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Nursing guidelines

Neonatal sleep maximisation in the hospital environment


  • Introduction 

    Sleep plays a crucial role in the development and function of the neonatal brain.

    1. Synaptic Development: During sleep neural circuits undergo synaptic pruning and consolidation, which is critical for the establishment of functional neural networks.
    2. Neuroplasticity: the brain's ability to reorganise and adapt in response to experiences and environmental stimuli.
    3. Memory Consolidation: Time in an active REM sleep state is associated with increased memory consolidation and learning processes.
    4. Brain Growth and Maturation: During sleep, the brain releases growth factors and hormones that support neuronal development, myelination, and overall brain health.
    5. Regulation of Brain Activity: Disruptions in sleep patterns or quality may impact the development of neural circuits and functional brain networks.
    6. Cognitive Development: Studies have shown that infants who experience regular sleep patterns and adequate sleep duration exhibit better cognitive outcomes and developmental milestones.

    Overall, sleep plays a fundamental role in shaping the structure, function, and connectivity of the neonatal brain. Optimising sleep quality and duration in newborns is essential for promoting healthy brain development and improving current and future optimal physical and cognitive outcomes.

    Neonates in a hospital setting are chronically sleep deprived. This 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 clinicians to help protect and maximise the sleep for neonates in the hospital environment.  

    The guideline will provide information on:

    •  Sleep states and recognising these
    • Protecting completion of sleep cycles
    • Supporting the development of circadian rhythm
    • Gestational recommendations on light exposure
    • Facilitating quiet time 
    • Use of music for sleep & settling
    • Empowering parents and caregivers

    Definition of Terms

    • 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.  It is believed to play a role in neural maturation and memory consolidation.
    • Deep sleep: Deep sleep is equivalent to non-REM sleep in adults. During deep sleep, newborns display low muscle tone, regular breathing, and slow, synchronous brainwave patterns, facilitating restorative processes and essential brain development.
    • Gentle human touch: Placing the fingertips of one hand above the eyebrow line with the palm touching the neonate’s crown while the other hand rests on the lower abdomen of the neonate encompassing the waist and hip or using support around the feet to flex at the knee.  
    • Indeterminate (transitional) sleep: The state of sleep where the characteristics are not clearly defined into active sleep or deep sleep is known as indeterminate sleep. 

    • Neonate: An infant less than 28 days old. 

    • Skin-to-skin care: Also known as kangaroo care, is a method of holding an infant against a caregiver's bare chest. This practice involves the bare infant on the caregiver’s chest with skin-to-skin contact between the baby's chest and the caregiver's chest.
    • Sleep cycle: The neonatal sleep cycle encompasses two primary states: deep sleep (non-REM sleep) and active sleep (REM sleep). Neonates spend a significant portion of their sleep time in active sleep, with sleep cycles typically lasting 40 to 60 minutes and characterized by frequent transitions between states.
    • Sleep period: A sleep period made up of connected sleep cycles. 
    • Sleep duration: Length of time a neonate has been asleep.
    • Marked mirroring: responding contingently to the baby's emotional states by imitating the infant's facial, gestural, or vocal behaviour.

    Assessment 

    Observe neonatal sleep cycles and durations and plan care around these whenever possible.
    Spend a period of time before handling baby observing and assessing the infant’s behavioural state to know when to ideally introduce touch and cares.


    Figure 1: Image created for The RCH COCOON program.


    Sleep state Signs Management
    State One: Deep Sleep
    Non- REM     		This is the optimal sleep state for rest, growth and development.
    • Regular breathing and heart rate
    • Little eye movement evident
    • No body movement
    • Bursts of sucking
    • Not easily awakened
    		Do not wake unless absolutely necessary - Use mother or caregiver’s voice if possible to rouse the infant.
    State Two: Active sleep
    Rapid eye movement (REM)     		Infants typically spend more time in an active sleep state than a deep sleep state in the first few months of life.
    • Rapid eye movements
    • Faster, more irregular breathing
    • More activity in the body is seen
    • Facial movement
    • Easily awakened and startled

    Neuronal connections & memories are made during this phase.

