Abstract

Aims: To determine risk factors associated with sleep problems in infants.

Methods: Parents of 112 infants aged 3 – 6 months in Manado who were selected
using proportional random sampling completed Brief Infant Sleep Questionnaire. This
study used analytical observation with cross sectional from July to December 2018.
Results: This study was conducted on infants aged 3-6 months from 4 health centers
in Manado City, who were selected randomly from July to December 2018. Of the 112
samples, we obtained 58 (51.8%) boys and 54 (48.2%) girls with an average age of
4.21 (SB 0.829) months. This study noted the factors affecting sleep problems in
infants and the most influential factors can be seen from the correlation value ( r ).
From the correlation value ( r ), the use of electronic media, patterns of breastfeeding,
maternal education level, socio-economic status, and sleep position associated with
sleep problems with values (= 0.839, = 0.771, = 0.624, = 0.433, and = 0.309) were
obtained. After conducting interviews using BISQ on 112 mothers of infants who met
the inclusion criteria of the study, we found 76 (67.86%) infants who had sleep
problems and 36 (32.14%) infants who did not have sleep problems.
Conclusions: The use of electronic media by parent before sleep is the most
influential risk factor associated with sleep problems, followed by patterns of
breastfeeding, maternal education level, socio-economic status, and sleep position
consecutively.

Key Words: Infants; sleep; Questionnaires; Education; Surveys.

Introduction
Sleep is a regular resting condition characterized by reduced body movement and
decreased level of awareness of the surroundings, reversible and quick. 1 Sleep is an
essential requirement for each individual, especially for an infant. Dramatic changes
occur during the first year of life and are sustained in children to adolescence. 1-3
Sleep problem is a collection of symptoms characterized by problems in the
quantity, quality and time of sleep.4 Until now, there are still many children who do not
have good quality or quantity of sleep.5-7 In 2016, the estimated population in
Indonesia based on the age group of 0 - 4 years is around 24 million people or 9.26%
of the population according to the Ministry of Health.8 Children with the age group of
0 - 4 years are the largest age group in the structure of the Indonesian population and
need a focus of attention and strategic intervention points for the development of
human resources. The study conducted by Sekartini and colleagues9 found the
prevalence of sleep problems in children under three years in five cities in Indonesia
at 44.2%.
Sleep problems in infants can cause developmental problems, not optimal
growth, behavioral disorders, fatigue, and can affect the relationship between mother
and infants. Sleep problems in infants are often not detected by parents and are not
handled properly.13,14 The results of studies in the United States found that more than
20% of health workers did not routinely screen for sleep problems in infants.10
Sleep problems in infants are influenced by several factors, both internal and
external factors. Internal factors that affect sleep in infants are child characteristics,
sex, history of low APGAR scores, prematurity, various neuropsychiatric disorders and
chronic diseases. Meanwhile external factors that can affect sleep include infant sleep
position, use of electronic media by parents before sleep, no breastfeeding, family and
environmental conditions such as socio-economic status, educational status, and
characteristics of parents.11-13
Assessment of sleep quality can be done in two methods, namely objective and
subjective methods. Objective assessment can be done using polysomnography and
actigraph.14 To assess the quality and quantity of sleep subjectively, a questionnaire
can be used. Subjective assessment of sleep problems can be considered less
accurate and not specific, compared to the objective method. This problem can be
overcome by using a standardized questionnaire.15
 The Brief Infant Sleep Questionnaire (BISQ) is a well-publicized and validated
measurement to capture sleep problems at an early age until the age of 3 years.15,16
BISQ is divided into 2, namely normal and sleep problem. This measuring instrument
consists of several indicators of sleep quality. The study from Sadeh et al 16 said that
BISQ can be used as a screening tool for sleep problems in infants.

Methods
Participants
The study was conducted at 4 Health Centers in Manado City, which were selected
randomly from 13 Health Centers in Manado. The study sample was taken based on
inclusion criteria: infants aged 3 - 6 months, healthy infants, parents willing and agreed
to participate in the study. Meanwhile the exclusion criteria in this study were infants
with a history of low birth weight, preterm birth history, and nutritional status. The
sample size was calculated based on the ‘rule of thumb’ formula. Complete
demographic data can be found in Table 1. There were equal boys (51.8%) and girls
(girls = 48.2%), and the average age of infants was 4.21 months.

