Best evidence summary of sleep protection in premature infants in the neonatal intensive care unit: a narrative review

Introduction

Background

Approximately 15 million preterm infants are estimated to be born globally each year (1), making it one of the leading causes of mortality in children under the age of 5 years (2). Fortunately, the rapid advancement of intensive care technologies has significantly elevated the survival rates of premature infants. Even those born with extremely low birth weights now boast a survival rate of 87.6% (3). However, multiple studies indicate that preterm infants face “high-risk” developmental challenges (such as attention deficit/hyperactivity disorder, cognitive impairments, and social difficulties) throughout their growth (4-6). Among very premature infants (born between 28 and 32 weeks), approximately 40–50% experience varying degrees of neurological developmental disorders, with 27.8% potentially exhibiting language impairments (7,8). Even in late preterm infants (born between 34 and 36 weeks), the risk of neurodevelopmental disorders surpasses that of full-term infants, with 2.67% showing motor delays and 5.01% exhibiting intellectual developmental delays (9). Therefore, studying factors that contribute to impaired growth and development in preterm infants, especially those that are modifiable (such as sleep function), holds significant clinical significance (10).

Sleep plays a crucial role in brain development and synaptic plasticity during the early stages of individual life, and it is considered as the neurobiological foundation for learning and memory in organisms (11). Plasticity refers to the brain’s ability to adjust and change in response to various contexts and demands. This process influences the interaction between infants and their environment, as well as the achievement of essential motor and language developmental milestones (12,13). It is worth noting that preterm infants spend as much as 90% of their time in sleep (14). Infants below the age of 6 months experience three sleep states: active sleep (AS), quiet sleep (QS), and indeterminate sleep (IS). The sleep cycle involves the transition from the AS phase, experiencing brief IS, to ultimately entering QS (15). The AS state, equivalent to rapid eye movement (REM) sleep, constitutes approximately 40–60% of the premature infant’s entire sleep cycle. During this stage, the sensation feedback from muscle twitches and jerks provides intrinsic stimulation for developing sensory and motor neuronal networks, laying the foundation for higher-level cognitive processing neural circuits (16). QS corresponds to non-rapid eye movement (NREM) sleep, contributing to synaptic reshaping and promoting the maturation of the brain, hippocampus, brainstem, and more, enhancing memory and learning abilities (16). Additionally, sleep is associated with the secretion of crucial hormones such as melatonin and growth hormone in the human body. Research indicates that poor sleep quality in the neonatal period is associated with lifelong developmental outcomes (17).

During intrauterine development, fetuses process the pitch and intensity of human voices in a protected manner. By limiting excessive stimulation and providing a relatively quiet and protected sleep environment, optimal conditions for growth and development are created (18). However, due to the risks of adverse outcomes such as apnea and mortality, preterm infants require specialized medical care and support in neonatal intensive care units (NICUs). In recent years, more and more scholars have focused on studying the correlation between stress responses (such as bright lights, noise, invasive procedures, etc.) in the NICU and neurodevelopmental impairments (19,20). Nist et al. proposed the Neonatal Stress Embedding (NSE) model, which suggests that stress responses from the NICU may affect the autonomic nervous system, hypothalamic-pituitary-adrenal (HPA) axis, and gene expression in preterm infants, leading to changes in brain structure and function (21). Exposure to stress may result in sleep deprivation in preterm infants (8). For example, one study indicated that infants experience up to 234 interruptions in sleep within a 24-hour period (22). Despite increasing awareness among healthcare professionals about protecting sleep, the NICU is still considered a hostile environment. Apart from the unfavourable external conditions, inherent pathologies and comorbidities themselves seem to hinder the sleep development of this population (23). However, the adverse effects on neurodevelopment (including social and emotional impairments, as well as attention deficits) are not transient and may persist into adulthood (10). In other words, certain neurodevelopmental issues in preterm infants originate from the NICU. It is imperative to optimize the healthy sleep of premature infants and safeguard the natural progression of sleep.

Unfortunately, the evidence supporting the implementation of sleep interventions in NICUs is limited. Despite some mention of sleep protection knowledge in certain guidelines and practices, the content is verbose, lacks focus, and the recommendations are scattered, hindering clinical dissemination and practice translation. Additionally, healthcare personnel may encounter situations inconsistent with infant safe sleep recommendations; for example, preterm infants may require specific therapeutic positions that conflict with the supine position recommended for safe infant sleep (24). Relying solely on clinical experience without scientific-practical guidance is not an optimistic approach to managing sleep in preterm infants. Despite sedatives being able to increase sleep duration to some extent, they often come with side effects such as respiratory depression, which is undoubtedly detrimental for premature infants (25).

Objective

The evidence summary aims to consolidate crucial perspectives, furnish clinical practitioners with dependable resources, and optimize clinical practice (26). Therefore, the primary aim of this review is to conduct a thorough evaluation and comprehensive analysis of the existing evidence on non-pharmacological sleep protection for preterm infants. Concurrently, closely integrating with safe sleep recommendations, given that ensuring a secure sleep environment is an indispensable prerequisite. By providing an evidence-based data repository, it serves as a reference for clinical decision-making protocols. We present this article in accordance with the Narrative Review reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-24-92/rc).

