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Early Child Development and Care

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Breastfeeding, maternal depressive mood and room sharing as predictors of

sleep fragmentation in 12-week-old infants: a longitudinal study
Valerie Simarda; Jessica Lara-Carrascobc; Tyna Paquettec; Tore Nielsencd
a
Department of Psychology, Université de Sherbrooke, Longueuil, Quebec, Canada b Department of
Psychology, Université de Montréal, Montreal, Quebec, Canada c Hôpital du Sacré-Coeur de Montréal,
Centre d'étude du sommeil, Montreal, Quebec, Canada d Department of Psychiatry, Université de
Montréal, Montreal, Quebec, Canada
First published on: 29 October 2010
To cite this Article Simard, Valerie , Lara-Carrasco, Jessica , Paquette, Tyna and Nielsen, Tore(2010) 'Breastfeeding,
maternal depressive mood and room sharing as predictors of sleep fragmentation in 12-week-old infants: a longitudinal
study', Early Child Development and Care,, First published on: 29 October 2010 (iFirst)
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Early Child Development and Care
2010, 1–15, iFirst Article
Breastfeeding, maternal depressive mood and room sharing as

predictors of sleep fragmentation in 12-week-old infants:
a longitudinal study
Valerie Simarda*, Jessica Lara-Carrascob,c, Tyna Paquettec and Tore Nielsenc,d
aDepartment of Psychology, Université de Sherbrooke, Longueuil, Quebec, Canada;
bDepartment of Psychology, Université de Montréal, Montreal, Quebec, Canada; cHôpital du
Sacré-Coeur de Montréal, Centre d’étude du sommeil, Montreal, Quebec, Canada; dDepartment of
Downloaded By: [Canadian Research Knowledge Network] At: 04:04 11 April 2011
Psychiatry, Université de Montréal, Montreal, Quebec, Canada

(Received 9 June 2010; final version received 2 August 2010)
Taylor and Francis
GECD_A_513434.sgm
Early
10.1080/03004430.2010.513434
0300-4430
Original
Taylor
02010
00
Miss
simardval@hotmail.com
000002010
ValerieSimard
Childhood
&Article
Francis
(print)/1476-8275
Development(online)
and Care
Sleep fragmentation in infancy can burden a family by disrupting the sleep of all
its members. However, there has been no longitudinal prospective investigation
of the determinants of infant sleep fragmentation. We undertook such an
investigation. New mothers (N = 106) completed questionnaires and were
administered structured telephone interviews at three, six and 12 weeks
postpartum. Pre- and postnatal maternal adjustment and sleep-related parental
practices were evaluated as potential predictors of infants’ sleep fragmentation.
Risk factors for infants sleeping less than six consecutive hours per night at 12
weeks were found to be mother’s depressed mood (OR = 1.55, p < .01),
breastfeeding (OR = 6.40, p < .01) and room sharing (OR = 2.91, p < .05). The
mother’s depressed mood and breastfeeding were also related to poor sleep
consolidation when the latter was assessed as a continuous outcome (p < .01). This
study identifies factors to target in sleep-focused interventions in families where
the child’s sleep has become a problem.
Keywords: sleep consolidation; infancy; postpartum depression; breastfeeding;
cosleeping; room sharing
Introduction
Because infants spend more time sleeping than engaging in any other activity, sleep
may be the brain’s single most important activity during early childhood (Dahl, 1996).
During the first year of life, there is a developmental progression consisting of a
decrease in total sleep duration over the 24-hour period, major reductions in diurnal
sleep and establishment of a clear day–night differentiation during the first four
months of life (Armstrong, Quinn, & Dadds, 1994). Additionally, nocturnal sleep
fragmentation decreases during the first year of life, with infants sleeping undisturbed
for longer time periods as they grow older. Specifically, from the age of three weeks
to three months, the longest nocturnal sleep period duration increases from 3.5 to 6
hours (Anders, Halpern, & Hua, 1992). By the age of 12 weeks, 75% of infants sleep
undisturbed for at least six consecutive hours (Adams, Jones, Esmail, & Mitchell,
2004).
*Corresponding author. Email: valerie.simard@usherbrooke.ca
ISSN 0300-4430 print/ISSN 1476-8275 online

