“If mommy’s not cranky, everybody else survives another day.” Sleep Perspectives from Multiethnic Community Parents, Pediatric Providers and Childcare Providers

Abstract

Objective:

To describe the perceptions of (1) parents, childcare and healthcare providers regarding sleep health among multiethnic infants and toddlers living with socioeconomic adversity; (2) factors that contribute to sleep health and its consequences; and (3) best ways to promote sleep health in these children.

Methods:

Nested within a larger community-engaged mixed methods study, we used a descriptive qualitative design to describe the experience of multiethnic young parents who were raising 6–36 month-old children, pediatric healthcare providers, and childcare providers living and working in an urban under-resourced community. Semi-structured interviews with 25 parents and 16 providers were conducted, transcribed, coded, and analyzed using thematic analysis, by a 6-member research team. Interviews continued until themes were saturated.

Results:

Parent responses and provider responses resulted in overlapping and divergent findings. Common themes among all respondents were the importance of sleep, interest and desire for more sleep health information, and common environmental/social impediments to healthy family sleep. Divergent themes included the importance of bedtime routines and timing, views on the family bed, importance of naps, and healthy sleep aids. Childcare centers were suggested as good sites for sleep health promotion programs.

Conclusions:

Sleep is a topic of interest and importance for young families. There are unique family challenges to be considered in any sleep health promotion program tailored to the needs of the community. The voices of parents and community providers are valuable assets informing development of novel family-friendly approaches for decreasing sleep disparities and improving the health of young children and families.

Sleep health, defined as adequate sleep duration, quality, and consistent sleep schedules, is critical to normal human development and health.^1,2 Infants and toddlers require 12–16 hours of sleep daily to support growth and brain development.^3–6 Sleep deficiency, including shorter than recommended sleep, frequent awakenings, poor sleep quality, and irregularly timed sleep is common in early childhood and may be linked with physical and mental health problems in childhood and into adulthood.^7–11 Children of diverse racial and ethnic backgrounds and those living in families experiencing economic adversity have more sleep deficiency than other children^12–15 and are often exposed to environmental, family-based, and community-based sources of stress that interfere with sleep.^11,16–19 Sleep deficiency may increase the risk for health problems such as obesity, diabetes, hypertension, injury, poor mental health and behavior problems.^16,17 Among infants ≥6 months old, sleep deficiencies and health outcomes have been less studied and may be more likely related to feeding patterns, parent-child, maternal mental health and family issues.^11,20

A recent review documented the efficacy of behavioral interventions to improve sleep among young children²¹ that often focus on establishing bedtime routines and age-appropriate bedtimes, eliminating nighttime awakenings, and providing adequate duration of sleep.^22–27 For example, providing consistent bedtime routines including a bath, massage (for infants) or applying lotion (for toddlers) and a quiet activity decreased the number and duration of night awakenings and improved parental perception of sleep.²⁸ Online interventions are acceptable to parents and have improved sleep duration and efficiency in young children.^29,30

Although sleep interventions for infants and toddlers may be efficacious, few have been designed for lower income families and thus may not reflect social and cultural contexts (e.g., home and neighborhood environment, family dynamics, parenting practices) relevant for sleep health.³¹ In order to develop tailored approaches responsive to specific needs of families the perspectives of key stakeholders, including parents and pediatric and childcare professionals caring for young children in diverse communities must be heard.

The purpose of this qualitative study, part of a larger mixed methods community-engaged research project ( NCT03045874), was to describe: (1) the perceptions of parents, childcare and healthcare providers regarding sleep health among racially and ethnically diverse infants and toddlers who live with economic adversity; (2) factors that contribute to sleep health and its consequences; and (3) best ways to promote sleep health in their children.³¹

METHODS

Study Design

This qualitative descriptive study was guided by the Social Ecological Model (SEM)³² that depicts layers of factors important for the health outcome of interest. We focused on the individual (child) surrounded by proximal factors (parents, family, local community) that influence sleep for the child and family.^32–35

Full details of the community engaged research process have been reported.³¹ We included community stakeholders to guide the study design, interviews, and interpretation of data. We met with community leaders convened by the Yale Center for Clinical Investigation to elicit their input and convened a community advisory committee (CAC) with community representatives including parents, healthcare, and childcare providers to guide our study.

