Effective Factors Related to Sleep Disorder in Infants Under 12 Months Old

Abstract

Objective Infant sleep problems are ranked as one of the leading sources of stress for many families. The present study was conducted to determine the effective factors related to sleep disorders in infants under 12 months old.

Materials and Methods In this cross-sectional study, 410 infants who were referred to the sleep department were evaluated. The Brief Infant Sleep Questionnaire (BISQ) was used to assess the infants' sleep patterns. Statistical tests such as analysis of variance (ANOVA), Chi-squared, and linear regression analysis were used to compare the mean and percentage across the infant age groups and to determine the risk factors related to infant sleep disorders.

Results Out of 410 infants, 289 (70.5%) had at least 1 of the symptoms of sleep disorder. The highest and lowest percentages for sleep disorders were related to “waking for more than 1 hour at night” and “sleeping less than 540 minutes in 24 hours” with 50% and 23.7%, respectively. The results of the linear regression analysis showed that the factors of age (β = −1.04; 95% CI; −1.55–0.53) and parent perception (β = −0.31; 95% CI; 0.24–0.37) had significant effects on infant sleep disorders.

Conclusion The percentage of infant sleep disorder was rather high among the samples studied, and the age and parent perception variables were recognized as effective factors related to sleep disorder. Health providers and medical staff need to pay more attention to providing the necessary interventions considering infants' age and parents' perception.

 

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Keywords

infant - parent - sleep disorder

Introduction

Adequate sleep plays a vital role in a child's growth, development, wellbeing, and health.[1] The sufficient amount of sleep for infants 0 to 12 months old that is recommended by international guidelines is up to 17 hour/day.[2] Infants and children younger than 3 years old sleep for the majority of their time, and it affects every aspects of their development.[3] It has been suggested that around 20 to 30% of children younger than 3 years of age suffer from sleep problems. Compared with other children and youth age groups,, infants of 0 to 1 year old have the highest percentage of insomnia, with 21%.[4] Sleep problems, including difficulty falling and staying asleep, night awakenings are especially common in infants due to a combination of environmental (e.g., sleep location), developmental, and caregiver (e.g., presence at bedtime) factors specific to this period,[5] as well as to parental behaviors.[6] [7] [8] [9] [10] According to the results of a study in Indonesia, the percentage of sleep problems in children 0 to 36 months old was 31%.[11] The results of a study in India showed that there was a higher percentage of sleep disorder among children (19.6%), while only 5.6% of parents thought their children had trouble sleeping.[12] Inadequate bedtime routine, parent-baby co-sleeping, and frequent nighttime feedings were the most common reasons for sleep disorders in infants.[13] [14] In recent decades, major changes have happened in people's lifestyles that have had negative effects on children's sleep quality.[15] For example, it has been shown that the growing use of electronic media devices by parents and the integration of these devices into people's everyday lives are associated with shorter sleep duration per night in early childhood.[16] [17] [18] [19] In addition, media exposure causes sleep disorders in infants, and concerning their parents, the results of a study showed that media exposure at ages younger than 1 year was associated with less cognitive development at 14 months of age.[20] Parental behavior can affect the sleep quality of infants. In a study, it was demonstrated that mothers were more involved in the care of infants than fathers, during both the day and night. Greater father involvement in infant care was associated with fewer nocturnal infant waking after breastfeeding.[21] Therefore, it has been recommended that screening for children's sleep problems be considered as part of primary health care, to understand the extent of the problem and provide appropriate health and medical services. Moreover, it is recommended to promote parents' knowledge so they can understand the children's sleep problems and prevent the adverse effects of sleep disorders on infants.[22] Although there is some evidence about the percentage of infant sleep disorders and the characteristics of parental behavior around the world,[11] [23] there is a lack of updated information in Iran. Knowing the profile of an infant's sleep disorder and parental perception and behavior helps to better understand the current condition and to develop a plan to prevent and treat the patients. Moreover, recognizing the effective factors on infant sleep disorders enables us to apply suitable interventions. This study was conducted to determine the effective factors related to them across various infant age groups under 12 months old.

