Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Sleep Patterns
Teresa Pinilla and Leann L. Birch
Pediatrics 1993;91;436
The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pediatrics.aappublications.org/content/91/2/436
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright 1993 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 0031-4005. Online ISSN: 1098-4275.
ABSTRACT. The study objective was to investigate is still relatively young, the disruption caused by an
whether exclusively breast-fed infants could be taught to infant whose sleep/wake schedules are not synchro-
sleep through the night (defined from 12:00 AM to 5:00 AM) nized with those of the parents is an issue of very
during the first 8 weeks of life. The design was short- high priority within the household
term longitudinal, from the last trimester of pregnancy
Despite the widely recognized advantages of hu-
until the eighth week after birth. Twenty-six first-time
man milk for the young infant,23 mothers in the
parents and their newborn were randomly assigned to
treatment and control groups (13 in each group). Treat- United States are discontinuing breast-feeding for a
ment parents were instructed to offer a focal feed (be- variety of reasons. While the incidence of lactation
tween 10 PM and 12 AM) to their infants every night, to has been increasing over the past three decades in the
gradually lengthen intervals between middle-of-the- United States,34 duration of lactation is still below
night feeds by carrying out alternative caretaking behav- the recommended goal of at least 6 months.56 Rea-
iors (eg, reswaddling, diapering, walking), and to maxi- sons for the discontinuation of breast-feeding include
mize environmental differences between day and returning to work,7 lack of support for breast-feed-
nighttime. All parents kept 72-hour diaries of their in-
ing, or maternal beliefs about breast-feeding.8 Breast-
fants feeding and sleeping patterns every week from
fed infants feed more frequently and have shorter
birth to 8 weeks of age and rated their infants tempera-
ment at birth and at 8 weeks. By 3 weeks, treatment
intermeal intervals, and this pattern is sustained
infants showed significantly longer sleep episodes at around the clock.9 The mothers need for an unin-
night. By 8 weeks 100% of treatment infants were sleep- terrupted nights sleep may be promoting the early
ing through the night compared to 23% of control infants. cessation of breast-feeding. Breast-feeding mothers,
Treatment infants were feeding less frequently at night comparing the sleep behaviors of their infants with
but compensated for the relatively long nighttime inter- those of formula-fed infants, may develop beliefs of
val without a feed by consuming more milk in the early personal inadequacy in mothering. Wide differences
morning. Milk intake for 24-hour periods did not differ
in sleep patterns between breast-fed and bottle-fed
between groups. Treatment infants were rated as more
infants have been noted in the literature; in particu-
predictable on Bates Infant Characteristics Question-
naire. It is concluded that parents can have a powerful lar, breast-fed infants have typically been observed to
influence on the development of their infants sleep pat- begin sleeping through the night (settling) at a later
terns. Frequent night waking in breast-fed infants often age than bottle-fed infants and to be frequent night
results in early termination of lactation. Parents can teach wakers,1116 so breast-feeding mothers may be
their breast-fed infants to lengthen their nighttime sleep tempted to change their feeding regimen in order to
bouts, making the continuation of breast-feeding easier get their infants to sleep through the night. Even in
for the new mother. Pediatrics 1993;91:436-444; breast- the popular press, sleeping through the night at an
I eeding, sleep patterns, behavioral entrainment, tempera-
earlier age is quoted as one of the advantages of
ment.
formula-feeding.17
Developmental factors, including biological/
ABBREVIATION. ANOVA, analysis of variance. neurological and maturational processes, are crucial
in the formation of sleep/wake cycles in infancy. The
Sleeping through the night has been assumed to be type of environment that parents provide can affect
the infants sleep patterns. Bedtime routines and/or
an early developmental milestone, governed primar-
ily by maturational factors. Relatively little attention the way parents respond in the middle of the night to
has been given to the hypothesis that the point at their crying infant can interfere with the formation of
which sleeping through the night begins can be in- diurnal sleep/wake cycles.12#{176} Finally, the infants
fluenced by environmental factors. Especially in in- temperament makes unique contributions to the de-
dustrialized, Western societies where mothers need velopment of sleep/wake routines. Several investi-
to return to work outside the home while the infant gators have observed a relationship between infant
temperament characteristics and nighttime sleep dis-
From the Division of Human Development and Family Studies, University turbances. Associations between low sensory thresh-
of Illinois at Urbana-Champaign. old14 and difficult temperament ratings224 and
Received for publication Jun 18, 1992; accepted Oct 7, 1992. night waking problems have been reported. The
Reprint requests to (L.L.B.) Dept of Human Development and Family Stud-
problem with these studies is that parents were
ies, The Pennsylvania State University, 110 Henderson Bldg. South, Univer-
asked to rate their perceptions of their infants tem-
sity Park, PA 16802.
