Sleep Medicine 81 (2021) 443e450

Contents lists available at ScienceDirect

Sleep Medicine
journal homepage: www.elsevier.com/locate/sleep

Original Article

Sleep patterns, problems, and ecology in young children born preterm

and full-term and their mothers
Francesca Lupini a, Erin S. Leichman a, Christina Lee b, Jodi A. Mindell a, c, *
a
Saint Joseph's University, United States
b
Johnson & Johnson Consumer Inc., United States
c
Children's Hospital of Philadelphia, United States

a r t i c l e i n f o a b s t r a c t

Article history: Background: Previous studies of sleep patterns and problems in preterm infants compared to full-term
Received 4 January 2021 infants have yielded mixed results, with little known about sleep ecology. The aims of this study were
Received in revised form to compare sleep patterns, sleep problems, and sleep ecology across developmental stages (birth to 36
28 February 2021
months) in preterm (3 or more weeks early) infants and toddlers to those born full-term, in addition to
Accepted 6 March 2021
Available online 12 March 2021
their mothers’ sleep.
Methods: Mothers of 834 young children in Brazil (ages 0e35.9 months), half preterm and half full-term
(matched for sex and chronological age), completed the Brief Infant Sleep Questionnaire and the Pitts-
Keywords:
Sleep
burgh Sleep Quality Index.
Infants Results: Across the entire sample, preterm and full-term infants were similar for most sleep parameters,
Preterm including sleep onset latency, number and duration of night awakenings, and sleep duration, as well as
Maternal sleep sleep ecology parameters, including falling asleep independently and sleep location. However, preterm
infants were more likely to be held to initiate sleep, given a bottle to resume sleep after waking, and less
likely to be breastfed to resume sleep after waking. Mothers of preterm infants, however, were more
likely to report a parent-perceived sleep problem, although maternal-perceived confidence in managing
child sleep and bedtime difficulty were similar. Finally, maternal sleep parameters were similar between
groups.
Conclusions: Overall, these results indicate that sleep patterns, sleep problems, and sleep ecology among
preterm infants and toddlers and their mothers are largely similar to those of full-term infants and
toddlers and their mothers, even within the first few months.
© 2021 Elsevier B.V. All rights reserved.

Sleep problems are common among young children. Studies
indicate that approximately 20e30% of young children experience
sleep problems, based on parental report [1,2]. Preterm births,
defined as birth before 37 weeks of pregnancy, are also relatively
common [3]. In 2011e2012, 11.5% of births were preterm in Brazil
[4]. Similarly, in the United States one in every ten babies was born
prematurely in 2018 [3]. However, the existing research conducted
on sleep patterns and problems in infants born preterm yields
inconsistent findings. Even less is known regarding sleep ecology in
preterm infants (eg, sleep location, method of falling asleep and
* Corresponding author. Department of Psychology, Saint Joseph's University,
Philadelphia, PA, 19131, United States.
E-mail address: jmindell@sju.edu (J.A. Mindell).
resuming sleep). Furthermore, studies of maternal sleep in this
population are scant.
1. Sleep in young children born preterm
Existing data regarding preterm infant sleep patterns and
problems are mixed. Several studies, for instance, have found that
sleep patterns and problems, such as sleep onset latency [5e8],
night awakenings [6,7,9,10], and sleep duration [5e9,11] among
preterm infants are comparable to those of full-term. In contrast,
differences between gestational groups have emerged in other
studies and/or when addressing specific sleep parameters within
the previously mentioned research [12e17]. For instance, Wolke
and colleagues [16,17] noted that preterm infants at 5 months of
age had fewer night awakenings than their full-term counterparts
(yet similar night awakening frequency at 20- and 56-months).

https://doi.org/10.1016/j.sleep.2021.03.011
1389-9457/© 2021 Elsevier B.V. All rights reserved.
F. Lupini, E.S. Leichman, C. Lee et al. Sleep Medicine 81 (2021) 443e450

Similarly, Bulut and colleagues [5] found that preterm children had Table 1
fewer night awakenings (but spent more time awake overnight) Demographics.

than full-term children at 1e3 years of age. However, a separate Total Preterm Full-term
study of infants born with gestational risk (i.e., preterm, small for % n % n % n
gestational age, or low birth weight) found that at 18-months those
Sex of child
with gestational risk had more night awakenings than infants born
Boy 54.7 456 54.7 228 54.7 228
without gestational risk [14]. In terms of differences in sleep Girl 46.3 378 46.3 189 46.3 189
duration, some studies showed shorter nighttime sleep duration in Age of child
preterm infants [10,13]. Alternatively, others have found increased 0e2 mos 16.1 134 16.1 67 16.1 67
3e5 mos 9.4 78 9.4 39 9.4 39
sleep duration at 6- and 18-months for preterm children [14].
6e11 mos 24.0 200 24.0 100 24.0 100
Similar discrepancies in results have been found regarding sleep 12e23 mos 26.4 220 26.4 110 26.4 110
ecology, such as sleep location and parental behaviors. One study 24e36 mos 24.2 202 24.2 101 24.2 101
indicated that preterm infants are more likely to fall asleep inde- Employment status
pendently than full-term infants and co-slept with parents less Full-time 29.7 248 31.9 133 27.6 115
Part-time 15.5 129 13.9 58 17 71
often [6]. In contrast, other studies with measures of sleep ecology
Home/student 48.2 402 46.2 193 50.1 212
found no significant differences between preterm and full-term Unemployed 6.6 55 7.9 33 5.3 22
participants [5,7,16]. Education
Elementary school 3.7 31 3.4 14 4.1 17
High school 31.2 260 30.0 125 32.4 135
2. Maternal sleep College 40.8 340 41.7 174 39.8 166
Post-graduate 24.3 203 24.9 104 23.7 99
Age of respondent
There has been little research examining maternal sleep pat- <25 20.0 167 17.3 72 22.8 95
terns and sleep problems of mothers of preterm infants as 25-29 24.3 203 21.3 89 27.3 114
compared to mothers of full-term infants. Of those conducted, 30-34 31.4 262 32.9 137 30.0 125
several report that mothers of preterm babies experience poor 35-39 19.9 166 22.3 93 17.5 73
40þ 4.3 36 6.2 26 2.4 10
sleep [18e20]. Across eleven studies, for example, a scoping review
Race/ethnicity of respondent
found that maternal sleep was poor, with the majority of studies Brazilian 89.7 748 89.2 372 90.2 376
focused on the early postpartum period of 0e5 months [21]. Only Other Latin American 0.5 4 0.2 1 0.7 3
two of the eleven studies included in this review, however, pro- European/white 6.5 54 6.7 28 6.2 26
African/black 2.0 17 2.4 10 1.7 7
vided a comparison to mothers of full-term infants, yielding mixed
Japanese 0.7 6 1.0 4 0.5 2
results. Other 0.6 5 0.5 2 0.7 3