© 2010 Taylor & Francis
DOI: 10.1080/03004430.2010.513434
http://www.informaworld.com
2 V. Simard et al.
Sleep problems affect 20–30% of children at least once during childhood (Owens,
2007) and are risk factors for both physical health problems such as overweight
(Taveras, Rifas-Shiman, Oken, Gunderson, & Gillman, 2008) and emotional problems
through childhood to adulthood (Breslau, Roth, Rosenthal, & Andreski, 1996; Gregory
& O’Connor, 2002). Sleep problems tend to be maintained across the preschool years
(Simard, Nielsen, Tremblay, Boivin, & Montplaisir, 2008a, 2008b) and their occur-
rence during infancy is the strongest predictor of preschool sleep difficulties (Simard
et al., 2008b). Therefore, there is a clear need to identify risk factors for signs of sleep
problems that are observed early in infancy. The main goal of this study was to identify
such risk factors (measured at the age of zero to six weeks) of later sleep fragmentation
(measured at 12 weeks). Two types of predictors were considered: maternal psycho-
logical factors and parental sleep-related practices.
Maternal psychological factors

Of all potential indicators of maternal mental health problems, the most studied in
relation to early infant sleep problems is postnatal depression. This condition affects
10–15% of mothers in the first postpartum year (O’Hara & Swain, 1996; Skouteris,
Wertheim, Rallis, Milgrom, & Paxton, 2009) and is widely considered to adversely
affect the child’s emotional development (Hay, Pawlby, Angold, Harold, & Sharp,
2003; Moehler et al., 2007). There is also increasing evidence that a child’s
sleep problems in the first year of life are closely related to poor maternal well-being
(Zuckerman, Stevenson, & Bailey, 1987) and to depression more specifically (Anders
et al., 1992; Armstrong, Van Haeringen, Dadds, & Cash, 1998; Dennis & Ross, 2005;
Hiscock & Wake, 2001; Karraker & Young, 2007). However, most of these studies
focus on the child’s sleep behaviours after a clear day–night differentiation has been
established, i.e., at the age of three months (Nishihara, Horiuchi, Eto, & Uchida,
2002). The present study examines predictors of poor sleep at the age of zero to six
weeks, before sleep consolidation is clearly established. Other forms of postnatal
maternal distress, such as feeling anxious or stressed, have not yet been studied
in relation to infant sleep consolidation and are included as predictors in the present
study.
Maternal psychopathology during the prenatal period may also have a negative
influence on infants’ sleep behaviours, since such psychopathology affects a number
of physiological (Field, Diego, & Hernandez-Reif, 2006) and emotional (O’Connor,
Heron, Golding, Beveridge, & Glover, 2002) components of child development.
Prenatal maternal depression is associated with less time spent in deep sleep (Field
et al., 2007), while prenatal psychological distress predicts night wakings at the age of
six to 12 months (Baird, Hill, Kendrick, & Inskip, 2009). To our knowledge, the
present study is the first to investigate whether prenatal maternal psychopathology is
associated with sleep fragmentation in the very first months of life.
Maternal history of primary insomnia is another factor suspected to contribute to
poor sleep early in infancy. Insomnia is the most common sleep disorder, with chronic
insomnia affecting up to 20% of the adult population (Dauvilliers et al., 2005) and
showing a familial aggregation (Dauvilliers et al., 2005; Drake, Scofield, & Roth,
2008) that may be partly attributed to genetic factors (Drake et al., 2008). Moreover,
insomnia onset at a young age has been found for familial insomnia (Dauvilliers et al.,
2005; Hauri & Olmstead, 1980) with a preferential maternal transmission (Dauvilliers
et al., 2005). Thus, we hypothesised that maternal history of insomnia would predict
Early Child Development and Care 3
infant sleep fragmentation, which might be considered a sign of protodyssomnia, an

