Publications by authors named "Robyn Stremler"

43 Publications

Objective Sleep Characteristics and Factors Associated With Sleep Duration and Waking During Pediatric Hospitalization.

JAMA Netw Open 2021 Apr 1;4(4):e213924. Epub 2021 Apr 1.

The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada.

Importance: Children's sleep may be affected by hospitalization, yet few objective determinations of sleep patterns are reported for children in intensive care or general medicine units. There is limited research on relationships between sleep in hospital and child (eg, age, pain), treatment (eg, medications, nurse presence), or environmental (eg, noise, light, type of unit) factors.

Objective: To determine sleep quantity and patterns in hospitalized children and determine factors associated with sleep quantity and nighttime waking for children in hospital.

Design, Setting, And Participants: This was a prospective cross-sectional study of children admitted to a general pediatric unit or a pediatric intensive care unit at a pediatric quaternary teaching hospital in Toronto, Ontario, Canada, from October 2007 to July 2008. Participants included children aged 1 to 18 years who were expected to stay in hospital for at least 2 nights. Demographic data, information about the hospital stay and illness, and usual sleep habits were collected. Children wore an actigraph for 1 to 3 consecutive days and nights and completed a sleep diary. Sound and light meters were placed at the bedside. Data analyses took place in April 2009.

Main Outcomes And Measures: The primary outcome was the mean number of minutes of child nighttime sleep from 7:30 pm to 7:29 am. Sleep variables were averaged over days and nights recorded (mean [SD] days and nights of wear, 2.54 [0.71]) and examined for associations with sleep quantity and patterns, as well as hazard of waking in the night.

Results: Of 124 eligible children approached for inclusion, 69 children consented (35 [51%] female; 20 [29%] aged 1-3 years, 10 [14%] aged 4-7 years, 17 [24%] aged 8-12 years, and 22 [32%] aged 13-18 years; 58 [84%] in the general pediatric unit). Children aged 1 to 3, 4 to 7, 8 to 12, and 13 to 18 years obtained a mean (SD) of 444 (132), 475 (86), 436 (114), and 384 (83) minutes of nighttime sleep, respectively; mean (SD) number of night awakenings was 14 (3), 18 (3), 14 (8), and 12 (6), respectively. Children on general pediatric units slept 258 minutes more per night than children sleeping in the pediatric intensive care unit (95% CI, 165.16-350.56 minutes; P < .001), children admitted for planned surgery slept 123 minutes more than children admitted for exacerbations of chronic illness (95% CI, 49.23-196.01 minutes; P < .01), and children sleeping in rooms with other patients slept 141 minutes fewer than children in private rooms (95% CI, -253.51 to -28.35 minutes; P = .01). Sound events greater than 80 dB were significantly associated with increased risk of instantaneous waking (hazard ratio [HR], 1.35; 95% CI, 1.02-1.80; P = .04), as were light events greater than 150 lux (HR, 1.17; 95% CI, 1.01-1.36; P = .03), receiving a medication that promoted sleep (HR, 1.04; 95% CI, 1.00-1.08; P = .03), and having a nurse in the room for most or all of the night (HR, 1.08; 95% CI, 1.03-1.13; P = .003). Sleeping on the general pediatrics unit was significantly associated with decreased risk of instantaneous waking (HR, 0.81; 95% CI, 0.77-0.85; P < .001), as was being admitted for planned surgery (HR, 0.95; 95% CI, 0.91-0.99; P = .04), receiving a medication that promoted wakefulness (HR, 0.96; 95% CI, 0.93-0.995; P = .02), and sharing a room with another patient (HR, 0.78; 95% CI, 0.72-0.84; P < .001).

Conclusions And Relevance: In this cross-sectional study of hospitalized children, children experienced considerable nighttime waking and sleep restriction to levels below national clinical recommendations at a time when they most needed the benefits of sleep. Given light and noise were the greatest contributors to nighttime waking in hospital, clinicians, administrators and hospital design experts should work together for solutions.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.3924DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8017466PMC
April 2021

Protocol for a randomised trial evaluating a preconception-early childhood telephone-based intervention with tailored e-health resources for women and their partners to optimise growth and development among children in Canada: a Healthy Life Trajectory Initiative (HeLTI Canada).

BMJ Open 2021 Feb 10;11(2):e046311. Epub 2021 Feb 10.

The Hospital for Sick Children, Toronto, Ontario, Canada.

Introduction: The 'Developmental Origins of Health and Disease' hypothesis suggests that a healthy trajectory of growth and development in pregnancy and early childhood is necessary for optimal health, development and lifetime well-being. The purpose of this paper is to present the protocol for a randomised controlled trial evaluating a preconception-early childhood telephone-based intervention with tailored e-health resources for women and their partners to optimise growth and development among children in Canada: a Healthy Life Trajectory Initiative (HeLTI Canada). The primary objective of HeLTI Canada is to determine whether a 4-phase 'preconception to early childhood' lifecourse intervention can reduce the rate of child overweight and obesity. Secondary objectives include improved child: (1) growth trajectories; (2) cardiometabolic risk factors; (3) health behaviours, including nutrition, physical activity, sedentary behaviour and sleep; and (4) development and school readiness at age 5 years.

Method And Analysis: A randomised controlled multicentre trial will be conducted in two of Canada's highly populous provinces-Alberta and Ontario-with 786 nulliparous (15%) and 4444 primiparous (85%) women, their partners and, when possible, the first 'sibling child.' The intervention is telephone-based collaborative care delivered by experienced public health nurses trained in healthy conversation skills that includes detailed risk assessments, individualised structured management plans, scheduled follow-up calls, and access to a web-based app with individualised, evidence-based resources. An 'index child' conceived after randomisation will be followed until age 5 years and assessed for the primary and secondary outcomes. Pregnancy, infancy (age 2 years) and parental outcomes across time will also be assessed.

Ethics And Dissemination: The study has received approval from Clinical Trials Ontario (CTO 1776). The findings will be published in peer-reviewed journals and disseminated to policymakers at local, national and international agencies. Findings will also be shared with study participants and their communities.

Trial Registration Number: ISRCTN13308752; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2020-046311DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7878148PMC
February 2021

Trajectory and Predictors of Fatigue Among Chinese Immigrant and Chinese Canadian-Born Women in the Postpartum Period.

J Obstet Gynecol Neonatal Nurs 2020 03 4;49(2):167-180. Epub 2020 Feb 4.

Objective: To describe the proportion of women with improving or worsening symptoms of fatigue at 1, 3, 6, and 12 months after birth; to model the trajectory of fatigue across the first year after birth and identify baseline predictors (e.g., immigrant status) and time-varying predictors; and to describe the degree to which fatigue interferes with activities of daily living across the first year after birth among a cohort of Chinese immigrant and Chinese Canadian-born women.

Design: Prospective cohort study.

Setting: Toronto, Ontario, Canada.

Participants: Chinese women who were recent immigrants (n = 244), nonrecent immigrants (n = 247), or Canadian born (n = 100).

Methods: Women completed surveys at 1, 3, 6, and 12 months after birth. We measured fatigue with the use of the Multidimensional Assessment of Fatigue scale. Fatigue predictor variables were classified as baseline (e.g., immigrant status) or time varying (e.g., depression). We used latent growth curve modeling to examine fatigue trajectories and identify predictors over time.