We obtained approval from the university human subjects committee and the research committee in the clinical setting. All participants signed consents.

Setting

We conducted this study in a city of 130,000 residents in the Northeastern United States of whom 44.1% are White, 33.0% are Black, 4.7% are Asian, 4.3% are two or more races and 13.9% report other races, while 30.3% are Latinx.³⁶ Twenty-six percent of residents are living in poverty and single female parents head 12.4% of families.³⁶ We recruited families from the pediatric primary care center at the local hospital, which serves 7,000 children per year, the majority of whom live in low-income households.

Sample

We used purposive sampling to recruit families,³¹ inviting English and Spanish speaking families with young children (6 to 36 months) to participate. Families with children with significant medical conditions or severe developmental delay were excluded.

We recruited childcare and healthcare providers, including pediatricians, pediatric nurse practitioners and pediatric nurses (practicing in urban clinics), with a snowball sampling method. Childcare providers were employed by publicly-funded centers or cared for children in their licensed childcare homes. We sampled from each of the three groups of participants until we reached thematic saturation.

Procedures

We held four meetings with the CAC prior to, during, and at the end of the study and provided updates and elicited feedback through email. We compensated CAC members for their time and provided food at meetings. Interview participants received $25.

Data Collection

We conducted semi-structured interviews with 25 parents, 6 childcare providers and 10 pediatric healthcare providers in private, convenient locations or in participants’ homes. With the CAC, we developed an interview guide organized by the literature³⁷ and the constructs of interest: sleep characteristics, the importance of sleep, sleep habits, sleep health, and individual, family and community contributing factors (Interview schedules available in published research protocol).³¹

We trained research assistants (RAs) who were graduate-level nursing students in qualitative research interview methods including prompting and follow up questioning.³¹ All interviews were audio-recorded, transcribed and entered into Atlas tiV7 software for data management. Spanish-speaking RAs conducted interviews in Spanish, and a Spanish-speaking transcriptionist transcribed the interviews. A native Spanish speaker translated them into English. While these transcripts were shorter in length, there were minimal other differences, so they were analyzed jointly. Three research team members experienced in qualitative interviewing conducted the healthcare and childcare interviews.³¹

Data Analysis

We used a qualitative descriptive approach³⁸ and a constant comparative method in which data from each group were collected and analyzed simultaneously to allow us to modify the interview schedule, as patterns or themes emerged.^31,39,40 We analyzed provider and parent transcripts separately. Six team members, including three experienced in qualitative research, worked in pairs to review transcripts, code, and analyze interview data. The team reviewed all transcripts, coded several transcripts, compared and discussed coding, and developed a “start list” of codes derived from the literature, followed by inductive or “open” coding, resulting in a final list of 15 codes with sub-codes (Appendix A, B).³⁹ Thematic analysis⁴¹ resulted in initial patterns blended into themes separately from the two groups (parents and providers) of participants. Themes were compared and contrasted within and across groups.⁴²

The use of research memos, an audit trail, and the multimember analysis team contributed to the rigor of the study and trustworthiness of the qualitative findings.^43,44 Research memos included methodological, theoretical, and clinical memos that aided the audit trail and interpretation of findings. The diversity of sampling strategies, inclusion of provider and family perspectives, and review of our study themes by CAC members added to study rigor.⁴⁵

RESULTS

Demographic characteristics of the sample are summarized in Table 1. The major themes that emerged in the responses from our parent participants included sleep knowledge 101, the importance of sleep, perceived barriers and aids to a good night’s sleep, the family bed, and the desire for more information about sleep for young children. Table 2 provides examples of theme development.

Table 1.