2.1. Current study

Overall, research to date has explored differences in sleep pat-
terns and parent-perceived sleep problems between preterm and
full-term infants with mixed results. Although studies have been
conducted comparing preterm infant sleep to full-term infant
sleep, few studies have explored sleep at various developmental
points from birth through toddlerhood, and very few have
considered maternal sleep in the same population. Furthermore,
many of the previous studies have not investigated differences in
sleep ecology variables. Thus, the aims of this study were to (1)
compare sleep patterns, sleep problems, and sleep ecology in pre-
term (3 or more weeks early) infants and toddlers to that of full-
term infants and toddlers (0e35.9 months), from here referred to
as ‘infants,’ (2) investigate these potential group sleep differences at
different developmental ages (newborn 0e2.9, young infant 3e5.9,
older infant 6e11.9, young toddler 12e23.9, and older toddler
24e35.9 months), and (3) compare maternal sleep between groups
(i.e., preterm vs. full-term) and across infant age.
3.2. Procedure
The current sample was derived by selecting all questionnaires
completed by mothers of young children (n ¼ 417; 11.1% of the
original sample of 3761) identified as having been born preterm.
Each mother of a preterm infant was matched with a mother of a
full-term infant based on child's race, sex, and chronological age
from the same study.
Participants completed the Brief Infant Sleep Questionnaire
(BISQ), the Pittsburgh Sleep Quality Index (PSQI), and provided
demographic information in January 2015. All questionnaires were
translated into Portuguese and back-translated to English to ensure
accuracy of translation. Data were collected online through a
popular website for parents (BabyCenter). Mothers were invited to
complete a sleep survey via a pop-up screen. Participation was
voluntary and there were no exclusion criteria. This study was
approved by a university-based Institutional Review Board. Full
procedural information is reported elsewhere [22].

