:

Head Start Preparedness. Beliefs and Practices (N=31)

How comfortable are you providing guidance to parents about…. [Preparedness]
	Not at all	Somewhat		Very
Why children need healthy sleep	0	14 (45%)		17 (55%)
Best practices surrounding bedtime routines	0	12 (40%)		18 (60%)
Cultural values in sleep practices	5 (16%)	14 (45%)		12 (39%)
Methods to help children get to/stay asleep	2 (7%)	15 (50%)		13 (43%)
Indicate whether you believe that…. [Beliefs]	Agree	Disagree		Neither/DK
Sleep problems often interfere with children’s ability to learn	31 (100%)	0		0
Sleep problems interfere with my ability to teach	23 (79%)	2 (7%)		4 (14%)
Educating parents about healthy sleep patterns and routines should be part of staff training	30 (100%)	0		0
Counseling parents about behavioral sleep problems should be part of staff training	27 (90%)	0 (7%)		3 (10%)
Screening for sleep problems is an appropriate function of Head Start	20 (69%)	1 (3%)		8 (30%)
It is within my scope of work to counsel parents about child sleep	17 (59%)	5 (17%)		8 (24%)
How often have you…. [Practices]	Rarely/Never		Sometimes/Often
Asked parents about their child’s sleep patterns	12 (39%)		19 (61%)
Reported to parent that child often seems sleepy	10 (32%)		21 (68%)
Talked with parents about healthy sleep	13 (43%)		17 (57%)
Told parents about a child’s breathing during sleep	21 (70%)		9 (30%)
Reported napping issues to staff	17 (61%)		11 (39%)
Asked by parent to keep child up at naptime	17 (59%)		12 (41%)

Stakeholder Interviews:

The interviewee organizations (n=15) are shown in Table 3, along with responses to closed-end items. Interviewees indicated higher personal familiarity with links between children’s sleep and their health and development (mean=3.47, range=1–4 [sd=0.62]), compared to colleagues’ familiarity (mean=2.60, range=1–4 [sd=1.14]). Similarly, the organizational relevance of sleep health of young children in ECE was rated highly (mean=4.08, range=1–5 [sd=0.95]) but its priority to the organization was rated lower (mean=2.31, range=1–5 [sd=1.32]).

Table 3:

Stakeholder Interviewees: Familiarity, Relevance and Priority Ratings (N=15)

	Own Familiarity: link between children’s sleep, and their social, cognitive, and physical health 1= Least Familiar 4= Most Familiar	Colleagues Familiarity: link between children’s sleep, and their social, cognitive, and physical health: 1= Least Familiar 4= most Familiar	Relevance of: sleep health of young children in ECE to your organization: 1= Not Currently 5= Very High	Priority of: sleep health of young children in ECE to your organization: 1= Not Currently 5= Very High
Mean (sd)	3.47 (0.62)	2.60 (1.14)	4.08 (0.95)	2.31 (1.32)
Government
(1) US Dept of Education	2	1	4	1
(2) Brazelton Touchpoints Center	4	1	5	5
(3) US Dept. of Health and Human Services Office of Child Care	3	1	4	3
(4) Colorado- Head Start State Collaborations	4	4	5	2
(5) Indiana- Head Start State Collaborations	4	3	5	1
(6) Nevada- Head Start State Collaborations	4	4	5	2
Nonprofit Organizations
(7) Brazelton Touchpoints Center	4	1	5	5
(8) Child Care Aware	3	2	3	2
(9) Child Trend	3	2	3	2
(10) Council for Exceptional Children	3	3	5	1
(11) National Head Start Association	3	3	3	1
(12) National Sleep Foundation	4	4	3	2
(13) Nemours Foundation	4	4	3	4
(14) National Resource Center for Health and Safety in Child Care and Early Education*	3	3	--	--
(15) Early Childhood Organization**	4	3	5	4

^*Audio-recording prior to querying respondent about items in 3^rd and 4^th columns.

^**Interviewee declined to have organization identified by name.

Six themes, described below, emerged from the qualitative data: 1) Perceptions of the relevance of sleep health; 2) Lack of knowledge about sleep health and its impact on development; 3) Current approaches to sleep health in ECE settings; 4) Resource and implementation challenges in ECE settings; 5) Current policy and program limitations, and; 6) Recommendations. Within quotes, bracketed grammar has been added for context along with bracketed numbers to identify organizations, when permissible, per their numbering in Table 3.