Demographic characteristics of parent and provider participants

Variable Providers	Parents			Pediatric Providers			Child Care
	N=25	%	Mean(s.d.)	N=10	%	Mean (s.d.)	N=6	%	Mean (s.d.)
Age			28.8(5.6)			54.8(9.9)			48.3(14.5)
Gender
Male	1	6.3%
Female	24	93.7%		10	100%		6	100%
Race
African American	10	40%		1	10%		4	66.7%
White	3	12%		8	80%		2	33.3%
Asian	1	4%		1	10%
Multiracial	3	12%
Other	6	24%
Unknown	2	8%
Ethnicity
Latinx	11	44%					1	16.7%
Parents w/infants	8	32%
Parents w/toddlers	17	68%
Number children per			2.3(range1–8)
household
Education
Years of education			12.5
Some college			(3.3)				1	16.7%
Associates degree				1	10%		1	16.7%
Bachelor’s degree				1	10%		3	50%
Master’s degree				4	40%		1	16.7%
Doctoral degree				4	40%
Years in practice						24.55(11.7)			18.17(13.26)
Child Care Type
Center-based							4	66.7%
Home-based							2	33.3%
Marital status
Single	17	68%
Married	8	32%
Employment
Unemployed	17	68%
Part/full time	8	32%
Health Insurance
Medicaid	16	64%
Private	3	12%
Uninsured	6	24%

Table 2.

Exemplar quotations, codes, and themes from parent and provider interview responses

Quotations	Codes	Theme
Parent Responses
Sleep- it affects his mood, his stability, his interest of things the next day, because if he doesn’t get enough sleep, he is, again, very grouchy. It’s like you can’t do anything or look at him in a weird way, because he’ll start to cry or he’ll start to scream, and he’ll get very attached to me, which makes my day even longer, because I can’t do anything.	Sleep and child behavior
If he doesn’t get enough sleep… he’s crying all the time. He’s just in a bad mood, so you get in a bad mood, too. What else? If they do get a lot of sleep, it’s a good thing, because they’re energetic and running around, and you can see that they’re happy,		Importance of Sleep
If she sleeps well, there is no problem. But if she does not sleep well, she does not eat well, like she does not feel well either. She is only crying and does not want anything
When I don’t get the proper amount of sleep, I’m like a slug. Like I don’t want to do anything, and it’s just like I’m not motivated. My whole day is just like very slow, and I’m tired, so I’m a little cranky. I’m groggy.	Benefits of Sleep for Mother
If I’m slightly agitated, the baby immediately feeds off of those emotions. I’m not exactly sure how he’s able to do that, but he becomes really clingy.
After a good night’s sleep… I feel refreshed. Like I want to do everything.
Provider Responses
Barriers to sleep in their homes….space, number of beds, noise….neighbors that they worry about and they’re worried about letting the child cry at night.	Crowding Neighborhood Issues
…when the mothers are bus drivers and they have to get their children up at 4:30 or 5…and the children actually ride the bus and are often falling asleep on the bus…It’s a matter of economic survival.
A mother’s stress or family stress whatever may be going on, the home environment, depending on who they’re living with. It could be a single parent raising a child with multiple kids…	Family Stressors	Getting to know each family
You know, if you’re going from house to house, just knowing where you’re going to lay your head or what you’re going to have to eat…..

Parent Beliefs about Sleep

Sleep Knowledge 101.

The parents’ sleep duration and beliefs about their sleep requirements varied. Parents reported personal sleep durations ranging from 4–10 hours per night. The amount of sleep they thought they should get ranged from 3–10 hours. Most parents believed that young children need 8–10 hours of sleep. All parents described a relationship between sleep and stress.

Importance of Sleep.

Parents consistently reported that sleep was important to themselves and their children. Parents felt that poor sleep affected their mood (anxiety, depression, “just leave me alone”), concentration (“my brain won’t work”), energy level (“I feel like a slug”), diet, and relationships with partners, family or co-workers (“If mommy’s not cranky, everybody else survives another day”). Parents also reported guilt when they lacked energy to play with their children.

Most parents believed that poor sleep affected their children’s behavior and led to increased tantrums, crankiness, acting out, and problems eating. “If he doesn’t get a good night’s sleep, then he would get a little frustrated and agitated. He won’t even want to change his diaper.” Another parent reported, “When he get cranky, like really, really fussy, cries for anything and whatever you try to do to help him. It doesn’t do nothing.” Parents noted better behavior and happier children when they had a good night’s sleep and that poor sleep affected learning or school performance.