3. Methods
3.1. Participants
Participants included 834 mothers (55.2% between 30 and 39
years old; 89.7% Brazilian) of infants (ages 0e35.9 months) residing
in Brazil. The current study is a secondary analysis of a subsample of
participants who engaged in research that addressed infant and
toddler sleep, mood, and development [22]. Half (n ¼ 417) of the
participants selected for the current analyses were mothers of
young children born preterm (i.e., 3 or more weeks early, indicated
by maternal report) and half (n ¼ 417) full-term (see Table 1).
444
3.2.1. Prematurity
Whether or not a baby was born preterm (i.e., 3 or more weeks
prior to due date, per maternal report) was utilized as the grouping
variable.
3.2.2. Brief Infant Sleep Questionnaire (BISQ)
All mothers completed the expanded version of the BISQ
[2,23,24]. The questionnaire consists of specific questions regarding
daytime and nighttime sleep patterns, and sleep-related behaviors
over the past two weeks. The BISQ is a widely published, well-
validated measure for use with infants and toddlers up to 3 years
of age [23,24]. Mothers reported on the following sleep parameters
F. Lupini, E.S. Leichman, C. Lee et al.
through the BISQ: bedtime, sleep onset latency, number and
duration of night awakenings, nighttime sleep duration, waketime,
number of naps, nap duration, and number of bedtime routines per
week. Mothers also reported on the following sleep ecology vari-
ables: bedtime difficulty, confidence in managing child sleep,
parent perception of a sleep problem, falling asleep independently,
sleep location, parent behaviors during sleep initiation, and parent
behaviors when resuming sleep following a night awakening.
Bedtime difficulty (“How difficult is bedtime?”) was reported on a
5-point scale (“very easy” to “very difficult”). Confidence in man-
aging child sleep (“During the past week, how confident have you
felt in managing your child's sleep?“) was reported on a 5-point
scale (“very unsure” to “very confident”). Mothers also provided
information about their perception of their child's sleep (“Do you
consider your child's sleep a problem?“) on a 5-point scale (“not a
problem” to “serious problem”), with those indicating a small,
moderate, or serious problem designated as having a parent-
perceived sleep problem.
3.2.3. Pittsburgh Sleep Quality Index (PSQI)
All mothers completed the PSQI to report their own sleep out-
comes [25]. The PSQI is a self-report measure that consists of 19
individual items that generate seven composite scores: subjective
sleep quality, sleep latency, sleep duration, sleep habitual efficiency,
sleep disturbance, use of sleep medication, and daytime dysfunc-
tion. A global score > 5 indicates a “poor sleeper” and has been
shown to have a diagnostic sensitivity of 89.6% and specificity of
86.5% [25]. The expanded version of the PSQI used in this study
included additional questions about night awakenings and naps,
but these additional questions were not included in the global
score. Questions were regarding sleep behaviors over the past
month. The following maternal sleep parameters were derived
from the PSQI for analysis: bedtime, sleep onset latency, number of
night awakenings, nighttime sleep duration, waketime, night
awakenings duration, and daytime sleep (naps).
3.3. Statistical analyses
Means and frequencies were used for descriptive results. To
detect medium differences (Cohen's d ¼ 0.5) with 80% power at
p < 0.001, a sample size of n ¼ 140 was estimated to be sufficient.
ANCOVAs were conducted to analyze the differences in sleep out-
comes presented above between preterm and full-term infants for
the whole sample and within each age group (i.e., 0e2.9 months,
3e5.9 months, 6e11.9 months, 12e23.9 months, 24e35.9 months).
Preterm mothers were older than full-term mothers (c2 ¼ 16.32,
p ¼ 0.003). As a result, maternal age was included as a covariate.
Bonferroni correction adjusted the alpha level to p < 0.001 for
determining statistical significance. Chi-square tests were used to
determine differences on the sleep ecology parameters mentioned
above. Chi-square tests were considered significant if p < 0.05.
For maternal sleep, analyses were performed on the PSQI sleep-
related variables mentioned above. Analyses were also performed
on PSQI composite scores and global scores. Bonferroni correction
adjusted the alpha level to p < 0.001.
4. Results
4.1. Demographics
Complete demographic data are provided in Table 1. Overall,
infants were on average 14.31 months old (SD ¼ 10.65). There were
more boys (n ¼ 456, 54.7%) than girls (n ¼ 378, 46.3%), c2 ¼ 7.30,
p ¼ 0.007. Respondents were primarily between 30 and 39 years
old (55.2%), most had a college degree (65.1%), and almost half were
445
Sleep Medicine 81 (2021) 443e450
employed outside the home (45.2%). The majority of respondents
self-identified as Brazilian (89.7%), with the rest indicating other
Latin American countries (0.5%), European origin (6.5%), African/
Black (2%), Japanese (0.7%), or other (0.6%). There were no differ-
ences between groups for education, employment, or race, p > 0.05.
4.2. Infant sleep patterns
All infant sleep outcomes are displayed in Table 2. On average
across the entire sample, infants went to bed at 10:04 pm
(SD ¼ 1.37), with a sleep onset latency of 28.64 min (SD ¼ 19.87).
During the night, they woke 1.42 times (SD ¼ 1.31) for an average of
27 min (SD ¼ 39.6). Average morning waketime was at 7:49 am
(SD ¼ 1.55) for 9.06 h of nighttime sleep (SD ¼ 1.90). During the day,
infants napped on average 2.24 times (SD ¼ 1.38) for 3.06 h
(SD ¼ 2.06). Across the entire sample and within all age groups,
preterm and full-term infants had similar weekly bedtime routine
frequency, bedtime, sleep onset latency, number of night awaken-
ings, night awakening duration, morning wake time, nighttime
sleep duration, and nap duration (p > 0.001).
4.3. Infant sleep ecology
Sleep ecology variables are displayed in Table 3. Across all in-
fants, sleep ecology variables were similar between preterm and
full-term groups, except for holding and feeding. Preterm infants
were more likely than those born full-term to be held to initiate
sleep at bedtime (32.9% vs. 25.9%; c2 ¼ 4.86, p ¼ 0.027) and to be
given a bottle to resume sleep after a night awakening (29.8% vs.
19.1%; c2 ¼ 8.93, p ¼ 0.003), but less likely to be breastfed to resume
sleep after a night awakening (45.6% vs. 55.2%; c2 ¼ 5.42,
p ¼ 0.020). Sleep locations were similar across all age groups.
Considering specific age time points, sleep ecology was again
similar, other than sleep-related feeding. Preterm infants were
more likely than full-term infants to be given a bottle to initiate
sleep at 0- to 2.9-months (16.4% vs. 4.5%; c 2 ¼ 5.11, p ¼ 0.024) and
at 6- to 11.9-months (28% vs. 15%; c2 ¼ 5.91, p ¼ 0.015). Further,
preterm infants in the 6- to 11.9-month group were less likely to be
breastfed to initiate sleep than full-term infants (29% vs. 53%;
c2 ¼ 11.91, p < 0.001). Furthermore, preterm infants in the 6- to
11.9-month group were more likely to be given a bottle to resume
sleep after a night awakening than full-term infants (40% vs. 22.5%;
c2 ¼ 5.16, p ¼ 0.023) and less likely to be breastfed to resume sleep
after waking during the night than full-term infants (38.7% vs.
66.2%; c2 ¼ 11.08, p < 0.001).
4.4. Sleep perceptions
Across the entire sample, mothers of preterm infants (25.2%)
were more likely to report a parent-perceived sleep problem than
mothers of full-term infants (18.0%), c2 ¼ 6.38, p ¼ 0.012. However,
when analyzed for each age group, this result was evident for only
ages 12- to 23.9-months (preterm 30%, full-term 16.4%, c2 ¼ 5.74,
p ¼ 0.017) and 24- to 35.9-months (preterm 23.8%, full-term 7.9%,
c2 ¼ 9.51, p ¼ 0.002). Parent perceived confidence in managing
child sleep and bedtime difficulty were similar between gestational
groups for the whole sample and within age groups.
4.5. Maternal sleep patterns
Maternal sleep outcomes are displayed in Table 4. Across the
entire sample, mothers went to bed at 11:26 pm (SD ¼ 1.37), with a
sleep onset latency of 26.52 min (SD ¼ 24.72). During the night,
they woke 2.66 times (SD ¼ 1.72). Average morning waketime was
7:22 am (SD ¼ 1.58) for 6.40 h of nighttime sleep (SD ¼ 1.70). During
F. Lupini, E.S. Leichman, C. Lee et al. Sleep Medicine 81 (2021) 443e450

the day mothers napped on average for 1.32 h (SD ¼ 1.70). Overall,

8:23 (1.48)
3.88 (1.22)

0.75 (1.03)

13.8 (0.51)

0.88 (0.45)

1.81 (1.06)
72.2% of mothers were considered to have poor sleep (PSQI
(n ¼ 202) (n ¼ 101) (n ¼ 101)
Preterm Full-term

(20.43)
M (SD)
score > 5).