    Do not wake unless absolutely necessary.

    Use mother or caregiver voice, if possible, to rouse the infant.

    State Three: Drowsy This transitional state is evident when the baby is either rousing from sleep or settling to sleep.
    • The infant may occasionally open and close their eyes
    • Yawn and may quietly fuss until they settle.
    • Variable movement
    • Irregular breathing
    • Delayed reaction time

    Infants in this state may require some support to transition to sleep, as environmental input may disrupt the transition into a sleep state.

    When an infant is in this state you can rouse the baby for caregiving using voice first then touch.
    State Four: Quiet Alert The baby should appear relaxed in their body and facial expression and be able to focus their attention on something in their environment.
    • Little body movement
    • Eyes wide open
    • Steady, regular breathing
    • Very responsive
    • Wants to play and interact
    • Requires energy and can make babies tired

    This is the optimal state for the caregiver to interact with their baby and for the baby to absorb input to learn.

    Encourage face to face contact, talking, marked mirroring, feeding.
    State Five: Active Alert The baby will appear more active in their body, and they may fuss while in this state.
    • Lots of movement
    • Irregular breathing
    • Eyes open, but not focused
    • Sometimes fussy
    • Sensitive to body and surroundings
    • Common before feeding
    		 The baby may require some support to transition to the more optimal ‘quiet, alert’ state for learning. For example: containment of their limbs with a cuddle/swaddle or modification of their environment- is it too noisy or bright?
    State Six: Crying This state depicts a baby who is stressed.
    • Tears
    • Jerky movements
    • Colour changes
    • Muscle tension
    • Rapid breathing
    • Generally, doesn’t respond quickly

    When a baby is in a crying state, the caregivers should physically support that infant to regulate and transition back to a more optimal awake state.

    Infants younger than 3 months old do not have the regulatory ability to calm themselves from a crying state without support from their caregivers. For example: hungry- needs a feed, dirty nappy- needs changing, needs to know their caregivers are close by- voice, physical contact, reassurance.

    It is also important to note that crying is normal process that infants use to communicate. Crying should always be responded to.

    Management 

    Protecting completion of sleep cycles

    Healthy term neonates usually sleep for at least 16-18 hours per day and preterm infants require more than 18 hours sleep per day for normal growth and development to occur: 

    • From 25 weeks gestation, sleep states can be well defined.
    • The average length of an infant’s sleep cycle is about 40-60 minutes.
    • Where possible schedule cares and interventions for when the neonate is in an alert state.
    • If the neonate must be woken, this should be from active sleep with talking (preferably a parent’s voice) and gentle touch.
    • Care and interventions should be clustered wherever possible, stopping to support the infant as needed. Sometimes fragile infants will require their cares to be broken up throughout their awake states, considering how much handling the baby can tolerate.
    • Assistance to return to sleep or to settle into a quiet awake state should be provided if the baby displays any unsettled or disorganised behaviour, such as: jerking, fussing, crying etc.
    • Remove visual distractions such as contrast cards or mobiles out of vision to promote sleep.
    • Support families to recognise sleep states and demonstrate settling techniques.

    Supporting the development of circadian rhythm

    Infants are born with the capacity for circadian rhythm although it is poorly developed due to the immaturity of neural control mechanisms. Establishing a circadian rhythm for infants in the hospital, in particular in the Neonatal Intensive Care Unit (NICU) or critical care areas which can be more challenging, but there are strategies that can help:

    1. Provide a Consistent Environment: Mimic natural day-night cycles by regulating light exposure. Dim the lights during the night to encourage sleep and gradually increase light levels during the day to simulate daytime.
    2. Encourage Exposure to Natural Light: Whenever possible, expose infants >32 weeks to natural daylight during the day. This helps regulate their circadian rhythm and promotes better sleep-wake patterns.
    3. Establish Regular Feeding and Care Times: Consistent feeding and care schedules can help signal to the infant's body when it's time to be awake and when it's time to rest.
    4. Limit Stimuli at Night: Keep noise levels low and minimise disturbances during nighttime care routines to promote better sleep.
    5. Encourage Parent/caregiver Involvement: Encourage parents/caregivers to participate in tasks during the day. Parental presence and touch can have a calming effect and help regulate the baby's circadian rhythm.
    6. Monitor and Adjust as Needed: Monitor the infant's response to environmental cues and adjust care practices as necessary to optimise their sleep-wake cycles.