A few parents believed that lack of sleep was not a problem for their infants because they believed that babies could sleep anywhere, at any time. Some believed their children’s health was affected by lack of sleep (increased susceptibility to colds and or illnesses), but others did not connect sleep with health.

The Family Bed.

Parents alluded to safety concerns related to infant sleep position and location. They understood healthcare providers’ advice to avoid bed-sharing with their infants, yet some struggled with this advice because of family traditions and preferences for bed-sharing. Two parents commented:

…the first child, you want to be around them and hold them so much, and let them sleep with you, but that develops bad sleeping habits. With my second child, I let her sleep in her own bed from birth. I kept her to herself. I let her go to sleep by herself and to this day, she can be in her room, by herself, and she’ll fall asleep by herself.

I didn’t have the security of having him be in a separate space from me. I wasn’t sleeping at all. The smallest turn he made, I was jumping up out of my sleep, versus if he’s in the bed next to me, he’ll lay on his back and I can feel him, so subconsciously I’m okay and I can sleep through the night.

Some described bed-sharing as reducing the quality of parent sleep (“If he moves a little, then that affects me…I can’t sleep properly”), but many believed that parents should sleep with their children, and different strategies were used to make it “safe” in the minds of the parents.

She (healthcare provider) had mentioned to me that co-sleeping parents, they’ve had deaths and that’s the reason why they advise that you don’t co-sleep and shown us articles about a woman losing her children because she was co-sleeping. It was terrifying. Even though I’m co-sleeping, I’m still making sure that he’s okay. He’s not completely up underneath me. I don’t move in my sleep, so that’s not one thing that I have to worry about, me rolling on him, but if he moves to get closer to me, I essentially will push him back over and to make sure that he’s still on his back.

Perceived Barriers and Aids to a Good Night’s Sleep.

Parents reported using various sleep aids, including reading, watching TV, playing games on the phone, showering, drinking tea or milk, nonprescription sleeping pills (study staff reviewed the transcripts of parents endorsing sleeping pill use to ensure that this was not associated with bedsharing), eating, exercising during the day, smoking cigarettes, aromatherapy, using dark curtains, music, dimming lights, turning off TV, white noise, and making sure the house was quiet. Parents noted many barriers to their own sleep, including children’s nighttime waking or bedtime resistance, environmental disturbances (neighborhood noises, husband waking for night shift). Some feared that their children’s crying would disturb family members or neighbors. They also reported “Fire trucks going down the road…people walking down the streets screaming at each other. Motorcycles going by. It just becomes extremely noisy at night”, and medical issues (pain, anxiety), “I have PTSD, which is where the anxiety and the depression comes in. It’s also the cause of my insomnia.”

Participants described stress and worry about personal issues, especially finances as interfering with sleep. “…sometimes money is not enough, or my parents get sick… That is it, the stress.” “Just my day-to-day worries, like about just my job. That affects my sleep.”

Many parents believed that screen time could aid sleep, although many also noted that social media or smartphone use interfered with sleep. “A good night’s sleep is me actually going to bed on time and not on my phone watching Netflix….”

Most parents believed that bedtime routines are helpful for children (“structure does help”) but many did not have consistent routines. They described the following ways to help children sleep: singing, reading, cuddling, feeding, ensuring diaper is clean, bath, massage, prayer, music, and watching TV. They mentioned several barriers, including diaper changes or nighttime hunger and breastfeeding, children’s medical issues (e.g., eczema, gastroesophageal reflux disease), bedtime resistance, environmental influences, including noise from older siblings, temperature and lighting in the room and overstimulation during the day.

…if we’re in a get-together or he’s around a crowd of a lot of people or, let’s say, like a birthday party or he’s at the park and there’s a lot of kids in the park and there’s a lot going on, it’s almost like he relives it during his sleep, and he doesn’t sleep well.

Parents recognized that using TV and other devices could interfere with children’s sleep. Some believed that their children’s personality traits, temperament and genetics influenced sleep. “My other daughter — they have different dads — she sleeps just like him, which is all the time.”

Parents were not consistently in favor of naps. Some thought that they were important, and others thought that naps delayed bedtime. “A nap, it ruins everything and it ruins the schedule…”.