 

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Materials and Methods

The present cross-sectional study was conducted on 410 infants who were referred to the sleep department for evaluation of sleep disorder from May 2021 to May 2022. The children's ages ranged from 0 to 11 months. This educational sleep department is affiliated with Qazvin University of Medical Sciences (Qazvin, Iran). Sampling was performed consecutively. Consecutive sampling is a systematic data collection method used in research and statistical analysis to gather information from participants or cases within a specific timeframe.[24] The purpose of the study was explained to the participants and after obtaining informed consent, parents entered the study and completed the questionnaire. Questionnaires were completed in the clinic while parents were waiting for a doctor's visit, and if the parents had any doubts, the necessary explanations were provided by the study colleagues.

Most of the participants were mothers (n = 296; 72.2%). The short form of the Brief Infant Sleep Questionnaire (BISQ) was used to assess the sleep patterns of infants.[5] [6] The BISQ includes a wider range of sleep behaviors in the 2 weeks prior to evaluation. This short form of the BISQ evaluates: 1) nocturnal sleep duration (between 7 pm–7 am); 2) daytime sleep duration (between 7 am–7 pm); 3) number of night awakenings; 4) wakefulness during the night hours (10 pm–6 am); 5) nocturnal sleep onset time (the time when the child falls asleep at night); 6) sleeping place; 7) age of the child; 8) sex of the child; and 9) the role of the respondent (who completed the questionnaire).[6] [25] Also, the BISQ is used as a measure for assessing infants' and toddlers' (0–36 months old) sleep patterns and ecology, as well as the parental perception of sleep.[6] The BISQ includes specific questions about infant daytime and nighttime sleep patterns and sleep-related behaviors. Sleeping arrangements, bedtime rituals, and other parental interventions are also assessed in the expanded version of the BISQ. The participants were asked to answer questions about their child's sleep behavior during the previous two weeks. In addition to the BISQ, demographic information was collected, including parental age, education, and employment status, as well as children's birth order. The questionnaire BISQ has been validated by Khaksar et al. in Persian.[26]

Sleep disorder was calculated based on three questions in the infant sleep (IS) scale (IS1, IS4, and IS5). Question IS1: “How many times does your child usually wake up during the night?” If a child woke up more than three times, it was considered as a sleep disorder. In question IS4, they were asked: “How much total time does your child spend sleeping during the night (between the time when your child goes to bed and wakes up for the day)?” In this question, sleeping less than 540 minutes in a 24-hour period was recognized as a sleep disorder. And, finally, in question IS5, they were asked: “How much total time during the night is your child usually awake (between the time when your child goes to bed and wakes up for the day?”). In this question, the child being awake for more than 60 minutes during the night was determined to be a sleep disorder. Sleep disorder was determined for any child who presented the symptoms described in at least one of the above questions (IS1, IS4, and IS5). The descriptive statistics of mean (standard deviation) and frequency (percentage) were used for quantitative and qualitative variables, respectively. Furthermore, the analysis of variance (ANOVA) and Chi-squared test were used to compare the mean and percentage across the age groups. The linear regression analysis was used to determine the risk factors related to infant sleep disorders. A p ≤ 0.05 was considered statistically significant. Data were analyzed using the IBM SPSS Statistics for Windows (IBM Corp., Armonk, NY, USA) version 22.0 software.

 

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Results

Out of 410 infants, 204 (49.8%) were male and 206 (49.7%) were female. Two hundred ninety-six (72.2%) of parent participants were mothers and the remainder were fathers. The demographic characteristics of the study participants are shown in [Table 1]. Two hundred eighty-nine (70.5%) children had at least one of the sleep disorder symptoms described in the 3 questions of the IS scale, including sleeping less than 540 minutes in a period of 24 hours, waking more than 1 hour at night, or waking more than 3 times per night ([Table 2]). The results of [Table 2] show that the highest and lowest percentages for sleep disorders were related to “waking more than 1 hour at night” and “sleeping less than 540 minutes during in 24 hours” with 50 and 23.7%, respectively. Infant sleep scores based on infant's age group showed that the highest and lowest sleep scores belonged to infants 0 to 2 and 6 to 8 months old, respectively ([Fig. 1-a]). It was shown that 68.8% (278) of mothers use breast milk feeding to put the infant back to sleep.

Table 1 Demographic characteristics of the samples studied.