    Benefits of cycled light in NICU

    • Significant reduction in length of stay compared to near darkness or continuous bright light.
    • Higher mean weight at three months corrected gestation among infants cared for in a cycled light environment.
    • Shorter time on the ventilator for the cycled light group compared to continuous bright light.
    • Cycled light results in a shorter time to first oral feeding compared with continuous bright light.

    On the other hand, continuous bright light in newborn intensive care units has been connected to increased levels of disorganised activity, decreased sleep and bradycardia.

    Gestational recommendations on cycled light exposure

    •  Less than 32 Weeks: low indirect cycled light - Use isolette cover and cover eyes when direct light exposure is necessary for procedures, cares or observation.

    • Greater than 32 Weeks: Introduce cycled low light - timed with awake periods through the day. Use venetian blinds to adjust for low natural light.
    • Greater than 34 Weeks: Longer periods of cycled light - timed with awake periods through the day.

    Day time - greater than 34 weeks

    • 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.

    Nighttime 

    • Blinds closed.
    • Lights dimmed to a safe level where the neonate can still be seen (using spotlight and dimmable over head 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 when appropriate to be worn by neonate to provide extra darkness, especially where lighting is unable to be dimmed. 

    Quiet time 

    Quiet time is allocated protected time from procedural touch. It provides opportunities for periods of undisturbed sleep, play & bonding.

    • Quiet time to be decided upon each shift by the nurse in collaboration with families and communicated with others. It should be flexible to work in with the infant’s natural sleep and wake cycles. Ideally 2-3 hours of no procedural touch. Skin-to-skin and responsive interaction is encouraged during this time.
    • During quiet time: 

    • If sleeping, blinds closed, and lights dimmed to a safe level where the neonate can still be seen. Use spotlight and parent lights if examination is needed.
    • Only parents to be present during quiet time.
    • Only time critical (urgent) procedures to be performed during quiet time. If quiet time is interrupted aim to make up the quiet time later in the day.
    • Skin-to-skin and calm baby led interactions with parent/caregiver ideal.
    • Lighting should be returned to daytime requirements once baby is awake or quiet time ends during the day.

    Using music 

    • The music therapy department can supply a mp3 player with a playlist specifically curated for use in NICU
    • This playlist can be used to complement settling and transitioning to sleep. 
    • Music should be played at a quiet speaking volume.
    • Do not play the music continuously – 20-30 minutes max. 
    • Do not play the music during procedures to avoid negative association. 
    • Turn off music if baby displays signs of overstimulation of distress. 

    Families will often wish to play their own music during this time, please encourage them to follow these steps and refer to music therapy for assessment.

    Family Centred Care 

    • Families are the best neurodevelopmental care intervention available. Empower them in the care and promotion of sleep maximisation for their baby.
    • Skin-to-skin care is one of the most robustly proven measures to improve neonatal sleep. Encourage and advocate for skin-to-skin care as much as possible.
    • Support families to recognise sleep states and demonstrate settling techniques.
    • Empower families with information on sleep states and cues. The document entitled ‘Cues' can be found on the COCOON webpage, under 'Getting to know your baby' please assist parents to find it.
    • Involve families in development of a care plan to include quiet time.

    Documentation 

    Document sleep and wake periods to assist with identifying sleep and wakefulness patterns to plan for caregiving and interaction.