Desire for More Information.

Parents were interested in improving sleep for themselves and their children. and viewed primary care clinics and childcare sites as good places to receive information. Parents felt that incentives to participate in group meetings or classes would be useful, including food, transportation, and childcare. Parents were open to receiving information online, by text, by email, or with social media platforms. “Everyone is 24/7, so offer information online, with Facebook or YouTube”.

Health and Childcare Providers’ Perceptions about Child Sleep

Five themes emerged from healthcare and childcare providers’ interviews including, the importance of getting to know each family, the importance of sleep routines, barriers to healthy sleep, the family bed, and current recommendations about sleep. Although there were two groups of providers, their responses were consistent, so we grouped all provider responses together for analysis, noting differences within themes.

The Importance of Knowing Each Family.

Providers expressed beliefs that all families are unique and that avoiding assumptions about their sleep patterns or habits is helpful. They suggested learning about each family by inquiring “with a listening ear,” about sleep routines, ideas, and practices. Childcare providers described knowing more details about each family because they saw and heard their concerns daily, while pediatric providers had much less contact. All thought that environmental stressors (e.g., noise, neighborhood safety) and maternal mental health issues (e.g., psychiatric conditions, drug involvement) affect family sleep. These and other significant stressors could easily overwhelm the family and claim priority over sleep health. As one healthcare provider stated about parents experiencing homelessness, “The last thing on the mind of the parent may be sleep, if they are living with chronic stress and their children may be afraid, from moving from place to place, and this disrupts their sleep.” And one childcare teacher sadly related the following description,

The problem I’m finding right now in childcare is homelessness. When a child is bouncing around from one couch to another couch, the child comes in looking like they came off a third shift, and they can’t function. Everything is wrong, and I can’t fix it, you know? I just do the best I can with that situation.

Bedtime Routines for Everyone.

All providers stressed the importance of structure and routine. They tried to help parents establish sleep routines by providing a template for “winding down” and establishing regular bedtimes. Healthcare providers advocated behavioral sleep approaches with parents of older infants and toddlers. All also tried to help parents recognize children’s cues that signaled sleepiness to avoid “over-tired” children, and they tried to help parents understand that creating structure and setting limits around bedtime helps children feel comfortable and secure. One childcare provider spoke about “free range” children with too few limits.

We’re in a society where structure is important… It’s not all about what I want… They need to know…there are limits to everything. Know that your children are in the real world and we, as much as we love them and we want them to be happy, we have to help them find happiness within the structure of our society.

Providers also stressed the advantages of regular child bedtimes for parents (e.g., reducing parental fatigue, allowing for alone time, increased ability to get work done, etc.). Some tried to help parents view sleep routines as ways to handle their own stressors.

Many understood that sleep needs varied by age and that all young children have natural drives and circadian rhythms for sleep that make early bedtimes ideal in most cases. In general, healthcare providers were more knowledgeable than childcare providers about children’s sleep requirements, (childcare providers estimated 8 hours), and the effects of sleep on health and brain development. As one healthcare provider stated, “Sleep is a gift to your child.” Although the childcare providers generally underestimated children’s normal sleep recommendations, they were eager to learn this information and pass it along to families.

Many providers stressed the importance of naps to supplement nighttime sleep but recognized that not all parents agree. One healthcare provider noted, “I still think toddlers need naps…daycare providers would give me feedback that the kids would come into daycare on Monday exhausted because they weren’t napping at home the way they did at daycare.” A childcare teacher commented, “Yeah, because after nap they are always talking, talking, talking… they love to talk, to read books after nap.”

Barriers to Healthy Sleep.

Providers reported that screen use interfered with their patients’ sleep, while conceding that screens were often used as soothing or distracting mechanisms in many homes. They acknowledged the ubiquity of screens and questioned whether using them in a sleep promotion intervention (e.g., smartphone apps) would be useful. They believed that parents’ schedules may be barriers to good sleep, since children may wake early or stay up late to spend time with a parent working late shifts or may awaken when picked up from a babysitter by a parent returning from an evening shift. As one healthcare provider related, “They’re put to sleep in a relative’s home or a babysitter’s home and the parent comes home from a shift at 11:00 at night, the child is woken up and then they’re transferred to another environment, all of which can disrupt sleep.” Providers acknowledged that parents who must balance school/college schedules with family needs and routines face many challenges regarding sleep. Some noted that parents who lacked regular schedules for work or school had less structured sleep routines than those who worked or attended school.

