Position
The Council of International Neonatal Nurses, Inc. (COINN) recommends that a neonate’s sleep is to be protected and supported. Sleep is important for brain development, growth, healing, and general health. The protection of sleep post-delivery and during the period of hospitalization particularly for premature neonates, is a core component of neonatal care.
Background and Factors
Newborn term healthy neonates on average sleep 16–18 hour per day, with sleep states generally defined as quiet sleep and active sleep - precursorsto non-rapid eye movement and rapid eye movement sleep states in adulthood (Bennet et al., 2018).
Active sleep is considered the most important behavioural state for neonates
(particularly premature neonates who spend 70-80% of their sleep time in this state). Active sleep plays a key role in organizing the central nervous system and is important for sensory input processing, consolidation and learning (Altimier & Phillips, 2016). During active sleep muscle tone is reduced with irregular breathing and heart rate, and spontaneous twitching and eye movements (Curzi-Dascalova et al., 1988).
Quiet sleep is necessary for energy restoration, tissue growth and repair, and
the maintenance of homeostasis (Altimier & Phillips, 2016). In quiet sleep there is higher muscle tone, absence of eye movements, and regular heart rate and respiration (Bennet et al., 2018). This state is limited for premature neonates due to immature physiological systems, reduced muscle tone, poor control of movements and limited ability for self-regulation. Distinctions of sleep states are difficult to determine before 30 weeks gestational age – prior to 30 weeks both sleep states are largely characterised as indeterminate sleep (Mirmiran et al., 2003).
Sleep is crucial to foster optimal brain development, cognition and behaviour,
however, disruptions can occur from the first hours of life (Grigg-Damberger, 2016). Sleep quality can be impaired by the environment, including the light and noise of neonatal intensive care units (NICU) (van den Hoogen et al., 2017) and treatment such as respiratory support (Collins et al., 2015). Neonatal nursing care interventions, whilst critical, can lead to physiological instability, and can be stressful for neonates, which together with sleep interference risk negatively impacting their neuromotor, behavioural, growth milestones and sleep patterns (Sanders & Hall, 2018). It is a priority that neonatal teams understand the importance of sleep for the neonates wellbeing and this is part of their education. It was recognised in a recent study that healthcare professionals view sleep as important but more theoretical knowledge would support strategies in practice (Groot et al., 2023). Ultimately, optimizing opportunities for sleep gives neonates a better chance of healthy brain maturation (Bik et al., 2022) – sleep has a protective effect on brain development in premature neonates (Ednick et al., 2022). General strategies to protect sleep involve optimizing the environment, comfortable positioning, minimizing stress and pain, integrating families in care, protecting skin integrity, and ensuring adequate nutritional status.
COINN Recommendations and Action Points
1. Recognize the significance of promoting and protecting sleep as a keystone of the
treatment of neonates in the NICU.
2. Include sleep theory in neonatal education.
3. Support neonatal sleep integrated teaching and education programs (e.g., e-
learning, parent information, flyers) targeted to nurses, physicians, parents, visiting
healthcare professionals and support personnel.
4. Observe and record sleep and wake periods of neonates to assist with identifying
sleep-wake patterns.
5. Incorporate appropriate sleep measurements (e.g., validated observational scales,
EEG, innovative non-obtrusive sleep measurements) into daily ward round
assessments to increase awareness of sleep as a key factor in neonatal health.
6. Establish good practice guidelines about elective care procedures which can be
postponed during sleep (e.g., routine blood testing, routine x-rays, routine cardiac
assessments).
7. Avoid (where possible) disrupting neonatal sleep no less than 60 minutes after a
previous sleep disruption.
8. Schedule care / interventions for when the neonate is naturally awake (where
possible)
9. When required to wake the neonate, undertake this with gentle touch and quiet
talking where possible.
10. Pay attention to intolerance of cares / interventions – provide clustered activities
and care as tolerated.
11. Practice regular scheduled unit-based quiet times/hours (dim lighting, quieter
environment, reduced visitors)
12. Promote opportunities for skin-to-skin contact (kangaroo care) and neonatal
massage.
13. Consider use of the following as appropriate to protect and support sleep:
a. Headphones
b. Alarm modifications
c. Nesting aids
d. Swaddling
e. Non-nutritive sucking
f. White noise
g. Music therapy
h. Eye masks
i. Incubator covers.
Disclosure
COINN (Council of International Neonatal Nurses, Inc) acknowledges that limited resources and/or personnel may restrict opportunities to implement the recommendations and action points. However, to improve health outcomes, the global neonatal care community must strive to uphold these recommendations.
Acknowledgement
Thank you to Professor Agnes van den Hoogen, Dr. Deanne August , and the *COINN
Education Committee for the development of this statement.
References
Altimier, L., & Phillips, R. (2016). The neonatal integrative developmental care model:
advanced clinical applications of the seven core measures for neuroprotective family-
centered developmental care. Newborn and infant nursing reviews, 16 (4), 230-244.
Bennet, L., Walker, D. W., & Horne, R. S. (2018). Waking up too early–the consequences ofpreterm birth on sleep development. The Journal of physiology, 596(23), 5687-5708.
Bik, A., Sam, C., de Groot, E. R., Visser, S. S., Wang, X., Tataranno, M. L., ... & Dudink, J.
(2022). A scoping review of behavioral sleep stage classification methods for preterm
infants. Sleep Medicine, 90, 74-82.
Collins, C. L., Barfield, C., Davis, P. G., & Horne, R. S. C. (2015). Randomized controlled trial to compare sleep and wake in preterm infants less than 32 weeks of gestation receiving two different modes of non-invasive respiratory support. Early Human Development, 91(12), 701-704.
Curzi-Dascalova, L. (2001). Between-sleep states transitions in premature babies. Journal of Sleep Research, 10(2), 153-158.
Ednick, M., Cohen, A. P., McPhail, G. L., Beebe, D., Simakajornboon, N., & Amin, R. S. (2009). A review of the effects of sleep during the first year of life on cognitive, psychomotor, and temperament development. Sleep, 32(11), 1449-1458.
Grigg-Damberger, M. M. (2016). The visual scoring of sleep in infants 0 to 2 months of
age. Journal of clinical sleep medicine, 12(3), 429-445.
de Groot, E. R., Ryan, M. A., Sam, C., Verschuren, O., Alderliesten, T., Dudink, J., & van den Hoogen, A. (2023). Evaluation of Sleep Practices and Knowledge in Neonatal
Healthcare. Advances in Neonatal Care, 10-1097.
Mirmiran, M., Maas, Y. G., & Ariagno, R. L. (2003). Development of fetal and neonatal sleep and circadian rhythms. Sleep medicine reviews, 7(4), 321-334.
Sanders, M. R., & Hall, S. L. (2018). Trauma-informed care in the newborn intensive care unit: promoting safety, security and connectedness. Journal of Perinatology, 38(1), 3-10.
van den Hoogen, A., Teunis, C. J., Shellhaas, R. A., Pillen, S., Benders, M., & Dudink, J. (2017). How to improve sleep in a neonatal intensive care unit: a systematic review. Early human development, 113, 78-86.
*COINN Education Committee Contributors: Tracey Jones, Chair, Wakako Eklund, Judy Hitchcock,
Carin Maree, Ann Martin, Aya Nakia, Linda Ng, Debra Nicholson, Julia Petty, Lynne Wainwright
Adopted: September 5, 2023 Next Review: 2026
2110 Yardley Road, Yardley, PA 19067, USA Email: ceo@coinnurses.org
Website: www.coinnurses.org “COINN – the Global Voice of Neonatal Nurses” A not for profit – 501C3.
Comments