PEDIATRICS (ISSN 0031 4005). Copyright 1993 by the American Acad- perament once sleep disturbances were an estab-
emy of Pediatrics. lished difficulty. Parents perceptions may have been
ents of 2-month-old infants reported that their chil- treatment or the control group was done prenatally when the sex
of the infant was not known, it was not possible to balance the
dren slept through the night, but when the infants groups by sex. In the treatment group there were eight girls and
sleep was recorded on time-lapse videotape, only five boys, while in the control group there were six girls and seven
15% actually slept through the night without boys.
awakening.228 Most infants are able to return to
Procedure
sleep on their own without their parents knowledge
that they had awakened. During the last trimester of pregnancy, parents in the treatment
group were given verbal and written instructions on how to teach
We investigated the effects of a behavioral training
their infants to sleep through the night. All couples were asked to
program focused on facilitating the breast-fed in- contact the researcher once their infants were born, within the first
fants transition to sleeping through the night. The 4 days after the birth. Once the infants were born, parents pro-
primary aim of this study was to compare the sleep- vided information on their infants births. Parents kept weekly
ing and feeding patterns of two groups of exclusively diaries of the infants feeding and sleeping patterns for 72 consec-
utive hours from birth until the infant was 8 weeks old. The
breast-fed infants from birth to 8 weeks of age. Half researcher visited the parents every week for 8 weeks after the
of the infants parents in the study received specific infants birth to pick up completed feeding and sleeping diaries.
instructions designed to facilitate sleeping through Problems that arose in the course of the study were also discussed
the night; the other half received no instructions. A in these meetings, as were the instructions for teaching the infants
in the treatment group to sleep through the night. The weekly
secondary aim was to compare temperament ratings
visits were scheduled on the same day every week. Parents were
of infants who were taught to sleep through the night instructed to begin keeping the diaries on the same evening of the
to ratings of those who were not. Parents whose in- visit. With the exception of the training instructions, contact with
fants slept through the night were expected to rate both groups was identical. The training instructions, described
below, consisted of two parts, one to be carried out as soon as the
their infants temperament more favorably than par-
mother returned home from the hospital, the other when the infant
ents whose infants continued to awaken. had met the following criteria: (1) was 3 weeks old, (2) was in good
health, and (3) was steadily gaining weight. Parents in the control
METHOD group were offered the same information on teaching their infants
The present experiment focused on breast-fed infants sleeping to sleep through the night at the end of the 8-week period.
and feeding patterns. Half of the infants parents were randomly Test-Weighing Procedure. The researcher visited the parents at
assigned to a treatment condition that focused on behavioral tech- their home within the first 4 days after the birth of the infant and
niques aimed at facilitating young infants transition to sleeping delivered an electronic pediatric scale (Acme model 30 infant
through the night from an early age; the other half were assigned scale, Acme Corp, San Leandro, CA), accurate to 2.8 g (0.1 oz),
to a control condition. All parents completed 72-hour dietary- which was used to determine the volume of the infants feeding.
activity diaries of the infants feeding and sleeping patterns each At this time each mother was trained on an individual basis on the
week from birth to 8 weeks of age and completed a revised version test weighing procedure, which involves weighing the infant im-
of Bates Infant Characteristics Questionnaire9 when the infants mediately before and after a feeding. The difference between pre-
were I and 8 weeks of age. The study was approved by the feeding and postfeeding weights was taken as the volume of the
Institutional Review Board of the University of Illinois.