The Family Bed.

All providers were clear about the importance of infants sleeping on their backs and not sharing a bed with adults to prevent Sudden Unexplained Infant Death (SUID). However, providers also realized that family traditions and routines were often not consistent with this recommendation, especially when children reached toddlerhood or older ages, when no longer at risk for SUID, or if the family could not afford a crib or toddler bed. Providers tried to understand family traditions and the parents’ perspectives on co-sleeping: “Many cultures believe in the family bed. Every culture defines what is good sleep and parents may rely on their own memories of sleeping in the family bed until ages 8 or 9.”

Providers’ Sleep Recommendations.

All providers were eager to help parents increase their knowledge and skills about sleep. They recommended the following: community based approaches (reaching parents through childcare programs, public service campaigns, 24-hour sleep hotlines), electronic delivery (videos demonstrating bedtime routines, media messaging, smartphone apps), teaching (classes, parents networking with other parents), printed materials (sleep education materials in waiting rooms, children’s “going to bed” books) and home visiting approaches with in-home assessments and interventions to promote healthy sleep.

Providers recommended developing and testing sleep programs within pediatric offices, schools, and childcare programs. Childcare providers expressed a desire to learn more about sleep and saw themselves in key positions to support sleep health, given their daily contact and experience with supporting parents and knowledge of family needs. All thought that childcare centers are potentially good locations for sleep workshops, as parent workshops on other topics are routinely well-attended. They also recommended “train-the-trainer” programs.

As a final stage in the analysis, we compared the themes from parent and provider interviews. There was consistency in many responses (e.g., sleep importance and relationship to behavior, schedules, stresses, and environmental and screen-related impediments, health and childcare providers as good sources of support for sleep, need for more sleep information, and the advantages of regular bedtimes for children and parents). However, parents and providers differed on views about co-sleeping, consistent bedtime routines, naps, and recommended sleep durations for young children. Providers favored clear routines and scheduled times for bedtimes and naps, while parents were less in favor of naps due to beliefs that they prevented children from sleeping well at night. Parents often did not follow consistent bedtimes or routines due to a variety of family disruptions or patterns. Providers discouraged bed-sharing according to medical and scientific knowledge about safe sleeping practices for infants. However, parents accepted bed-sharing, despite pediatric advice, often because of family traditions and the strong desire to keep children close at night. While parents described a variety of sleep aids, providers uniformly advocated reading books at bedtime and healthcare providers also advised about behavioral sleep interventions (structured approaches for promoting independence in falling asleep, self-soothing, and returning to sleep after brief awakenings at night) for older infants and young children, many parents described worries about children awakening and crying at night, especially when crying was prolonged and could disturb others.

DISCUSSION

This study added the perspectives of multi-ethnic families and health and childcare providers to the growing research in sleep in young children and their families. It was notable that despite having to cope with many life stressors and some misconceptions about sleep, parents believed that sleep was important, and they were open to ideas about improving sleep health in their families. Although there were differences between parent and provider’s perspectives and some misconceptions, there was general agreement about sleep, and barriers and facilitators noted by all participants. These ideas to improve sleep provide a strong basis for sleep health interventions for multi-ethnic families who also live with economic challenges. Our participants and community advisory committee agreed that childcare centers are good centralized locations for families to learn about sleep, and the childcare providers were eager to learn more about sleep to support this.

Our findings helped us determine how parents of young children living in a lower-income urban community balanced the relative importance of sleep and sleep routines with many other daily challenges. Parents reported many challenges to children’s sleep including non-modifiable factors (such as shift work, holding multiple jobs, family financial stressors, neighborhood noises and safety) and potentially modifiable factors (e.g., bedtimes, bedtime routines, ubiquity of electronic screens in the bedroom, family co-sleeping).

