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Clinical Guidelines (Nursing)

Neonatal sleep maximisation in the hospital environment

  • Introduction

    Aim

    Definition of terms

    Assessment

    Management

    Family Centred Care

    Documentation

    Evidence Table

    References

    Introduction

    • Optimal sleep is essential to normal growth and development and aids recovery.
    • There is increasing awareness that sleep has a role in the development and function of the brain.
    • Sleep deprivation may have a negative impact on the health and development of the newborn and lowers the threshold for pain.

    Aim

    This guideline provides an outline for medical, nursing and allied health staff to maximise the total hours of sleep per day for neonates in the hospital environment.  The guideline will aim to provide advice on:

    • Supporting completion of sleep cycles
    • Cycling lighting to reflect day and night
    • Facilitating quiet time
    • Providing assistance with settling if required
    • Promoting normal growth and development
    • Supporting recovery
    • Neonatal sleep physiology to increase caregiver understanding

    Definition of Terms

    • Neonate:    An infant less than 28 days old.
    • Active sleep:  Active sleep is analogous to rapid eye movement (REM) sleep in adults. This state involves REM underneath closed eyelids along with uneven respiration, muscle atonia and increased myoclonic jerks when compared to adults.
    • Quiet sleep:  Quiet sleep is equivalent to non-REM sleep in adults. This state involves no eye movement underneath closed eyelids, regular respiration and stillness.
    • Indeterminate (transitional) sleep:    The state of sleep where the characteristics are not clearly defined into active sleep or quiet sleep is known as indeterminate sleep.
    • Sleep cycle:  Neonates fall to sleep with a brief episode of active sleep, followed by a short period of indeterminate sleep before the onset of quiet sleep. Subsequent active sleep is longer. This occurs either directly from quiet sleep or through a short period of indeterminate (transitional) sleep.  The cycle continues until awakening.
    • Sleep period:  A sleep period made up of connected sleep cycles.
    • Sleep duration:   Length of time a neonate has been asleep.
    • Gentle human touch: Placing the fingertips of one hand above the eyebrow line with the palm touching the neonates crown while the other hand rests on the lower abdomen of the neonate encompassing the waist and hip
    • Skin-to-skin care: Also known as kangaroo care, refers to the method of holding an infant in an upright and prone position, skin-to-skin, on the parent’s chest for a period of time.

    Assessment

    • Observe neonatal sleep cycles and durations before waking them.
     Sleep state  Signs
    Active sleep (AS) - Rapid eye movement (REM)
    • Closed eyes
    • Rapid or slow eye movements under closed eyelids
    • Irregular breathing, more rapid and shallow
    • Variability in heart rate
    • Twitching arms and legs 
    • May grimace or appear to smile
    • Periodic groaning or crying 
    Quiet sleep (QS) - Non- REM
    • Closed eyes 
    • No eye movements under closed eyelids
    • Deep, regular breathing
    • Lying still with the occasional myoclonic jerk or startle
    Indeterminate sleep (IS)
    • Sleep characteristics are not clearly definable between AS and QS
    • The period of IS at the beginning of sleep and between QS and AS is called transitional sleep

    Management

    Maximising neonatal sleep durations

    Healthy term neonates usually sleep for at least 16 - 18 hours per day.   It could therefore be assumed that a sick term neonate may require at least 16 -18 hours of sleep per day for normal growth and development. Preterm neonates require more than 18 hours sleep per day for normal growth and development to occur:

    • A sleep period of 60 minutes or more is required to complete a sleep cycle. Wherever possible babies should have no less than 60 minutes between sleep disruptions
    • Where possible schedule care/interventions for when the neonate is naturally awake
    • If the neonate must be woken, this should be from active sleep with talking and gentle touch where possible
    • Care/interventions should be clustered wherever possible, taking into account how much the baby can tolerate
    • Assistance to return to sleep or settle upon waking should be provided if the baby displays unsettled behaviour, such as crying.