Results: Fatigue followed a nonlinear pattern: it improved from 1 to 6 months after birth and then worsened from 6 to 12 months after birth. Depression, anxiety, infant sleep characteristics, and breastfeeding problems, but not immigrant status, significantly increased risk for fatigue. Several daily activities were significantly influenced by fatigue, particularly early in the postpartum period as well as later, which showed a U-shaped relationship between fatigue and activities of daily living.

Conclusion: Fatigue is common and persistent across the postpartum period. Modifiable risk factors related to mental health, infant sleep, and breastfeeding difficulties suggest that preventive strategies for maternal fatigue warrant further investigation.
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http://dx.doi.org/10.1016/j.jogn.2019.12.003DOI Listing
March 2020

A comparative study of mothers of infants hospitalized in an open ward neonatal intensive care unit and a combined pod and single-family room design.

BMC Pediatr 2020 01 29;20(1):38. Epub 2020 Jan 29.

Neonatology, Jewish General Hospital, 3755 Côte-Ste-Catherine Rd, Montréal, Québec, H3T 1E2, Canada.

Background: The well-being of mothers of infants requiring Neonatal Intensive Care Unit (NICU) hospitalization may be affected by the architectural design of the unit. A few recent studies suggest there may be some drawbacks of single-family rooms (SFRs) for infants and their mothers, such as isolation of mothers and reduced exposure to auditory stimulation for infants.

Purpose: To compare NICU-stress, symptoms of depression, perceptions of nurse-parent support and family-centered care, sleep disturbances, breastfeeding self-efficacy and readiness for discharge in mothers of infants cared for in an open ward (OW) to those cared for in a unit that includes both pods and SFRs.

Methods: A pre-post quasi-experimental study was conducted in a Canadian level 3 unit before and after transitioning to a new unit of 6-bed pods and SFRs. OW data were collected in 2014 and pod/SFR data 1 year after the transition in 2017 to 2018. Mothers of infants hospitalized for at least 2 weeks completed questionnaires about stress, depressive symptoms, support, family-centered care, and sleep disturbances. In the week prior to discharge, they responded to breastfeeding self-efficacy and readiness for discharge questionnaires. They described their presence in the NICU at enrollment and again prior to discharge.

Results: Pod/SFR mothers reported significantly less NICU-stress compared to OW mothers. OW mothers had greater sights and sounds stress and felt more restricted in their parental role. Pod/SFR mothers reported greater respect from staff. Controlling for maternal education, pod/SFR mothers perceived their infant's readiness for discharge to be greater than OW mothers. There were no significant differences between groups in depressive symptoms, nurse-parent support, sleep disturbances, and breastfeeding self-efficacy. At enrollment and again in the weeks preceding discharge, pod/SFR mothers were present significantly more hours per week than OW mothers, controlling for maternal education.

Conclusions: Further study of small pods is indicated as these units may be less stressful for parents, and enhance family-centered care, as well as maternal presence, compared to OWs.
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http://dx.doi.org/10.1186/s12887-020-1929-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6988355PMC
January 2020

A call to action for expanded sleep research in pediatric oncology: A position paper on behalf of the International Psycho-Oncology Society Pediatrics Special Interest Group.

Psychooncology 2020 03 3;29(3):465-474. Epub 2019 Nov 3.

St. Jude Children's Research Hospital, Department of Psychology, Memphis, Tennessee.

Sleep and circadian rhythms are closely related to physical and psychosocial well-being. However, sleep and circadian rhythm disruptions are often overlooked in children with cancer, as they are frequently considered temporary side effects of therapy that resolve when treatment ends. Yet, evidence from adult oncology suggests a bidirectional relationship wherein cancer and its treatment disrupt sleep and circadian rhythms, which are associated with negative health outcomes such as poor immune functioning and lower survival rates. A growing body of research demonstrates that sleep problems are prevalent among children with cancer and can persist into survivorship. However, medical and psychosocial outcomes of poor sleep and circadian rhythmicity have not been explored in this context. It is essential to increase our understanding because sleep and circadian rhythms are vital components of health and quality of life. In children without cancer, sleep and circadian disturbances respond well to intervention, suggesting that they may also be modifiable in children with cancer. We present this paper as a call to (a) incorporate sleep or circadian rhythm assessment into pediatric cancer clinical trials, (b) address gaps in understanding the bidirectional relationship between sleep or circadian rhythms and health throughout the cancer trajectory, and (c) integrate sleep and circadian science into oncologic treatment.
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http://dx.doi.org/10.1002/pon.5242DOI Listing
March 2020

Acceptability to nurses of reducing NICU light and noise levels during skin-to-skin care: A pilot study.

Appl Nurs Res 2019 06 22;47:29-31. Epub 2019 Mar 22.

Faculty of Nursing, Université de Montréal, C.P. 6128 Succ. Centre-ville, Montréal, QC, H3C 3J7, Canada; CHU Sainte-Justine Research Center, 3175 Chemin de la Côte-Sainte-Catherine, Montréal, QC, H3T 1C5, Canada.

Introduction: Light and noise levels may influence preterm infants and their mothers when they are experiencing skin-to-skin contact [SSC] in the Neonatal Intensive Care Unit [NICU].

Methods: A pilot randomized controlled trial [RCT] of an intervention aiming at reducing light and noise levels during SSC was conducted. Twenty-one neonatal nurses from a level III NICU completed questionnaires assessing their acceptability of NICU light and noise levels reduction during SSC, whether it interfered with their care delivery, in addition to acceptability of specific interventions reducing these levels.

Findings: The majority of nurses considered that the reduction of NICU light and noise levels during SSC was acceptable in general, did not interfere with their care delivery, and that the nine selected interventions were also acceptable.

Conclusion And Research Implications: Nurses found it acceptable to reduce NICU light and noise levels during SSC. These findings support the conduct of a full-scale RCT to evaluate the effect of such an intervention on preterm infants and mothers' well-being.
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http://dx.doi.org/10.1016/j.apnr.2019.03.001DOI Listing
June 2019

Self-Reported Sleep Quality and Actigraphic Measures of Sleep in New Mothers and the Relationship to Postpartum Depressive Symptoms.

Behav Sleep Med 2020 May-Jun;18(3):396-405. Epub 2019 Apr 21.

Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.