Parents and childcare providers under-estimated the amount of sleep needed by young children, a finding that was also consistent with recent systematic reviews.^14,46 It is important to help parents understand that adequate sleep might be a protective factor for young children’s health and development, while also acknowledging their developmentally changing circadian rhythms and need for consistency of sleep schedules from day to day.^18,21,47 Although providers were advocates for regular bedtimes and soothing bedtime routines, these practices were not consistently reported by parents. Incorporating these practices, if acceptable within the context of family traditions and lifestyles, may improve sleep. For example, in some of our study families, parents routinely applied lotion to their children after bathing, as a part of daily skin care. In a recent study, massage integrated into bedtime routines of young children, was associated with fewer night time awakenings, so massage might be suggested in addition to lotion application.⁴⁸

Earlier children’s bedtimes might also benefit parents by allowing them more free time in evenings, and this may be an added incentive to this practice. Providers advocated for regular naptimes for children 6–36 months related to positive effects on sleep/wake cycles.^18,21 Some parents noted that naps interfered with night-time sleep, similar to studies noting the association of regular napping with later melatonin and sleep onset⁴⁹ or less night-time sleep duration⁵⁰ in young children.

Often parents were reluctant to let their children cry at night because they worried about neighbors or waking other household members. Therefore, they were reluctant to consider behavioral sleep strategies, such as unmodified extinction, an approach that often involves periods of crying.⁵¹ However, offering parents choices with approaches such as graduated extinction, with parents checking and consoling the crying child at specified time, or suggesting sleep strategies for older toddlers and preschoolers, such as fading parental presence, including the “Excuse-Me Drill” may be helpful.^8,21 While these approaches involve crying, behavioral sleep interventions are helpful with infant and toddler sleep and do not negatively affect maternal stress, child emotional/behavioral problems, or secure attachment.^52,53 Providers can also integrate counseling on the importance of self-soothing and emotional regulation and provide a “note” explaining the temporary crying for parents to give to noise-sensitive neighbors.⁵⁴

Our findings are consistent with many themes from the few available qualitative studies. For example, Lindsay and colleagues⁵⁵ conducted focus groups with low-middle income Brazilian immigrant families of young children, living in urban U.S. communities. They reported complicated households, changing parental work shifts/schedules, inconsistent bedtimes/routines, and many parent stressors that interfered with sleep. As in our study, Zambrano, et al.⁵⁶ found that African American mothers with young infants attributed poor sleep to home environments, parental worry about daily life stressors, and commitments to employment and school schedules. These stressors are not easily addressed with clinical interventions.

Our findings are also similar to a recent mixed methods study of culturally diverse, low income mothers of toddlers and pre-school aged children living in a different urban center.³⁷ Parents also described the importance of sleep for themselves and their children, effective and less effective sleep aids, the importance of feeling close and protective of their children by sleeping together in the same bed, and the profoundly negative effects of life stressors on parental sleep. The misconceptions about sleep needs among young children and preferences for learning more about ways to improve sleep for their families converged with the findings from our study, while our study extended this to understanding the perspectives of parents of infants and health and childcare providers.

Clinical and Research Implications

Approaches to sleep health promotion for young parents and children need to consider family traditions and beliefs, housing and sleep environments, and daily realities of family life and schedules that may include negotiations among several households in the case of separated or divorced parents, or between parents and grandparents caring for infants and young children. Information campaigns about young children’s healthy sleep duration and routines, like the campaigns about safe sleep for infants, might be developed and offered to the community. Clearly, some problematic areas noted by our parents might be addressed with more information and counseling, while some areas, such as beliefs about the family bed, are more complex, and suggest a need for individualized conversations and supports.