early manifestation of insomnia.
Sleep regulation in infancy might also be determined by familial relational factors,
more specifically by relational insecurity of the mother. In line with this hypothesis,
maternal separation anxiety was found to be associated with the child’s night wakings
at 10 and 12 months (Scher, 2008; Scher & Blumberg, 1999). Similarly, more sleep
problems were found among the children of mothers showing an insecure (dismissing
or preoccupied), as opposed to a secure-autonomous, attachment when interviewed
about past relationships (Benoit, Zeanah, Boucher, & Minde, 1992). This suggests that
a parent’s insecure attachment to his/her own parental figures leads to sleep problems
in the child. However, this has never been tested in very young infants. In the present
study, the mother’s perception of bonding with her own parental figures, thought to
be related to maternal sensitivity, was measured and examined in relation to early
sleep regulation.
Parental practices
Breastfeeding is widely recognised to have numerous benefits to infant health (Heinig
& Dewey, 1996) and is usually recommended as the first choice method for feeding
infants aged zero to six months (American Academy of Pediatrics, 2005; World Health
Organization, 2001). However, it is also an important predictor of sleep fragmentation
in five-month-old infants (Touchette et al., 2005) and of sleep dysregulation in the first
three years of life (Sadeh, Mindell, Luedke, & Wiegand, 2009). The association between
breastfeeding and poor sleep in both parents and infants might be partly attributed to
the well-known relationship between breastfeeding and cosleeping (Goldberg & Keller,
2007). Cosleeping, defined as sharing the parent’s bed or room for part or all of the
night, is associated with lighter infant sleep, more night wakings (Adair, Bauchner,
Philipp, Levenson, & Zuckerman, 1991; Mao, Brunham, Goodlin-Jones, Gaylor, &
Anders, 2004; Mosko, Richard, & McKenna, 1997) and the persistence of sleep prob-
lems from one to two years of age (Morrell & Steele, 2003). However, few studies have
examined sleep outcomes of cosleeping before the age of three months. Anders et al.
(1992) reported that three-month-old infants who were put to bed awake were more
likely than those put to bed already asleep to self-comfort after later nocturnal awak-
enings, hence suggesting a detrimental effect of parent–child proximity at bedtime.
Based on the literature reviewed above, we hypothesised that sleep fragmentation
in 12-week-old infants would be predicted by: (1) postpartum distress of the mother,
defined as feeling depressed, anxious and stressed from zero to six weeks; (2) prenatal
psychological distress of the mother; (3) pre-pregnancy maternal insomnia; (4) mater-
nal perception of having received poor parenting; and (5) parental practices involving
parent–child proximity at night (breastfeeding, feeding the child in bed and room shar-
ing). Two alternative indicators of sleep consolidation were investigated in the study:
sleeping less or more than six consecutive hours at night (categorical outcome) and
number of consecutive hours of sleep at night (continuous outcome).
Methods
Participants
The sample consisted of 106 new mothers aged 18–45 years (M = 30.5 ± 5.2 years),
each of whom had given birth in the Hôpital du Sacré-Coeur de Montréal (Montreal,
4 V. Simard et al.
Canada) within the last 24 hours and had agreed to take part in a study on the sleep
and dream experiences of new mothers. Each of these mothers completed question-
naires within 48 hours of giving birth and were later contacted by telephone at home
to complete structured interviews at three, six and 12 weeks postpartum. All mothers
were selected based on the following inclusion criteria: (1) no active neurological,
psychiatric or major sleep disorder; (2) not currently taking medication known to
influence sleep; (3) no evidence of substance abuse during pregnancy; and (4)
comprehension of English or French.
Most mothers in the final sample were Caucasians (98.1%), born in Canada
(96.2%), and spoke French as their first language (96.2%). Half of the mothers were
living in common law relationships (51.4%), while 39.1% were married and 9.5%
were single. With regard to education level, 42.9% had a university degree, 28.6% had
a college diploma, 22.9% had a high school diploma and 5.7% did not complete high
school. Most (63.5%) families earned more than $50,000, whereas 10.6% earned less
than $20,000 annually.
Measures
Interviews
The same structured interview was conducted at three, six and 12 weeks postpartum.
Interviews covered the period since the child’s birth (Week 3 interview) or their last
contact with a research assistant (Weeks 6 and 12 interviews). Responses to all ques-
tions were tape-recorded and typed into a database by one of three interviewers. Each
interview included 71 questions, nine of which were assessed in the present analyses
(see Table 1).
Table 1. Description of telephone interview items administered at three, six and 12 weeks
postpartum.
Item Type of variable
How many hours does he/she sleep consecutively during the Continuous
night?
Does he/she sleep through the night? Dichotomous (yes/no)
How many hours does your baby sleep on average in a 24-hour Continuous
period?
How often do you feed your baby in your bed? Continuous (times/week)
Are you breastfeeding? Dichotomous (yes/no)
How stressed have you been feeling about the new 11-point scale (0 – not at all to
responsibilities of being a mother? 10 – extremely)
How anxious have you been feeling since coming home from 11-point scale (0 – not at all to
the hospital (or the last interview)? 10 – extremely)
Have you been feeling depressed since coming home from the 11-point scale (0 – not at all to
hospital (or the last interview)? 10 – extremely)
Where does your baby sleep? Categorical (In your room, In
baby’s room without
monitor, In baby’s room
with monitor)
Questionnaires
General information questionnaire. This instrument assesses 11 sociodemographic
items, including mother’s age, education and familial income levels, number of chil-
dren, marital status, language spoken at home, infant’s birth weight, etc.
Sleep Disorders Questionnaire – Abbreviated (SDQ-A). This 81-item instrument was