: This study's purpose is to examine relationships between self-reported sleep quality, actigraphy data, and depressive symptoms in a sample of women at 6 and 12 weeks postpartum. : This secondary analysis of data from a randomized controlled trial (RCT) of a behavioral sleep intervention measured sleep with actigraphy and self-report. Self-reported measures included the General Sleep Disturbance Scale (GSDS) and mothers' reports of their sleep as a "small/big/no" problem. Depression was measured with the Edinburgh Postnatal Depression Scale (EPDS). Control variables included group allocation, baseline EPDS, and social support. Logistic regression estimated the association between self-reported and actigraphic measures of sleep and the presence of postpartum depressive symptoms. Separate models estimated the odds of depression according to each sleep variable. : In 217 first-time mothers, GSDS scores in the last week of pregnancy were not related to depression; however, GSDS scores at 6 weeks postpartum were associated with > 3 times the odds of depressive symptoms (OR = 3.56; 95% CI = 1.73-7.33) at either 6 or 12 weeks postpartum. The perception that sleep was a "small" or "big" problem at 6 weeks was associated with > 3 (OR = 3.40; 95% CI = 1.54-7.46) and > 8 (OR = 8.29; 95% CI = 2.41-28.59) times the odds of depressive symptoms at either 6 or 12 weeks, respectively. Significant associations between actigraphic sleep measures and depressive symptoms were not found. : Self-reported sleep quality is strongly associated with postpartum depressive symptoms. Sleep concerns may be an important clinical indicator of low mood in the postpartum period. Future intervention studies to improve mood could target sleep concerns via cognitive-behavioral strategies.
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http://dx.doi.org/10.1080/15402002.2019.1601629DOI Listing
June 2020

JPP Student Journal Club Commentary: Technology Use and Sleep in Adolescents With and Without Attention-Deficit/Hyperactivity Disorder.

J Pediatr Psychol 2019 06;44(5):527-529

Lawrence S. Bloomberg Faculty of Nursing, University of Toronto and The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada.

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http://dx.doi.org/10.1093/jpepsy/jsz023DOI Listing
June 2019

Sleep in parents of preterm infants: A systematic review.

Midwifery 2019 Jun 5;73:35-48. Epub 2019 Mar 5.

Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada; The Hospital for Sick Children (SickKids), Toronto, Ontario, Canada.

Background: Sleep disruption during the first postpartum year is associated with several negative health outcomes including postpartum depression. Such disruption may be a greater issue for parents of preterm neonates, yet literature on this subject has not been critically reviewed.

Objective: To synthesize literature on sleep quantity, sleep quality, and factors influencing sleep among parents of preterm infants during infant hospitalization and following discharge.

Design: A systematic review.

Data Sources: Medline, EMBASE, CINAHL, PsycINFO, Scopus, and Cochrane Database of Systematic Reviews were searched from their inception to February 2017.

Methods: Potentially eligible citations were reviewed by two independent reviewers. Both quantitative and qualitative studies were eligible for inclusion. Data on eligible studies and review outcomes were extracted using a customized form.

Findings: Eighteen reports from 16 studies met inclusion criteria. Four studies included a control group of parents of full-term infants. Three studies reported sleep quantity means, of which only one provided values for an exclusive sample of mothers of preterm infants and found on average, mothers obtained 6.3 h of sleep/day in the first 5-10 days. Twelve studies reported on sleep quality; most (n = 10) relied on self-reported measures and identified poor subjective sleep quality whereas two studies objectively measured sleep of poor quality. Parental stress was the most consistent factor associated with sleep quality.

Conclusion And Implications: Quality and quantity of sleep among parents of preterm infants is inadequate and may negatively influence family health outcomes. Further research on correlates and changes in sleep is required to identify at-risk parents and inform targeted clinical recommendations and interventions aimed at maximizing sleep for parents of preterm infants.
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http://dx.doi.org/10.1016/j.midw.2019.01.009DOI Listing
June 2019

Prevalence and Predictors of Postpartum Maternal and Infant Bed-Sharing Among Chinese-Canadian Women.

Behav Sleep Med 2020 Jan-Feb;18(1):120-130. Epub 2018 Dec 25.

Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.

: Our primary objective was to describe and identify predictors of any and predominant bed-sharing at 4 and 12 weeks postpartum among Chinese-Canadian mothers. : We conducted a longitudinal study of 570 Chinese immigrant and Canadian-born women in Toronto, Ontario. : Any bed-sharing, defined as sharing a bed or mattress for any part of the night on any night in the previous week, and predominant bed-sharing, defined as sharing a bed or mattress for most of the night, on more than half the nights of the previous week, were evaluated at 4 and 12 weeks postpartum. Predictors of bed-sharing, evaluated in multivariable logistic regression models, were background (age, parity, education, household size, delivery mode, social support), cultural (immigrant status, acculturative stress, acculturation, postpartum ritual uptake), and postpartum variables (mental health, breastfeeding problems, fatigue, sleep knowledge, plans for bed-sharing, perceptions of infant sleep problems, cognitions about infant sleep). : One in five women (20.7%) reported bed-sharing as the predominant sleep location for their infant at 4 weeks postpartum, with nearly half (45.6%) reporting any bed-sharing at this time. The prevalence of any bed-sharing remained relatively stable at 12 weeks postpartum (46.5%), while predominant bed-sharing increased to 30.1%. The most consistent predictors of any and predominant bed-sharing at 4 and 12 weeks postpartum were lower education level, greater acculturative stress, and predelivery plans to bed-share. : These findings have implications for the development of clinical recommendations given to expectant and new parents to promote infant sleep practices that are consistent with American Academy of Pediatrics recommendations.
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http://dx.doi.org/10.1080/15402002.2018.1546179DOI Listing
March 2020

Sleep Outcomes for Parents of Children With Neurodevelopmental Disabilities: A Systematic Review.

J Fam Nurs 2018 05 8;24(2):217-249. Epub 2018 May 8.

1 University of Toronto, Ontario, Canada.

Parents of children with Neurodevelopmental Disabilities (NDDs) are at risk of sleep loss. No comprehensive systematic reviews examining parental sleep outcomes in caregivers of children with NDDs exist. A systematic search was conducted between June and August 2016 examining sleep quantity, quality, sleepiness, and fatigue outcomes of caregivers of children with NDDs. Of 7,534 citations retrieved, 33 met eligibility criteria. Most studies ( n = 27) were cross-sectional, included a range of NDDs and were of "poor" ( n = 14) or "fair" ( n = 17) quality. Few good quality studies compared objectively measured sleep in parents of children with NDDs with parents with typically developing children. Parents of children with NDDs consistently reported significantly poorer subjective sleep quality. There is a paucity of good quality comparative studies, using well-validated measures, examining parental sleep outcomes. Future research should aim to fill this gap, providing greater insight to parents' experiences, and identifying targets for intervention design and evaluation.
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http://dx.doi.org/10.1177/1074840718773381DOI Listing
May 2018

A Pilot Randomized Controlled Trial of an Intervention to Promote Psychological Well-Being in Critically Ill Children: Soothing Through Touch, Reading, and Music.

Pediatr Crit Care Med 2018 07;19(7):e358-e366

Department of Pediatrics, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.

Objectives: To examine the feasibility and acceptability of a PICU Soothing intervention using touch, reading, and music.

Design: Nonblinded, pilot randomized controlled trial.

Setting: The PICU and medical-surgical wards of one Canadian pediatric hospital.

Patients: Twenty PICU patients age 2-14 years old and their parents, randomized to an intervention group (n = 10) or control group (n = 10).

Intervention: PICU Soothing consisted of: 1) parental comforting (touch and reading), followed by 2) a quiet period with music via soft headbands, administered once daily throughout hospitalization.

