Early childhood overweight and obesity is a growing public health problem, and an equity issue: it affects nearly half of all Hispanic children.1 Additionally, Hispanic children face a disproportionately high morbidity for obesity-related negative health outcomes such as Type 2 diabetes or fatty liver disease, even in early childhood.2,3 An increasing body of evidence suggests that obesity, once entrenched as a diagnosis, is difficult to reverse; thus, preventative measures are most effective within the first “1,000 days” (prenatal to age two) .4 Within this window, feeding and sleep habits are potentially modifiable behaviors that may be protective against rapid weight gain. 5-7 Pediatrician visits offer opportunities for counseling and parent coaching, but must be sensitive to the many systemic factors that influence families beyond the clinic. A qualitative exploration of Hispanic mothers’ experiences managing these behaviors may provide insights for pediatricians who work with Hispanic families.
Role of Sleep
Sleep medicine experts recommend 12-16 hours of total daily sleep (including daytime naps) from four to twelve months of age; and 11-14 hours from ages one to two years. 8 In addition to poor outcomes for emotional regulation and development, poor infant and toddler sleep duration has been associated with childhood obesity.7,9-11 Children who sleep less than ten hours at night are in the top quartile for obesity risk; possibly through a mechanism of greater energy intake associated with decreased sleep.5,6 Touchette showed that children sleeping less than 10 hours per night have a four-fold risk of obesity by age six;12 Taveras showed that infants sleeping less than 12 hours per night is associated with two-fold risk of overweight at age three 13. Later bedtimes are also associated with obesity, regardless of total sleep.14 There are cultural factors related to timing of daily routines: Hispanic children have delayed bedtimes when compared to their Caucasian counterparts as well as a shorter sleep duration.15 In a recent study, Hispanic infants at six months slept 38 minutes less than their non-Hispanic white counterparts and were less likely to meet minimum sleep recommendations.16 There is a need for research on the markers of sleep quality that may be associated with obesity and into the socioenvironmental factors that may preclude recommended sleep duration.
Sleep researchers make specific recommendations for infant sleep duration starting at four months; as prior to that age there is significant variability.8 From six to twelve months, there are fewer variations in sleep latency and duration; however as early as six months, 20-30% of infants experience sleep difficulties with frequent night wakings.17. Nighttime wakings are influenced by parent behaviors: responding to night waking with feeding is most directly associated with infants’ not consolidating sleep.12 Additionally, if parents feed at each nighttime waking, toddlers may increase their overall daily energy intake: predominantly nighttime feeding increased BMI-for-age Z score in 12-24 month children.18 Number of nighttime wakings, or fragmented sleep, may also be associated with obesity risk through increasing serum cortisol.19
Co-sleeping, defined here as bedsharing rather than room-sharing, has also been strongly associated with fragmented sleep for infants and toddlers12, and may also increase the feeding-to-sleep association. The type of food offered at waking is also important: breastfeeding offered at waking is less obesogenic than formula20, and co-sleeping is more closely associated with breastfeeding than formula feeding.21 Co-sleeping varies by culture and was found to occur at a higher rate in Hispanic families compared to white families.22 There are mixed studies on the association of co-sleeping and obesity; in a Danish study of 2-6 year old children, co-sleeping was associated with a decreased risk of overweight.23 There is a need for more research into obesity risk for nighttime formula intake compared to nighttime breastmilk intake.