Methods

Establishment of the problem

According to the PIPOST tool, the clinical question was transformed to an evidence-based question: (I) P (population): live-born infants with gestational age <37 weeks; (II) I (intervention): measures associated with sleep protection for premature infants, including assessment and care; (III) P (professionals): pediatric healthcare personnel; (IV) O (outcome): improvement in sleep quality; (V) S (setting): NICU ward; (VI) T (type of evidence): guidelines, expert consensus, expert opinions, practice recommendations, meta-analyses, systematic reviews, best clinical practice manuals, clinical decision, technical reports and randomized controlled studies (RCTs).

Retrieval strategy

We conducted a comprehensive search using the keywords “neonate, preterm infant, very preterm infant, extremely preterm infant, sleep protecting, sleep safety, sleeping environment, sleep position, development care, guideline, consensus, opinion, practice recommendation, evidence summary, meta-analysis, systematic review, RCT and randomized controlled trial” to retrieve relevant information from authoritative sources such as “UpToDate, BMJ Best Practice, Guidelines International Network (GIN), National Institute for Health and Clinical Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN), National Guideline Clearinghouse (NGC), Registered Nurses Association of Ontario (RNAO), Joanna Briggs Institute (JBI), World Health Organization (WHO), Cochrane Library, Web of Science, PubMed, China National Knowledge Infrastructure (CNKI), Wanfang Data, and China Biology Medicine disc (CBM)”. The detailed steps for searching English databases, using PubMed as an example, can be found in Table S1. The search period was set from January 2014 to May 2024. The primary reason for selecting articles published in 2014 or later is that those published earlier may lack the most current information and thus would be unable to effectively guide our clinical practice. Additionally, only full-text articles that have undergone peer review are included to ensure their academic value. The research methods utilized in this review are detailed in Table 1.

Literature inclusion and exclusion criteria

Inclusion criteria: (I) the study population was preterm infants; (II) the content of the literature was related to sleep-related studies; (III) the types of studies were guidelines, expert consensus, expert opinion, practice recommendations, meta-integration, meta-analysis, systematic evaluation, best clinical practice manuals, clinical decision-making, technical reports and RCTs; and (IV) the languages were limited to English and Chinese. Exclusion criteria: (I) the type of literature was guideline interpretation, guideline effect evaluation, guideline research plan or proposal; (II) updated guidelines; (III) duplicated publications, which could not be accessed in the original text; (IV) literature with low quality and (V) RCTs that have already been incorporated into guidelines or systematic reviews. This study was registered with the Centre for Evidence-based Nursing, Fudan University, China (ES20232650).

Quality evaluation of the literature

We have chosen appropriate evaluation criteria based on the different types of literature. These criteria primarily include: (I) clinical guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation Instrument (AGREE II) (27). AGREE II comprises six domains, totaling 23 key items. The degree of agreement for each item is assessed on a scale ranging from 1 (strongly disagree) to 7 (strongly agree). The standardized percentage for each domain is calculated using the formula: (obtained score − minimum possible score)/(maximum possible score − minimum possible score) ×100%. Based on the standardized scores, the recommendation levels are categorized as follows: Grade A (strong recommendation) if all six domains have scores ≥60%, Grade B (weak recommendation) if ≥3 domains have scores ≥30% and at least one domain has a score <60%, and Grade C (not recommended) if ≥3 domains have scores <30%. (II) Systematic reviews and expert consensus were assessed using the criteria established by the JBI Centre for Evidence-Based Healthcare [2016] (28). Evaluation is conducted with the response options “yes”, “no”, “unclear”, or “not applicable”. (III) Summaries of evidence, practice recommendations, and technical reports were evaluated using the Critical Appraisal for Summaries of Evidence (CASE) tool (29), which comprises 10 items. Evaluation options include “yes”, “no”, or “partial yes”. (IV) Randomized controlled studies were assessed using the evaluation criteria established by the JBI Centre for Evidence-Based Healthcare (30).

Literature quality assessment was carried out independently by two researchers (1st to 2nd authors of this article) based on inclusion and exclusion criteria, and in case of doubt, the decision was made after a joint discussion by our evidence-based team. All evidence-based team members were trained and passed an evidence-based nursing course.

Evidences extraction and summary

The evidence was comprehensively summarized by members of the evidence-based group according to the following principles: (I) in cases of consistent content, a preference is given to selecting sentences that are more easily understandable; (II) when multiple sources complement each other, they are consolidated into one piece of evidence; (III) in the event of conflicting conclusions from different sources of evidence, we adhere to the principles of prioritizing evidence based on its quality, credibility, and the latest authoritative publications. The classification criteria for evidence are as follows: Level 1 consists of RCTs or meta-analyses of RCTs, Level 2 includes quasi-experimental studies, Level 3 comprises observational analytical studies, Level 4 encompasses observational descriptive studies, and Level 5 consists of expert opinions and basic research.