Measurements And Main Results: Acceptability and feasibility of the intervention and methods were assessed via participation rates, observation, measurement completion rates, semistructured interviews, and telephone calls. Psychological well-being was assessed using measures of distress, sleep, and child and parent anxiety in the PICU, on the wards and 3 months post discharge. Forty-four percent of parents agreed to participate. Seventy percent and 100% of intervention group parents responded positively to comforting and music, respectively. Most intervention group parents (70%) and all nurses felt children responded positively. All nurses found the intervention acceptable and feasible. Measurement completion rates ranged from 70% to 100%. Pilot data suggested lower intervention group child and parent anxiety after transfer to hospital wards.

Conclusions: PICU Soothing is acceptable and feasible to conduct. Results support the implementation of a full-scale randomized controlled trial to evaluate intervention effectiveness.
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http://dx.doi.org/10.1097/PCC.0000000000001556DOI Listing
July 2018

Evaluation of an Internet-Based Behavioral Intervention to Improve Psychosocial Health Outcomes in Children With Insomnia (Better Nights, Better Days): Protocol for a Randomized Controlled Trial.

JMIR Res Protoc 2018 Mar 26;7(3):e76. Epub 2018 Mar 26.

Department of Psychology & Neuroscience, Dalhousie University, Halifax, NS, Canada.

Background: Up to 25% of 1- to 10-year-old children experience insomnia (ie, resisting bedtime, trouble falling asleep, night awakenings, and waking too early in the morning). Insomnia can be associated with excessive daytime sleepiness and negative effects on daytime functioning across multiple domains (eg, behavior, mood, attention, and learning). Despite robust evidence supporting the effectiveness of behavioral treatments for insomnia in children, very few children with insomnia receive these treatments, primarily due to a shortage of available treatment resources.

Objective: The Better Nights, Better Days (BNBD) internet-based program provides a readily accessible electronic health (eHealth) intervention to support parents in providing evidence-based care for insomnia in typically developing children. The purpose of the randomized controlled trial (RCT) is to evaluate the effectiveness of BNBD in treating insomnia in children aged between 1 and 10 years.

Methods: BNBD is a fully automated program, developed based on evidence-based interventions previously tested by the investigators, as well as on the extant literature on this topic. We describe the 2-arm RCT in which participants (500 primary caregivers of children with insomnia residing in Canada) are assigned to intervention or usual care.

Results: The effects of this behavioral sleep eHealth intervention will be assessed at 4 and 8 months postrandomization. Assessment includes both sleep (actigraphy, sleep diary) and daytime functioning of the children and daytime functioning of their parents. Results will be reported using the standards set out in the Consolidated Standards of Reporting Trials statement.

Conclusions: If the intervention is supported by the results of the RCT, we plan to commercialize this program so that it is sustainable and available at a low cost to all families with internet access.

Trial Registration: ClinicalTrials.gov NCT02243501; https://clinicaltrials.gov/show/NCT02243501 (Archived by WebCite at http://www.webcitation.org/6x8Z5pBui).
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http://dx.doi.org/10.2196/resprot.8348DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5891669PMC
March 2018

Effectiveness of interventions during NICU hospitalization on the neurodevelopment of preterm infants: a systematic review protocol.

Syst Rev 2017 11 3;6(1):225. Epub 2017 Nov 3.

Faculty of Nursing, Université de Montréal, Montréal, Canada.

Background: Previous systematic reviews have examined preterm infants' long-term neurodevelopment after neonatal intensive care unit (NICU) discharge, although none have explored the effectiveness of interventions on preterm infants' neurodevelopment during NICU hospitalization. The aim of this review is to evaluate whether interventions, i.e., sensory stimulation, parental involvement, and control of environment, improve preterm infants' neurodevelopment during their NICU hospitalization.

Methods: Experimental studies such as randomized controlled/clinical trials (RCTs) and cluster RCT will be included in this systematic review. Selected studies will be published in English or in French, in the past 15 years from 2002 to 2017. The following electronic databases will be searched to locate relevant studies: CINAHL, MEDLINE, PubMed, EMBASE (OVID), Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science. For all steps in selecting studies, agreement will be reached between two experts in neonatology. Data extraction will be performed independently by the two same experts and will then be compared. The Cochrane assessment tool will be used to screen the studies for risk of bias. A meta-analysis will be performed if the included studies are sufficiently homogeneous. Results will be analyzed using a standardized mean difference (with a 95% confidence interval). Statistical heterogeneity will be evaluated using the χ test at the significance level of 0.1 and the I with the classification suggested by PRISMA-P. If possible, subgroup analyses will be carried out considering preterm infants' gestational age, length of NICU hospitalization, and the characteristics of the intervention such as who delivered it, the type, the dose, the frequency, and the duration. Data synthesis will be performed using the RevMan 5.1 software. Publication bias and selection of variables in publication will be examined using the graphical method of funnel plot and with the statistical test of Egger. Quality of the evidence of all outcomes will be assessed using the Grades of Recommendations Assessment, Development and Evaluation (GRADE) Working Group.

Discussion: The results of this systematic review will highlight which interventions are effective for promoting preterm infants' neurodevelopment during NICU hospitalization and will contribute to the body of knowledge in neonatal care by providing guidance for NICU clinical practice and research.

Systematic Review Registration: PROSPERO CRD42017047072.
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http://dx.doi.org/10.1186/s13643-017-0613-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5670699PMC
November 2017

Sleep disturbance in family caregivers of children who depend on medical technology.

Arch Dis Child 2018 02 26;103(2):137-142. Epub 2017 Oct 26.

Hospital for Sick Children, Toronto, Ontario, Canada.

Objectives: Family caregivers of children who depend on medical technology (CMT) provide highly skilled care up to 24 hours per day. Sleep disruption places family caregivers at risk for poor health and related outcomes that threaten their long-term caregiving capacity. Few studies exist that have measured sleep in family caregivers, and most have relied entirely on subjective measures.

Methods: In a prospective cohort study, family caregivers of CMT (n=42) and caregivers of healthy children (n=43) were recruited. Actigraphy data and a concurrent sleep diary were collected for 6 days/7 nights. Measures of sleep quality, depression, sleepiness, fatigue and quality of life were also administered.

Results: Family caregivers of CMT averaged fewer hours of sleep per night (mean (SD)) (6.56 ± 1.4 vs 7.21 ± 0.6, p0.02) of poorer quality (7.75 ± 2.9 vs 5.45 ± 2.8, p0.01) than the control group. Three times as many family caregivers of CMT scored in the range for significant depressive symptomatology (12(33%) vs 4(10%), p0.01) and experienced excessive daytime sleepiness (16(38%) vs 5(12%), p0.01). Fatigue was also more problematic among family caregivers of CMT (22.12 ± 9.1 vs 17.44 ± 9.0, p0.02).

Conclusions: Family caregivers of CMT are at risk of acute and chronic sleep deprivation, psychological distress and impaired daytime function that may threaten their capacity for sustained caregiving. Family caregivers of CMT may be important targets for screening for sleep disorders and the development of novel sleep-promoting interventions.
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http://dx.doi.org/10.1136/archdischild-2016-312205DOI Listing
February 2018

Psychological Outcomes in Parents of Critically Ill Hospitalized Children.

J Pediatr Nurs 2017 May - Jun;34:36-43. Epub 2017 Mar 6.

The Hospital for Sick Children (SickKids), Toronto, Canada.