    Cycled lighting

    Cycled lighting which mimics day and night helps to develop normal transition to night-time sleeping patterns

    Day time

    • Blinds open
    • Lights turned on if sunlight is limited
    • Incubator covers to be removed to allow exposure to light. A small cover may be used to prevent bright lights shining into the neonate's eyes
    • Eye covers to be removed

    Night time

    • Blinds closed
    • Lights dimmed to a safe level where the neonate can still be seen (using spotlight and parent lights where possible to reduce extra light for other neonates in the room)
    • Incubators to be covered wherever possible to provide extra darkness
    • Eye covers to be worn by neonate to provide extra darkness, especially where lighting is unable to be dimmed.

    All neonates should be assessed on a regular basis and additional lights should be turned on for assessments.

    Quiet time

    Quiet time assists neonates to become used to sleeping in dim light and quieter environments.

    • Quiet time to be provided:  (these times are used in NICU and may be modified for individual wards)
      • From 12:00 to 14:00 during the day
      • From 03:00 to 05:00 during the night
    • During quiet time
      • Blinds closed
      • Lights dimmed to a safe level where the neonate can still be seen (using spotlight and parent lights where possible to reduce extra light for other neonates in the room)
      • Eye covers to be worn by neonate to provide extra darkness, especially where lighting is unable to be dimmed
    • Only parents to be present during quiet time 
    • Only time critical (urgent) procedures and activities of daily living to be performed during quiet time 

    Lighting should be returned to day time requirements once quiet time ends during the day.

    Family Centered Care

    • Provide parents with a copy of the brochure entitled 'Helping your baby sleep in the hospital environment' to enable them to participate in care and decision making
    • Encourage parents to develop day and night routines for their neonate to assist with the development of day and night rhythms and the transition to nighttime sleeping

    Documentation

    • Record sleep and wake periods on patient to assist with identifying sleep and wakefulness patterns

    Evidence Table

    Neonatal sleep maximisation in the hospital environment evidence table

    References

    • Bertelle, V., Sevestre, A., Laou-Hap, K., Nagahapitiye, M. C., and Sizun, J. (2007).  Sleep in the neonatal intensive care unit.  Journal of Perinatal and Neonatal Nursing, 21 (2), 140-148.
    • Bijari, B.B., Iranmanesh, S., Eshighi, F., and Baneshi, M. R. (2012).  Gentle Human Touch and Yakson:  The Effect on Preterm’s Behavioural Reactions.  ISRN Nursing. Published online 2012 June 25
    • Davis, K. F., Parker, K. P., and Montgomery, G. L.  (2004).  Sleep in infants and young children: part one: normal sleep. Journal of Pediatric Health Care, 18 (2), 65-71.
    • Heussler, H. S. (2005). Common causes of sleep disruption and daytime sleepiness: childhood sleep disorders II. Medical Journal of Australia, 182 (9), 484-489.
    • Lavie, P. (2001).  Sleep-wake as a biological rhythm.  Annual Review of Psychology, 52, 277-303.
    • Merenstein, G. B., and Gardner, S. A.  (2006). Handbook of Neonatal Intensive Care.  Sixth Edition.  Mosby Elsevier.  United States of America.
    • Onen, S. H., Alloui, A., Gross, A., Eschallier, A., and Dubray, C. (2001). The effects of total sleep deprivation, selective sleep interruption and sleep recovery on pain tolerance in healthy subjects. Journal of Sleep Research, 10, 35-42.
    • Rivkees, S. A., Mayes, L., Jacobs, H., and Gross, I. (2004).  Rest-activity patterns of premature infants are regulated by cycled lighting.  Pediatrics, 133 (4), 833-839.
    • Teunis, C. J., Van den Hoogen, A., Benders. M., Dudink, J., Shellhass, R. A., and Pillen, S. (2017).  How to improve sleep in a neonatal intensive care unit: A systematic review.  Early Human Development, 113, 78-86.  

    Please remember to read the disclaimer.


    The development of this nursing guideline was coordinated by Laura Moore & Amanda Stevens Butterfly, Newborn Intensive Care, and approved by the Nursing Clinical Effectiveness Committee. Updated March 2020.