Subsequently, we conducted an expert meeting, which included two chief physicians in neonatology, two head nurses, and one deputy director of the nursing department, along with three key neonatology nurses. Based on the FAME principle, which stands for feasibility, appropriateness, meaningfulness, and effectiveness of the evidence, the recommended levels of evidence were determined, including Grade A recommendation (strong recommendation) and Grade B recommendation (weak recommendation).

Results

Results of literature screening

Figure 1 illustrates the literature retrieval process. A total of 9,440 documents were searched in this study, and after de-duplication, reading the title, abstract and full text, 22 documents were finally included (10,12,22,24,25,31-47). These included two guidelines (34,36), 11 systematic reviews (10,22,25,31-33,35,38,41,42,45), 1 evidence summary (37), 1 technical report (24), 2 practice recommendations (12,39), and 5 randomized controlled trials (40,43,44,46,47). The basic characteristics of the included literature are shown in Table 2.

Figure 1 Literature screening flow chart. GIN, Guidelines International Network; WHO, World Health Organization; NICE, National Institute for Health and Clinical Excellence; RNAO, Registered Nurses Association of Ontario; CNKI, China National Knowledge Infrastructure; CBM, China Biology Medicine disc.

Quality evaluation results of the included literature

Quality evaluation results of the guidelines

Two guidelines were included in this study, one from Queensland Health (34), and one from the RNAO (36). Both guidelines had a recommendation of B for inclusion. See Table 3.

Quality assessment of systematic reviews

Eleven systematic reviews were incorporated into the study (10,22,25,31-33,35,38,41,42,45). These studies were characterized by their comprehensive and rigorous design, warranting their inclusion. For details, refer to Table 4.

Quality assessment of evidence summaries, practice recommendations and technical reports

This research incorporated one technical report from the American Academy of Pediatrics (AAP) (24), one practice recommendation by the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) (12), an evidence synthesis by the Chinese Medical Association (37) and a practice recommendation from the Gravens Consensus Committee on Infant and Family Centered Developmental Care (39). Each study was rich in content and was therefore included in the analysis. For further information, please refer to Table 5.

Quality assessment of randomized controlled trials

The present study has incorporated a total of five randomized controlled trials (40,43,44,46,47), and the results of their quality assessments are presented in Table 6.

Summary of evidence

A summary of the evidence from eight areas of sleep team building, risk factor assessment, sleep assessment tools, position management, noise control, light management, sensory stimulation and hospital-home transition sleep management resulted in 27 pieces of evidence, as shown in Table 7.

Discussion

Forming a sleep management team

Healthcare professionals are the primary caregivers during the hospitalization of premature infants. Ensuring a high level of sleep management knowledge and practice is fundamental to ensuring good sleep quality for premature infants. However, research indicates that healthcare professionals tend to prioritize the diagnosis, treatment, and care of premature infant illnesses rather than focusing on sleep management (48). Their understanding of sleep management knowledge is relatively lacking, and they underestimate the importance of sleep management. The lack of relevant beliefs and knowledge remains a barrier to safe sleep management. The key to providing high-quality care lies in continuously integrating knowledge, values, attitudes, and skills into practice to enhance nursing capabilities (49). One-time education or internal meetings have a limited impact on knowledge acquisition (50). Therefore, there is an urgent need to establish interdisciplinary teams for safe sleep management, collaborate with obstetric and community nursing staff, and provide continuing education resources related to safe sleep practices. Regular internal and external training should be organized to stay up-to-date with the latest sleep management strategies. Attention should be given to promoting awareness and understanding of safe sleep practices among healthcare professionals, and sleep knowledge should be incorporated into assessment standards. In addition to training healthcare professionals, it is also encouraged to involve premature infants’ parents in the implementation of sleep development programs (12,22,33,34,36). However, a study shows that only 22.5% of parents have received relevant sleep education training (51). Providing health education to parents can result in some degree of change in their health behaviors, regardless of the environment they are in. Furthermore, interventions involving parents yield the best results (52).

Risk factor assessment

Sleep-related unexpected death is the primary cause of infant mortality in the United States, accounting for 28% (53). Similarly, in China, Sudden Infant Death Syndrome (SIDS) accounts for approximately 15% to 20% of infant deaths (54). Accurately identifying the risk factors for premature infants during sleep is an important measure for effective prevention of death. High-quality evidence indicates that the prone position and elevated body temperature are independent risk factors for sudden infant death in newborns (10,24,31,34). The prone position increases the risk of SIDS by 14 times (55). Currently, it is widely believed that premature infants lack the ability to self-arouse. The prone position/external pressure leads to prolonged oxygen deprivation, resulting in hypercapnia and abnormal serotonergic function in the brainstem, ultimately leading to SIDS (56). Therefore, this study suggests that premature infants should always maintain a supine position during hospitalization unless there are specific medical contraindications, and this practice should be continued until at least reaching 1 year of age (54). Swaddling can reduce crying in premature infants and increase the duration of QS. However, it is important to note that when swaddling, the supine position should always be maintained, and if the premature infant attempts to roll, swaddling should be immediately discontinued to prevent rolling into the prone position, which can lead to SIDS (24,54). Considering the pros and cons, this study does not recommend swaddling as a routine strategy to promote sleep in premature infants. Another risk factor for SIDS is elevated body temperature and heat stress reactions. The pathophysiological mechanisms underlying this need further investigation. Véronique Bach et al. suggest that heat stress alters the respiratory function of premature infants and may interact with other factors in the environment (such as smoke), ultimately leading to SIDS (57). It is worth noting that due to the head being the main area for heat dissipation in infants, the use of head coverings and similar items may accelerate overheating of the brain, causing symptoms similar to heatstroke and posing a life-threatening risk. Therefore, this study recommends continuous monitoring of environmental temperature during hospitalization to avoid high body temperature and overheating in the sleep environment. Additionally, loosely covered crib bedding increases the risk of suffocation (24), so it is important to avoid using any loose bedding items and instead choose tight-fitting sheets. In conclusion, healthcare professionals should enhance their insight and be vigilant in avoiding potential risk factors that may lead to accidental death in premature infants, promptly removing any potential hazards.