Procedures
Samples were taken by two-step random sampling, namely by randomizing health
centers in Manado City, then from infants aged 3-6 months in 4 health centers, they
were proportionally randomized to get 112 samples, as seen in Table 2. All parents of
selected infants were given an explanation of the advantages and objectives of the
study. If the parents gave permission for the babies to participate in this study, then
they signed an informed consent sheet. A healthy baby can be defined as a baby who
is in good health. In this study, the infant health condition will be determined based on
history and physical examination. When completing the Brief Infant Sleep
Questionnaire (BISQ), parents were accompanied. Assessment of sleep problems by
using the Brief Infant Sleep Questionnaire (BISQ) was divided into sleep problems or
no sleep problems. In this study, univariate analysis was carried out to analyze infant
characteristics, while bivariate analysis was done to analyze the relationship of each
variable with sleep problems using the Chi-Square test and correlation coefficient phi
( r ). Significant variables were then obtained by calculating the Odds Ratio (OR) and
confidence index (CI) values of 95%. Multivariate analysis was carried out to analyze
the independent variables together to assess which factors that most contributed to
sleep problems using multiple logistic regression. For significance, the significant
value used was p <0.05.

Ethics approval
This study was carried out under the approval of the Ethics Committee of RSUP Prof.
dr. R.D. Kandou Manado and informed consent to parents were obtained before
carrying out a physical examination and completing BISQ.

Results
Data analysis was based on SPSS for Windows version 25. In this study, sleep
problems were determined based on BISQ. Sleep problem is if one or more conditions
are found, such as nighttime sleep (from 7 pm to 7 am) less than 9 hours, wake up at
night (from 10 pm to 6 am) more than 3 times and long awake more than 1 hour at
night. This study determined the factors that influence sleep problems in infants,
among others, the use of electronic media by parents, socio-economic status,
maternal education level, pattern of breastfeeding, and infant sleep position.
Of the 40 infants whose parent had low socio-economic status, 38 (95%) infants
had sleep problems and 2 (5%) problems did not experience sleep problems. Whereas
from 72 infants with upper-middle socio-economic status, there were 38 (52.8%)
infants having sleep problems and 34 (47.2%) infants not having sleep problems.
Socio-economic factors affect sleep problems with OR 17.0 (95% CI: 3.8 – 75.8)
Of the 57 infants with mothers who did not graduate high school, 55 (96.5%)
infants had sleep problems and 2 (3.5%) infants did not experience sleep problems.
Whereas from 55 infants with mothers who graduated from high school, there were 21
(38.2%) infants having sleep problems and 34 (61.8%) infants not having sleep
problems. After analyzing using the Chi-Square test, there was a significant
relationship between the factors of maternal education level with sleep problems (p
<0.0001).
Of the 28 infants who slept in prone position based on BISQ tests, 26 (92.8%)
infants had sleep problems and 2 (7.2%) infants did not experience sleep problems.
Whereas from 84 infants with supine sleeping positions who were tested by BISQ, 50
(59.5%) infants had sleep problems and 34 (40.5%) infants did not experience sleep
problems. Infants with a prone sleeping position will have a risk of 8.8 times having a
sleep problem.
Based on the use of electronic media, from 74 infants whose parents used
electronic media one hour before going to bed in one room with infants tested by BISQ,
71 (95.9%) infants had sleep problems and 3 (4.1%) infants did not experience sleep
problems. Whereas from 38 infants whose parents who did not use electronic media
one hour before going to bed, 5 (13.16%) infants had sleep problems and 33 (86.84%)
infants did not experience sleep problems. The status of the use of electronic media
by parents one hour before sleep in one room with their infants affects sleep problems.
Of the 81 infants with non-exclusive breastfeeding pattern tested by BISQ, 73
(90.1%) infants had sleep problems and 8 (9.9%) infants did not experience sleep
problems. Whereas from 31 infants who received exclusive breastfeeding, 3 (9.7%)
infants had sleep problems and 28 (90.3%) infants did not experience sleep problems.
After analyzing the Chi-Square test, it was found that there was a significant
relationship between the pattern of breastfeeding and sleep problems (p <0.0001).
The pattern of breastfeeding affects sleep problems with OR 85.2 (95% CI: 21.1 –
344.2). Infants with non-exclusive breastfeeding pattern will have a risk of 85.2 times
having a sleep problem.
The most influential factor can be seen in the correlation value ( r ). The highest
value is the most associated factor with sleep problems. From the correlation value (
r ), the use of electronic media, patterns of breastfeeding, maternal education level,
socio-economic status, and sleep position associated with sleep problems were
obtained. Table 3 shows the correlation value ( r ) associated with sleep problems.
Of the 5 factors analyzed using multivariate analysis with logistic regression on
the relationship with sleep problems, no factor was found to have a relationship with
sleep problems. Factors of socio-economic status, maternal education level, sleep
position, use of electronic media, and patterns of breastfeeding had no relationship
with sleep problems with p values (p = 0.995, p = 0.997, p = 0.998, p = 0.995 and p =
0.993)