Parents of children in pediatric intensive care units (PICUs) are subjected to significant psychological stress. The purpose of this study was to determine the prevalence of, and factors associated with anxiety, depressive symptoms and decisional conflict in parents of children hospitalized in the PICU. The study employed a descriptive, cross-sectional design to investigate the psychological status of 118 parents of 91 children (74 mothers and 44 fathers) admitted to the PICU, using measures of anxiety (STAI), depression (CES-D), and decisional conflict (DCS). Using hospital data and self-administered questionnaires, information on child and parent characteristics and psychological outcomes were collected. Objective measures of parental sleep also were examined using actigraphy and sleep diaries. The research findings indicated that 24% of parents achieved scores characteristic of severe anxiety. Proportions of parents with symptoms indicative of major depression and significant decisional conflict were 51% and 26% respectively. For all psychological outcomes, higher levels of social support were protective. Inconsistency in sleep schedule and sleep location affected psychological outcomes and are possible targets for future interventions. Given evidence that parents of children admitted to the PICU are at risk for developing post-traumatic stress symptoms, future studies should examine the effects of hospitalization on long-term parental psychological outcomes. Screening for those at risk and implementing interventions to promote coping strategies and reduce decisional conflict may be beneficial. Pediatric nurses have a critical role in assessing parents' psychological distress and promoting family health during a child's hospitalization.
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http://dx.doi.org/10.1016/j.pedn.2017.01.012DOI Listing
April 2018

A Sleep Hygiene and Relaxation Intervention for Children With Acute Lymphoblastic Leukemia: A Pilot Randomized Controlled Trial.

Cancer Nurs 2017 Nov/Dec;40(6):488-496

Author Affiliations: Division of Haematology/Oncology (SickKids) (Mss Zupanec and Jones) and Division of Neurosurgery, Neurology, & Trauma (Ms McRae), The Hospital for Sick Children (SickKids); Faculty of Health Sciences, University of Ontario Institute of Technology (Dr Papaconstantinou), Oshawa; Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada (Ms Weston and Dr Stremler).

Background: Sleep disturbance and fatigue are common and distressing pediatric cancer-related outcomes. Sleep hygiene education and relaxation techniques are recommended to improve sleep in healthy children and adult cancer survivors. No studies have tested these interventions to improve sleep and fatigue for children with acute lymphoblastic leukemia (ALL) in the home setting.

Objectives: The aim of this study is to establish the feasibility and acceptability of a sleep hygiene and relaxation intervention to improve sleep and fatigue for children receiving maintenance chemotherapy for ALL. The child's fatigue and sleep data were collected to inform sample size calculations for a future trial.

Methods: In this pilot randomized controlled trial, 20 children were allocated randomly to the sleep intervention or control group. The sleep intervention group received a 60-minute educational session to discuss sleep and fatigue in children with cancer and strategies to improve sleep, including use of 2 storybooks to teach deep breathing and progressive muscle relaxation. Objective sleep data were collected using actigraphy and fatigue was measured using the Childhood Cancer Fatigue Scale.

Results: The intervention was acceptable to families, and feasibility of the intervention and data collection was clearly established. Although not statistically significant, increases in mean nighttime sleep and decreases in mean wake time after sleep onset in the sleep intervention group represented clinically important improvements.

Conclusions: This pilot study demonstrated the feasibility and acceptability of a sleep hygiene and relaxation intervention for children undergoing maintenance chemotherapy for ALL.

Implications For Practice: Given the clinically important improvements in sleep observed, replication in a larger, adequately powered randomized controlled trial is merited.
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http://dx.doi.org/10.1097/NCC.0000000000000457DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5647114PMC
December 2017

A Behavioral-Educational Intervention to Promote Pediatric Sleep During Hospitalization: A Pilot Randomized Controlled Trial.

Behav Sleep Med 2018 Jul-Aug;16(4):356-370. Epub 2016 Sep 15.

c Lawrence S. Bloomberg Faculty of Nursing , University of Toronto , Toronto , Canada.

Objective/background: Hospitalization can contribute to common sleep difficulties in children. Interventions aimed at hospitalized children need to be developed and piloted with rigorous evaluative methods. The primary purpose of this study was to examine the feasibility and acceptability of a behavioral-educational intervention aimed at increasing nighttime sleep for hospitalized children.

Participants: Hospitalized children aged 4-10 years and their caregivers.

Methods: A pilot randomized, controlled trial with concealed-group allocation was conducted. Forty-eight hospitalized children (ages 4-10) and their care-givers were randomized to either the Relax to Sleep (RTS) intervention group (n = 24) or the Usual Care (UC) comparison group (n = 24). The RTS intervention was comprised of a one-on-one educational session for the parent that was guided by a standardized booklet containing information on sleep and instructions for training the child in the use of a diaphragmatic breathing exercise. UC participants received no information about sleep or relaxation. Children wore actigraphs for 3 days and nights and completed sleep diaries. Outcome measures included feasibility, acceptability, and sleep outcomes.

Results: Parental reports indicated they enjoyed the discussion on sleep, found the information helpful, and their child found diaphragmatic breathing easy to use, and would use it again in the future. Children in the RTS group averaged 50 minutes more nighttime sleep, and had less wake after sleep onset time compared to children in the UC group.

Conclusion: Sleep is critically important to children's health and well-being and should be given important consideration during hospitalization. Although the results of this pilot trial seem promising, more interventional studies are needed.
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http://dx.doi.org/10.1080/15402002.2016.1228639DOI Listing
November 2018

Technology-Enabled Remote Monitoring and Self-Management - Vision for Patient Empowerment Following Cardiac and Vascular Surgery: User Testing and Randomized Controlled Trial Protocol.

JMIR Res Protoc 2016 Aug 1;5(3):e149. Epub 2016 Aug 1.

McMaster University, Hamiltion, ON, Canada.

Background: Tens of thousands of cardiac and vascular surgeries (CaVS) are performed on seniors in Canada and the United Kingdom each year to improve survival, relieve disease symptoms, and improve health-related quality of life (HRQL). However, chronic postsurgical pain (CPSP), undetected or delayed detection of hemodynamic compromise, complications, and related poor functional status are major problems for substantial numbers of patients during the recovery process. To tackle this problem, we aim to refine and test the effectiveness of an eHealth-enabled service delivery intervention, TecHnology-Enabled remote monitoring and Self-MAnagemenT-VIsion for patient EmpoWerment following Cardiac and VasculaR surgery (THE SMArTVIEW, CoVeRed), which combines remote monitoring, education, and self-management training to optimize recovery outcomes and experience of seniors undergoing CaVS in Canada and the United Kingdom.

Objective: Our objectives are to (1) refine SMArTVIEW via high-fidelity user testing and (2) examine the effectiveness of SMArTVIEW via a randomized controlled trial (RCT).