Age (month; mean, SD)	5.14 (3.31)
Sex (freq. %)
Male	204 (49.8)
Female	206 (50.2)
Parent participant (freq. %)
Mother	296 (72.2)
Father	114 (27.8)
Father's job (freq. %)
Employee	129 (31.5)
Worker	50 (12.2)
Freelancer unemployed	220 (53.7)
Unknown	2 (0.5)
	9 (2.2)
Mother's job (freq. %)
Housewife	337 (82.2)
Employee	55 (13.4)
Worker	1 (0.2)
Freelancer	10 (2.4)
Unknown	7 (1.7)
Father's schooling level (freq. %)
High school	54 (13.2)
Diploma	150 (36.6)
Bachelor	154 (37.6)
Master	42 (10.2)
Ph.D.	2 (0.5)
Unknown	8 (2)
Mother's schooling level (freq. %)
High school	44 (10.7)
Diploma	130 (31.7)
Bachelor	189 (46.1)
Master	39 (9.5)
Ph.D.	1 (0.5)
Unknown	7 (1.7)

Abbreviations: SD, standard deviation.

Table 2 Sleep disorder symptom frequency and percentage.

Symptoms of sleep disorder	Frequency	%
Waking more than three times per night	146	35.6
Remaining awake for more than one hour at night	205	50
Sleeping less than 540 minutes in 24 hours	97	23.7
Having at least one of the above symptoms	289	70.5

Fig. 1 (A) Infant sleep score based on infant age groups (months); (B) Waking more than three times at night among infants based on infant age groups (months); (C) Sleeping less than 540 minutes during the 24 hours among infants based on infant age groups (months); (D) Parents' perception scores about infant sleep based on infant age groups (months).

With regard to waking more than three times at night based on infants' age groups, the highest and lowest scores belonged to infants of 9–11 and 0–2 months old, respectively ([Fig. 1-b]). On the other hand, regarding sleeping less than 540 minutes during the 24 hours, the highest and lowest scores belonged to 9 to 11- and 0 to 2-month-old infants, respectively ([Fig. 1-c]). Parents' perception scores regarding infants' sleep revealed that the highest and lowest scores belonged to 9 to 11- and 3 to 5-month-old infants, respectively ([Fig. 1] day-. Regarding parents' behavior scores, the highest and lowest scores belonged to 0 to 2- and 9 to 11-month-old infants, respectively ([Fig. 2]). There were no significant differences between mean hours of infant sleep measures, including nighttime sleep, night awakenings, longest sleep episode, and nocturnal wakefulness between 4 groups of infants based on age (p > 0.05) ([Table 3]). Also, there were no statistically significant differences between the sleep initiation and resuming methods across the studied age groups ([Table 4]). The linear regression analysis showed that factors of age and parent perception significantly affected infant sleep disorders so that for a 1-month increase in infants' age, the sleep condition score is expected to change by −1.04, on average, while controlling the effects of other variables (β = −1.04; 95% C.I; −1.55–0.53). Moreover, for a 1-unit increase in parent perception score, the sleep condition score is expected to change by 0.31 (β = −0.31; 95% CI; 0.24–0.37) ([Table 5]).

Fig. 2 Parents' behavior scores about infants' sleep based on infant age groups (months).

Table 3 Infant sleep measures per infant age groups.

	Age groups (months)
	0–2 n = 107	3–5 n = 104	6–8 n = 112	9–11 n = 85	p-value
	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)
Nighttime sleep (h)	7.95 ± 0.24	8.43 ± 0.22	8.11 ± 0.21	8.51 ± 0.23	0.3
Night waking (h)	0.93 ± 0.11	0.67 ± 0.09	0.82 ± 0.10	0.72 ± 0.11	0.2
Longest sleep episode (h)	4.65 ± 0.26	4.52 ± 0.30	4.47 ± 0.26	4.69 ± 0.31	0.8
Nocturnal wakefulness (h)	2.47 ± 1.38	2.94 ± 1.34	2.92 ± 1.32	2.87 ± 1.17	0.5

Abbreviations: SD, standard deviation.

Table 4 Frequency and percentages of sleep measures per infant age groups.

