Sleep updated: 4/18/10 & 4/2/2014

Altimier, 2001 PT, review article that includes sleep outcomes of KC

Arora 2008 FT. review, says parents can SLEEP with baby in KC

Bauer, Uhrig et al. 1997 PT, pretest-test-posttest one group. Quiet time (Brueck score of 3 or less behaviorally observed) was 93 in pre, 96 in KC, 91 in posttest NO SIG DIFF.

Bauer, Pyper et al., 1998 PT, pretest-test-posttest one group. Sleep increased in KC during 2nd week but not in 1st week of life for 25-27 and 28-30 weekers. Behavioral measure of sleep (Brueck score 3 or 4).

Begum et al., 2009 PT, pretest-test-posttest one group. Behavioral state by Brazelton Neonatal Behavioral Assessment Scale, percentage of infants with quiet sleep increased from 15.4% to 61.5% in middle of KC and 76.9% at tend of 60 mins of KC. Percentage of infants with active sleep decreased from 53.8 to 23.1 in middle of KC and to 54.0% 30 mins after end of KC.

Bosque et al. 1995 PT, one group pretest test posttest and found in the 8 infants lower percentage of total sleep time in KC compared to incubator, and no difference in QS time.

Canadian Ped Soc 2012 PT, Position statement supporting KC with infant>26wks GA because they sleep better and have more organized sleep which promotes brain development.

Castral et al., 2012 PT, correlational, showed that maternal anxiety/depression/salivary cortisol levels did NOT influence infant’s state (sleep.wakefulness,crying) after heel stick pain or after this stressor

Cong et al., 2009 PT, randomized cross over trial of 60 min of KC before KC heelstick and 60 mins of incubator before incubator heelstick. No diff in QS (65% in KC; 60% of time in incubator) nor AS (24% of time in both groups)during baseline. NO DIFFs.

Cong et al. 2012 PT, Randomized cross over trial of 28 preterm infants with 15, 30 mins of KC vs. incubator. During KC there was more quiet sleep than when in incubator. BEHAVIORAL STATE

Chwo et al, 2002 PT, RCT of 60 min of KC on 2nd day of life. Sig more quiet sleep (62% vs.22%) for controls. Used ABSSS.

Davidson et al., 2012 FT TEXTBOOK on page 1036 says that newborn (term and late

preterm) can rest together comfortably in KC and that newborn

assessments should be done in KC. This is in TEXTBOOK including

KC section of the KC Bib.

De Chateau et al., 1977b FT, RCT At 3 months follow up, no sig diff in infant sleeping

De Chateau et al., 1984 FT, RCT At 1 yr, more KC infants were sleeping own room than

Control infants who did not get 15-20 of KC in postpartum.

De Leeuw et al., 1991 PT pretest-test-posttest one group.KC has no lasting effect on sleep but changes while it was being done. State 1 increased (not sig.) during KC and State 2 decreased (not sig) during 60 mins of KC.

DiMenna, 2006 PT, review that states that KC improves state organization

Eichel, 2001 PT, Clinical report.Vented babies had sound sleep in KC

Feldman 2004,2007 PT, explains how KC improves state regulation, and state development

Feldman & Eidelman, 2003 PT, Cont. Trial without randomization, Behavioral state measured in 10 sec epochs x 4 hrs B4 KC and at 37 wks – more rapid improvement in state organization (longer periods of quiet sleep, longer period of alert wakefulness and shorter periods of active sleep.

Feldman,Weller,S &E2002 PT, Controlled Trial without randomization,State measured in 10 sec epochs over 4 hrs before KC and at 37 weeks. No differences. @term, KC more mature state distribution, more organized sleep-wake cyclicity, @ 3mos KC had higher threshold to negative emotionality and more efficient arousal modulation with complex stimuli. At 6 mos KC infants had longer duration and shorter latencies to shared attention and sustained exploration in toy session.

Feldman et al. 2013 PT, quasi-exp of 73 infants who got 1hr KC/day X14 consecutive days in 2002 study. 10 year follow-up showed KC infants had better organized sleep than non kcers.

Ferber & Makhoul, 2004 FT, RCT, 60 minutes of KC starting 15-20 min post birth tested at 4 hours

postbirth had longer sleep, mostly in quiet sleep state, had less time in

transitional , fussy, crying, and alert states (using 6 state Brazelton

scoring).KC influences state organization and motor system modulation

shortly after delivery

Gale, Frank, Lund 93 PT, clin. Report. Infants slept longer and their sleep was better organized and restful after KC.