Downloaded from pediatrics.aappublications.org by Harvey Karp on August 10, 2011 ARTICLES 437
feed. Several test trials were performed until the mother mastered time of data collection, no temperament instrument existed for use
the technique consistently. This protocol to determine volume of with newborns. The original version was designed for 6-month-
feeding has been extensively used in other studies31-32 and is con- old infants, and only the items that were relevant to a newborn
sidered an accurate index of human milk intake.33- were left in the questionnaire. Parents were asked to rate their
Infant Feeding and Sleeping Patterns. The infants sleep/wake infants on 17 aspects of the infants behavior, using a 7-point
and feeding patterns were recorded on the dietary-activity diaries. Likert-type scale. Both parents rated the infant when the infant
The record itself consisted of a 24-hour chart on which the parent was I and 8 weeks of age. Four clusters of scores were formed
shaded in the periods of time when the infant was asleep, left according to the authors coding instructions. These are used to
blank the periods of time when the infant was awake, and used a categorize different dimensions of infant temperament as follows:
symbol (the letter F) to designate the times when the infant was easy-difficult, unadaptabiity, unpredictability, and dullness. A
fed. Immediately under the chart were two blank lines labeled fifth dimension was included; it consisted of a single question
prefeeding weight and postfeeding weight. On these lines, about the infants ability to self-soothe and was based on previous
and exactly below the time block on which the parent had marked work on infant temperament.35 This item was analyzed separately
that a feed occurred, the parent recorded the corresponding in relation to the feeding and sleeping variables.
weights of the infant before and after the feeding.
The diaries were adapted from similar ones used by Ferber8 RESULTS
and from Wolfson,2#{176} who used them to determine the effects of
parent training on infant sleep patterns. Similar diaries have been The principal question was whether the onset of
used in other studies.1326-27 These 24-hour diaries kept by parents sleeping through the night (defined as the period
were found to be highly reliable (over 90%) when compared with
from midnight to 5:00 s) could be facilitated among
time-lapse video recordings of the infants sleep patterns for the
exclusively breast-fed infants. Concomitant differ-
same day.26-27 From the dietary activity diaries, several measures
were calculated for statistical analyses: (1) total sleep; (2) longest ences in feeding patterns were evaluated. Finally, dif-
sleep episode; (3) average length of sleep per episode; (4) volume ferences in temperament ratings were assessed be-
of each feed; and (5) time of feeding. These were coded and ana- tween infants who slept and infants who did not
lyzed for each 24-hour period and for a nighttime period defined
sleep through the night.
between midnight and 5:00 i.
The information the parents recorded on these forms was coded
by five research assistants, who transcribed it for quantitative Parent Training Effects
analysis. All coders were blind to experimental condition and
To determine the effect of the training procedures
sex of the infant. There was a principal research assistant who
coded all the diaries once; then four other research assistants
on infant sleep as the infant matured over the first 8
shared the responsibility of recoding and checking the information weeks of life for 24 hours and the nighttime periods,
transcribed by the first coder. All coders worked individually and repeated-measures analyses of variance (ANOVAs)
independently on the diaries, and all 624 diaries (26 subjects X 8 were conducted on the sleep variables. The mean for
weeks x 3 days = 624) were coded twice. Reliability among the
the 72 hours of data recorded by the parents on the
five coders was estimated by the percent of agreements between
the principal coder and the four assistants who recoded the data. diaries was taken for each infant at each week sepa-
The percent of agreements ranged from 94% to 100%, and the rately.
mean was 98% for all variables derived from the diaries.