Discussion
Sleep problem is a collection of conditions characterized by a problem in the quantity,
quality, or sleep time of a child.17 The period of the first year is when a child’s sleep
pattern changes dramatically. The maturation process of the circadian rhythm occurs
at the age of 2 – 3 months and changes in the child’s sleep pattern occur. In particular,
increased sensitivity to light underlies the gradual transition of polyphasic sleep
patterns from the newborn period into sleep patterns at night and awake in during the
day.18
This study aims to determine the relationship between factors of socio-
economic status, maternal education level, infant sleep position, use of electronic
media by parents, and patterns of breastfeeding with sleep problems. Based on the
BISQ test conducted on 112 infants, 76 (67.86%) infants had sleep problems and 36
(32.14%) infants did not experience sleep problems. From this study, it can be seen
that most infants have sleep problems. This finding is supported by a study conducted
by Mindell19, where Asian races tended to have sleep problems compared to
Caucasians with a prevalence of 66.82%, with a ratio between men and women of
52.05% and 47.95%.
Low socio-economic status is associated with significant limitations in the
quality of family life which cover various fields, such as nutrition, health, and education.
Children from low socio-economic status are said to have higher respiratory problems
during sleep, shorter sleep times, poorer quality of sleep, and an increase in nap
time.12
In this study, infants with low socio-economic status had 17 times the risk of
having a sleep problem. This finding is supported by a study conducted by Tikotzky 7,
who reported that environmental factors, medical conditions, and psychosocial
conditions have been shown to be associated with sleep. In terms of home enviroment
conditions, low socio-economic status tends to have fewer bedrooms and more people
share in one room. The less ideal ventilation system, high levels of allergens can affect
the number and quality of sleep for a child. 14
Maternal education level will correlate with how they care for children.
Meanwhile parenting is closely related to child development. This means that the
higher the level of education of the mother, the better the way to care for children, and
consequently the development is positively affected. Conversely, the lower the level
of education of the mother will be less good at raising children, so that child
development is hampered. 13,14
The study by Touchette12 said that the influence of families on children’s sleep
patterns mainly centered on parents’ attitudes and behaviors to children. A responsive
and interactive attitude towards children and the availability of a conducive home
environment for children can reduce sleep problems in children. Especially regarding
the problem of lack of mental stimulation by parents, it is generally due to the low level
of education so that they do not understand how important the quality and quantity of
sleep is related to the growth and development of a child.12
In this study, infants with a prone sleeping position will have a risk of 8.8 times
having a sleep problem. This is supported by previous study by Ammari et al,20 stating
that infants who slept in prone position showed lower metabolic rates than those who
slept in a supine position. A prone sleeping position can cause an increase in heart
rate, respiratory frequency, and respiratory quotient (RQ).
The increasingly rapid development and exposure to electronic media has
increased our awareness and knowledge, but on the other hand is also a risk factor
for the occurrence of sleep problems, especially in childhood. This finding is supported
by research carried out by Chang et al21 which confirmed that bright screen exposure
from electronic media is sufficient to inhibit melatonin production. The study by Carter
et al22 showed that electronic media exposure including access to media devices in
the bedroom, although not actively used before bedtime, was associated with sleep
problems (OR, 1.79; 95% CI, 1.39 – 2.31).
Exclusive breastfeeding is breastfeeding without additional food and drinks.
The most important component of breast milk is melatonin. Melatonin is secreted at
night in adults but not in infants. The results of this study are supported by a previous
study by Engler et al23 which revealed that breast milk contains melatonin with a
circadian pattern, resembling melatonin levels in blood. Melatonin has the effect of
improving the quality of infant sleep and can reduce infantile colic.
The most influential factor can be seen in the value r . From the value r , the
factors of the use of electronic media, patterns of breastfeeding, maternal education
level, socio-economic status, and sleep position were found to be associated with
sleep problems with values ( r = 0.839, r = 0.771, r = 0.624, r = 0.433, and r
= 0.309). Based on multivariate tests, there were no risk factors that were significantly
associated with sleep problems (p> 0.05). This is because each of the risk factors in
this study influences the occurrence of sleep problems in infants. According to
statistical theory, in a multivariate test, there should be no significant relationship
between independent variables.
 This study found several limitations that could be taken into consideration for
further research, namely this study has not assessed the effect of child characteristics,
maternal medical conditions, nutritional status and parenting patterns on sleep
problems. In addition, this study is a cross-sectional study so it is not known when
infants experience sleep problems.