	0–2 n = 107	3–5 n = 104	6–8 n = 112	9–11 n = 85	p-value
	Freq. (%)	Freq. (%)	Freq. (%)	Freq. (%)
Sleep initiation method
Bottle feeding	72 (67.3)	78 (75.0)	78 (70.3)	70 (82.4)	0.1
Nursing	33 (30.8)	27 (26.0)	30 (26.8)	27 (31.8)	0.7
Watching TV, use/show smartphone/tablet	86 (80.4)	78 (75.0)	90 (80.4)	63 (74.1)	0.5
Put infnat in the crib alone in the room	5 (4.6)	11 (10.5)	12 (10.7)	14 (16.5)	0.06
Put infant in their own bed	12 (11.1)	10 (9.5)	11 (9.8)	7 (8.2)	0.9
Put infant in parents' bed	26 (24.1)	27 (25.7)	25 (22.3)	23 (27.1)	0.8
Bassinet/infant seat	8 (7.4)	4 (3.8)	8 (7.1)	3 (3.5)	0.4
Co-sleeper (attached to parents' bed)	37 (34.3)	37 (35.2)	43 (38.4)	29 (34.1)	0.9
Put infant in parents' room	80 (74.1)	69 (65.7)	67 (59.8)	59 (69.4)	0.1
Put infant in another room of the house	17 (15.7)	24 (22.9)	23 (20.5)	12 (14.1)	0.3
Resuming sleep
Holding or rocking to sleep	81 (77.9)	90 (86.5)	95 (87.2)	73 (85.9)	0.1
Picking up/returning awake	24 (22.4)	18 (17.3)	23 (20.5)	21 (24.7)	0.6
Bottle feeding	33 (30.8)	27 (26.0)	30 (26.8)	27 (31.8)	0.7

Table 5 Results of linear regression analysis related to the effective factors on infant sleep disorders.

Variable	Unstandardized coefficient		Standardized coefficient	95% CI for β		p-value
	β	SD	β	Lower	Upper
Gender (male)	−1.42	1.41	−0.074	−4.21	1.36	0.3
Premature (no)	−6.63	4.67	−0.07	−15.82	2.55	0.1
Family number	−0.26	1.52	−0.009	−3.25	2.72	0.8
Father's job	0.14	0.84	0.01	−1.51	1.81	0.5
Mother's job	0.90	1.27	0.038	−1.59	3.40	0.4
Father's schooling level	−1.57	1.12	−0.09	0.16	−3.78	0.64
Mother's schooling level	1.22	1.09	0.07	−0.91	3.37	0.1
Age (month)	−1.04	0.26	−0.19	−1.55	−0.53	0.001
Parent perception	0.31	0.03	0.42	0.24	0.37	0.001
Parent behavior	0.09	0.06	0.06	−0.04	0.2	0.1
Constant	62.49	6.51

Abbreviations: CI, confidence interval; SD, standard deviation.

 

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Discussion

The current study aimed to determine the parental perception and behavior about infants' sleep in a sleep clinic in Qazvin city. Adequate sleep during infancy plays an important role in a child's growth, development, and overall wellbeing. However, infant sleep disorders are a prevalent issue among families, posing significant challenges for parents. The findings of the present study showed that 70.5% (289) of children had at least one of the sleep disorder symptoms, including sleeping less than 9 hours per night, staying awake for more than 1 hour at night, or waking more than 3 times per night. Various studies have been conducted to determine the percentage of infant sleep disorders, and the results highlight just how widespread these challenges can be. In a study investigating the sleep patterns of 147 children aged 1 to 36 months, it was determined that 33.3% of them had sleep problems.[27] In another study in Indonesia, a total of 493 children were enrolled, and the results showed that 31% of them had experienced sleep problems, and the most common problem was nocturnal sleep duration being less than 9 hours with a 16% prevalence.[11] The high percentage of sleep disorders in the current study may be due to two reasons; first, the children's ages in the current study ranged from 0 to 11 months, while in both above-mentioned studies, the range of children's ages was from 0 to 36 months[28]; and secondly, Iranian mothers typically do not consider the infants' behaviors as symptoms of sleep disorder; therefore, they do not consider sleep disorders as a disease, and they visit the doctor less often to treat them.[29]