Nighttime Period. Figure 1 shows the sleep patterns
Parent Training Protocol. At the prebirth home visit, the re-
during the nighttime period (midnight to 5:00 ri) for
searcher presented treatment group parents with the material on
helping infants to sleep through the night. This consisted of a infants in treatment and control groups over the first
two-page handout with instructions for the parents on how to 8 weeks of life. From birth to week 3, treatment and
respond to the infants signals and the establishment of a focal feed: control infants were comparable on all sleep van-
a scheduled feed between 10:00 PM and midnight, from the first
ables, but treatment infants were sleeping more and
few days after birth. The researcher reviewed the instructions on
the handout with the parents at this time and gave a brief back-
sustaining longer sleep bouts thereafter. For example,
ground on the research from which these were derived. The focus at week 1, longest sleep bouts were comparable for
was placed on getting the infant to start on the right track2#{176} and treatment and control infants: 3 hours 8 minutes and
consisted of preparatory steps that parents could take before ac- 2 hours 53 minutes, respectively, but were signifi-
tually training their infants to sleep through the night. The parents
cantly different by week 8: 4 hours 50 minutes com-
were instructed to try not to hold, rock, or nurse their infants to
sleep, to accentuate differences in environmental cues for day and pared to 3 hours 42 minutes. The sleep variables were
nighttime hours (eg, high levels of stimulation during the day but analyzed by repeated-measures ANOVAs, and in-
low during the night), to feed the infant at a focal feeding time fants sleep patterns were significantly affected by
each night (between 10:00 PM and midnight), and to make sure the
the interventions: total sleep F(l,24) = 16.82, P < .01;
infant was really complaining before picking him or her up (the
difference between crying and whimpering was discussed). average duration of sleep bout F(1,24) = 22.45, P <
At the first home visit after the infants birth, the researcher .01; and longest sleep episode F(1,24) = 24.29, P < .01.
discussed the training instructions with the parents once more, There was a corresponding age effect as the sleep
highlighting the main points. When the infant was 3 weeks old
patterns of infants in both groups matured from birth
and had met the specified criteria described earlier indicating
adequate growth, parents began the second part of the program. to 8 weeks (P < .01). The interaction of age by group
This consisted of lengthening the latency to feeding time in the was significant for all of the sleep variables, except
middle of the night (between midnight and 5:00 AM) by following mean total sleep (P < .01), showing that age effects
a step-by-step procedure. Parents were instructed not to leave the were less pronounced for the control than for the
infant alone crying; rather, alternative interventions were encour-
aged: reswaddling, patting, diapering, or walking the infant in lieu
treatment group.
of feeding. If, after these interventions, the infant continued to cry, Week by week univariate ANOVAs revealed that
then a feed was offered. The goal was to stretch nighttime feed- at weeks I and 2 there were no differences in the
ing intervals by breaking the association between awakening at
sleep variables between the treatment and control
night and being fed. The weekly home visits allowed the re-
groups. At week 3 (and thereafter), infants in the
searcher to reinforce the parents who might experience difficulties
and to make sure they were following the protocol consistently. treatment group showed longer mean total sleep,
Infant Temperament Measure. An adapted version of Bates In- longer duration of sleep per episode, and greater
fant Characteristics Questionnaire was used in this study. At the longest sleep episode.
Downloaded from pediatrics.aappublications.org by Harvey Karp on August 10, 2011 ARTICLES 439
week 1 week 5
10
.E
0
.I I
2j
_ _ r1
I
0 FFNFP .
. pp NW pp NFl
Tr.ent c00t0g Tiestm.id Control
week 6
week 2 12
12
PP NW
1:::::::::.::::::::.::::::: :
0
0
4
10
8-
- - 1OJ1
a 6
0
4
10
. if NW . pp NFl . pp NW if NW
T1SgiURI6 Control TronIniont Cougiol
week 4 week 8
121 1
io.I:
8i
I -I
. pp NFP . FF NW
Tr.Mmeig Ca6i
PP NIP . F? hei
g
tribution of offering a focal feed on the infants sleep for infants in the treatment group, showing that meal
status could be analyzed, given the presence of such size was increased as the interval between feeds in
feeds among control infants. The results showed that the middle of the night increased. A repeated-meas-
focal feed alone was not enough to modify sleep ures ANOVA was conducted with group as the be-
status (P > .05). tween-subjects factor (two levels), and both age
(eight levels) and time of day (six levels) as the re-
Diurnal Variations in Feeding Patterns peated measures. Results showed no significant
To determine whether patterns of human milk in- group main effect (P > .05), but both significant age
take differed for the two groups, intake data were and time of day main effects (P < .0001), reflecting
divided into six discrete 4-hour periods as follows: the maturational factor on one hand and the diurnal
2:00 6:00 10:00 2:00 PM, 6:00 PM, and 10:00 variations of human milk intake on the other. There
PM. If a feed was recorded between midnight and 4:00 were significant interaction effects between age X
AM, then it was included in the 2:00 ri average; if a time, time X group (P < .0001); the latter reflects that
feed was recorded between 4:00 us and 8:00 i, then differences in milk intake between treatment and
it was included in the 6:00 ivi period. Figure 3 shows control infants varied according to time of the day.