Conclusion
Based on the results of this study, it can be concluded that there is a relationship
between socio-economic status, maternal education level, infant sleeping position,
use of electronic media, patterns of breastfeeding with sleep problems. The use of
electronic media by parents before sleep is the most influential risk factor associated
with sleep problems, followed by patterns of breastfeeding, maternal education level,
socio-economic status, and sleep position consecutively.

Acknowledgements
The authors sincerely express their deepest gratitude to the Professors, teaching staff,
and colleagues of the Department of Child Health, Faculty of Medicine, Sam Ratulangi
University, Manado, who provided guidance, advice, encouragement and support, and
all parents, doctors, midwives and cadres at Health Centers who have been willing to
assist in the implementation of this study.

References
1. El-Sheikh M, Sadeh A. Sleep and development: introduction to the monograph.

Monogr Soc Res Child Dev.2015; 80:1-14. 


2. Bernier A, Matte-Gagne C, Bouvette-Turcot AA. Examining the interface of

children’s sleep, executive functioning, and caregiving relationships: a plea

against silos in the study of biology, cognition, and relationships. Curr Dir Psychol

Sci. 2014; 23:284-9. 


3. Bruni O, Baumgartner E, Sette S, Ancona M, Caso G, Di Cosimo ME, dkk.

Longitudinal study of sleep behavior in normal infants during the first year of life.

J Clin Sleep Med. 2014; 10:1119-27.

4. Mindell JA, Lee C. Sleep, mood, and development in infants. Infant Behav Dev.

2015; 41:102–7.

5. Hysing M, Harvey AG, Torgersen L, Ystrom E, Reichborn- Kjennerud T, Sivertsen

B. Trajectories and predictors of nocturnal awakenings and sleep duration in

infants. J Dev Behav Pediatr. 2014; 35:309-16. 


6. Sadeh A, Tikotzky L, Scher A. Parenting and infant sleep. Sleep Med Rev. 2010;

14:89-96. 


7. Tikotzky L. Parenting and sleep in early childhood. Curr Opin Psychol. 2017; 15:

118-24.

8. Departemen Kesehatan RI. Laporan Nasional riset kesehatan dasar 2016.

Jakarta. Badan penelitian dan pengembangan kesehatan, 2017.

9. Sekartini R, Adi NR. Gangguan tidur pada anak usia bawah tiga tahun di lima kota

di Indonesia. Sari Pediatri. 2006; 7(4): 188-93.

10. Bathory E, Tomopoulos S. Sleep regulation, physiology and development, sleep

duration and patterns, and sleep hygiene in infants, toddlers, and preschool-age

children. Curr Probl Pediatr Adolesc Health Care. 2017;47: 29-42.

11. Allen SL, Howlett MD, Coulombe JA, Corkum PV. ABCs of sleeping: A review of

the evidence behind pediatric sleep practice recommendations. Sleep Med Rev.