Among the sleep disorder symptoms herein studied, staying awake for more than 1 hour at night had the highest percentage, with 50%. These findings are consistent with the results of another study that showed that nocturnal awakening was the most frequent problem.[26] In a study by Retnosari et al., 81.7% of children aged 0 to 36 months had nocturnal awakening. In this study, waking more than 3 times at night was observed in 12.8% of the studied sample.[11] One of the reasons for the high percentage of waking up at night in this study is that the included children were 0 to 11 months old. This group of children was fed with a bottle of breast milk during the night, and this condition caused them to wake up several times.[28] [29] Nevertheless, there was no statistical difference in night awakening based on infants' age groups that included 0 to 2-, 3 to 5-, 6 to 8-, and 9 to 11-month-old infants. Taking that into consideration, by the age of 3 to 4 months, most infants no longer physiologically require nighttime feeding.[30] Some main points should be considered regarding the worsening of sleep disorders among the studied infants at 6 months. First, at this age, anxiety due to separation from parents begins, and the child becomes more dependent on them.[28] [31] This condition causes insomnia and the need for parents to help the child sleep.[28] [31] Secondly, there is no need for nighttime breastfeeding for 6-month-old infants, and they should be weaned gradually. In the Iranian culture, the breastfeeding of infants continues until the age of 1,[32] which is the most common cause of frequent awakenings and lack of self-soothing behavior in children.[14] [32] Third, the use of mobile phones and tablets is one of the main issues at this age. When the infants'/children's visual development improves, the surrounding world becomes more attractive to them, and this will result in poor sleep quality.[33] The education of mothers is a cost-effective intervention that improves the infant's sleep quality. In a study conducted in Australia, a 45-minute consultation was provided for 80 mothers of 6 to 12-month-old infants. In this study, the mothers reported a decrease in the mean number of night awakenings and improved sleep quality.[34] Therefore, it is important to educate mothers about children's sleep health and improve the sleep quality of infants by changing parental behaviors, as sleep disorders and insomnia can continue from infancy to elementary school age and have a significant impact on a child's learning, physical growth, and development.

One of the interesting results of this study is related to the sleep initiation method. Studies have shown that exposure to television before bedtime can disrupt an infant's sleep. The bright lights, fast-paced action, and stimulating content can overstimulate their developing brains, making it harder for them to fall asleep peacefully.[35] [36] In the current study, contrary to the expectations, it was observed that watching TV and using a smartphone or tablet in 9 to 11-month-old infants was lower than other infant age groups including 0 to 2-, 3 to 5-, and 6 to 8-month-olds. One study found that the prevalence of daily use of smartphones increases substantially with age, and it is 51% among 6 to 11-month-old infants.[36] This could be due to a lack of parents' awareness of their effect on children's sleep. It is important to disseminate information to increase awareness about the impact that technology can have on children's sleep. Creating a sleep-friendly environment with minimal exposure to screens before bedtime can help promote healthier sleep patterns and happier babies (and parents).[33]

One of the limitations of the current study is the non-random sampling method. However, given the limited research on infant sleep in Iran and the emphasis placed on addressing this issue and evaluating its significance in our investigation, it is crucial to acknowledge that our study's scope is a strength. However, the fact that our study was performed within an urban setting with literate parents also presents a constraint. Therefore, it is advisable to incorporate a more diverse range of participants in upcoming research endeavors. Subsequently, these challenges can be effectively addressed.

 

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Conclusions

The percentage of infant sleep disorders was rather high among the studied sample. The parental perception and behavior about the infants' sleep was rather low and there were no significant differences in parental perception and behavior about the infants' sleep across the different age groups of infants (0–2, 3–5, 6–8, and 9–11 months old). Therefore, health providers and medical staff need to pay more attention to providing the necessary interventions in this regard.

Given the significance attributed to educating mothers on the subject of their child's sleep patterns and sleep-related ailments, it is advisable to undertake an interventional inquiry in this field. Subsequently, based on the findings, it is suggested that educational initiatives focusing on sleep health and sleep disorders be considered for all mothers within the healthcare system.

 

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Conflict of Interests

There are no conflicts of interest.

Acknowledgment

We would like to extend our sincere thanks to Professor Jodi A. Mindell for her recommendations and guidance as well as for providing the questionnaire.

Authors' Contributions

KK: writing and editing the review, conceptualization, investigation, supervision, and project administration. AR: writing the original draft, writing and editing the review, conceptualization, software, data collection, methodology, supervision, and formal analysis. IMZ: writing and editing the review, software, and methodology. SS: writing and editing the review, software, and methodology. All the authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript.

Institutional Review Board Statement

All the experiments were performed in accordance with the relevant guidelines and regulations (such as the Declaration of Helsinki). The questionnaire used in this study was designed and implemented strictly with ethical principles and guidelines to ensure the wellbeing, privacy, and rights of all the participants involved. Data collection was performed after the approval of the Ethics Committee and obtaining informed consent from the patients' parents. The study was approved by the Ethics Committee of Qazvin University of Medical Sciences under code IR.QUMS.REC.1399.152.

Data Availability Statement

Data can be accessed by contacting the authors of the manuscript.

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Publikationsverlauf

Eingereicht: 25. Februar 2024

Angenommen: 20. September 2024

Artikel online veröffentlicht:
26. Juni 2025