Sleep assessment tools

The factors influencing sleep quality mainly include iatrogenic factors (such as apnea, pain, medication, uncomfortable positions, frequent medical procedures, drugs, etc.) and environmental factors (such as noise, lighting, temperature, humidity) (10,12,22,31,33). A comprehensive and multidimensional assessment should be conducted based on individual differences. Evaluation tools for sleep quality mainly comprise electroencephalograms (EEGs), actigraphy, and direct behavioral observation (12,33). Although multi-channel sleep EEGs are considered the gold standard for assessing sleep in infants and adults, their reliability is lower in premature infants due to incomplete development of their nervous system (12). Moreover, they are costly and require a significant amount of labor, including skilled technicians for operation, coding, and recording, along with complex equipment support (58), which can itself become a stimulus for premature infants. Regarding actigraphy, relevant research suggests that during AS periods, there is a considerable amount of limb movement (58). The use of actigraphy may mistakenly interpret these movements as wakefulness in infants, thus unable to accurately predict the sleep or wakeful state of premature infants. Direct behavioral observation methods mainly include the Neonatal Behavioral Assessment Scale (NBAS), the Assessment of Preterm Infants’ Behavior (APIB), the Anderson Behavioral State Scale (ABSS), and the Thoman Scoring System (12). Among them, NBAS is mainly suitable for infants aged 36 to 44 weeks (12) and assesses three sleep states (deep sleep, light sleep, drowsiness) and three wakeful states (quiet awake, active awake, crying). Its advantage lies in its ability to differentiate the six sleep-wake states relatively simply (59). APIB and ABSS (12) are sleep monitoring scales developed specifically for premature infants, characterized by greater detail and sensitivity in identifying unique sleep patterns in high-risk newborns. The advantage of the Thoman Scoring System is its wider age range applicability. This study suggests incorporating sleep measurements into daily rounds and taking timely measures to optimize the sleep quality of premature infants (12).

Non-pharmacological sleep promotion programmes

The sleep promotion plan for premature infants mainly consists of positional management, noise control, light management, and sensory stimulation (12,24,25,33,34,36). Several studies have shown that hospitalized premature infants should primarily maintain a supine position (24,34,36). The authoritative practice standard setter, the AAP, added a section on premature infants with special conditions in their 2021 technical report, supplementing recommendations for positional management (24). For acute respiratory diseases, the prone position has been found to improve ventilation and reduce apnea. However, continuous monitoring of cardiopulmonary function and blood oxygen saturation is also necessary. The supine position is equally preferable for premature infants with gastroesophageal reflux (55). Elevating the head of the bed, contrary to expectations, has been shown to increase the risk of airway obstruction and does not effectively reduce gastroesophageal reflux. Additionally, due to the lack of sufficient evidence, at present, to prove that timed repositioning during phototherapy for hyperbilirubinemia offers a superior bilirubin decline rate within 24 hours compared to the supine position, premature infants receiving phototherapy should also be placed in a supine position to prevent adverse events such as suffocation or aspiration (60). Multiple studies have indicated that the use of positional support tools such as nests, water beds, and hammocks helps establish boundaries around premature infants, maintaining their physiological flexion which promotes sleep (35,37,40). Among them, the hammock position is a specialized posture for preterm infants. It effectively mimics the fetus’s comfortable posture within the womb, aiding the infant in maintaining a natural, curled position with both arms and legs close to the midline of the body. This helps the premature infants relax and reduce energy expenditure. When lying on their sides in a hammock with their hands near their mouths, they can more easily engage in self-soothing behaviors, such as sucking on their fingers or fists (40). Nevertheless, the potential adverse effects of the hammock position, including safety risks and the need for optimal standards concerning the hammock’s size, material, and angle, require further investigation. It is essential to emphasize that any use of positional support tools must be thoroughly tested and adjusted to ensure they provide stable and reliable support.