Methods: CaVS patients and clinicians will engage in two cycles of focus groups and usability testing at each site; feedback will be elicited about expectations and experience of SMArTVIEW, in context. The data will be used to refine the SMArTVIEW eHealth delivery program. Upon transfer to the surgical ward (ie, post-intensive care unit [ICU]), 256 CaVS patients will be reassessed postoperatively and randomly allocated via an interactive Web randomization system to the intervention group or usual care. The SMArTVIEW intervention will run from surgical ward day 2 until 8 weeks following surgery. Outcome assessments will occur on postoperative day 30; at week 8; and at 3, 6, 9, and 12 months. The primary outcome is worst postop pain intensity upon movement in the previous 24 hours (Brief Pain Inventory-Short Form), averaged across the previous 14 days. Secondary outcomes include a composite of postoperative complications related to hemodynamic compromise-death, myocardial infarction, and nonfatal stroke- all-cause mortality and surgical site infections, functional status (Medical Outcomes Study Short Form-12), depressive symptoms (Geriatric Depression Scale), health service utilization-related costs (health service utilization data from the Institute for Clinical Evaluative Sciences data repository), and patient-level cost of recovery (Ambulatory Home Care Record). A linear mixed model will be used to assess the effects of the intervention on the primary outcome, with an a priori contrast of weekly average worst pain intensity upon movement to evaluate the primary endpoint of pain at 8 weeks postoperation. We will also examine the incremental cost of the intervention compared to usual care using a regression model to estimate the difference in expected health care costs between groups.

Results: Study start-up is underway and usability testing is scheduled to begin in the fall of 2016.

Conclusions: Given our experience, dedicated industry partners, and related RCT infrastructure, we are confident we can make a lasting contribution to improving the care of seniors who undergo CaVS.
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http://dx.doi.org/10.2196/resprot.5763DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4999307PMC
August 2016

Sleep disturbance in family caregivers of children who depend on medical technology: A systematic review.

J Pediatr Rehabil Med 2015 ;8(2):113-30

The Hospital for Sick Children, Toronto, ON, Canada.

Purpose: Society relies on family caregivers of children who depend on medical technology (e.g. mechanical ventilation), to provide highly skilled and vigilant care in their homes 24 hours per day. Sleep disturbance is among the most common complaints of these caregivers. The purpose of this review is to systematically examine studies reporting on sleep outcomes in family caregivers of technology dependent children.

Methods: All relevant databases were systematically searched: MEDLINE, EMBASE, PsycINFO and CINAHL. Given the heterogeneity of the studies, a qualitative analysis was completed and thus results of this review are presented as a narrative.

Results: Thirteen studies were retrieved that met eligibility criteria for inclusion. All of the studies reported on family caregivers of children with medical complexity living at home. Moreover, all of the studies relied entirely on self-report, not objective sleep measures. No intervention studies were found. Sleep disturbance was found to be common (51-100%) along with caregiver reports of poor sleep quality. Sleep quantity was seldom measured, but was found in the few studies that did, to be approximately 6 hours, or less than recommendations for optimal health and daytime function. Multiple caregiver, child and environmental factors were also identified that may negatively influence caregiver sleep, health and daytime function.

Conclusion: Findings of this review suggest that family caregivers of children with medical complexity who depend on medical technology achieve poor sleep quality and quantity that may place them at risk of the negative consequences of sleep deprivation. Recommendations for practice include that health care providers routinely assess for sleep disturbance in this vulnerable population. The review also suggests that studies using objective sleep measurement are needed to more fully characterize sleep and inform the development of targeted interventions to promote sleep in family caregivers of technology dependent children.
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http://dx.doi.org/10.3233/PRM-150325DOI Listing
July 2016

Nurses' views of factors affecting sleep for hospitalized children and their families: A focus group study.

Res Nurs Health 2015 Aug 13;38(4):311-22. Epub 2015 May 13.

Clinical Nurse Specialist, Bereavement Coordinator, Critical Care, The Hospital for Sick Children, Toronto, Canada.

Light, noise, and interruptions from hospital staff lead to frequent awakenings and detrimental changes to sleep quantity and quality for children who are hospitalized and their parents who stay with them overnight. An understanding of nurses' views on how care affects sleep for the hospitalized child and parent is crucial to the development of strategies to decrease sleep disturbance in hospital. The purpose of this descriptive qualitative study was to gain an understanding of nurses' views on their role in and influence on sleep for families; perceived barriers and facilitators of patient and parent sleep at night; strategies nurses use to preserve sleep; the distribution, between parent and nurse, of care for the child at night; views of the parent as a recipient of nursing care at night; and the nature of interactions between nurses and families at night. Thirty registered nurses from general pediatric and critical care units participated in one of four semi-structured focus groups. Four main influences on sleep were identified: child factors; environmental factors; nurse-parent interaction factors; and nursing care factors. Some of these restricted nurses' ability to optimize sleep, but many factors were amenable to intervention. Balancing strategies to preserve sleep with the provision of nursing assessment and intervention was challenging and complicated by the difficult nature of work outside of usual waking hours. Nurses highlighted the need for formal policy and mentoring related to provision of nursing care at night in pediatric settings.
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http://dx.doi.org/10.1002/nur.21664DOI Listing
August 2015

Children's psychological and behavioral responses following pediatric intensive care unit hospitalization: the caring intensively study.

BMC Pediatr 2014 Oct 26;14:276. Epub 2014 Oct 26.

The Montreal Children's Hospital, McGill University Health Centre, 2300 Tupper Street, Montreal, Quebec, Canada.

Background: Pediatric intensive care unit (PICU) hospitalization places children at increased risk of persistent psychological and behavioral difficulties following discharge. Despite tremendous advances in medical technology and treatment regimes, approximately 25% of children demonstrate negative psychological and behavioral outcomes within the first year post-discharge. It is imperative that a broader array of risk factors and outcome indicators be explored in examining long-term psychological morbidity to identify areas for future health promotion and clinical intervention. This study aims to examine psychological and behavioral responses in children aged 3 to 12 years over a three year period following PICU hospitalization, and compare them to children who have undergone ear, nose and/or throat (ENT) day surgery.

Methods/design: This mixed-methods prospective cohort study will enrol 220 children aged 3 to 12 years during PICU hospitalization (study group, n = 110) and ENT day surgery hospitalization (comparison group, n = 110). Participants will be recruited from 3 Canadian pediatric hospitals, and followed for 3 years with data collection points at 6 weeks, 6 months, 1 year, 2 years and 3 years post-discharge. Psychological and behavioral characteristics of the child, and parent anxiety and parenting stress, will be assessed prior to hospital discharge, and again at each of the 5 subsequent time points, using standardized measures. Psychological and behavioral response scores for both groups will be compared at each follow-up time point. Multivariate regression analysis will be used to adjust for demographic and clinical variables at baseline. To explore baseline factors predictive of poor psychological and behavioral scores at 3 years among PICU patients, correlation analysis and multivariate linear regression will be used. A subgroup of 40 parents of study group children will be interviewed at years 1 and 3 post-discharge to explore their perceptions of the impact of PICU hospitalization on their children and enhance our understanding of findings generated from standardized measures in the larger cohort study. An interpretive descriptive approach will guide qualitative data collection and analysis.

Discussion: This study aims to generate new information regarding the magnitude and duration of psychological and behavioral disturbances among children admitted to PICUs, potentially leading to remedial or preventive interventions.
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http://dx.doi.org/10.1186/1471-2431-14-276DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4286947PMC
October 2014

Evaluating the feasibility of a parent-briefing intervention in a pediatric acute care setting.

J Spec Pediatr Nurs 2014 Jul 11;19(3):219-28. Epub 2014 Mar 11.