adapted from the Sleep Disorders Questionnaire (Douglass et al., 1994) and assesses
the presence of sleep disorders symptoms using five-point rating scales (1 = never, 2
= rarely, 3 = sometimes, 4 = usually, 5 = always). Only the 12 items assessing insom-
nia were used in this study. These items target diverse aspects of insomnia, such as
lack of sleep (e.g. I get too little sleep at night, I wake up often during the night), and
ruminations and worries at night (e.g. At bedtime, I worry about things; My sleep is
disturbed by thoughts racing through my head).
Parental Bonding Instrument (PBI). This widely used questionnaire measures the
adult’s perception of bonding with parental figures for the age of 16 and earlier (Parker,
Tupling, & Brown, 1979). It includes 25 items, each rated on a four-point scale from
very like to very unlike, and yields scores on two subscales: affection and protection.
The questionnaire is completed once for each parental figure.
Symptom Checklist-90-Revised (SCL-90-R). This 90-item instrument assesses psycho-

pathology with nine validated clinical subscales: somatization, obsessive-compulsive,
interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid
ideation and psychoticism (Derogatis, 1977). Additionally, a Global Severity Index
(GSI) derived from these subscales provides information about general psychopathol-
ogy level. The questionnaire was used to probe psychological distress only during the
last month of pregnancy. The SCL-90-R has good internal consistency in the present
study (Cronbach’s alpha = .95).
Results
Data reduction
To reduce the number of predictors and minimise multicollinearity, the following vari-
ables were combined and averaged: mother-reported stress and anxiety levels at three
and six weeks postpartum (rs between .59 and .72, p < .01), and depressive symptoms
level at three and six weeks (r = .41, p < .01). Most of the SCL-90-R subscales were
highly inter-correlated (rs between .33 and .82, p < .01). Thus, only the GSI was used
in the analyses.
Preliminary analyses
Preliminary analyses were undertaken to identify potential sociodemographic covari-
ates of the study dependent variables (consecutive hours of sleep at 12 weeks), i.e.,
child’s gender, mother’s parity, marital status, age, education level and family yearly
income. Children differed significantly as a function of mother’s parity, with children
of multipara mothers sleeping fewer hours in a row (M = 6.5 ± 2.2 hours) than children
of primipara mothers (M = 7.4 ± 2.2 hours; t[104] = 2.09, p < .05). Only parity was
6 V. Simard et al.
identified as a possible confounder, and was therefore included as a covariate in subse-

quent analyses.
Longitudinal progression of sleep consolidation from the age of three to 12 weeks