(1.12)

(1.57)
10:08

31.15

10.00
Between gestational groups for the whole sample and for each
age group, mothers of preterm and full-term infants were similar
across all measured sleep parameters: bedtime, sleep onset latency,

(24.68)
M (SD)

(1.28)

(1.24)

(1.25)

(0.67)

(1.49)

(1.42)

(0.61)

(0.98)
10:11

31.22

8:16
3.70

0.96

20.4

9.49

1.03

1.89
wake time, nighttime sleep duration, number of night awakenings,
night awakening duration, nap duration, PSQI subjective sleep
24e35 m

quality, PSQI sleep latency, PSQI sleep duration, PSQI sleep habitual
(22.60)
M (SD)

(1.25)

(1.18)

(1.15)

(0.60)

(1.48)

(1.52)

(0.54)

(1.02)
9:55 (1.27) 10:10

31.18

7:59 (1.39) 8:20

4.06 (1.17) 3.79

1.13 (1.12) 0.86

19.8 (0.57) 17.4

9.64 (1.54) 9.74

1.62 (0.72) 0.96

2.55 (1.27) 1.85

efficiency, PSQI sleep disturbances, PSQI sleep medication, PSQI
All

global score, PSQI hours in bed, and PSQI actual efficiency.

(n ¼ 220) (n ¼ 110) (n ¼ 110)
Preterm Full-term

(18.80)
M (SD)

27.60

5. Discussion

Overall, this study found similar sleep outcomes in preterm

(13.35)
M (SD)

infants as compared to full-term infants. Most sleep ecology vari-

(1.25)

(1.30)

(1.21)

(0.51)

(1.56)

(1.80)

(0.72)

(1.22)
26.64
9:57

8:08
3.91

1.42

18.6

9.52

1.67

2.56
ables, except holding and sleep-related feeding, and sleep locations
were similar between gestational groups. Across the entire sample,
12e23 m

(16.27)
M (SD)

more mothers of preterm infants reported a perceived sleep

(1.21)

(1.28)

(1.17)

(0.54)

(1.48)

(1.67)

(0.72)

(1.25)
27.12
9:59 (1.33) 9:56

7:52 (1.49) 8:04

4.03 (1.19) 3.99

1.47 (1.33) 1.27

22.2 (0.55) 19.2

8.95 (1.67) 9.58

2.49 (0.80) 1.65

2.62 (1.17) 2.55

problem than mothers of full-term infants. However, this result was
All

only evident for toddlers when looking at specific age groups.

(n ¼ 39) (n ¼ 200) (n ¼ 100) (n ¼ 100)
Preterm Full-term

Bedtime difficulty and maternally-perceived confidence in man-

(18.04)
M (SD)

28.69

aging sleep also were comparable at all time points. Finally,

maternal sleep was similar between gestational groups, both for
the entire sample and at every age.
(15.02)
M (SD)

(1.17)

(1.47)

(1.50)

(0.46)

(1.52)

(1.66)

(0.80)

(1.23)

Previous literature comparing preterm and full-term infant and

26.14
9:41

7:32
3.89

1.62

19.2

9.19

2.51

2.70

child sleep patterns, problems, and ecology has been largely mixed,
with several studies indicating differences in either direction and
21 (0.51)
6e11 m

(16.61)
M (SD)

others indicating no differences. Current study findings indicate

(1.18)

(1.40)

(1.42)

(1.51)

(1.66)

(0.80)

(1.20)
27.42
9:50

7:43
3.96

1.55

9.07

2.50

2.66
Full-term All

that sleep in preterm infants is comparable to that of full-term

infants, echoing results of several of these prior studies (eg,
(19.43)
M (SD)

Refs. [5e8,11]). This lack of differences was evident at every age

(1.20)

(1.33)

(1.14)

(0.47)

(1.35)

(1.70)

(1.23)

(1.49)
26.38
9:54

7:32
3.92

1.51

23.4

8.88

3.26

3.38

point, from the newborn period through toddlerhood. The simi-

larity in sleep patterns between gestational groups may suggest
(n ¼ 67) (n ¼ 78) (n ¼ 39)
Preterm

(15.33)

that infant sleep is influenced by behavioral aspects, such as sleep

M (SD)

Note: There were no significant differences found; M ¼ mean; SD ¼ standard deviation; min ¼ minutes.
(1.20)

(1.45)

(1.16)

(0.38)

(1.57)

(1.57)

(1.01)

(2.00)
10:01

27.28

7:34
4.13

1.64

26.4

9.03

3.67

3.92

ecology, moreso than biological factors such as gestational age.

Interestingly, the current study found differences in breast-
(17.39)
3e5 m

M (SD)

feeding and bottle-feeding behaviors related to sleep, with overall

(1.20)

(1.38)

(1.15)

(0.42)

(1.45)

(1.62)

(1.14)

(1.77)
26.83
9:57

7:33
4.03

1.58

25.2

8.96

3.46

3.65
Full-term All

more preterm infants being bottle-fed to resume sleep after waking

at night, whereas more full-term infants were breastfed back to
63 (0.83)
(19.75)

sleep. Looking at specific age groups, this difference in feeding was

M (SD)

(1.39)

(1.64)

(1.29)

(1.44)

(2.10)

(1.24)

(2.43)
10:32

29.18

7:04
3.10

2.12

7.38

3.99

5.55

evident in sleep initiation behaviors for newborns and older in-

fants, with more preterm infants being bottle-fed and more full-
66 (0.90)
(n ¼ 134) (n ¼ 67)
Preterm

term infants being breastfed. These results are consistent with

(30.51)
M (SD)

(1.52)

(1.57)

(1.17)

(1.59)

(1.98)

(1.26)

(2.81)
10:31

31.21

6:56
3.40

2.37

7.03

4.15

6.32

previous research suggesting potential associations of infant char-

acteristics such as birthweight and prematurity with breastfeeding.
For instance, studies have noted an association between low birth
(25.62)
0e2 m

