Professional Documents
Culture Documents
644 PRICE et al
Downloaded from by guest on January 26, 2016
ARTICLE
or adult fading (also known as camping you?” were eligible for the trial (n = 328, trained to deliver specific sleep man-
out), should parents choose to use 47%). Maternal and child health nurses agement techniques.
them. In comparison with controls, in- excluded infants born ,32 weeks’ ges-
tervention parents reported fewer tation and mothers with insufficient
Follow-up Patients and Procedures
sleep problems at infant age 10 months English to complete questionnaires.
(56% [intervention] vs 68% [control]; From April to October 2009, we recon-
After baseline recruitment, we ran-
adjusted odds ratio [aOR] 0.6 [95% tacted all families. Of the original 328
domized the 49 maternal and child
confidence interval 0.4–0.9]) and 12 Infant Sleep Study children,3 326 were
health nurse centers (clusters) which,
months (39% vs 55%; aOR 0.5 [0.3– eligible at age 6, whereas 2 met our
in turn, determined participant alloca-
0.8]),3 with a sustained reduction in prespecified exclusion criteria of in-
tion.3 Because nurses were responsible
maternal depression at 2 years (15% vs tellectual disability or developmental
for delivering the intervention, ran-
26%; aOR 0.4 [0.2–0.9]).7 delay (Fig 2). Parents who returned
domizing clusters rather than partici-
written informed consent were mailed
To determine long-term harms and/ pating families minimized the likelihood
a questionnaire and phoned to arrange
or benefits of this infant behavioral of contamination between trial arms.
a 40- to 60-minute home-based as-
sleep intervention, we now report our Centers were ranked within each stra- sessment as close as practicable to the
2009 follow-up at age 6 years. We hy- tum according to the number of infants child’s sixth birthday, during which the
pothesized that there would be no evi- recruited at 4 months, randomizing the trained researchers (1) administered
dence of intervention versus control largest center and alternately allocating the Pediatric Quality of Life Inventory15
group differences in: (1) child emo- subsequent ones to avoid a marked to the child and (2) showed families
tional and conduct behavior (primary imbalance in cluster sizes between trial how to collect salivary cortisol (see
outcomes), sleep, psychosocial health- arms. Because all the centers were Table 1).
related quality of life, and diurnal corti- recruited before randomization and
sol as a marker of stress; (2) child-parent Families selected a nonschool day
ranked by using a criterion that could
relationship, disinhibited attachment; (weekend or holiday) to collect 2 cor-
not be influenced by the investigators,
or (3) maternal mental health or par- tisol samples: (1) 30 to 40 minutes after
allocation concealment was achieved.
enting styles. waking to avoid the postawakening rise,
Researchers involved in data collection
because its meaning in relation to the
and entry were blinded; nurses and
METHODS diurnal cortisol profile or psychosocial
parents, however, could not be blinded
stress is unclear,16 and (2) before
Design and Setting to group allocation.