the daily patterns of human milk intake for each The three-way interaction age X time X group was
period of the day, from week 1 through week 8, for also significant. As shown in Table 2, across weeks,
infants in the treatment and control groups. The 6:00 the development of diurnal patterns in volume of
AM feed progressively increased as a function of time feedings differed for treatment and control infants.
130
120 120
I) C 110
E 100 100
C
90
80 80
70
2am Born lOam 2pm 6pm 10pm 2am 6am lOsm 2pm 6pm i Opm
week 6
week 2
140 140
130 130
120 120
C 110 C 110
100 100
90 90
80 80
70 70
Fig 3. Volume of human milk intake
60 80
(grams) (mean, SEM) for infants in lam 6am lOam 2pm 6pm 10pm
2sm 6am loam 2pm 8pm 10pm
treatment (El]) and control () groups
for six discrete periods of the day over
the first 8 weeks of life. *No treatment
week 3 week 7
infants received a feed at this time. 140 140
130 130
120 120
It 110 C 110
100
L1PA:i\Fc4 90
80
70
60
2am 6am lOam 2pm 6pm 10pm 2am 6am 1 Oam 2pm 6pm I Opm
week 4 week 8
140 140
130 130
120 120
0 110 C 110
100 100
0I 90 90
80 80
70 70
60 60
2am 6am lOam 2pm 6pm 10pm 2am Sam 1 Oam 2pm 6pm 1 Opm
Volume of intake per feed, per day, and per kilo- DISCUSSION
gram of body weight per day were comparable for The results of this study show that, from birth,
infants in the two groups. Similarly, weekly weight parents play a very important role in the develop-
and weight gain were not affected by the experimen- ment of their infants sleep patterns. Through a be-
tal manipulations. These variables were comparable havioral training program, parents were able to fa-
for male and female infants. ciitate the onset of sleeping through the night and to
Downloaded from pediatrics.aappublications.org by Harvey Karp on August 10, 2011 ARTICLES 441
TABLE 3. Infant Temperature Questionnaire Ratings: Treat- The techniques used in this study have been used
ment and Control Pa rents (mean, SEM)
in previous research, as interventions later in infancy
Dimension Treatment Control when parents report that their childrens sleep pat-
Mothers Fathers Mothers Fathers
terns have become problematic. A study conducted
by Schaefer similarly demonstrates that a combina-
Difficultness
tion of interventions such as teaching the infant to
Week 1 19.5 19.8 19.7 19.7
(0.9) (1.4) (1.2) (1.1) fall asleep without external help, reducing or elimi-
Week 8 19.9 19.8 20.3 20.3 nating unnecessary nighttime feedings, and forming
(1.9) (1.7) (1.8) (1.8) a stable sleep-wake cycle is successful in reducing
Unadaptability night waking in older infants and toddlers. Sleep
Week I 3.2 3.3 2.8 2.9
disturbances in the first and second year of life have
(0.4) (0.4) (0.4) (0.3)
Week 8 2.7 3.8 2.4 3.4
been associated with frequent nighttime feeding and
(0.4) (0.8) (0.4) (0.9) increased crying before falling asleep.37
Unpredictability* Significant differences in sleeping through the
Week I 5.6 5.9 7.6 7.4 night emerged as early as 3 weeks, indicating that
(0.6) (0.5) (0.7) (0.7)
behavioral entrainment of sleep can occur this early.