M (SD)

(1.46)

(1.60)

(1.23)

(0.86)

(1.51)

(2.04)

(1.25)

(2.65)
10:32

30.19

7:00
3.84 (1.26) 3.25

2.25

64.8

7.21

4.07

5.94

weight and suboptimal infant breastfeeding behavior [26], early

All

cessation of breastfeeding among mothers of very low birth weight

7:52 (1.50)
1.31 (1.26)

26.4 (0.66)

9.13 (1.89)

2.18 (1.37)

2.95 (1.91)
(n ¼ 834) (n ¼ 417) (n ¼ 417)
Preterm Full-term

infants [27], as well as a decrease in breast milk production in

(19.21)
M (SD)

(1.33)
10:05

preterm mothers [28]. Furthermore, it is possible that preterm in-

28.86

fants may require nutritional supplementation, and may be

receiving supplemented breast milk, donor breast milk, or preterm
All ages (0e36 m)

(20.53)
M (SD)

formula [29].
(1.29)

(1.41)

(1.35)

(0.67)

(1.61)

(1.90)

(1.40)

(2.19)
10:02

28.42

7:47
3.79

1.53

27.6

8.99

2.30

3.16

Interestingly, more mothers of preterm infants reported

perceived sleep problems than mothers of full-term infants, which
27 (0.66)
(19.87)

is consistent with findings of one previous study that found

M (SD)

(1.28)

(1.37)

(1.31)

(1.55)

Duration (hours) (1.90)

(1.38)

(2.06)
10:04

Sleep Onset Latency 28.64

7:49
3.82

Night Awakenings 1.42

9.06

2.24

3.06

mothers of preterm infants reporting more worry about child sleep

All

problems than mothers of full-term infants [10]. However, this

Infant sleep outcomes.

Duration (mins)

previous study found this result for mothers of infants corrected

Bedtime Routine

Wake time (AM)

Number of Naps
Nighttime Sleep
(days of the

Night Waking

age 10e22 months, whereas when analyzed by age group, the

Bedtime (PM)

Nap Duration

present study found this result only among toddlers

(hours)
(mins)
week)

(12e36 months). Furthermore, increased maternal report of sleep

Table 2

problems of those with an infant born prematurely in this study

does not align with the actual lack of differences in all sleep
446
 F. Lupini, E.S. Leichman, C. Lee et al.
Table 3
Infant sleep ecology.

All ages (0e36 m) 0e2 m 3e5 m 6e11 m 12e23 m 24e35 m

All Preterm Full-term All Preterm Full-term All Preterm Full-term All Preterm Full-term All Preterm Full-term All Preterm Full-term
(n ¼ 834) (n ¼ 417) (n ¼ 417) (n ¼ 134) (n ¼ 67) (n ¼ 67) (n ¼ 78) (n ¼ 39) (n ¼ 39) (n ¼ 200) (n ¼ 100) (n ¼ 100) (n ¼ 220) (n ¼ 110) (n ¼ 110) (n ¼ 202) (n ¼ 101) (n ¼ 101)

% (N) % (N) % (N) % (N) % (N) % (N) % (N) % (N) % (N) % (N) % (N) % (N) % (N) % (N) % (N) % (N) % (N) % (N)
Sleep initiation method
Bottle feeding 19.8 21.3 (89) 18.2 (76) 10.4 (14) 16.4 (11) 4.5 (3) 9.0 (7) 7.7 (3) 10.3 (4) 21.0 (42) 28.0 (28) 14.0 (14) 26.8 (59) 25.5 (28) 28.2 (31) 21.3 (43) 18.8 (19) 23.8 (24)
(165)
Breast feeding 33.7 31.7 (132) 35.7 (149) 73.9 (99) 71.6 (48) 76.1 (51) 55.1 56.4 (22) 53.8 (21) 41.0 (82) 29.0 (29) 53.0 (53) 20.0 (44) 21.8 (24) 18.2 (20) 6.4 (13) 8.9 (9) 4.0 (4)
(281) (43)
Rocking 20.5 19.2 (80) 21.8 (91) 32.8 (44) 28.4 (19) 37.3 (25) 30.8 30.8 (12) 30.8 (12) 28.5 (57) 26.0 (26) 31.0 (31) 17.7 (39) 19.1 (21) 16.4 (18) 3.5 (7) 2.0 (2) 5.0 (5)
(171) (24)
Holding 29.4 32.9 (137) 25.9 (108) 53.7 (72) 61.2 (41) 46.3 (31) 46.2 51.3 (20) 41.0 (16) 40.0 (80) 46.0 (46) 34.0 (34) 21.8 (48) 24.5 (27) 19.1 (21) 4.5 (9) 3.0 (3) 5.9 (6)
(245) (36)
Resuming sleep
Holding or rocking 19.6 20.0 (61) 19.1 (53) 32.2 (40) 29.7 (19) 35.0 (21) 21.0 15.6 (5) 26.7 (8) 23.3 (34) 24.0 (18) 22.5 (16) 16.4 (24) 21.5 (17) 10.4 (7) 2.9 (3) 3.6 (2) 2.0 (1)
to sleep (114) (13)
Rub or pat in crib 16.7 (97) 17.0 (52) 16.2 (45) 5.6 (7) 9.4 (6) 1.7 (1) 8.1 (5) 3.1 (1) 13.3 (4) 19.2 (28) 20.0 (15) 18.3 (13) 21.1 (31) 22.8 (18) 19.4 (13) 25.0 (26) 21.8 (12) 28.6 (14)
Giving a bottle 24.7 29.8 (91) 19.1 (53) 13.7 (17) 18.8 (12) 8.3 (5) 17.7 21.9 (7) 13.3 (4) 31.5 (46) 40.0 (30) 22.5 (16) 30.1 (44) 32.9 (26) 26.9 (18) 25.0 (26) 29.1 (16) 20.4 (10)
(144) (11)
Breast feed back to 50.2 45.6 (139) 55.2 (153) 85.5 79.7 (51) 91.7 (55) 77.4 78.1 (25) 76.7 (23) 52.1 (76) 38.7 (29) 66.2 (47) 31.5 (46) 29.1 (23) 34.3 (23) 15.4 (16) 20.0 (11) 10.2 (5)
sleep (292) (106) (48)
Giving a pacifier 28.0 31.1 (95) 24.5 (68) 18.5 (23) 18.8 (12) 18.3 (11) 19.4 18.8 (6) 20.0 (6) 37.7 (55) 44.0 (33) 31.0 (22) 37.7 (55) 39.2 (31) 35.8 (24) 17.3 (18) 23.6 (13) 10.2 (5)
447