Graven, 2006 Did big review of importance of sleep to infants.

Graven 2000 KC babies spent more time in sleep, shown as necessary for neurosensory development, preservation of brain plasticity, learning and long term memory.

Hardy, 2011 PT, Review of L-H’s developmental care chapter and reiterates for readers that KC improves sleep and reducers agitated states.

Harris, 1994 FT, clin report. Shows fullterms going to breast immediately postpartum. Says sometimes they doze off and you need to stroke the back to have him resume journey to breast (pg. 468).

Harrison, 2010 FT, Case study of 12 day old left hypoplastic heart baby who BF in KC and then went deeply asleep and mom said she had never seen him sleep so deeply before. Tolerated it all well.

Johnston et al., 2008 PT, RCT of pain but noticed that infants fall deeply asleep within one minute of onset of KC (pg. 7).

Karlsson 1996 FT have increased sleep time and reduced awake time.

Lai et al., 2005 PT, RCT, significantly more Quiet Sleep during 60 minutes of KMC+music over three consecutive days than in incubator infants.

Lehtonen & Martin, 2004 PT, behavioral state review. KC may been shown to improve the integrity of sleep.

Laudert et al. 2007 PT, review of 16 developmental interventions for PT in NICU. They need tactile stimulation, exposure to mother’s scent, and preservation of sleep.

Ludington 1990 PT, Descriptive evaluative of one group, doubling of QS, decrease in AS during 3 hours of KC as compared to pretest-posttest in crib.

Ludington-Hoe 2003 PT, RCT, sleep organization improves with KC. Abstract

Ludington-Hoe et al., 2006 PT, RCT, EEG sleep organization improves during 3 hrs KC based on n=28. All SSC associated changes in sleep are analogous to more mature sleep organization.

Ludington-Hoe et al., 2005 PT, randomized one group cross over design of KC before KC heel stick and incubator with incubator heelstick. Infants slept more (ABSSS) in KC than in incubator.

Mallet et al.., 2007 PT, descriptive of NICU staff knowledge of benefits of KC and none knew of sleep benefits at all. French study. All wanted more information about KC.

Messmer et al., 1997 PT, pretest-test-postest of 1 hour of KC which increased % of Quiet Sleep time.

Morgan et al. (Bergman) 2011 FT, Rcross over trial. 2 day old infants slept one hour in KC and one hour in cot. There was a 176% increase in autonomic activity and a 86% decrease in quiet sleep duration during maternal neonatal separation compared to KC sleep. Sleep latency was time from entry into SSC or cot until onset of quiet sleep. All 16 babies entered into active sleep, but only 6 entered into quiet sleep in both places. Separation had a profoundly negative impact on quiet sleep duration.

Nguah et al. 2011 PT, in Ghana and mothers increasingly slept at night with their babies over the first month of life. No problems.

Romano & Lothian, 2008 FT, review of evidence for KC at birth and says that mom and newborn can rest comfortably in this position and that VS and assessments should be done in the KC position.

Scher et al., 2007 Review of ontogeny of sleep. Says KC promotes sleep GET THIS FROM HIM Also, did same thing in 2011.

Scher et al., 2011 REVIEW of ontogeny of sleep.

Scher et al., 2009 PT, descriptive comparative of 8 infants who got KC 1.5 hrs/day x 4 days/wk from 32-40 wks Had more quiet sleep, better cycling, fewer arousals than non KC historical controls.

Shiau 1999 (Chinese) FT, RCT. Kcers had more sleep on days 1,2,3 than controls.

Smith, 2007 PT, Implementation report to teach staff stages of infant sleep, importance of sleep for development and growth, and then KC was used earlier in child’s NICU stay to promote sleep.

Swinth et al., 2003 PT, Case study of ventilated KC. Baby remained in deep sleep during all KC sessions.

Tornhage et al.,1999 PT, descriptive of 17 infants.

Van Sleuwen et al., 2007 Cochrane showing that swaddling improves continuity and duration of sleep. Not a KC study per se, but compares swaddling to KC for hypothermia and this citation is on the bib.

Wilkerson & Crout1998 PT, Descriptive, KC infants have longer rest, deeper sleep in KC than in incubator even when intubated. Not a publication, proceedings.