lunch. We based our collection protocol
The Kids Sleep Study is the 5-year follow- Intervention nurses were trained to on the standardized procedures pro-
up of the Infant Sleep Study, a ran- deliver a brief, standardized behav- vided by the pathology laboratories
domized controlled trial (International ioral sleep intervention at the routine responsible for testing samples. Chil-
Standard Randomized Controlled Trial 8-month well-child check to mothers dren avoided brushing teeth, eating or
Number 48752250) for which we have reporting infant sleep problems (Fig 1 drinking for 30 minutes before collec-
previously reported methods for out- and Guide show details). Based on their tion, then thoroughly rinsed their
comes at ages 123 and 247 months. In needs and preferences, each family mouth with water 3 times, chewed
brief, the Infant Sleep Study aimed chose which (if any) type or mix of a piece of Wrigley’s sugarfree gum,
to recruit all mothers with children strategies they would use to try and EXTRA peppermint, and collected 4 mL
born in June to July 2003 who attended manage their infant’s sleep.3 One hun- of saliva in a plain tube. Families re-
the free, universal 4-month well-child dred of the 174 intervention mothers corded children’s waking and saliva
check with their maternal and child attended their nurse well-child check collection times. Families stored sam-
health nurse in 6 sociodemographically visits to discuss infant sleep problem ples at room temperature before mail-
diverse local government areas (n = management for an average of 1.52 ing them back within 1 to 2 weeks of
982). Of these, 782 (80%) expressed visits, with mean duration for the first collection,17 when we froze them at 2
interest in participating; 692 (70%) and subsequent visits of 25 and 19 18°C. Cortisol levels were measured by
returned the 7-month questionnaire. minutes, respectively. Control families 2 local laboratories owing to an un-
Mothers who responded “Yes” to the received usual care, which meant they expected company merger (by using
7-month screening questionnaire item were free to attend the scheduled the Roche Modular and Avida Centaur
“Over the last 2 weeks, has your baby’s 8-month visit and ask for sleep advice; systems, respectively). Interassay co-
sleep generally been a problem for control nurses, however, were not efficients of variation fell below 5.3%
646 PRICE et al
Downloaded from by guest on January 26, 2016
ARTICLE
expected any cluster effects to fade over adjusted for maternal education, and method.24 Intracluster (intra–maternal
the 5 years since the intervention. (2) child “moderate/severe” sleep prob- and child health unit) correlation coef-
We compared trial arms by fitting lem, which was not adjusted for child ficients from adjusted analyses are
random effects linear regression mod- gender, maternal depression, or educa- reported according to the CONSORT re-
els estimated by using maximum likeli- tion, because there were potentially too commendations for cluster-randomized
hood for quantitative outcomes, and few subjects with clinically high SDQ trials.25,26 All data files were analyzed
marginal logistic regression models by scores or a sleep problem to obtain by using Intercooled Stata, version
using generalized estimating equations, stable estimates from models with all 11.1 for Windows (Stata Corp, College
assuming an exchangeable correlation potential confounders included as pre- Station, TX).
structure with information sandwich dictors. The omitted variables were not Both the original trial (23067B) and 6-
(“robust”) estimates of SE for binary strongly related to the respective binary year-old follow-up (28137F) were ap-
outcomes.23 Both methods allow for outcomes. proved by the Human Research Ethics
correlation between outcomes of par- All retained participants were analyzed Committee of The Royal Children’s
ticipants from the same cluster. We in the groups to which they were ran- Hospital, Melbourne.
conducted analyses unadjusted and domized, applying the intention-to-treat
adjusted for the potential confounders, principle. Confidence intervals from RESULTS
with the exception of analyses of (1) analyses of quantitative outcomes At age 6 years, 225 of 326 children (69%)
SDQ binary outcomes, which was not were validated by using the bootstrap participated (see Fig 2, participant
TABLE 2 Baseline Characteristics According to Follow-up Status (ie, Retained or Lost to Kids Sleep Study) at Age 6 Years
Baseline Characteristics (4 mo) Total (N = 326) Intervention (n = 173) Control (n = 153)
Retained (n =225) Lost (n = 101) Retained (n = 122) Lost (n = 51) Retained (n = 103) Lost (n = 50)
Child
Male 54.7 53.5 50.8 52.9 59.2 54.0
Age (months), mean (SD) 4.6 (0.6) 4.6 (0.6) 4.6 (0.5) 4.7 (0.6) 4.5 (0.7) 4.5 (0.7)
Difficult temperament 24.4 27.7 23.0 21.6 26.2 34.0
Mother
Age (years), mean (SD) 33.1 (4.4) 32.9 (4.9) 32.6 (4.2) 33.4 (4.5) 33.6 (4.6) 32.3 (5.1)
Depression (EPDS), mean (SD) 8.5 (5.1) 8.2 (5.3) 8.4 (5.1) 8.3 (5.6) 8.5 (5.2) 8.2 (5.0)
Depression (EPDS) .9 39.6 39.6 36.1 41.2 43.7 38.0
Education status
Did not complete high school 15.6 21.8 15.6 19.6 15.5 24.0
Completed high school 30.2 35.6 30.3 31.4 30.1 40.0
University degree 54.2 42.6 54.1 49.0 54.4 36.0
Family
Index of Social Disadvantage
High disadvantage 15.1 24.8 13.9 13.7 16.5 36.0
Medium disadvantage 33.3 26.7 36.9 33.3 29.1 20.0
Low disadvantage 51.6 48.5 49.2 52.9 54.4 44.0
Language other than English 16.0 26.0 14.8 25.5 17.5 26.5
All values are percentages, except where otherwise stated. EPDS, Edinburgh Postnatal Depression Scale, where EPDS .9 is the community cut point for depression; SEIFA, Socioeconomic
Indexes for Areas, 2002 Australian census data for socioeconomic status by postal code.