(163) (12)
Changing diaper 24.2 25.2 (77) 23.1 (64) 62.9 (78) 64.1 (41) 61.7 (37) 19.4 28.1 (9) 10.0 (3) 12.3 (18) 14.7 (11) 9.9 (7) 18.5 (27) 17.7 (14) 19.4 (13) 5.8 (6) 3.6 (2) 8.2 (4)
(141) (12)
Bring child into 15.8 (92) 14.4 (44) 17.3 (48) 10.5 (13) 6.3 (4) 15.0 (9) 4.8 (3) 3.1 (1) 6.7 (2) 13.0 (19) 10.7 (8) 15.5 (11) 22.6 (33) 24.1 (19) 20.9 (14) 23.1 (24) 21.8 (12) 24.5 (12)
parents' bed
Sleep location
Crib or cot 55.0 56.1 (234) 54.0 (225) 59.0 (79) 58.2 (39) 59.7 (40) 74.4 79.5 (31) 69.2 (27) 67.5 (35) 69.0 (69) 66.0 (66) 59.1 56.4 (62) 61.8 (68) 28.2 (57) 32.7 (33) 23.8 (24)
(459) (58) (130)
Own bed 12.6 11.5 (48) 13.7 (57) 0.7 (1) 0.0 (0) 1.5 (1) 0.0 (0) 0.0 (0) 0.0 (0) 3.5 (7) 2.0 (2) 5.0 (5) 10.5 (23) 11.8 (13) 9.1 (10) 36.6 (74) 32.7 (33) 40.6 (41)
(105)
Parents' bed 27.5 27.1 (113) 27.8 (116) 18.7 (25) 14.9 (10) 22.4 (15) 21.8 17.9 (7) 25.6 (10) 27.5 (55) 28.0 (28) 27.0 (27) 28.6 (62) 30.9 (34) 26.4 (29) 34.2 (69) 33.7 (34) 34.7 (35)
(229) (17)
Other (bassinet, 4.9 (41) 5.3 (22) 4.6 (19) 21.6 (29) 26.9 (18) 16.4 (11) 3.8 (3) 2.6 (1) 5.1 (2) 1.5 (3) 1.0 (1) 2.0 (2) 1.8 (4) 0.9 (1) 2.7 (3) 1.0 (2) 1.0 (1) 1.0 (1)
swing)
Falls asleep in his/ 18.2 16.5 (69) 19.9 (83) 10.4 (14) 7.5 (5) 13.4 (9) 17.9 17.9 (7) 17.9 (7) 15.0 (30) 16.0 (16) 14.0 (14) 18.6 (41) 15.5 (17) 21.8 (24) 26.2 (53) 23.8 (24) 28.7 (29)
her (152) (14)
independently
Sleep problem 21.6 25.2 (105) 18.0 (75) 23.1 (31) 25.4 (17) 20.9 (14) 19.2 12.8 (5) 25.6 (10) 25.5 (51) 26.0 (26) 25.0 (25) 23.2 (51) 30.0 (33) 16.4 (18) 15.8 (32) 23.8 (24) 7.9 (8)
(180) (15)

Sleep Medicine 81 (2021) 443e450

Confidence in 47.2 46.7 (195) 47.7 (199) 39.6 (53) 34.3 (23) 44.8 (30) 52.6 56.4 (22) 48.7 (19) 48.0 (96) 51.0 (51) 45.0 (45) 48.2 42.7 (47) 53.6 (59) 48.5 (98) 51.5 (52) 45.5 (46)
managing child's (394) (41) (106)
sleep
Bedtime difficulty 22.4 23.0 (96) 21.8 (91) 25.4 (34) 26.9 (18) 23.9 (16) 14.1 10.3 (4) 17.9 (7) 27.5 (55) 29.0 (29) 26.0 (26) 20.0 (44) 22.7 (25) 17.3 (19) 21.3 (43) 19.8 (20) 22.8 (23)
(187) (11)

Note: Black lines under the means indicates a significant ANCOVA difference; h ¼ hour; min ¼ minutes.
 F. Lupini, E.S. Leichman, C. Lee et al.
Table 4
Maternal sleep outcomes.

All ages (0e36 m) 0e2 m 3e5 m 6e11 m 12e23 m 24e36 m

All Preterm Full-term All Preterm Full-term All Preterm Full-term All Preterm Full-term All Preterm Full-term All Preterm Full-term
(n ¼ 834) (n ¼ 417) (n ¼ 417) (n ¼ 134) (n ¼ 67) (n ¼ 67) (n ¼ 78) (n ¼ 39) (n ¼ 39) (n ¼ 200) (n ¼ 100) (n ¼ 100) (n ¼ 220) (n ¼ 110) (n ¼ 110) (n ¼ 202) (n ¼ 101) (n ¼ 101)

M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD)

