Sleep is as essential part of our health, development, growth, and well-being.

“Sleep is the single most effective thing we can do to reset our brain and body health each day — Mother Nature’s best effort yet at contra-death.” Matthew Walker, Why We Sleep: Unlocking the Power of Sleep and Dreams

Sleep is essential to support our:

  • Rest and recovery: Sleep provides time for repair and rejuvenation of cells and tissues.
  • Brain function: sleep supports memory consolidation, learning and problem solving.
  • Emotional well-being: Sleep impacts massively on our mood, you all know how you feel and action when you have not had enough sleep.
  • Physical health: sleep regulates our hormones and helps our immune system function. Lack of sleep is known to put you at greater risk of developing heart disease, obesity and diabetes.

Florence Nightingale recognised the importance of sleep to heal and recover. During the Crimean War, Nightingale noticed that soldiers who were provided with adequate sleep, improved much quicker than those who were sleep deprived. She recognised the importance of creating a calm, healing sensory environment for all to rest and recover.

Nightingale was ahead of her time, she also highlighted the need to look after the workforce, if they were to provide the best care for her patients. She advocated for nurses to be given sufficient rest and downtime to ensure they were not sleep deprived, therefore improving their ability to function in highly traumatic environments.

Unfortunately, the importance of sleep is often overlooked into days hospital practice. Colleagues are often asked to flit between day shift and night shift, without recognising the impact of sleep deprivation on staff.

Furthermore, supporting sleep for infants, families and colleagues in neonatal and hospital settings has its challenges.

Strategies to support sleep in a hospital setting.

  • Protected time: consider having protected time where patients know they will not be disturbed by staff or visitors.
  • Try to keep noise levels down in hospital: in the neonatal unit, staff are encouraged to speak at 45 DB and below, this is probably helpful throughout the hospital if we are to embed the work of Florence Nightingale and recognise the importance of sleep.
  • Encourage natural light rather than bright overhead lights, the constant flicker of the overhead light, is very draining for both patient, families, and staff.
  • Medication: wherever possible medication and procedures should be scheduled to support sleep cycles.
  • Comfortable sleeping environment: pillow and duvet that smells of home will help support sleep. It is essential in neonatal and paediatric care that there is a chair or bed to sleep on next to the baby/child. In neonatal and newborn care, a comfortable sleep environment is in skin-to-skin contact on their parents.
  • Other supportive sleep practices include supporting relaxation groups, meditation, mindfulness.

Newborn babies and sleep

Wolff (1959) identified 5 awake and sleep states. Brazelton (1973) classified 6 behavioural states:

  • State one: deep sleep
  • State two: light sleep
  • State three: drowsy
  • State four: quiet alert
  • State five: active alert
  • State six: crying

He observed how some infants moved with ease from one state to the next, whereas others required maximum support from their parents to assist with co-regulation and smooth transition between states.

A newborn baby will spend large amounts of their day asleep. Spending anything from 12-20 hours asleep. 50% of their sleep will be light sleep and 50% of their sleep deep sleep. This ratio will gradually change as they grow and develop until deep sleep accounts for 80% of the sleep cycle. They may experience around 20 minutes of quiet alert state scattered throughout the day.

Parents use the sensory environment to help co-regulate their baby into sleep and awake states.

  • During first few weeks the infant is often held in skin-to-skin contact on the parents. This multi-sensory experience of all eight senses helps the newborn adjust to the sensory stimulating world.
  • Parents might introduce baby wearing, the slow vestibular input can help the infant feel safe and secure.
  • The newborn has been able to recognise the difference between mother and father voice from as early as 28 weeks’ gestation and maternal voice is the primary sound they are used to.
  • Singing songs and reading books can help a newborn settle.
  • Parents often learn very quickly that having something that smells of them in the baby’s bed space helps the infant settle.

Safe Sleep

The Lullaby Trust is a UK-based charity that provides advice and support for safe sleep practices to reduce the risk of sudden infant death syndrome (SIDS). Safe sleep practices identified by the Lullaby Trust include the following:

  • Back to Sleep: Always place babies on their back to sleep, both for naps and night-time sleep, until they are 1 year old.
  • Firm Sleep Surface: Babies should be placed on a firm and flat sleep surface, such as a crib or bassinet, covered with a fitted sheet. Soft surfaces, such as sofas, chairs, and waterbeds, should never be used for sleep.
  • Room Sharing: The Lullaby Trust recommends that babies sleep in the same room as their parents or caregivers for the first 6-12 months of life, but not in the same bed.
  • Keep It Clear: The sleep environment should be kept clear of any soft objects, loose bedding, or toys, which can pose a suffocation risk. A sleep sack or wearable blanket can be used to keep babies warm.
  • Avoid Overheating: Babies should be dressed appropriately for the room temperature, and overheating should be avoided. The ideal room temperature for a baby’s sleep is between 16-20°C.
  • No Smoking: Parents and caregivers should never smoke around a baby or expose them to second-hand smoke, as it increases the risk of SIDS.
  • Breastfeeding: Breastfeeding can help reduce the risk of SIDS and is encouraged for all babies, if possible.

Preterm infant and the neonatal unit

The importance of sleep for the preterm infant for energy conservation, growth and healing is widely acknowledged and is a critically part of developmental care. (Salisbury and Kolberg, 2023)

Developmental sequence of sleep for preterm infant.

  • 24-27 weeks: Predominately undifferentiated states. At first what looks like sleep is not a true sleep state and it is called indeterminate or intermediate sleep.
  • 28-30 weeks: REM sleep emerges.
  • 32 weeks: Differentiation of quiet and active asleep (REM sleep is very important for CNS organisation and sensory development, it is in REM sleep that ocular dominance columns for the visual cortex develop) During Active sleep the brain generates activity that stimulate sensory systems development. It is also during sleep that experiences are processed and stored as memories. It is often thought that as babies look more active in active awake states that this means it is OK to wake them up, but this is not the case. Active sleep needs to be protected because it is so important for the brain.
  • 34 weeks: increasingly robust sleep states
  • 36 weeks to term: clearly identifiable sleep and wake states

Recommendations to support sleep in the neonatal unit

“Sleep organisation in the newborn has been related to developmental outcomes and may be shaped by early interactions between infant and the physical and caregiving environment.” Graven S, Brown J 2009)

  • Skin to skin contact, the best place for an infant to grow is in the loving arms of their parents.
  • Consider cycled lighting to promote circadian rhythms.
  • Recognise infant sleep and wake states, look at duration, quality and transitions and adopt a cue-based approach to care guided by the infant’s readiness for interaction.
  • Reduce stress and pain.
  • Support comfort and postural development while sleeping. Sleeping in a position that supports flexion, comfort and alignment is needed for good quality sleep.
  • Create a healing environment to promote sleep development (although protected time can be a lovely concept to support parent infant interaction, it is essential that we have quiet time for 24 hours as an infant’s brain is continually growing.)
  • As the infant preparest to go home it is important that the family have been provided with information about safe sleep practice.

Sleep is important for all of us, every night we return to a ‘womb-like’ space to rest and recover. The sensory qualities are dark, quiet, warm, flexed, tucked. When looking to promote sleep for families, staff, children or infants, think about creating womb like spaces.

“We are such stuff as dreams are made on; and our little life is rounded with a sleep.” — William Shakespeare

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