Daphne Cockwell School of Nursing, Ryerson University, Toronto, Ontario, Canada.

Purpose: The purpose of this study was to test the feasibility of a parent-briefing intervention for parents of hospitalized children with complex healthcare needs.

Design And Methods: A phase I, single-group, posttest study. There were 18 physicians, 25 nurses, and 31 parents who participated in the study. Participants were asked to sit while carrying out the briefings with parents. Parents and clinicians completed a feasibility questionnaire post briefings.

Results: Sixty-eight briefings were carried out. Parents and nurses evaluated the briefings in a favorable manner, whereas physicians' ratings were mixed.

Practice Implications: Further inquiry is recommended to understand the effects of a structured communication intervention on parent-professional decision-making practices.
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http://dx.doi.org/10.1111/jspn.12073DOI Listing
July 2014

Bourdieu at the bedside: briefing parents in a pediatric hospital.

Nurs Inq 2014 Dec 28;21(4):327-35. Epub 2014 Jan 28.

Daphne Cockwell School of Nursing, Faculty of Community Services, Ryerson University, Toronto, ON, Canada; The Hospital for Sick Children, Toronto, ON, Canada.

The philosophy of family-centered care (FCC) promotes partnerships between families and staff to plan, deliver, and evaluate services for children and has been officially adopted by a majority of pediatric hospitals throughout North America. However, studies indicated that many parents have continued to be dissatisfied with their decision-making roles in their child's care. This is particularly salient for parents of children with chronic ongoing complex health problems. These children are dependent upon medical technology and require frequent hospitalizations during which parents must contribute to difficult decisions regarding their child's care. Given this clinical issue, an alternative theoretical perspective was explored to redress this problem. Pierre Bourdieu's theoretical concepts of field, capital, and habitus were used to analyze the hierarchical relationships in pediatric acute care hospitals and to design a briefing intervention aimed at improving parents' satisfaction with decision making in that health care setting.
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http://dx.doi.org/10.1111/nin.12063DOI Listing
December 2014

Sleep, sleepiness, and fatigue outcomes for parents of critically ill children.

Pediatr Crit Care Med 2014 Feb;15(2):e56-65

1Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada. 2The Hospital for Sick Children (SickKids), Toronto, ON, Canada. 3Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.

Objectives: To describe sleep quantity, sleep patterns, fatigue, and sleepiness for parents of critically ill hospitalized children.

Design: Prospective observational study.

Setting: Quaternary academic PICU.

Participants: One hundred eighteen parents of 91 children recruited during their child's PICU stay.

Interventions: None.

Measurements And Main Results: For 5 days and nights, parents wore an actigraph to determine objective sleep-wake times and reported sleep location, level of fatigue (Fatigue Visual Analogue Scale), and sleepiness (Stanford Sleepiness Scale). Mean amounts of nocturnal sleep were less than recommended for optimal health (398 min, fathers vs 422 min, mothers; p = 0.04). Parents woke frequently (7.8 wakes, fathers; 7.2 wakes, mothers) and spent over an hour awake at night (65 min, fathers; 60 min, mothers). On 130 nights (26%), parents slept less than 6 hours and 209 nights (44%) were evaluated as "worse" sleep than usual. Fifty-four parents (53%) experienced more than 30% difference in minutes of sleep between consecutive nights. Mean morning fatigue levels (41 mm, fathers vs 46 mm, mothers; p = 0.03) indicated clinically significant fatigue. Sleeping in a hotel, parent room, or residence was associated with 3.2 more wakes per night (95% CI, 0.61-5.78; p = 0.015) than sleeping in a hospital lounge or waiting room.

Conclusions: We performed a prospective observational study of 118 parents of critically ill children using objective measures of sleep and validated scales to assess fatigue and sleepiness. We found that more than a quarter of nights met criteria for acute sleep deprivation, there was considerable variability in the amount of nocturnal sleep that individual participants slept on different nights, and sleep was fragmented with a large portion of the night spent awake. Future research should focus on interventions that improve parents' ability to return to sleep upon awakening and maintain regular sleep-wake schedules.
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http://dx.doi.org/10.1097/01.pcc.0000436198.15337.15DOI Listing
February 2014

Repeated hands-and-knees positioning during labour: a randomized pilot study.

PeerJ 2013 12;1:e25. Epub 2013 Feb 12.

Lawrence S. Bloomberg Faculty of Nursing , University of Toronto , Toronto , Canada.

Background. Caesarean birth rates in North America continue to rise, in the absence of benefit for mothers and babies. One reason may be that hospitalized labouring women spend most of their labours in recumbent or semi-recumbent positions. Although hands-and-knees position has theoretical advantages, efforts to encourage its adoption in practice are severely hampered by the lack of compelling evidence that it is beneficial. Before a definitive, large scale trial, with spontaneous vaginal birth as the primary outcome, could be justified in terms of time, effort, and expense, several feasibility and acceptability questions had to be addressed. We aimed to enrol 60 women in a pilot study to assess feasibility and acceptability of the trial protocol, and to obtain estimates of treatment effects on method of birth and persistent back pain. Methods. We conducted a pilot study at two North American hospitals. In ten months of recruitment, 30 nulliparous women in labour at term were randomly allocated to either usual care (use of any position during labour except hands-and-knees) or to try hands-and-knees for 15 min every hour during labour. Data were collected about compliance, acceptability, persistent back pain, intrapartum interventions, and women's views of their experiences. Results. Although mean length of time from randomization to delivery was over 12 hours, only 9 of the 16 women allocated to repeated hands-and-knees used it more than twice. Two of the 14 in the usual care group used hands-and-knees once. Twenty-seven women had regional analgesia (15 in the hands-and-knees group and 12 in the usual care group). Eleven in the hands-and-knees group and 14 in the usual care group had spontaneous vaginal births. One woman (in the hands-and-knees group) had a vacuum extraction. Four women in the hands-and-knees group and none in the usual care group gave birth by caesarean section. Hourly back pain ratings were highly variable in both groups, covering the full range of possible scores. Given the low compliance with the hands-and-knees position, it was not possible to explore relationships between use of the position and persistent back pain scores. When asked to rate their overall satisfaction with their birth experiences, the hands-and-knees group's ratings tended to be lower than those in the usual care group, although 11 in the hands-and-knees group and 8 in the usual care group stated they would probably or definitely try the position in a subsequent labour. Conclusion. We concluded that we could not justify the time and expense associated with a definitive trial. However such a trial could be feasible with modifications to eligibility criteria and careful selection of suitable settings.
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http://dx.doi.org/10.7717/peerj.25DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3629039PMC
July 2013

Effect of behavioural-educational intervention on sleep for primiparous women and their infants in early postpartum: multisite randomised controlled trial.

BMJ 2013 Mar 20;346:f1164. Epub 2013 Mar 20.

Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.

Objective: To evaluate the effectiveness of a behavioural-educational sleep intervention delivered in the early postpartum in improving maternal and infant sleep.

Design: Randomised controlled trial.

Setting: Postpartum units of two university affiliated hospitals.

Participants: 246 primiparous women and their infants randomised while in hospital with an internet based randomisation service to intervention (n=123) or usual care (n=123) groups.