Perceptions of the relevance of sleep health Consistent with rankings of relevance (Table 3), comments reflected the pertinence of sleep health for interviewees, staff, and families. High personal interest was expressed by comments such as: “I am so happy and impressed that NIH is funding this project” and “[This is a] huge passion of mine…and so underestimated. [I’m] glad you are doing this [8].” In reference to ECE staff, one interviewee stated “I know for sure that poor sleep patterns impact their lives. It makes it more difficult for them to maintain their classroom [8].” An advocate for families of children with disabilities noted that parents frequently voice concerns about “challenging behavior related to going to bed and the bedtime routine [10].”

Lack of knowledge about sleep health and its impact on development.

While affirming the importance of sleep, nearly half (7/15) described limited understanding of specific content, e.g.: “I couldn’t tell you all the research and science to back it up but I could certainly tell you about the socio behavioral and health impact.” One participant cited a lack of understanding among line staff: “[While line staff] understand… that sleep is important… [they may] not know all the underlying health and medical as well as social emotional development issues [8].” Another noted that key policy makers were similarly unaware: “I don’t have the sense that state leaders know a lot about the specifics about the significance of sleep.”

Myriad factors contribute to the knowledge gap. Several (3/15) stakeholders expressed a view that sleep health got lost amidst the focus on Sudden Infant Death Syndrome (SIDS) and other safe sleep issues: “…we get all of the stories of kids that are dying as a result of SIDS [3].” Terminology led to a muddling of the issues: “[it is] hard for people in the field to differentiate the conversation about safe sleep from sleep generally [15].” Several participants noted that other child health issues take priority, drawing attention away from sleep issues, e.g.: “A lot of folks are focused on physical activity and nutrition and the sleep thing kind of catches us by surprise.” Child care staff access to research was cited as a barrier by one participant: “…some folks who may or may not be familiar with research or inclined to read it or have access to that type of information [8].” Compared with knowledge about healthy sleep among pediatrics and mental health professionals one stakeholder noted “…I don’t think it’s in the early childhood world. [7].”

Current approaches to sleep health in ECE settings.

All stakeholders deemed sleep health as low priority in their agencies or institutions (Table 3). This view was reflected in comments such as: “not that [it] is not a current priority in itself [10],” “…much of the work we’re doing now is not creating new content but repackaging and repurposing [15],” and “I don’t think it’s as ripe as some other issues [13].” Sometimes, sleep health is bundled with other health issues such as obesity: “sleep is not on my policy agenda but certainly sleep as obesity prevention is something I’m encouraging…[8],” asthma: “…in our asthma projects, we talked about sleep [14],” or challenging behavior: “Challenging behavior is a major priority…[and is obviously] related to issues of healthy sleep patterns [10].” A couple of stakeholders observed positive change: one told us of a local Head Start that invited a sleep medicine expert to give a presentation. Another recalled observing children in an early childhood setting engaged in quiet alternatives to naptime and commented “I wouldn’t have seen that five years ago [14].”

Resource and implementation challenges in ECE settings.

Limited resources such as tight budgets and decreased professional development time are a barrier to getting sleep health on the ‘front burner.’ Fitting teacher training into work hours is difficult- “need modules like 5 or 10 minutes” suggested one stakeholder. Several participants spoke in detail about the problem of naptime. Several had observed staff resistance to foregoing naps, “…research coming out saying that kids over two may not need naps…teachers aren’t going to give that…up because it’s their down time. [14].” Conversely, a senior official with the federal department of education reported hearing “… a lot of pushback from districts and schools…why are we paying you to watch them rest? [1].”

Current policy and program limitations.

None of the stakeholders conveyed the view that sleep health was reflected in ECE programs, regulations, or policies: “We haven’t had any policies or initiatives about healthy sleep [12].” A stakeholder from a sleep education and advocacy organization lamented that early childhood sleep issues were relatively neglected. While adult and adolescent sleep, for example, had received considerable attention, “We are far behind [with issues of early childhood sleep [13].” There was a lack of state and federal support: “states talk about sleep and nap duration…but no one really has sleep education requirements [8].” During the development of joint policy statements by the federal departments of education and health, a stakeholder recalled: “I don’t remember anyone saying anything about sleep in that whole discussion on health [1].” One stakeholder offered a practical suggestion: “If states thought that this is so critical to basic health and safety…then they can put it in the quality improvement [plans].” Safety concerns predominated ECE policies on naptime, e.g., “They think about nap time [in terms of] how far away do the mats have to be… [they focus on] reducing the spread of germs and supervision and less about how to encourage healthy sleep].”

Recommendations.