648 PRICE et al
Downloaded from by guest on January 26, 2016
ARTICLE
TABLE 3 Results of Regression Analyses Comparing the 2 Trial Arms on Child, Child-Parent, and Maternal Outcomes at Age 6 Years
Outcome Descriptive Statisticsa Comparative Statistic: I Compared With Cb (95% CI)
conducted. Where possible, we used the 95% confidence intervals did not associated with poorer child and ma-
well-validated, reliable outcome meas- rule out smaller long-term harms or ternal well-being suggests that it was
ures15,27–31 collected from multiple benefits of the intervention that could indeed functioning as a stress biomarker
sources, including parent report, child be meaningful in public health research.7 (A.P., M.W., H.H., unpublished data).
report, and objective physiologic bio- Nonetheless, the precision of the confi- Our findings were entirely consistent
markers. Although details of the 30% dence intervals make clinically mean- with the longest follow-up study be-
(290/982) of families originally ex- ingful group differences unlikely. Loss to fore the Kids Sleep Study,6,20 which
cluded from the population sample follow-up can also introduce internal bi- reported no differences between in-
were unknown, the enrolled partic- as and reduce generalizability. Regarding tervention and control arms on child
ipants covered a broad socioeco- bias, the retained intervention and con- internalizing and externalizing prob-
nomic range and were similar to trol participants were fairly balanced lems, sleep, or maternal mental health
Australian and US normative data for (Table 2); however, as more non–English- at child age 3 to 4 years (3 years
maternal well-being and child tem- speaking and disadvantaged families postintervention). Thus, these new
perament characteristics,32 meaning were lost to follow-up, our findings may data, when interpreted with shorter
that our findings should generalize be less generalizable to these participant follow-up data from .50 interven-
to English-speaking families. groups. Finally, no validation studies of tion studies (including 9 randomized
The study also had some limitations. the categorical cortisol variable were controlled trials), suggest that behav-
Because 31% (101/326) of the original available, but our own exploratory anal- ioral sleep interventions have short-
sample was lost to follow-up at age 6 yses within the combined cohort show- to medium-term benefits that fade
years, the lower and upper bounds of ing that abnormal cortisol was beyond 2 to 3 years’ postintervention.
REFERENCES
1. Hiscock H, Canterford L, Ukoumunne OC, of sleep, behavior, and maternal well-being. aracy.org.au/publicationDocuments/ARACY
Wake M. Adverse associations of sleep Pediatrics. 2003;111(3). Available at: www. %20Unsettled%20Infant%20Behaviour%20
problems in Australian preschoolers: na- pediatrics.org/cgi/content/full/111/3/e203 report%20FINAL.pdf. Accessed July 27, 2012
tional population study. Pediatrics. 2007; 7. Hiscock H, Bayer JK, Hampton A, Ukou- 11. Blunden SL, Thompson KR, Dawson D.
119(1):86–93 munne OC, Wake M. Long-term mother and Behavioural sleep treatments and night
2. Hiscock H, Wake M. Infant sleep problems and child mental health effects of a population- time crying in infants: challenging the sta-
postnatal depression: a community-based based infant sleep intervention: cluster- tus quo. Sleep Med Rev. 2011;15(5):327–334
study. Pediatrics. 2001;107(6):1317–1322 randomized, controlled trial. Pediatrics. 12. Sadeh A, Mindell JA, Owens J. Why care
3. Hiscock H, Bayer J, Gold L, Hampton A, 2008;122(3). Available at: www.pediatrics. about sleep of infants and their parents?