The longitudinal progression from three to 12 weeks of children with consolidated
sleep (‘sleeping at least or less than six consecutive hours’) at night is displayed in
Figure 1. Only a small proportion of children was already sleeping six hours in a row
at three weeks (8.5%), and 100% of this number continued to do so at six and 12
weeks. Among the majority (91.5%) of infants who slept less than six hours at three
weeks, most (76.3%) still had short nocturnal sleep periods at six weeks. However, at
12 weeks the tendency towards consolidated sleep was stronger than the tendency
towards non-consolidated sleep among infants who were previously sleeping less than
six hours (62.2% vs. 37.8%). At 12 weeks, the majority (70.8%) of infants slept at
least six consecutive hours nightly.
Figure 1. Evolution of children sleeping less than or at least six consecutive hours at night at three, six and 12 weeks of age.
Predictors of sleeping less than six hours in a row at 12 weeks

Binary logistic regression analyses were conducted, with a forced entry of the covariate
(parity) in a first step, followed by the inclusion of all predictors of interest using a
forward-stepwise likelihood ratio method, in a second step. The inclusion of the cova-
riate significantly added to a constant-only model (χ2[1, N = 106] = 4.36, p < .05);
however, parity was no longer a significant predictor in the final model (see Table 2).
Figure 1. Evolution of children sleeping less than or at least six consecutive hours at night at
three, six and 12 weeks of age.
Table 2. Final logistic regression model for predicting sleeping less than six consecutive
hours at night at 12 weeks.
Predictors %Refa %Catb Wald statistic Odds ratio (95% CI)
Primipara motherc 50.67% 32.26% 2.79 0.38 (0.13–1.18)
Mean (SD) Mean (SD)
Mother’s report of feeling 2.03 (1.79) 2.71 (1.62) 7.19** 1.55 (1.13–2.13)
depressed from zero to
six weeks
%Refa %Catb
Breastfeeding at six weeksd 64.00% 83.33% 7.37** 6.40 (1.68–24.48)
Sleeping in mother’s 38.36% 70.00% 4.08* 2.91 (1.03–8.18)
bedroom at six weekse
*p < .05; **p < .01.

a
Percentage within the group of children sleeping at least six hours in a row at night (reference category).
b
Percentage within the group of children sleeping less than six hours in a row at night.
c
The reference category was being a multipara mother.
d
The reference category was bottle-feeding.
e
The reference category was the infant sleeping in his/her own room.
Three predictors achieved entry in the final model (χ2[4, N = 106] = 23.68, p < .01).
The order of stepwise entry of these predictors was: (1) maternal depressive symptoms
(from zero to six weeks) (improvement χ2[1, N = 106] = 5.54, p < .01), (2) breastfeed-
ing during Weeks 3–6 (improvement χ2[1, N = 106] = 9.59, p < .01), and (3) sleeping
in mother’s room during Weeks 3–6 (improvement χ2[1, N = 106] = 4.19, p < .05).
All these predictors remained significant in the final model (see Table 2).
Predictors of number of consecutive hours of nocturnal sleep at 12 weeks