Bedtime (PM) 11:26 11:28 11:25 11:47 11:46 11:49 11:28 11:26 11:28 11:27 11:27 11:27 11:20 11:23 11:18 11:18 11:23 11:13
(1.37) (1.40) (1.34) (1.45) (1.50) (1.41) (1.45) (1.48) (1.45) (1.29) (1.32) (1.27) (1.38) (1.43) (1.33) (1.33) (1.35) (1.31)
Sleep Onset 26.52 26.17 26.87 21.03 22.31 19.75 26.28 26.67 25.90 23.08 22.83 23.34 28.65 26.91 30.38 31.33 31.04 31.62
Latency (min) (24.72) (25.01) (24.45) (22.31) (24.48) (20.02) (31.91) (33.82) (30.32) (18.74) (19.91) (17.59) (27.87) (25.26) (30.27) (23.63) (25.27) (21.99)
Wake Time (AM) 7:22 7:20 7:25 (1.56) 6:59 6.59 7:00 7:20 7:17 7:23 7:10 6:55 7:25 (1.55) 7:31 7:36 7:26 (1.48) 7:41 7:41 7:41 (1.58)
(1.58) (1.61) (1.81) (1.87) (1.77) (1.51) (1.74) (1.26) (1.55) (1.50) (1.45) (1.43) (1.57) (1.57)
Nighttime Sleep 6.40 6.35 6.46 (1.71) 5.21 5.18 5.25 6.35 6.35 6.35 6.28 6.34 6.22 (1.59) 6.83 6.65 7.01 (1.57) 6.87 6.79 6.95 (1.61)
Duration (1.70) (1.69) (1.67) (1.59) (1.76) (1.35) (1.39) (1.32) (1.51) (1.44) (1.66) (1.74) (1.66) (1.72)
(hours)
Night Awakenings 2.66 2.74 2.59 (1.77) 3.37 3.16 3.58 2.86 3.15 2.56 2.70 2.87 2.54 (1.68) 2.37 2.47 2.26 (1.41) 2.40 1.46 2.35 (1.64)
(1.72) (1.66) (1.98) (1.44) (2.39) (1.62) (1.79) (1.39) (1.76) (1.83) (1.42) (1.43) (1.68) (1.72)
SOL after Waking 20.79 21.06 20.51 28.44 29.60 27.27 18.77 20.11 17.41 19.62 19.38 19.97 18.15 19.46 16.83 20.17 18.85 21.52
(min) (19.98) (18.94) (21.00) (24.79) (25.72) (23.95) (16.74) (18.12) (15.32) (20.72) (18.82) (22.64) (16.41) (15.05) (17.65) (19.24) (16.10) (21.62)
448

Nap Duration 1.32 1.36 1.28 (0.75) 1.32 1.20 1.44 1.47 1.52 1.40 1.02 1.19 0.91 (0.40) 1.45 1.44 1.47 (0.95) 1.39 1.58 1.26 (0.61)
(hours) (0.76) (0.78) (0.83) (0.78) (0.86) (0.57) (0.54) (0.63) (0.48) (0.56) (0.84) (0.77) (0.81) (1.02)
PSQI Subjective 1.51 1.55 1.48 (0.85) 1.88 1.93 1.84 1.19 1.10 1.28 1.53 1.53 1.53 (0.81) 1.45 1.58 1.32 (0.90) 1.44 1.45 1.44 (0.85)
Sleep Quality (0.86) (0.87) (0.81) (0.86) (0.77) (0.77) (0.79) (0.76) (0.84) (0.88) (0.88) (0.85) (0.85) (0.84)
PSQI Sleep Latency 1.17 1.15 1.19 (1.05) 0.93 1.04 0.81 0.96 1.03 0.90 1.05 1.02 1.07 (0.94) 1.26 1.20 1.33 (1.06) 1.45 1.36 1.54 (1.04)
(1.02) (1.00) (0.99) (0.93) (1.05) (1.03) (1.06) (1.00) (0.98) (1.04) (1.03) (1.00) (1.01) (0.98)
PSQI Sleep 1.19 1.25 1.13 (0.96) 1.94 2.01 1.87 1.14 1.15 1.13 1.24 1.22 1.25 (0.97) 0.97 1.09 0.85 (0.84) 0.91 0.97 0.84 (0.82)
Duration (0.98) (0.99) (1.02) (1.04) (1.01) (0.86) (0.93) (0.80) (0.92) (0.88) (0.90) (0.94) (0.86) (0.89)
PSQI Sleep 1.06 1.05 1.06 (1.18) 1.52 1.52 1.52 1.06 1.13 1.00 1.07 0.85 1.29 (1.23) 0.89 1.00 0.77 (1.08) 0.92 0.96 0.87 (1.03)
Habitual (1.17) (1.17) (1.28) (1.28) (1.30) (1.19) (1.24) (1.15) (1.15) (1.03) (1.13) (1.17) (1.09) (1.15)
Efficiency
PSQI Sleep 1.20 1.20 1.19 (0.52) 1.19 1.21 1.16 1.13 1.18 1.08 1.08 1.06 1.10 (0.48) 1.22 1.25 1.18 (0.53) 1.33 1.30 1.37 (0.58)
Disturbances (0.52) (0.53) (0.49) (0.57) (0.41) (0.47) (0.45) (0.48) (0.51) (0.53) (0.52) (0.52) (0.56) (0.54)
PSQI Sleep 0.15 0.15 0.14 (0.55) 0.13 0.12 0.15 0.12 0.10 0.13 0.10 0.07 0.12 (0.50) 0.16 0.15 0.18 (0.64) 0.19 0.27 0.12 (0.52)
Medication (0.55) (0.54) (0.55) (0.54) (0.56) (0.51) (0.50) (0.52) (0.42) (0.33) (0.58) (0.52) (0.62) (0.71)
PSQI Daytime 1.49 1.55 1.43 (0.83) 1.69 1.72 1.67 1.44 1.54 1.33 1.54 1.64 1.43 (0.90) 1.38 1.45 1.31 (0.82) 1.45 1.46 1.45 (0.76)
Dysfunction (0.84) (0.85) (0.85) (0.92) (0.79) (0.82) (0.76) (0.87) (0.86) (0.80) (0.83) (0.84) (0.81) (0.87)
PSQI Global Score 7.76 7.90 7.63 (3.44) 9.28 9.55 9.01 7.04 7.23 6.85 7.59 7.39 7.79 (3.40) 7.33 7.72 6.94 (3.37) 7.69 7.72 7.62 (0.87)
(3.53) (3.62) (3.50) (3.72) (3.27) (3.51) (3.65) (3.39) (3.32) (3.23) (3.53) (3.66) (3.51) (3.61)
PSQI Hours in Bed 7.93 7.86 8.00 (1.74) 7.20 7.23 7.18 7.87 7.85 7.90 7.71 7.46 7.97 (1.58) 8.18 8.22 8.13 (1.51) 8.38 8.30 8.47 (1.95)