Stakeholders were enthusiastic about change and offered specific ideas for embedding sleep health into ECE. Nearly half cited a general need to increase knowledge about sleep health. Two stakeholders explicitly suggested promoting sleep’s connection to health and development through simple, actionable messaging, e.g.,: “…public awareness campaigns around the value of sleep [4].” One suggested a “Learn the Signs” campaign for sleep health.” (Learn the Signs is a Centers for Disease Control and Prevention (CDC) initiative to promote developmental monitoring and screening in young children.) Other suggestions included linking sleep health to ‘hot topics’ such as “…chronic absenteeism and suspensions and expulsions [1]” or using sleep health practices as a way of “differentiate higher quality programs from lower quality programs.” A couple of stakeholders suggested approaching sleep health in the context of routines, “We’re thinking more about how we help parents with routines [14]” and “If we could work those sleep habits into these children’s lives… [6].”

Discussion:

We conducted an environmental scan to better understand the landscape of sleep health in the ECE, pediatrics, and sleep communities. Its overarching goal was to assess where sleep health fits within existing US policy and practice and to determine possible levers to promote sleep health education within the ECE community. The scan’s specific aims were to assess: a) knowledge about links between sleep health and child development, b) the perceived salience and application of this knowledge, and c) opportunities for facilitating knowledge translation of sleep health science to ECE program and policy. Data were gathered via a scan of pediatric and early childhood websites, Head Start staff surveys, and stakeholder interviews.

Regarding knowledge about the links between sleep health and development, the website scan found that most sites contained sleep hygiene tips. However, half of the websites reviewed lacked detail linking sleep’s impact on children’s health and development, and just 5 (of 15) had ‘actionable’ information. All Head Start staff agreed that children’s sleep problems impact teaching and learning, indicating at least general understanding of these links to the developmental growth they work to promote. Regarding how prepared staff were to explain to parents why children need healthy sleep, responses were more mixed (45% ‘Somewhat,’ 55% ‘Very’) -- suggesting limited knowledge of the scientific rationale undergirding these links and a means to integrate this knowledge into ECE practice. In particular, stakeholders reported that connections between healthy sleep and school readiness lacked depth and specificity (e.g., to learning, memory, obesity) across ECE training, program, and policy. Several mentioned the tendency for sleep health to get lost in the focus on SIDS-- a key safety issue for ECE as reflected in current training and regulations.

The second aim of the environmental scan was to assess the perceived salience of sleep health for ECE policies and programs, and its integration in actual practice. Staff and stakeholders affirmed the value of incorporating sleep health promotion and prevention of sleep disorders into ECE. Yet, this affirmation is not reflected in current ECE practices, programs, and policies as evidenced in limited inclusion of sleep health in federal and state regulations, lack of ECE program quality indicators, and strong views on daytime rest and naptime. Additional barriers to integrating sleep health into ECE included a lack of training and time, confounding of ‘sleep health’ with SIDS/safe sleep issues, and disciplinary ‘silos’ between the education and pediatrics communities. Interestingly, this disconnect between salience and practices, to some extent, parallels a disconnect between parents’ beliefs and practices. That is, prior research both in the US (S. B. Bonuck K, Schechter C., 2016) and other countries (Ahn, Williamson, Seo, Sadeh, & Mindell, 2016; McDowall et al., 2017) finds that preschool parental beliefs about their child having healthy sleep do not align with actual sleep practices.

The third aim of the environmental scan was to identify opportunities for knowledge translation from sleep science to ECE programs and policy. For context, we note that a national healthy sleep awareness project in the US has focused on children, teens, and adults, but not the youngest children from the age of birth to five. (Morgenthaler et al., 2015) A stakeholder from the sleep community affirmed this lack of focus on the early childhood period, compared to adolescence and adulthood. Our findings suggest that an early childhood focused sleep awareness campaign is warranted. As one stakeholder commented, “I feel like you need to have a ‘Learn the Signs’ campaign on healthy sleep,” referring to the CDC campaign to promote parental knowledge, communication and action regarding concerns young children’s developmental milestones. While parents affirm the value of ‘Learn the Signs,’ an evaluation of the campaign suggests the need for more specificity for ‘why’ and ‘how’ they should act early. (Raspa et al., 2015) Similarly, findings from this environmental scan’s three data sources support the need for more specific and evidence-based, actionable information about healthy sleep (and sleep problems) in ECE program and practice. In addition, to the extent that sleep medicine can define and promote ‘sleep health,’ (Buysse, 2014) the ECE community will be more able to differentiate it from SIDS/safe sleep issues.