The AAP recommends that the daytime noise level in the NICU should be controlled below 45 decibels (dB). Nevertheless, research indicates that the noise in the NICU exceeds the recommended levels significantly (61). It is crucial to employ noise monitoring devices to continuously monitor and record the volume of various environments within the NICU. When designing NICU facilities, it is advisable to utilize soundproofing materials as much as possible. In cases where environmental changes are unfeasible, controlling noise generated by activities becomes an integral component of establishing a “culture of tranquility”. Policies in certain countries encourage designated QS periods in the NICU where all lights are turned off, device alarms are silenced, and non-essential procedures are postponed (23). In China, where the number of preterm births ranks second globally, NICU bed occupancy remains overwhelming. While promoting such policies is worthwhile, ensuring their absolute safety during implementation remains debatable. However, it can be affirmed that the most cost-effective method for both staff and family members is to reduce their vocal volume and keep their communication devices on silent or vibrate mode. Whenever feasible, providing individual family rooms should be considered (32). It’s important to note that incubators do not prevent high-frequency noise in the NICU and may even act as noise sources, such as when the cabinet doors of incubators open or close, producing significant noise (37). Consequently, healthcare professionals must refrain from engaging in conversations, laughter, or any impacts above the incubators, as the internal space amplifies sound.

The report’s another principal concern arises from the 24-hour constant bright light conditions in the NICU (25). Existing study has indicated that most of the photoreceptors and visual proteins emerge during early pregnancy, suggesting that premature infants may also possess a certain photo perception ability (62). Pupils, as the gateway for perceiving light, may stimulate premature infants under irregular or continuous illumination. Therefore, it is recommended to avoid direct light exposure to premature infants’ eyes and instead utilize dark shading to cover the incubator (37). The circadian rhythm system, functioning as a fundamental biological clock, plays a crucial role in regulating various physiological processes within organisms. Premature birth may disrupt the development of this system, as preterm infants are frequently exposed to artificial light sources that differ from the intrauterine environment (lacking a discernible 24-hour environmental rhythm and presenting confusing temporal signals), which can hinder the regular secretion of melatonin (12,63). Therefore, for those with a corrected gestational age greater than 32 weeks, implementing a simulated day-night light cycle (approximately 12 hours of light followed by 12 hours of darkness) can promote sleep. This lighting regimen aids in the visual development of preterm infants and facilitates the establishment and regulation of circadian rhythms, as well as hormonal levels (10,12,25,33,37).

This article summarizes evidence-based strategies for promoting sleep in premature infants through sensory stimulation. The evidence suggests that, under stable medical conditions, early skin-to-skin contact or kangaroo care should be initiated as soon as possible starting from 31 to 32 weeks of gestation (12,25,33,37). Through direct skin contact with their parents, preterm infants can experience their parents’ body temperature, heartbeat, and breathing rhythms. The sound of their parents’ heartbeats and breathing serves as a familiar and comforting auditory stimulus, helping the infants relax and facilitating deeper sleep (39). Additionally, personalized gentle touch is recognized as an effective non-pharmacological intervention (39). When infants are awake or exhibit signs of distress, caregivers can employ gentle touch techniques. The frequency and duration of touch should be adjusted according to the infant’s physiological responses to ensure appropriateness and safety. Furthermore, touch can be combined with tactile stimulation through limb movements. However, for high-risk infants, caregivers should exercise extra caution when administering touch and maintain continuous monitoring to prevent potential adverse reactions, such as a decrease in oxygen saturation.

In recent years, with the increasing focus on the auditory development and well-being of premature infants, music therapy has gained widespread recognition as an effective intervention. Research by Yan et al. suggests that there may be a connection between music, hormones, and the sleep cycles of newborns (47). Music therapy can promote the release of endorphins in the brain, aiding in the regulation of the sympathetic nervous system and having a positive impact on the overall development of preterm infants (38). Additionally, music therapy may be associated with an increase in the release of serotonin within the body. Serotonin is a crucial neurotransmitter that plays a key role in the regulation of sleep architecture (47). However, when implementing music therapy, it is essential to strictly control the volume to ensure that the sound intensity does not exceed the continuous noise threshold of 40 to 45 dB per hour, to avoid unnecessary auditory stress on preterm infants (38). Studies recommend incorporating professional music therapists into interdisciplinary teams, as they possess the specialized skills to provide music interventions and can consciously manipulate musical elements to enhance the potential for interaction with preterm infants and their parents, meeting the multidimensional needs of the natural “musical communication” between mother and child (38,46). The optimal duration, volume intensity, frequency, and the interplay between the effects of music therapy and environmental factors remain subjects for further investigation.

Hospital-home transition sleep management

According to the recommendations of the AAP, healthcare professionals should assume the responsibility of educating families to ensure that infants are in a secure sleep environment after discharge (24). Research indicates that premature infants’ mothers have a lower compliance rate with supine sleeping position compared to mothers of full-term infants (64). However, Barsman et al. found that only 60% of nurses transition infants to the supine sleeping position before discharge (65). Therefore, based on the combined evidence from this study, it is recommended that stable premature infants should be placed in the supine position for sleep prior to anticipated discharge (24,34,36). For parents who may have chosen prone or lateral positions for their premature infants during hospitalization, it is essential to provide an explanation of the benefits of the supine position in a home environment. Before discharge, it is suggested to inquire about the at-home sleep plan with the primary caregiver. For parents with limited understanding, the frequency of training sessions should be increased. It is suggested to tailor interventions to individual circumstances of premature infants to effectively improve post-discharge sleep safety habits.