Week 8 4.9 5.8 5.1 6.9
(0.6) (0.7) (0.7) (0.6) Moreover, a developmental shift in sleep patterns
Dullnesst emerged spontaneously among infants in the control
Week 1 4.5 4.5 3.8 4.5 group when they were exactly 6 weeks of age, they
(0.4) 0.3) (0.3) (0.6) showed a dramatic increase in their ability to sustain
Week 8 5.3 4.8 4.9 4.9
longer sleep bouts and to awaken less frequently at
(0.4) (0.3) (0.3) (0.4)
Self-soothing
night (see Fig 1). Because of the longitudinal design
Week I 3.9 4.0 4.5 4.0 of this experiment, these developmental changes in
(0.5) (0.3) (0.4) (0.3) spontaneous sleep behaviors of young infants could
Week 8 4.2 4.2 4.3 4.4 be observed on a weekly basis. The literature on the
(0.2) (0.4) (0.3) (0.4)
development of infant sleep patterns does not refer
* Group main effect, P < .05.
to this particular and noteworthy change that occurs
t Time main effect, P < .05.
spontaneously among breast-fed infants around the
sixth week of life.
With respect to settling age, Woifson2#{176} reported
modify their infants sleep-wake schedules, reducing that many parents in her study noticed that their
night waking from a very early age. At 4 weeks, 38% infants were sleeping through the night spontane-
of infants in the treatment group were sleeping ously by 8 weeks. Wolfson suggested that the focal
through the night, compared with 7% of control in- feed and the use of the sleep charts alone may have
fants. By 8 weeks, all infants whose parents received been sufficient to have an impact on the infants
training instructions were sleeping through the sleep/wake development. Other researchers have
night, compared with only 23% in the control group. also observed improvements in night waking behav-
Sleep patterns changed as a function of normal de- ions in infants with the use of sleep charts alone.3839
velopment and maturation for all infants in the This suggests that the differences between treatment
study; all infants were able to sustain longer sleep and control infants may have been underestimated in
episodes as they matured. However, the results re- this research because even the control parents had
vealed the parents role in establishing a diurnal or- the benefit of keeping the diaries. It is possible that
ganization of their infants sleep/wake cycles. the use of sleep diaries affected the development of
nighttime sleep by increasing all participating par-
Sleeping Through the Night ents awareness of both the childs and their own
The onset of sleeping through the night occurs behaviors with respect to the development of sleep/
later and the frequency of night waking is higher wake patterns. However, our results indicate that
among breast-fed compared with bottle-fed in- sleep diaries alone, and, in fact, sleep diaries plus
fants.9116 This suggests that (1) breast-fed infants focal feeding, were not sufficient to facilitate sleeping
may be more prone to develop sleep problems in through the night to the extent seen in the treatment
infancy and (2) breast-feeding, despite being optimal group. It is evident that offering a focal feed alone is
for the infant, may be discontinued because of the not enough for the infant to make the transition to
frequent and continued night waking of the infant to sleeping through the night; in fact, a sizable propor-
feed and the consequent lack of sleep for the mother. tion of the families in the treatment group did not
The results of this study show that breast-feeding follow the instructions to focal feed. The gradual
need not be associated with night waking, that stretching of the nighttime feedings and the environ-
breast-fed infants can be behaviorally entrained to mental distinctions between nighttime and daytime
sleep through the night, and that continued lactation activities appeared to be influential for the transition
can be compatible with the mothers sleep/wake pat- to sleeping through the night. Moreover, sleeping
terns. The total amount of sleep per day was compa- through the night was facilitated at a very early age.
rable for the two groups at all points in development, Despite the high reliability previously reported for
indicating that the normal sleep requirements of the the use of sleep diaries1328 and the high intercoder
infants in the treatment group were not altered by the reliability reported in the present study (average
experimental interventions. 98%), a more thorough assessment would have been
perament as more predictable. Even at I week, treat- 17. Cheny SH. Deciding whether to breast-feed. Parents. September
1991:175-176
ment parents rated their infants as more predictable
18. Ferber R. Solve Your Childs Sleep Problems. New York, NY: Simon and
than control parents. It is possible that parental per- Schuster; 1985
ceptions were modified by the expectation that their 19. Cuthbertson J, Schevill S. Helping Your Child Sleep Through the Night.