Interventions: The behavioural-educational sleep intervention included a 45-60 minute meeting with a nurse to discuss sleep information and strategies to promote maternal and infant sleep, a 20 page booklet with the content discussed, and phone contacts at one, two, and four weeks postpartum to reinforce information, provide support, and problem solve. The usual care group received calls at weeks one, two, and four to maintain contact without provision of advice.

Main Outcome Measures: Primary outcome was maternal nocturnal (9 pm to 9 am) sleep (minutes) and secondary outcome was longest stretch of infant nocturnal sleep (minutes) measured at six and 12 weeks postpartum by actigraphy. Other outcomes measured at six and 12 weeks were number of maternal and infant night time awakenings by actigraphy, fatigue visual analogue scale, general sleep disturbance scale, and Edinburgh postnatal depression scale. Rates of exclusive breast feeding were measured at 12 weeks postpartum only.

Results: All women who completed any outcome measures at six or 12 weeks were included in analysis. Sleep outcomes were completed at one or both of six and 12 weeks postpartum for 215 of 246 (87%) women (110/123 intervention and 105/123 usual care). Longitudinal mixed effects model analyses indicated no significant differences between the groups on any of the outcomes. The estimated mean difference in maternal nocturnal sleep between the intervention and usual care groups was 5.97 minutes (95% confidence interval -7.55 to 19.5 minutes, P=0.39). No differences in any outcomes were noted based on the specific nurse delivering the intervention or the number of phone contacts received.

Conclusion: A behavioural-educational intervention delivered in the early postpartum, in hospital, and in the first weeks at home, was ineffective in improving maternal and infant sleep or other health outcomes in the first months postpartum.

Trial Registration: ISRCT No 13501166.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3603553PMC
http://dx.doi.org/10.1136/bmj.f1164DOI Listing
March 2013

The Postoperative Pain Assessment Skills pilot trial.

Pain Res Manag 2011 Nov-Dec;16(6):433-9

University of Toronto, Toronto, Canada.

Unlabelled: BACKGROUND⁄

Objectives: Pain-related misbeliefs among health care professionals (HCPs) are common and contribute to ineffective postoperative pain assessment. While standardized patients (SPs) have been effectively used to improve HCPs' assessment skills, not all centres have SP programs. The present equivalence randomized controlled pilot trial examined the efficacy of an alternative simulation method - deteriorating patient-based simulation (DPS) - versus SPs for improving HCPs' pain knowledge and assessment skills.

Methods: Seventy-two HCPs were randomly assigned to a 3 h SP or DPS simulation intervention. Measures were recorded at baseline, immediate postintervention and two months postintervention. The primary outcome was HCPs' pain assessment performance as measured by the postoperative Pain Assessment Skills Tool (PAST). Secondary outcomes included HCPs knowledge of pain-related misbeliefs, and perceived satisfaction and quality of the simulation. These outcomes were measured by the Pain Beliefs Scale (PBS), the Satisfaction with Simulated Learning Scale (SSLS) and the Simulation Design Scale (SDS), respectively. Student's t tests were used to test for overall group differences in postintervention PAST, SSLS and SDS scores. One-way analysis of covariance tested for overall group differences in PBS scores.

Results: DPS and SP groups did not differ on post-test PAST, SSLS or SDS scores. Knowledge of pain-related misbeliefs was also similar between groups.

Conclusions: These pilot data suggest that DPS is an effective simulation alternative for HCPs' education on postoperative pain assessment, with improvements in performance and knowledge comparable with SP-based simulation. An equivalence trial to examine the effectiveness of deteriorating patient-based simulation versus standardized patients is warranted.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3298048PMC
http://dx.doi.org/10.1155/2011/278397DOI Listing
February 2012

Sleep and fatigue and the relationship to pain, disease activity and quality of life in juvenile idiopathic arthritis and juvenile dermatomyositis.

Rheumatology (Oxford) 2011 Nov 25;50(11):2051-60. Epub 2011 Aug 25.

Department of Pediatrics, Technion Institution, Pediatric Department Rheumatology Unit, Technion Faculty of Medicine, Meyer Children’s Hospital of Haifa, Haifa, Israel.

Objectives: To determine and compare the prevalence of disturbed sleep in JIA and JDM and the relationship of sleep disturbance to pain, function, disease activity and medications.

Methods: One hundred fifty-five patients (115 JIA, 40 JDM) were randomly sampled and were mailed questionnaires. Sleep disturbance was assessed by the sleep self-report (SSR) and the children's sleep habits questionnaire (CSHQ). Fatigue, pain and function were assessed by the paediatric quality of life inventory (PedsQL) and disease activity by visual analogue scales (VASs). Joint counts were self-reported.

Results: Eighty-one per cent responded, of whom 44% reported disturbed sleep (CSHQ > 41); there were no differences between disease groups. Poor reported sleep (SSR) was highly correlated with PedsQL fatigue (r = 0.56, P < 0.0001). Fatigue was highly negatively correlated with quality of life (r = -0.77, P < 0.0001). The worst pain intensity in the last week was correlated to sleep disturbance (r = 0.32, P = 0.0005). Fatigue was associated with prednisone and DMARD use.

Conclusions: Sleep disturbance and fatigue are prevalent among children with different rheumatic diseases. Sleep disturbance and fatigue are strongly associated with increased pain and decreased quality of life. Strategies aimed at improving sleep and reducing fatigue should be studied as possible ways of improving quality of life for children with rheumatic illness.
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http://dx.doi.org/10.1093/rheumatology/ker256DOI Listing
November 2011

The cues and care randomized controlled trial of a neonatal intensive care unit intervention: effects on maternal psychological distress and mother-infant interaction.

J Dev Behav Pediatr 2011 Oct;32(8):591-9

Department of Psychiatry, Jewish General Hospital, Montreal, Canada.

Objective: This study tested the efficacy of a brief intervention (Cues program) with mothers of very low birth weight (VLBW <1500 g) infants. The primary hypothesis was that mothers in the Cues program would report lower levels of anxiety compared with mothers in the control group. Secondary hypotheses examined whether Cues mothers would report less stress, depression, and role restriction, and exhibit more sensitive interactive behavior, than control group mothers.

Methods: A total of 121 mothers of VLBW infants were randomly assigned to either the experimental (Cues) intervention or an attention control (Care) condition. The Cues program combined training to reduce anxiety and enhance sensitivity. The control group received general information about infant care. Both programs were initiated during the neonatal intensive care unit stay. Maternal anxiety, stress, depression, and demographic variables were evaluated at baseline, prior to randomization. Postintervention outcomes were assessed during a home visit when the infant was ∼6 to 8 weeks of corrected age.

Results: Although mothers in the Cues group demonstrated greater knowledge of the content of the experimental intervention than mothers in the Care group, the groups did not differ in levels of anxiety, depression, and symptoms of posttraumatic stress. They were similar in their reports of parental role restrictions and stress related to the infant's appearance and behavior. Cues and Care group mothers were equally sensitive in interaction with their infants.

Conclusion: Nonspecific attention was as effective as an early skill-based intervention in reducing maternal anxiety and enhancing sensitive behavior in mothers of VLBW infants.
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http://dx.doi.org/10.1097/DBP.0b013e318227b3dcDOI Listing
October 2011