Conclusions

This study conducted an extensive search of domestic and international literature concerning the safe sleep management of premature infants. From various aspects including sleep team construction, risk factor assessment, sleep assessment tools, positional management, noise control, light management, sensory stimulation, and hospital-home transition sleep management, a comprehensive compilation of 27 evidence-based recommendations was formed. These findings aim to provide healthcare professionals with evidence-based guidance for clinical practice. It is advised that healthcare personnel take into account the local medical environment and carefully select relevant evidence for evidence-based translation in order to enhance the quality of nursing care.

Acknowledgments

Funding: The study was supported by the Top Talent Support Program for Young and Middle-aged People of Wuxi Health Committee (No. BJ2023091).

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-24-92/rc

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-24-92/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-24-92/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Adane HA, Iles R, Boyle JA, et al. Maternal occupational risk factors and preterm birth: Protocol for a systematic review and meta-analysis. PLoS One 2023;18:e0283752. [Crossref] [PubMed]
2. Cao G, Liu J, Liu M. Global, Regional, and National Incidence and Mortality of Neonatal Preterm Birth, 1990-2019. JAMA Pediatr 2022;176:787-96. [Crossref] [PubMed]
3. Cao Y, Jiang S, Sun J, et al. Assessment of Neonatal Intensive Care Unit Practices, Morbidity, and Mortality Among Very Preterm Infants in China. JAMA Netw Open 2021;4:e2118904. [Crossref] [PubMed]
4. Fraiman YS, Guyol G, Acevedo-Garcia D, et al. A Narrative Review of the Association between Prematurity and Attention-Deficit/Hyperactivity Disorder and Accompanying Inequities across the Life-Course. Children (Basel) 2023;10:1637. [Crossref] [PubMed]
5. Tsakalidis C, Rallis D, Drogouti E, et al. Emotional and behavioural outcomes at 8 years of age in preterm-born children: A longitudinal study. Acta Paediatr 2023;112:993-1000. [Crossref] [PubMed]
6. Xing L, Zhang D, Cao M, et al. The relationship between NICU stress and neurodevelopmental outcomes of preterm infants: A multi-center prospective cohort study in China. J Pediatr Nurs 2023;71:e90-6. [Crossref] [PubMed]
7. Gebus M, Chevallier M, Hatton LA, et al. Neurodevelopment at two years and appropriate schooling at five years in children born very preterm. Acta Paediatr 2022;111:1729-35. [Crossref] [PubMed]
8. Tang X, Sha S, Shen N, et al. Multisensory stimulation bundles on sleep and neurobehavioral development in the first year after birth in very preterm infants: a randomized crossover controlled study protocol. Trials 2023;24:732. [Crossref] [PubMed]
9. Saha AK, Mukherjee S. Neurodevelopment outcome of late prematurity: a retrospective cohort study from a developing country. Eur J Pediatr 2023;182:2715-22. [Crossref] [PubMed]
10. Gogou M, Haidopoulou K, Pavlou E. Sleep and prematurity: sleep outcomes in preterm children and influencing factors. World J Pediatr 2019;15:209-18. [Crossref] [PubMed]
11. Feld GB, Born J. Sculpting memory during sleep: concurrent consolidation and forgetting. Curr Opin Neurobiol 2017;44:20-7. [Crossref] [PubMed]
12. Park J. Sleep Promotion for Preterm Infants in the NICU. Nurs Womens Health 2020;24:24-35. [Crossref] [PubMed]
13. Dang-Vu TT, Desseilles M, Peigneux P, et al. A role for sleep in brain plasticity. Pediatr Rehabil 2006;9:98-118. [Crossref] [PubMed]
14. Trickett J, Hill C, Austin T, et al. The Impact of Preterm Birth on Sleep through Infancy, Childhood and Adolescence and Its Implications. Children (Basel) 2022;9:626. [Crossref] [PubMed]
15. Hoppenbrouwers T, Hodgman JE, Rybine D, et al. Sleep architecture in term and preterm infants beyond the neonatal period: the influence of gestational age, steroids, and ventilatory support. Sleep 2005;28:1428-36. [Crossref] [PubMed]
16. Knoop MS, de Groot ER, Dudink J. Current ideas about the roles of rapid eye movement and non-rapid eye movement sleep in brain development. Acta Paediatr 2021;110:36-44. [Crossref] [PubMed]
17. Uchitel J, Vanhatalo S, Austin T. Early development of sleep and brain functional connectivity in term-born and preterm infants. Pediatr Res 2022;91:771-86. [Crossref] [PubMed]
18. Hernández-Salazar AD, Gallegos-Martínez J, Reyes-Hernández J. Level and Noise Sources in the Neonatal Intensive Care Unit of a Reference Hospital. Invest Educ Enferm 2020;38:e13. [Crossref] [PubMed]