2016; 29: 1-14.

12. Touchette E. Factors associated with sleep problems in early childhood. Early

Child Educ J. 2011;3: 1-7.

13. McDowall PS, Galland BC, Campbell AJ, Elder DE. Parent knowledge of children’s

sleep: A systematic review. Sleep Med Rev. 2017; 31: 39-47.

14. Simard V, Chevalier V, Bedard MM. Sleep and attachment in early childhood: a series of

meta-analyses. Attac Hum Dev. 2017;19: 298-321.

15. Iwasaki M, Iwata S, Iemura A, Yamashita N, Tomino Y, Anme T, dkk. Utility of subjective

sleep assessment tools for healthy preschool children: A comparative study between

sleep logs, questionnaires, and actigraphy. J Epidemiol 2010;20(2):143-149.

16. Sadeh A. A brief screening questionnaire for infant sleep problems: validation and finding

for an internet sample. Pediatrics. 2004; 113:570-7.

17. Field T. Infant sleep problems and interventions: A review. Infant Behav Dev. 2017; 47:

40–53.

18. Sadeh A, Mindel JA, Luedtke K, Wiegand B. Sleep and sleep ecology in the first

3 years: A web-based study. J Sleep Res. 2009;18: 60-73.

19. Mindell JA, Sadeh A, Wiegand B, How TH, Goh DYT. Cross cultural differences

in infant and toddler sleep. Sleep Med. 2010;11: 274-80.

20. Ammari A, Schulze KF, Ohira-Kist K, Kashyap S, Fifer WP, Myers MM, dkk.

Effects of body position on thermal, cardiorespiratory and metabolic activity in low

birth weight infants. Early Hum Dev. 2010;85 (8): 1-13.

21. Chang AM, Aeschbach D, Du JF, Czeisler CA. Evening use of light-emitting eReaders

negatively affects sleep, circadian timing, and next-morning alertness. Proc Natl Acad Sci

USA. 2015; 112:1232–1237. 


22. Carter B, Rees P, Hale L, Bhattacharjee D, Paradkar MS. Association between

portable screen-based media device access or use and sleep outcomes: A

systematic review and meta-analysis. JAMA Pediatr. 2016;170(2): 1202-08.

23. Engler AC, Hadash A, Shehadeh N, Pillar G. Breastfeeding may improve

nocturnal sleep and reduce infantile colic: potential role of breast milk melatonin.

Eur J Pediatr. 2012;171(4): 729–32.


Tables
Table 1. Characteristics of Samples.
Variable Sample (n=112)

Age (month)
- Mean (SB) 4.21(SB 0.829)
Sex (child)
- Female (%) 54 (48.2)
- Male (%) 58 (51.8)
Maternal Working Status
- Work (%) 33 (29.46)
- Housewife (%) 79 (70.54)
Socio-economic status
- Low (%) 40 (35.7)
- Upper-middle (%) 72 (64.3)
Maternal Education Level
- Graduate from High School (%) 55 (49.1)
- Did not graduate from High School (%) 57 (50.9)
Sleep position
- Supine (%) 84 (75)
- Prone (%) 28 (25)
Use of electronic media
- Yes (%) 74 (66.1)
- No (%) 38 (33.9)
Patterns of breastfeeading
- Exclusive (%) 31 (27.68)
- Non-exclusive (%) 81 (72.32)
Sleep problems
- Yes (%) 76 (67.86)
- No (%) 36 (32.14)
Table 2. Distribution of Sample by Health Centers.
No. Health Center Age Representation

3 - 6 months of Sample

1 Minanga

105/588 x 112 20

2 Sario

205/588 x 112 39

3 Teling atas

168/588 x 112 32

4 Wawonasa

110/588 x 112 21

Total 588 112

Table3. Correlation coefficient ( r ) of factors associated with sleep problems.

Correlation
Factors affecting sleep problems P
coefficient Phi

Use of electronic media r = 0.839 < 0.0001

Patterns of breastfeeding r = 0.771 < 0.0001

Maternal education level r = 0.624 < 0.0001

Socio-economic status r = 0.433 < 0.0001

Sleep position r = 0.309 = 0.001