The American Academy of Pediatrics (AAP) recommends against co-sleeping and promotes a studied set of specific safe sleep and nighttime behaviors for infants (back sleeping, separate sleep surface, avoiding bedsharing) to reduce the risk of sudden infant death syndrome (SIDS).24 While the AAP does not specifically endorse sleep training (or “cry it out” methods), they do encourage independent nighttime sleep by recommending phasing out nighttime feeding after six months of age and putting the infant in their crib when they are “drowsy but awake”.25 However, pediatricians may fail to give families practical strategies for their household, and conflict may occur when this advice differs from that of other family members.26 Parents rely heavily on their own experience from their family of origin; their particular “parenting style” comes from cultural experiences within one’s own family as well as response to the child’s temperament .27 Psychologists agree that an authoritative style, with both high demandingness and high responsiveness, is associated with positive child academic and social outcomes.28 Numerous studies have also found associations between parenting styles and childhood obesity: authoritative styles are more protective than permissive. 22,23 Notably, controlling and permissive styles have been found in Hispanic families that may contribute to overfeeding.29-31 Research into infant obesity prevention focuses on responsive feeding, recommending parents pay close attention to hunger and satiety cues, but limiting feeding at other times, i.e. an authoritative style.32 However, research does not include attention to similar behaviors related to sleep, such as trained feeding-to-sleep behavior, that may have roots in overly responsive (permissive) parenting behavior.33,34
Cultural disparities in sleep and obesity
The socioecological model assumes that there are reciprocal interactions between individuals and their environment: an individual’s behavior is connected to the features of their institutions, community, and policy environment as well as interpersonal and intrapersonal characteristics.35 Disparities in sleep and obesity in different racial and ethnic groups can be described using this framework. At the societal level, Americans value individualism and view a child sleeping in a crib or another room as “independence-training”,36 the majority of commercial sleep books in the United States support this view.37 Additionally, emphasis on individual self-regulation is consistent with societal recommendations from large professional organizations, such as the AAP recommendations on following a bedtime routine, practicing self-soothing, and placing the infant in their own bed to sleep38. Alternatively, a number of parenting sleep books espouse bedsharing as integral to the breastfeeding dyadic relationship and strong attachment.21,37 Along these lines, immigrant communities and other minority groups may value interdependence (and thus co-sleeping) more highly.39 Such information can be contradicting, and parents turn to their friends and family for advice.
Beliefs regarding sleep vary amongst different ethnic communities in America, and Hispanic families have been found to have later bedtimes, co-sleep more frequently, and experience greater sleep curtailment.15,22,40 Often times, families engage in parenting behaviors similar to the practices of those around them. 39 At the nuclear family level, Hispanic families tend to have lower socioeconomic status (SES) than that of non-Hispanic white families; financial stress may impact practical concerns regarding sleep.41 For example, material hardship may result in longer and later work hours, variable shift work and decreased routine, and greater likelihood of bedroom-sharing due to a smaller home. Longer parent work hours (both mother and father) have been associated with increased childhood obesity.42,43 Bedtimes may also be impacted by SES and socio-cultural context. If parents arrive home from work in late evening, children may stay awake for a later mealtime or other nighttime family activities. All levels entrenched in the socioecological model influence these individual parent behaviors: leaving parents conflicted in their concern over pediatrician recommendations versus desires to follow cultural norms. Screening for such practices could identify opportunities for early obesity-prevention interventions.
Consideration of the sociocultural context and socioeconomic reality is crucial to understanding the constraints of each family and delivering recommendations that are feasible for them. There is a gap in the literature examining parents’ feelings about nighttime behaviors such as co-sleeping, nighttime routines, and nighttime feeding, particularly in a sample of low-income Hispanic mothers with children at risk for childhood obesity. Pediatricians offering well-intentioned advice need to be sensitive to the real-world needs of families, including their space and schedule constraints, to determine if best practices are “practical”, and how thus to best coach families towards optimal healthy environments.
Rationale for this Study
Qualitative literature examining parents’ experiences managing sleep behaviors of young children is sparse. In 2015, Martinez and Thompson-Lastad conducted a similar study to the current study.44 They focused on a sample of Latina mothers from California. The current study aims to add to this study by possibly confirming their findings and expanding on findings from a similar sample in Texas. Quantitatively, Ochoa and Berge’s literature review of home environment factors that contribute to childhood obesity, noted that deeper investigation into poor sleep and obesity in children is needed.45 Thus, even though quantitative research has explored this area, more qualitative research on this topic is needed to get a deeper understanding of barriers for parents managing sleep behaviors of young children at risk for obesity. The current study comes from a larger study where we conducted qualitative semi-structured interviews to explore the parenting experience of Hispanic caregivers of infants and toddlers who were already at risk for overweight or obesity. In a previous manuscript using the same sample of 14 mothers, we found that parents describe ambivalence around recommended healthy behaviors, often struggle to provide structure while responding to the needs of their child, and meet with conflicting advice from partners and family; permissive parenting behaviors were common.46 Sleep was a dominant theme, encompassing nighttime feeding, sleep location, and logistics of the bedtime routine. We hypothesized that parenting behaviors associated with obesogenic feeding may also extend to sleep behaviors, and aimed to better characterize the behaviors of our group. We also aimed to identify family behaviors around the sleep environment, schedule, and nighttime rituals that may be targets for intervention.