Ukoumunne OC, Wake M. Improving infant org/cgi/content/full/122/3/e621 Sleep Med Rev. 2011;15(5):335–337
sleep and maternal mental health: a clus- 8. Mindell JA, Telofski LS, Wiegand B, Kurtz ES. 13. Baumrind D. Child care practices anteced-
ter randomised trial. Arch Dis Child. 2007; A nightly bedtime routine: impact on sleep ing three patterns of preschool behavior.
92(11):952–958 in young children and maternal mood. Genet Psychol Monogr. 1967;75(1):43–88
4. Mindell JA, Kuhn B, Lewin DS, Meltzer LJ, Sleep. 2009;32(5):599–606 14. Wake M, Nicholson JM, Hardy P, Smith K.
Sadeh A; American Academy of Sleep Medi- 9. Morgenthaler TI, Owens J, Alessi C, et al; Preschooler obesity and parenting styles of
cine. Behavioral treatment of bedtime prob- American Academy of Sleep Medicine. mothers and fathers: Australian national
lems and night wakings in infants and young Practice parameters for behavioral treat- population study. Pediatrics. 2007;120(6).
children. Sleep. 2006;29(10):1263–1276 ment of bedtime problems and night wak- Available at: www.pediatrics.org/cgi/con-
5. Ramchandani P, Wiggs L, Webb V, Stores G. ings in infants and young children. Sleep. tent/full/122/3/e1520
A systematic review of treatments for 2006;29(10):1277–1281 15. Varni JW, Limbers CA, Burwinkle TM. How
settling problems and night waking in 10. Fisher J, Rowe H, Hiscock H, et al. Un- young can children reliably and validly self-
young children. BMJ. 2000;320(7229):209– derstanding and responding to unsettled report their health-related quality of life?:
213 infant behaviour. A Discussion paper for an analysis of 8,591 children across age
6. Lam P, Hiscock H, Wake M. Outcomes of the Australian Research Alliance for Chil- subgroups with the PedsQL 4.0 Generic Core
infant sleep problems: a longitudinal study dren and Youth. 2011. Available at: www. Scales. Health Qual Life Outcomes. 2007;5(1):1
650 PRICE et al
Downloaded from by guest on January 26, 2016
ARTICLE
16. Jessop DS, Turner-Cobb JM. Measurement 25. Moher D, Hopewell S, Schulz KF, et al. and the Child Behavior Checklist: is small
and meaning of salivary cortisol: a focus CONSORT 2010 explanation and elaboration: beautiful? J Abnorm Child Psychol. 1999;27
on health and disease in children. Stress. updated guidelines for reporting parallel (1):17–24
2008;11(1):1–14 group randomised trials. BMJ. 2010;340:c869 35. Quach J, Hiscock H, Canterford L, Wake M.