19. Zhao T, Griffith T, Zhang Y, et al. Early-life factors associated with neurobehavioral outcomes in preterm infants during NICU hospitalization. Pediatr Res 2022;92:1695-704. [Crossref] [PubMed]
20. Cong X, Wu J, Vittner D, et al. The impact of cumulative pain/stress on neurobehavioral development of preterm infants in the NICU. Early Hum Dev 2017;108:9-16. [Crossref] [PubMed]
21. Nist MD, Harrison TM, Steward DK. The biological embedding of neonatal stress exposure: A conceptual model describing the mechanisms of stress-induced neurodevelopmental impairment in preterm infants. Res Nurs Health 2019;42:61-71. [Crossref] [PubMed]
22. Firmino C, Rodrigues M, Franco S, et al. Nursing Interventions That Promote Sleep in Preterm Newborns in the Neonatal Intensive Care Units: An Integrative Review. Int J Environ Res Public Health 2022;19:10953. [Crossref] [PubMed]
23. Robinette B, Palokas M. Promoting sleep and rest of infants using nonpharmacological interventions within the neonatal intensive care unit at Children's of Mississippi. JBI Evid Implement 2023;21:78-86. [Crossref] [PubMed]
24. Goodstein MH, Stewart DL, Keels EL, et al. Transition to a Safe Home Sleep Environment for the NICU Patient. Pediatrics 2021;148:e2021052045. [Crossref] [PubMed]
25. Liao JH, Hu RF, Su LJ, et al. Nonpharmacological Interventions for Sleep Promotion on Preterm Infants in Neonatal Intensive Care Unit: A Systematic Review. Worldviews Evid Based Nurs 2018;15:386-93. [Crossref] [PubMed]
26. Jordan Z, Lockwood C, Munn Z, et al. Redeveloping the JBI Model of Evidence Based Healthcare. Int J Evid Based Healthc 2018;16:227-41. [Crossref] [PubMed]
27. Brouwers MC, Kho ME, Browman GP, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. J Clin Epidemiol 2010;63:1308-11. [Crossref] [PubMed]
28. Aromataris E, Fernandez R, Godfrey CM, et al. Summarizing systematic reviews: methodological development, conduct and reporting of an umbrella review approach. Int J Evid Based Healthc 2015;13:132-40. [Crossref] [PubMed]
29. Foster MJ, Shurtz S. Making the Critical Appraisal for Summaries of Evidence (CASE) for evidence-based medicine (EBM): critical appraisal of summaries of evidence. J Med Libr Assoc 2013;101:192-8. [Crossref] [PubMed]
30. Barker TH, Stone JC, Sears K, et al. The revised JBI critical appraisal tool for the assessment of risk of bias for randomized controlled trials. JBI Evid Synth 2023;21:494-506. [Crossref] [PubMed]
31. Skelton H, Psaila K, Schmied V, et al. Systematic Review of the Effects of Positioning on Nonautonomic Outcomes in Preterm Infants. J Obstet Gynecol Neonatal Nurs 2023;52:9-20. [Crossref] [PubMed]
32. Almadhoob A, Ohlsson A. Sound reduction management in the neonatal intensive care unit for preterm or very low birth weight infants. Cochrane Database Syst Rev 2015;1:CD010333. [Crossref] [PubMed]
33. van den Hoogen A, Teunis CJ, Shellhaas RA, et al. How to improve sleep in a neonatal intensive care unit: A systematic review. Early Hum Dev 2017;113:78-86. [Crossref] [PubMed]
34. Safer infant sleep: Queensland Government; [2023-7-16]. Available online: https://www.health.qld.gov.au/qcg/publications#neonatal
35. Yang L, Fu H, Zhang L. A systematic review of improved positions and supporting devices for premature infants in the NICU. Heliyon 2023;9:e14388. [Crossref] [PubMed]
36. Ontario RNAO. Working with Families to Promote Safe Sleep for Infants 0-12 Months of Age: RNAO; [2023-7-16]. Available online: https://rnao.ca/bpg/guidelines/safe-sleep-practices-infants
37. Lin N, Zhu J, Jin C, et al. Evidence summary on the management of the developmentally supportive environment in the neonatal intensive care unit. Chin J Appl Clin 2022;37:1325-30.
38. Costa VS, Bündchen DC, Sousa H, et al. Clinical benefits of music-based interventions on preterm infants' health: A systematic review of randomised trials. Acta Paediatr 2022;111:478-89. [Crossref] [PubMed]
39. Browne JV, Jaeger CB, Kenner C, et al. Executive summary: standards, competencies, and recommended best practices for infant- and family-centered developmental care in the intensive care unit. J Perinatol 2020;40:5-10. [Crossref] [PubMed]
40. Costa KSF, Fernandes DDS, Paula RAP, et al. Hammock and nesting in preterm infants: randomized controlled trial. Rev Bras Enferm 2019;72:96-102. [Crossref] [PubMed]
41. Palaskar P, Ramekar SD, Sant N, et al. Ideal Mode of Auditory Stimulation in Preterm Neonates in Neonatal Intensive Care Unit: A Systematic Review. Cureus 2023;15:e34496. [Crossref] [PubMed]