Yang & Chang, 2006 Review article of importance of sleep to infants.

Related literature:

Sahni R, Saluja K.F., Kashyap S, Ohira-Kist,K, Fifer, W.P. et al.,2002. Quality of diet, body position and time after feeding influence behavioral states in low birth weight infants. Ped Res 53 (3), 399-404

Sahni, R., Schulze K.F., Kashyap S., Ohira-Kist, K., Fifer, W.P., & Myers, M.M. (1999). Postural differences in cardiac dynamics during quiet and active sleep in low birthweight infants. Acta Paediatr 88, 1396-1401.


Chwo et al., 2002 PT have more quiet sleep compared to incubator infants (62% vs. 22%)

Feldman & Eidelman, 2003 PT, RCT, Behavioral state measured in 10 sec epochs x 4 hrs B4 KC and at 37 wks – more rapid improvement in state organization (longer periods of quiet sleep, longer period of alert wakefulness and shorter periods of active sleep.


Feldman & Eidelman, 2003 PT, RCT, Behavioral state measured in 10 sec epochs x 4 hrs B4 KC and at 37 wks – more rapid improvement in state organization (longer periods of quiet sleep, longer period of alert wakefulness and shorter periods of active sleep.


Feldman & Eidelman, 2003 PT, RCT, Behavioral state measured in 10 sec epochs x 4 hrs B4 KC and at 37 wks – more rapid improvement in state organization (longer periods of quiet sleep, longer period of alert wakefulness and shorter periods of active sleep.

Karlsson 1996 FT have reduced awake time.


Arch Dis Child. 2008 Nov;93(11):982-5. Epub 2008 Jul 24.

The physiology of sleep in infants.

Heraghty JL, Hilliard TN, Henderson AJ, Fleming PJ.


Institute of Child Life and Health, University of Bristol, and Bristol Royal Hospital for Children, Bristol, UK.


Despite the fact that infants spend more time asleep than awake, an understanding of the importance and effects of sleep on the pathophysiology of illness in infancy is a relatively recent development, and is commonly overlooked in paediatric training. In this review we describe some of the characteristics of sleep in infancy, with particular reference to normal developmental physiology and its relevance to the signs, symptoms and pathophysiology of illness in this age group.


No – no difference in sleep between experimental and control groups of preterm infants in:

1. Becker 1993’s study of 18 minutes of sleep and used behavioral measures (Becker PT, grunwald PC, Moorman J, Stuhr S. Effects of developmental care on behavioral organzaiton iwn VERY LOW BIRTH WEIGHT infants. Nurssing research, 1993, 42: 214-220)

2. In Westrup et al. (2002)’s randomized controlled trial and found no changes in quiet sleep percentage at 32 and 36 weeks PMA using amplitude-integrated EEG (a single channel displaying both frequency and amplitude information). Westrup B, Hellstroms-Westas L, Stjernqivst K, Lagercrantz H. 2002. No indications of increased quiet sleep in infants receiving care based on the individualized dcevelopmental care and assessment program. Acdta Paediatrics, 91, 318-322. (NIDCAP)

3. Ariagno et al. 1997 no differences in sleep organization between 36 and 52 weeks postmenstrual age even though statistical power was decreased because of small sample sizes (Tyebkhan, et al., 1999). Ariagno RL, Thoman EB, Boeddiker MA, Kugener S, Constantiou JC, Mirmiran M. et al., 1997. Develoopmetnal care does not alter sleep and development of premature infants. Pediatrics 100: e9; Tyebkhan J Peters K, McPherson C, Cote J, Robertson, C. 1989. Developmental care does not alter sleep and development of premature infants. Pediatrics 104: 1169-1170.

NIDCAP does improve developmental outcomes (See development chart):

RELATED LITERATURE – Reviews and importance of sleep

Calciolari, G., & Montirosso, R. (2011). The sleep protection in the preterm infants. Journal of Maternal Fetal Neonatal Medicine, 24(Suppl 1): 12-14. Doi: 10.3109/14767058.2011.607563. Importance of sleep in development is only now beginning to be understood: sleep and established sleep cycles have an important rolein the normal neurosensory and cortex development. Environmental differences can affect the sleep patterns in preterm infants in NICU. It is important to know the relationship between sleep organization and neurocognitive and socio-emotional outcomes. This article reports potentially better practices (i.e. cycled lighting) that preserve and promote infant sleep in the NICU.