infants would be sleeping through the night from a New York, NY: Doubleday; 1985
very early age, or that the infants already differed. 20. Wolfson AR. The Effects of Parent Training on the Development of Infant
Sleeping Patterns. St Louis, MO: Washington University; 1987. Unpub-
lished doctoral dissertation
CONCLUSIONS/IMPLICATIONS
21. Weissbluth M. Sleep duration and infant temperament. I Pediatr.
Although breast-feeding is typically associated 1981;99:817-819
with frequent and continued night waking and later 22. Schaefer CE, Lachman ME. Personality change during the transition to
settling, this research indicates that continued parenthood: the role of perceived infant temperament. Dev Psychol.
1985;21:558-567
night waking is not a necessary component of breast-
23. Jimmerson KR. Maternal, environmental, and temperamental charac-
feeding. Additional research is needed to determine teristics of toddlers with and toddlers without sleep problems. I Pediatr
which components of the training procedure are re- Health Care. 19915:71-77
sponsible for the treatment effects; keeping elaborate 24. Keener MA, Zeanah CH, Anders IF. Infant temperament, sleep organi-
Downloaded from pediatrics.aappublications.org by Harvey Karp on August 10, 2011 ARTICLES 443
zation, and nighttime parental interventions. Pediatrics. 1988;81 :762-771 infants: relationship between feeding size and interval. Dev Psychobiol.
25. Anders T. Maturation of sleep patterns in the newborn. In: Weitzman E, 1990;23:511-518
ed. Advances in Sleep Research. New York, NY: Spectrum Publications; 33. Woolridge MW, Butte N, Dewey KG, Ferris AM, Garza C, Keller RP.
1975;2:43-66 Methods for the measurement of milk volume intake of the breast-fed
26. Anders TF, Keener M. Developmental course of nighttime sleep-wake infant. In: Jensen RG, Neville MC, eds. Human Lactation. New York, NY:
patterns in full-term and premature infants during the first year of life. Plenum Press; 1985:5-21
Sleep. 1985;8:173-192 34. Whitfield MF, Kay R, Stevens S. Validity of routine clinical test weighing
27. Anders TF. Night waking in infants during the first year of life. Pediat- as a measure of the intake of breast-fed infants. Arch Dis Child.
rics. 1979;63:860-864 1981;56:919-921
28. Paret I. Night waking and its relation to mother-infant interaction in 35. Rothbart MK. Social development. In: Hanson MJ, ed. Atypical Infant
nine month-old infants. In: Call J, Galeson E, Tyson RL, eds. Frontiers of Development. Baltimore, MD: University Park Press; 1984:207-236
Infant Psychiatry. New York, NY: Basic Books; 1983;171-177 36. Schaefer CE. Treatment of night wakings in early childhood: mainte-
29. Bates JE. Infant Characteristics Questionnaire. 1978 nance of effects. Percept Mot Skills. 1990;70:561-562
30. Pinilla T, Birch LL Diurnal feeding patterns of human milk-fed infants 37. Tassel EB. The relative influence of child and environmental character-
at 4 and 8 weeks. Urbana, IL: University of Illinois at Urbana-Cham- istics on sleep disturbances in the first and second years of life. Dcv
paign, Division of Human Development and Family Studies; 1990. Un- Be/nv Pediatr. 1985;6:81-86
published manuscript 38. Largo RH, Hunziker UA. A developmental approach to the manage-
31 . Janas LM, Picciano MF, Hatch TF. Indices of protein metabolism in term ment of children with sleep disturbances in the first three years of life.
infants fed either human milk or formula with reduced protein concen- Eur J Pediatr.1984;142:170-173
tration and various whey/casein ratios. J Pediatr. 1987;110:828-848 39. Inglis S. The nocturnal frustration of sleep disturbance. Am Mat Child
32. Matheny R, Birch LL, Picciano ME Control of intake by human milk-fed Nurs. 1976;1 :280-287
Aequitron Medical challenges class action suit involving apnea monitor (Press Release). Aequitron
Medical, Inc.; December 16, 1991.
Noted by J.F.L., MD
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright 1993 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
Online ISSN: 1098-4275.