In addition to receptivity to messaging around healthy sleep in ECE, findings suggest opportunities for screening and counseling for sleep problems— job functions supported by nearly 70% and 90% respectively of the ECE staff surveyed. Such a role would be consistent with Head Start screening for other pediatric health problems, e.g., asthma (Bonner et al., 2006) and obesity risk(Townsend et al., 2018). Even in more traditional/less holistic ECE programs than Head Start, the link between sleep problems and the school readiness mission of ECE could be used to support sleep problem training, screening, and counseling. Worldwide, ECE attendance among 3–5 year-olds ranges from 10% to 60%.(Unicef Global Database, 2017) From a public health perspective, ECE programs represent significant opportunities for both primary and secondary prevention of sleep problems.

Integrating surveillance of sleep needs and problems into ECE programs could begin to address the lack of such surveillance in not only in general pediatric populations, (Chen, 2017) but also in and at-risk populations.(Bonuck KA et al., 2011) Among preschoolers with developmental delays/disorders the rate of BSPs is more than twice that of typically developing children.(Reynolds et al., 2019) Screening for sleep problems in ECE settings could therefore aid in identification of children with or at risk of developmental delays/disorders as well as facilitate timely treatment for children known to have developmental conditions.(Beebe, 2016) Fortunately, sleep difficulties experienced by children with developmental conditions don’t always need specialized care. Techniques used with typically developing children are often effective for these children, but may take more time. For both groups, interventions such as establishing bedtime routine, as well as behavioral strategies (e.g., bedtime pass) are often successful and don’t require a sleep expert. (Lord, 2019)

This study has several strengths. It expands policy and practice discussions about sleep in ECE beyond daytime rest periods (Benjamin Neelon, Duffey, & Slining, 2014; Staton, Smith, Pattinson, & Thorpe, 2015), the first such research, to our knowledge. The study’s triangulation of data, i.e., cross-verification of the same phenomena through multiple sources and disciplines (ECE, pediatrics, sleep science) may increase validity. This paper adds to the growing literature on environmental scans in public health. A knowledge translation oriented environmental scan of US health departments explored child maltreatment programming and prioritization, which is typically a social service or criminal justice issue.(Richmond-Crum, Joyner, Fogerty, Ellis, & Saul, 2013) In Canada, environmental scans were used to identify an evidence-practice gap in school-based vision screening,(Bennett & Maloney, 2017) to plan pediatric obesity interventions,(Ball, Mushquash, Keaschuk, Ambler, & Newton, 2017) and to develop navigation programs for children with complex conditions.(Luke, Doucet, & Azar, 2018) A PubMed search for “environmental scan” + “sleep” yielded no results, thereby highlighting the novelty of our study.

The study has several limitations. The websites and stakeholders for the environmental scan necessarily represent a selected sample, based upon recommendation of one of us (AS), a nationally known ECE consultant. The small number of websites with scan results (n=15) and stakeholders interviewed (n=15) may limit representativeness. Further, generalizability of qualitative research data, e.g., such as that obtained from our stakeholder interviews, has limitations. Finally, Head Start staff interviewed were from agencies participating in our larger NIH study to promote healthy sleep. Thus, they may not be representative of all ECE staff within and outside of the US.

This environmental scan is guiding efforts to bridge the research-practice gap between sleep science, and ECE programs and policy. With a team of early childhood partners, we engaged in deliberative dialogues, a knowledge translation strategy used to promote evidence informed policy.(Boyko, Lavis, & Dobbins, 2014) As a major first step, our efforts resulted in revisions to Caring for Our Children, 3^rd Edition, the national (US) health and safety standards for ECE, including standards to educate children and parents about sleep hygiene. Prior versions of these standards had only referenced sleep in relation to SIDS, cot spacing during naptime, and staffing during rest periods. (National Resource Center for Health and Safety in Child Care and Early Education, 2019) The partners engaged in Deliberative Dialogues are working on an action plan with the objectives of: a) providing ECE programs with training and turn-key tools, b) educating administrators and policymakers, and c) integrating sleep health with state policy systems. Action items include: pairing sleep health with obesity, suspensions/expulsions and other ECE-relevant messages, and identifying platforms for disseminating screening and educational tools.

ECE represents a promising global venue for promoting sleep health education and awareness of sleep problems. All three of the data sources used in this environmental scan converge to underscore the need for translating knowledge beyond sleep science to settings and populations where this knowledge could be practicably applied. This conclusion affirms prior reports from research and scientific organizations, including the NIH, Sleep Research Society, and Institute of Medicine. Such activities would optimally incorporate multi-sectoral public health campaigns.(Perry GS et al., 2013) Future research is needed to evaluate the implementation of these and additional efforts, to bring the fruits of sleep medicine research to early childhood settings.