The family bed includes diverse family traditions, and parents reported multiple reasons and advantages to bed sharing, such as being available to comfort the child, to monitor the child, to reduce crying, to feel close, and the ease of breastfeeding.^11,57,58 The American Academy of Pediatrics states that infants between birth and 12 months should room in (share a room) with a caregiver, but not share the same bed, to prevent incidences of SUID.⁴⁸ Even though parents were aware of safe sleeping recommendations for infants regarding bed-sharing, there was ambivalence about them. Strong family patterns of sharing the family bed were difficult for some parents to resist. Respectful counseling that clearly reinforces safe sleep for infants but also provides parents with information about sleep duration and consistent sleep routines while acknowledging and exploring family sleep traditions, may help parents weigh the risks and benefits of bed-sharing for children beyond infancy. Ascertaining the reasoning behind room or bed-sharing may help facilitate discussion of alternative solutions, such as positioning the infant’s crib directly next to the parent’s bed. Integrating the comment, “If mommy’s not cranky, everybody else survives another day” suggests a humorous and gentle way to discuss potential benefits from less disrupted sleep for parents and children.

Based on our study findings, we developed an array of clinical approaches and suggestions for curricula, programs or individual counseling regarding healthy sleep for young families (Table 3). These findings have informed the next phase of our research, which includes development and feasibility-testing of a community-based behavioral sleep health intervention at childcare centers. The sleep health intervention will focus on several simple and modifiable sleep behaviors and is designed to be delivered by trained childcare staff (teachers, nurse consultants, family advocates) working with parents of infants and toddlers. Health literacy recommendations and culturally acceptable components of the program were directly informed by our study findings and input from our CAC.

Table 3.

Clinical application and approaches for healthy sleep in young families

Sleep Issue	Suggested Approach
Sleep critically important for the whole family	Reinforce this perspective and highlight health benefits for children and lifestyle benefits for parents
Misinformation about sleep duration, bedtimes, many inconsistent bedtime routines	Multi-modal knowledge building with resources such as videos, handouts, and public service announcements; Provide simple references about healthy bedtimes49 and sleep duration.50 Provision of basic information about benefits of healthy sleep for growth and brain development, with plans for bedtime routines that fit with family traditions
Sleep aids used by parents and children: some helpful; some with opposite effects of promoting sleep	Provide information about commonly used sleep aids that help (warm bath, massage) or that may hinder (tea with caffeine, chocolate, candy) sleep
Parents struggled to find time for themselves	Earlier child bedtimes have advantages for parents as well as children. Help parents to develop individualized plan with a goal of increasing sleep duration by at least 45 minutes in “baby steps”
Co-sleeping in family often has strong family traditions	Provide parents with information about sleep characteristics, sleep duration, and consistency in children who co-sleep, while acknowledging and respectfully exploring family sleep traditions. Ask about reasons for room or bed-sharing. Help parents weigh risks and benefits of co-sleeping for children beyond infancy, with focus on behavioral benefits to parent and child for less disrupted sleep. Reinforce safety issues and risk of SUID to discourage infant co-sleeping, while presenting alternatives (eg. placing crib next to parent’s bed)
Daily stressors, difficult work schedules and parental worries interfere with sleep	Suggest culturally appropriate stress-reduction approaches, mindfulness, soothing music, etc. Consider case management to address daily stressors experienced by families
Worries about child crying at bedtime or at night	Discuss realities of nighttime crying and disruption for family or neighbors. Consider bedtime massage to decrease night awakenings.
Poor sleep results in irritable parents and children; fatigue	Share information about link between sleep duration and behavior in adults and children.
Households & environments with noise, electronics in bedrooms	Suggest plan for decreasing lighting, electronics/screens, and noise in sleeping areas when possible. Consider use of white noise and privacy screens to block view of TV for room-sharing child

Strengths and Limitations

To our knowledge, this is the first study with interviews of parents, childcare and healthcare providers in an urban community regarding their knowledge, approaches and perspectives about sleep for parents and young children. The study was guided by community members, and a multidisciplinary team conducted the qualitative analysis. Limitations of the study included that parent interviews were conducted by multiple RAs, resulting in some variation in interview quality, despite training and supervision. While the cultural diversity in the parent sample largely reflects the predominant cultural groups living in the community, it would have been advantageous to sample from other more diverse cultural groups, also living in the community.

CONCLUSION

Sleep is a topic of interest and importance for young families. Unique family challenges must be addressed in any sleep health promotion program tailored to the needs of the community. The voices of parents and community providers are valuable assets informing development of novel and family-friendly approaches for decreasing sleep disparities and improving the health of young children and families.