17. Hanrahan K, McCarthy AM, Kleiber C, 26. Schulz KF, Altman DG, Moher D; CONSORT Outcomes of child sleep problems over the
Lutgendorf S, Tsalikian E. Strategies for Group. CONSORT 2010 statement: updated school-transition period: Australian pop-
salivary cortisol collection and analysis guidelines for reporting parallel group ulation longitudinal study. Pediatrics. 2009;
in research with children. Appl Nurs Res. randomised trials. BMJ. 2010;340:c332 123(5):1287–1292
2006;19(2):95–101 27. Hawes DJ, Dadds MR. Australian data and 36. Varni JW, Seid M, Kurtin PS. PedsQL 4.0:
18. Kirkwood BR, Sterne JAC. Essential Medical psychometric properties of the Strengths reliability and validity of the Pediatric
Statistics. Hoboken, NJ: Wiley-Blackwell; 2003 and Difficulties Questionnaire. Aust N Z J Quality of Life Inventory version 4.0 generic
19. Australian Bureau of Statistics. 2039.0: In- Psychiatry. 2004;38(8):644–651 core scales in healthy and patient pop-
formation Paper: Census of Population and 28. Henry JD, Crawford JR. The short-form ulations. Med Care. 2001;39(8):800–812
Housing – Socio-Economic Indexes for Areas, version of the Depression Anxiety Stress 37. Gunnar MR, Donzella B. Social regulation of
Australia, 2001. Last updated February Scales (DASS-21): construct validity and the cortisol levels in early human develop-
15, 2008. Available at: www.abs.gov.au/ normative data in a large non-clinical sam- ment. Psychoneuroendocrinology. 2002;27
AUSSTATS/abs@.nsf/allprimarymainfeatures/ ple. Br J Clin Psychol. 2005;44(pt 2):227–239 (1-2):199–220
09D68973F50B8258CA2573F0000DA181? 29. NICHD ECRN. Affect dysregulation in the 38. Heim C, Ehlert U, Hellhammer DH. The
opendocument. Accessed July 27, 2012 mother-child relationship in the toddler potential role of hypocortisolism in the
20. Hiscock H, Wake M. Randomised controlled years: antecedents and consequences. Dev pathophysiology of stress-related bodily
trial of behavioural infant sleep intervention Psychopathol. 2004;16(1):43–68 disorders. Psychoneuroendocrinology. 2000;
to improve infant sleep and maternal mood. 30. Owens JA, Spirito A, McGuinn M. The 25(1):1–35
BMJ. 2002;324(7345):1062–1065 Children’s Sleep Habits Questionnaire 39. Heim C, Nemeroff CB. The role of childhood
21. Vittinghoff E, McCulloch CE. Relaxing the (CSHQ): psychometric properties of a sur- trauma in the neurobiology of mood and
rule of ten events per variable in logistic vey instrument for school-aged children. anxiety disorders: preclinical and clinical
and Cox regression. Am J Epidemiol. 2007; Sleep. 2000;23(8):1043–1051 studies. Biol Psychiatry. 2001;49(12):1023–
165(6):710–718 31. Varni JW, Limbers CA, Burwinkle TM. Parent 1039
22. Wake M, Hiscock H, Bayer J, Mathers M, proxy-report of their children’s health- 40. Chisholm K. A three year follow-up of at-
Moore T, Oberklaid F. Growing the evidence related quality of life: an analysis of tachment and indiscriminate friendliness in
base for early intervention for young chil- 13,878 parents’ reliability and validity children adopted from Romanian orpha-
dren with social, emotional and/or behav- across age subgroups using the PedsQL 4.0 nages. Child Dev. 1998;69(4):1092–1106
ioural problems: systematic literature Generic Core Scales. Health Qual Life Out- 41. Paterson G, Sanson A. The association of
review. Melbourne, Australia; Victorian De- comes. 2007;5:2 behavioural adjustment to temperament,
partment of Human Services Report (2008) 32. Bayer JK, Hiscock H, Hampton A, Wake M. parenting and family characteristics among
23. Hanley JA, Negassa A, Edwardes MD, For- Sleep problems in young infants and ma- 5-year-old children. Soc Dev. 1999;8(3):293–
rester JE. Statistical analysis of correlated ternal mental and physical health. J Pae- 309
data using generalized estimating equa- diatr Child Health. 2007;43(1-2):66–73 42. Statistics Canada. National Longitudinal
tions: an orientation. Am J Epidemiol. 2003; 33. Goodman R. The Strengths and Difficulties Survey of Children: Overview of Survey
157(4):364–375 Questionnaire: a research note. J Child Instruments for 1994–1995 Data Collection
24. Davidson A, Hinkley DV. Bootstrap Methods Psychol Psychiatry. 1997;38(5):581–586 Cycle 1. Available at: http://publications.gc.
and Their Application. Cambridge, UK: 34. Goodman R, Scott S. Comparing the ca/Collection/Statcan/89F0078X/89F0078XIE
Cambridge University Press; 1997 Strengths and Difficulties Questionnaire 1996001.pdf. Accessed July 27, 2012
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/early/2012/09/04/peds.2011-3467