    Resources

    Kids Health Information : Sleep problems – babies and toddlers (rch.org.au)


    Evidence Table 

    Reference 

    Source of Evidence

    		 Key findings and considerations 
     

    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. doi:https://doi.org/10.1053/ j.nainr.2016.09.030 

         		 Other
    • The structural and functional development of the brain is shaped by the influence and interaction of several major factors, one of these is sleep and environment. 
    • Sleep preservation is essential for the normal neurodevelopment and adequate growth and healing. 
    • At approximately 28 weeks' gestation, individual sleep patterns begin to emerge. 
    • REM and NREM sleep cycling are essential for early neurosensory development, learning and memory, and preservation of brain plasticity for the life of the individual. 
    • Sleep deprivation (both REM and NREM) results in a loss of brain plasticity which is manifested by smaller brains, altered subsequent learning, and long-term effects on behaviour and brain function. 
    • Safeguarding sleep is also essential to promote healing and growth.   
      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   Other
      • Sleep has an important role in the development and function of the brain.  
      • Sleep deprivation has a negative impact on health and development.  
      • Mean duration of sleep cycles 40-70 minutes.  
      • Observational indications of sleep states.  
      • Cycled lighting may be a better environment to achieve a more physiologic homeostatic state.  
      • Clustering of cares and interventions increase durations of rest periods   
        Canet, E., Gaultier, C., D'Allest, A. M., & Dehan, M. (1989). Effects of sleep deprivation on respiratory events during sleep in healthy infants. Journal of applied physiology (Bethesda, Md. : 1985), 66(3), 1158–1163. https://doi.org/10.1152/jappl.1989.66.3.1158 
        		 Cohort study
        • Short-term sleep deprivation in healthy infants increases the number and timing of respiratory events, especially obstructive events in active sleep   

           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.  Other
          • Newborns sleep for 16 -18 hours in 24 hours.  
          • Circadian rhythm emerges around 2-3 months when infants become increasingly responsive to environmental cues such as light and dark and social cues such as feeding, nap times, and night-time routines. 
            Franco, P., Seret, N., Van Hees, J.N., Lanquart, J., Groswasser, J., & Kahn, A. (2003). Cardiac changes during sleep in sleep-deprived infants. Sleep, 26 7, 845-8 .   Cohort Study
          • Infants exposed to short-term sleep deprivation manifest changes in cardiac autonomic controls during sleep Neonatal Intensive Care Unit (NICU). 
           Graven, S. N., & Browne, J. V. (2008). Sleep and brain development. In J. J. West (Ed.), Respiratory physiology: Development, aging, and disease (pp. 297-312). DOI: 10.1007/978-0-387-71967-6_16    Other
          • Overview of the interplay between sleep and brain development, highlighting the importance of healthy sleep patterns for optimal cognitive and neurobehavioral functioning in infants and children.   

            Hazelhoff, E. M., Dudink, J., Meijer, J. H., & Kervezee, L. (2021). Beginning to See the Light: Lessons Learned From the Development of the Circadian System for Optimizing Light Conditions in the Neonatal Intensive Care Unit. Frontiers in neuroscience, 15, 634034. https://doi.org/10.3389/fnins.2021.634034   Other
            • The initial structures of the eye and beginnings of circadian rhythm are present at 24 weeks of gestation 
            • Cycled light is beneficial for the development of preterm babies.   
            • Increasingly important to focus on optimizing the NICU environment and thereby help improve preterm infants’ health and wellbeing later in life.     
              Levy, J., Hassan, F., Plegue, M. A., Sokoloff, M. D., Kushwaha, J. S., Chervin, R. D., Barks, J. D., & Shellhaas, R. A. (2017). Impact of hands-on care on infant sleep in the neonatal intensive care unit. Pediatric pulmonology, 52(1), 84–90. https://doi.org/10.1002/ppul.23513   Cohort Study 
              • Hypopnea was most likely to occur following disruption of infants in active sleep 
              Limperopoulos, C., Gauvreau, K. K., O'Leary, H., Moore, M., Bassan, H., Eichenwald, E. C., Soul, J. S., Ringer, S. A., Di Salvo, D. N., & du Plessis, A. J. (2008). Cerebral hemodynamic changes during intensive care of preterm infants. Pediatrics, 122(5), e1006–e1013. https://doi.org/10.1542/peds.2008-0768  Cohort Study
              • Routine caregiving procedures in critically ill preterm infants are associated with major circulatory fluctuations that are clinically underappreciated and under detected by current bedside monitoring. 
               Merenstein & gardner’s handbook of neonatal intensive care : an interprofessional approach (9th ed.). (2021). . Elsevier. June 11, 2024.   Other
              • Consistent routines help to regulate the neonate’s rhythms.  
              • Neonates should not be woken while sleeping. If they must be woken, it should be during active sleep by gentle touch and talking.  
              • Clustering of cares and interventions increase durations of rest periods.  
              • Quiet time assists neonates to become used to sleeping in dim and quieter environments.   
                Morag, I., & Ohlsson, A. (2016). Cycled light in the intensive care unit for preterm and low birth weight infants. Cochrane Database of Systematic Reviews(8). doi:10.1002/14651858.CD006982.pub4    Systematic Review
                • Using cycled lighting in the NICU resulted in a significant reduction in length of stay compared to near darkness or continuous bright light. 
                • Higher mean weight at three months corrected gestation among infants cared for in a cycled light environment. 
                • Shorter time on the ventilator for the cycled light group compared to continuous bright light. 
                • Cycled light results in a shorter time to first oral feeding compared with continuous bright light. 
                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
                		  Cohort Study
                • Changes in sleep patterns may influence the perception of pain.  
                • The lowering of pain threshold appeared to correlate with the duration of sleep deprivation. 