Multiple regression analyses were performed on sleep consolidation as a continuous
outcome (number of consecutive hours of nighttime sleep) at the age of 12 weeks as
for the previous model. Mother’s parity was entered in a forced first step then all other
predictors were entered in a stepwise fashion. As for the previous analysis, breastfeed-
ing during Weeks 3–6 (∆R2 = 0.12, ∆F(1,98) = 13.44, p < .01) and the mother feeling
depressed during Weeks 3–6 (∆R2 = 0.08, ∆F(1,97) = 9.57, p < .01) were significant
predictors of poor sleep consolidation at 12 weeks (see Table 3). Unexpectedly, being
a primipara mother was associated with more consecutive hours of nighttime sleep
(∆R2 = 0.05, ∆F(1,99) = 5.25, p < .05). Parity remained a significant predictor in the
final model (see Table 3). Room sharing was not a significant predictor of sleep
consolidation assessed as a continuous variable.
Post-hoc analyses: association between room sharing and breastfeeding

At three weeks, 60.0% of children were sleeping in mother’s room, whereas 40.0%
were sleeping in their own room and 75.5% were breastfed, as opposed to 24.5% who
were formula-fed. Similarly, at six weeks, most (69.5%) children were breastfed.
However, 47.6% children were sleeping in their own room. Chi-square analyses were
undertaken to investigate whether mother–infant room sharing and breastfeeding
were inter-related. At three weeks, the proportion of room sharing was higher among
8 V. Simard et al.
Table 3. Final multiple regression model for predicting the number of consecutive hours of
nocturnal sleep at the age of 12 weeks.
Predictor β (95% CI) t
Primipara mothera .23 (.23 to 1.82) 2.54*
Breastfeeding at six weeksb −.40 (−2.79 to −1.05) −4.39**
Mother’s report of feeling depressed from zero to six weeks −.28 (−.58 to −.12) −3.10**
*p < .05; **p < .01.
a
The reference category was being a multipara mother.
b
The reference category was bottle-feeding at six weeks.
bottle-feeding (76.9%) than among breastfeeding (54.4%) mothers (χ2[1, n = 105] =

4.12, p < .05). However, this difference was not significant at six weeks (χ2[1, n =
102] = 0.03, ns). Finally, there was no interaction effect between breastfeeding and
room sharing in predicting impaired sleep consolidation at 12 weeks, using either
dichotomous or continuous measures.
Discussion
We examined the longitudinal progression of an infant’s sleep consolidation during
the immediate postpartum period and identified predictors of failing to reach this
developmental milestone by the age of 12 weeks. While relatively few infants slept at
least six consecutive hours at night (8.5%) at three weeks of age, there was a dramatic
increase in sleep consolidation between six (30.2%) and 12 (70.8%) weeks. This
pattern of developmental change is consistent with the view of sleep maturation as a
discontinuous process, with the most acute changes in sleeping through the night
occurring seven weeks after birth (Fukuda & Ishihara, 1997). Consistent with a previ-
ous report (Adams et al., 2004; Anders et al., 1992), most children in the present study
had consolidated sleep by the time they reached 12 weeks of age, which supports the
idea that synchronisation between the homeostatic and circadian processes, thought to
be reflected in the absence of awakenings over a six-hour period at night, is attained
between the age of six and 12 months (Jenni & LeBourgeois, 2006).
Nonetheless, a considerable number of families (25–30%) were still dealing with
non-consolidated sleep when the child was 12 weeks old. The present study revealed
two postpartum factors that may explain this developmental delay: breastfeeding
during Weeks 3–6 and the mother’s depressive affect. These factors reliably predicted
impaired sleep consolidation at 12 weeks whether assessed as a dichotomous or a
continuous measure and independent of sociodemographic factors. Mother–infant
room sharing also predicted poor sleep consolidation only for the dichotomous
measure while multipara status predicted poor sleep consolidation only for the contin-
uous measure. Altogether, the findings support the idea that maternal-related cues and
behaviours are prominent determinants of sleep regulation from infancy (Nishihara
et al., 2002) throughout the preschool years (Touchette et al., 2005).
Maternal practices: breastfeeding and room sharing