Sleep Medicine 81 (2021) 443e450

(1.68) (1.63) (1.82) (1.82) (1.83) (1.45) (1.40) (1.52) (1.62) (1.64) (1.49) (1.47) (1.74) (1.51)
PSQI Actual 82.66 82.44 82.89 75.72 74.80 76.63 82.69 82.86 82.52 83.56 86.64 80.49 85.05 82.47 87.63 83.78 83.17 84.39
Efficiency (21.86) (20.88) (22.83) (26.27) (24.41) (28.17) (19.09) (19.51) (18.93) (21.85) (17.84) (24.95) (21.28) (21.92) (20.39) (19.43) (19.48) (19.47)

Note: There were no significant differences found; m ¼ months; M ¼ mean; SD ¼ standard deviation; min ¼ minutes.
F. Lupini, E.S. Leichman, C. Lee et al.
outcomes. Qualitative studies of these increased parent-perceived
sleep outcomes may help elucidate the concerns of mothers of
preterm infants, as well as whether there are other differences in
sleep behaviors not captured in this study. In contrast, other mea-
sures of maternal perceptions of child sleep, including perceived
difficulty at bedtime and parental confidence in managing child
sleep, did not differ between gestational groups.
Although little is known about sleep in mothers of preterm in-
fants, studies have noted an increased propensity for postpartum
depression and postpartum post-traumatic stress symptoms in
these women [30e36]. Given that changes in sleep are often
associated with depressive symptoms and stress, increased sleep
concerns among mothers of preterm infants were expected
[18,37e39]. Surprisingly, maternal sleep outcomes in mothers of
preterm infants were similar to those outcomes in mothers of full-
term infants in this study, although these results were consistent
with at least one previous study [40]. But these results do contra-
dict findings by McMillen and colleagues [41] that mothers of
preterm infants slept less, spent more time awake during the night,
had less time asleep, and had fewer sleep bouts per 24 h than
mothers of full-term infants during the first eight weeks. Presence
of postpartum depression and postpartum post-traumatic stress
symptoms were not collected in the current study, which may
unveil differences between groups. More striking than the lack of
differences across groups, however, was that a majority (almost
three-quarters) of mothers were found to have poor sleep. This
finding suggests that sleep in mothers of infants and toddlers is
generally poor, regardless of gestational group or the age of their
infant.
It is important to note the limitations of this study. As with any
internet-based study, the sample was likely skewed toward par-
ticipants with higher education and a more urban sample
[22,23,42]. Although this study was based on a Brazilian sample
and may be generalizable to infants and mothers in other countries,
future research in other countries is necessary. Furthermore, as this
was a secondary analysis, some participant information of interest
was unavailable. For example, it is unknown whether participants
were reporting information on sleep that occurred at home or at
the hospital, especially as the preterm infants were more likely to
have extended hospital stays. It is likely, however, that participants
completed the survey based on their infant sleeping at home rather
than the hospital. If so, the results reported here may not be
reflective of preterm infant sleep in neonatal intensive care units
(NICU). The potential lack of inclusion of sleep could explain the
similarity between preterm and full-term sleep outcomes, as the
more severe preterm infants residing in the NICU were likely not
included. Similarly, mothers only indicated whether their child was
born before 37 weeks’ gestation, but did not provide the exact
gestational age at birth. It is likely that there was variability in the
sample of the level of infant prematurity. The severity of prema-
turity could impact sleep outcomes. This variability of level of
prematurity likely exists across all previous studies, which may
explain the mixed nature of the literature in this area. Furthermore,
it is possible that infants born prematurely had medical assistance,
such as a gastronomy tube, which may have improved sleep and
skewed results. Thus, future research should consider including
additional demographic information including severity of prema-
turity and comorbidities which may impact sleep outcomes. Finally,
we may have been underpowered to detect small to medium group
differences in some of the age sub-groups, which should be taken
into consideration.
Overall, sleep patterns and sleep problems in preterm and full-
term infants were quite similar when prematurity was defined as
being born before 37 weeks’ gestation. Sleep ecology differed
across gestational groups only in bottle feeding versus breast
449
Sleep Medicine 81 (2021) 443e450
feeding behaviors at night. Furthermore, across the entire sample
more mothers of preterm infants reported a perceived sleep
problem than mothers of full-term infants, but this was only
evident for mothers of toddlers and not at any other age point.
These lack of sleep differences were evident from even the earliest
newborn period. Finally, maternal sleep outcomes across gesta-
tional groups and age were similar. The results of this study suggest
that perhaps biological factors such as gestational age are not as
important in sleep outcomes as environmental and behavioral
factors, such as sleep ecology.
Acknowledgements
This study was supported by Johnson & Johnson Consumer Inc.
Conflict of interest
Drs. Leichman and Mindell are recipients of an unrestricted
grant and serve as consultants for Johnson & Johnson Consumer
Inc.
Ms. Lee is an employee of Johnson & Johnson Consumer Inc.
The ICMJE Uniform Disclosure Form for Potential Conflicts of
Interest associated with this article can be viewed by clicking on the
following link: https://doi.org/10.1016/j.sleep.2021.03.011.
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