                  Pineda R, Kellner P, Ibrahim C, (2023). SENSE Advisory Team Working Group, Smith J. Supporting and Enhancing NICU Sensory Experiences (SENSE), 2nd Edition: An Update on Developmentally Appropriate Interventions for Preterm Infants. Children 10(6):961. https://doi.org/10.3390/children10060961
                  		 Systematic Review 
                  • Good evidence for use of cycled light, starting at 32 weeks PMA
                  • Prior to 32 weeks avoid complete darkness but protect eyes from direct or bright light during this period
                  • face-to-face interaction with a parent starting at 34 weeks PMA.  
                  Pineda, R., Raney, M., Smith, J. (2019). Supporting and enhancing NICU sensory experiences (SENSE): Defining developmentally-appropriate sensory exposures for high-risk infants. Early Human Development, 133, 29-35. https://doi.org/10.1016/j.earlhumdev.2019.04.012 Systematic Review
                  • Guidelines for providing personalised developmentally appropriate sensory experiences for infants in the NICU. 
                  Peng, N., Bachman, J., Chen, C., Huang, L., Lin, H., Li, Y. (2014). Energy Expenditure in Preterm Infants During Periods of Environmental Stress in the Neonatal Care Unit. The Journal of Nursing Science, 11(4), 241-247. https://doi.org/10.1111/jjns.12025
                  		Explorative Secondary Analysis 
                  • Environmental stressors may impact the growth and developmental outcomes in preterm infants by increasing their energy expenditure. 
                  • Research found a significant relationship between an increase in energy expenditure and a decrease in oxygen saturation in preterm infants.   

                    Van den Hoogen, A., Teunis, C., Shellhaas, R., 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. https://doi.org/10.1016/j.earlhumdev.2017.07.002 

                    		 Systematic Review
                    • Active sleep is important for fetal and neonatal brain maturation. 
                    • Lack of active sleep in early stages of brain development leads to behavioural problems and sleep disturbances.  
                    • Kangaroo care improves sleep and organisation of sleep-wake states. 
                    • Gentle human touch promotes increased sleep and decreased awake and ‘fussy’ states.  
                    • Music interventions are promising in promoting sleep in neonates. 
                    • Cycled lighting effects day-night time activity after 20-30 days. 
                    • Incorporating sleep measurements into assessments increases awareness of sleep as a key factor of neonatal health.  
                    • Postpone elective care procedures during sleep.   



                      Please remember to read the disclaimer.


                      The revision of this nursing guideline was coordinated by Jenna Rhodes, RN, Newborn Intensive Care Unit, and approved by the Nursing Clinical Effectiveness Committee. Updated June 2024.