42. Carneiro MMC, Ribeiro SNS, Menegol NA, et al. Nest positioning on motor development, sleep patterns, weight gain in preterm infants: systematic review. Pediatr Res 2024; Epub ahead of print. [Crossref] [PubMed]
43. Alinejad-Naeini M, Heidari-Beni F, Mohagheghi P, et al. The effect of M technique massage on behavioral state and weight gain in preterm neonates: A randomized controlled trial. J Child Health Care 2023; Epub ahead of print. [Crossref] [PubMed]
44. Düken ME, Yayan EH. The effects of massage therapy and white noise application on premature infants' sleep. Explore (NY) 2024;20:319-27. [Crossref] [PubMed]
45. Fadlalmola HA, Elhusein AM, Abedelwahed HH, et al. The effects of Yakson touch and gentle human touch on preterm infants: A systematic review and meta-analysis. Afr J Reprod Health 2023;27:99-108. [PubMed]
46. Kobus S, Diezel M, Dewan MV, et al. Music Therapy Is Effective during Sleep in Preterm Infants. Int J Environ Res Public Health 2021;18:8245. [Crossref] [PubMed]
47. Yan K, Ji F, Yuan H, et al. Musical intervention increases quiet sleep time of preterm infants: A randomized controlled trial. Chinese Journal of Evidence-Based Pediatrics 2020;15:269-73.
48. Zhuo R, Lin C, Wang W. Survey on Nurses' Knowledge, Attitude, and Practice on Sleep Management of Preterm Infants in Neonatal Intensive Care Unit. Modern Nurse 2023;46-9.
49. Nabizadeh-Gharghozar Z, Alavi NM, Ajorpaz NM. Clinical competence in nursing: A hybrid concept analysis. Nurse Educ Today 2021;97:104728. [Crossref] [PubMed]
50. Lee HN, Cho H. Effectiveness of Nicu nurses' competence enhancement program for developmentally supportive care for preterm infants: A quasi-experimental study. Heliyon 2023;9:e12944. [Crossref] [PubMed]
51. Alahmadi TS, Sobaihi M, Banjari MA, et al. Are Safe Sleep Practice Recommendations For Infants Being Applied Among Caregivers? Cureus 2020;12:e12133. [Crossref] [PubMed]
52. Séassau A, Munos P, Gire C, et al. Neonatal Care Unit Interventions on Preterm Development. Children (Basel) 2023;10:999. [Crossref] [PubMed]
53. Mery JN, Day-Watkins J, Schnell LK, et al. Evaluating caregivers arrangement of infant sleeping environments in the home. J Appl Behav Anal 2023;56:483-93. [Crossref] [PubMed]
54. Xing W, Zhou F, Wang J, et al. Evidence summary of safe infant sleeping environment for the prevention of Sudden Infant Death Syndrome. Chinese Nursing Management 2020;20:1831-7.
55. Vincent A, Chu NT, Shah A, et al. Sudden Infant Death Syndrome: Risk Factors and Newer Risk Reduction Strategies. Cureus 2023;15:e40572. [Crossref] [PubMed]
56. Martin RJ, Mitchell LJ, MacFarlane PM. Apnea of prematurity and sudden infant death syndrome. Handb Clin Neurol 2022;189:43-52. [Crossref] [PubMed]
57. Bach V, Libert JP. Hyperthermia and Heat Stress as Risk Factors for Sudden Infant Death Syndrome: A Narrative Review. Front Pediatr 2022;10:816136. [Crossref] [PubMed]
58. Derbin M, McKenna L, Chin D, et al. Actigraphy: Metrics reveal it is not a valid tool for determining sleep in neonates. J Sleep Res 2022;31:e13444. [Crossref] [PubMed]
59. Schmidt F, Kalil Neto F, Radaelli G, et al. Effects of non-invasive respiratory support on sleep in preterm infants evaluated by actigraphy. Sleep Sci 2021;14:72-6. [PubMed]
60. Thukral A, Deorari A, Chawla D. Periodic change of body position under phototherapy in term and preterm neonates with hyperbilirubinaemia. Cochrane Database Syst Rev 2022;3:CD011997. [PubMed]
61. Sabetsarvestani R, Köse S, Geçkil E, et al. Noise in a Neonatal Intensive Care Unit: Exploring Its State and Solutions. Adv Neonatal Care 2022;22:E183-90. [Crossref] [PubMed]
62. Hazelhoff EM, Dudink J, Meijer JH, et al. Beginning to See the Light: Lessons Learned From the Development of the Circadian System for Optimizing Light Conditions in the Neonatal Intensive Care Unit. Front Neurosci 2021;15:634034. [Crossref] [PubMed]
63. Sánchez-Sánchez M, García TL, Heredia D, et al. Effect of a light-darkness cycle on the body weight gain of preterm infants admitted to the neonatal intensive care unit. Sci Rep 2022;12:17569. [Crossref] [PubMed]
64. Hwang SS, Lu E, Cui X, et al. Home care practices for preterm and term infants after hospital discharge in Massachusetts, 2007 to 2010. J Perinatol 2015;35:880-4. [Crossref] [PubMed]
65. Barsman SG, Dowling DA, Damato EG, et al. Neonatal nurses' beliefs, knowledge, and practices in relation to sudden infant death syndrome risk-reduction recommendations. Adv Neonatal Care 2015;15:209-19. [Crossref] [PubMed]