As hypothesised on the basis of previous findings (Sadeh et al., 2009; Touchette et
al., 2005), breastfeeding predicted delayed sleep consolidation in 12-week-old
infants. After controlling for sociodemographic factors (parity), the risk of delayed
sleep consolidation at the age of 12 weeks was more than eight times higher if the
child had been breastfed from the age of three to six weeks. Consistent with this find-
ing, a recent case study found that nocturnal awakenings are closely related to the
need for milk intake in breastfed infants younger than four months of age (Oda et al.,
2008). This does not mean that, in order to improve infant’s sleep, breastfeeding
should be avoided, since the practice has numerous benefits to the child’s health
(Heinig & Dewey, 1996). There is clinical evidence that the optimal delay between a
child’s expression of a need (e.g. hunger) and a caregiver’s response to it is short in
the very first weeks of life (American Academy of Pediatrics, 2005). However,
lengthening the delay between the infant’s nighttime crying and breastfeeding by
introducing alternatives to feeding as a first response to the crying (e.g. diapering,
walking the infant, patting) results in a reduced frequency of night waking and
reduced likelihood of seeking help for crying and sleeping (Pinilla & Birch, 1993; St
James-Roberts, Sleep, Morris, Owen, & Gillham, 2001). That such procedures are not
associated with weight loss suggests that crying does not automatically imply a need
for immediate feeding.
Mother–infant room sharing can also interfere with the development of self-
soothing strategies. Indeed, such a sleep arrangement promotes a faster response by
the mother to the child’s cries, and hence may interfere with sleep consolidation
through processes similar to those related to breastfeeding. Consistent with this, we
found that room sharing predicted the subsequent absence of sleep consolidation in
12-week-olds. Specifically, 12-week-olds who at six weeks had slept in their mother’s
bedroom were over two times more at risk of sleeping less than six consecutive hours
at night than were 12-week-olds who had slept in their own room with or without a
monitor. These findings support the considerable body of evidence for a link between
cosleeping and sleep problems during childhood (Adair et al., 1991; Adams et al.,
2004; Anders et al., 1992; Mao et al., 2004; Morell & Steele, 2003; Mosko et al.,
1997). However, we found that cosleeping was not a predictor of sleep consolidation
when measured in a continuous fashion.
Despite the well-known relationship between cosleeping and breastfeeding (Gold-
berg & Keller, 2007) and the fact that both practices are thought to interfere with sleep
through similar processes relating to enhanced proximity with the child, they were not
interrelated at the age of six weeks in the present study. Moreover, there was a larger
proportion of cosleepers among bottlefed (76.9%) than among breastfed (54.4%)
infants at the age of three weeks. This unexpected finding is at odds with previous
research suggesting that breastfeeding and cosleeping are mutually supportive (Ball,
2003). One possible explanation is that mothers who bottle-feed do so knowingly
counter to the recommendations of public health policies and paediatricians, and are
thereby more inclined to compensate their lack of proximity with the child through
sharing of the same room. Finally, in the present study, there was no interaction
between practices in predicting sleep consolidation. Thus, in the first three months of
life, room sharing and breastfeeding each appear to have a unique contribution to
delayed sleep consolidation.
In the present results, mother’s parity was unexpectedly related to infant sleep
fragmentation. While multipara status was found to predict poor sleep consolidation,
this was not reliably so for the continuous dependent measure. One possible explana-
tion for this finding is that primipara mothers benefit from a greater involvement of
fathers in nocturnal care of infants and thus incorrectly judge them to have slept more
10 V. Simard et al.
hours. Alternatively, it may be that the infants of multipara mothers are disturbed
more by the presence of other children in the household – and possibly even in the
same bedroom, although this factor was not evaluated in the present study.
Depressive affect of the mother

As expected, the mother’s postnatal depressive affect was found to predict disrupted
sleep consolidation at the age of 12 weeks. A maternal depressed mood from zero to
six weeks postpartum increased the child’s subsequent risk for sleeping less than six
consecutive hours at night by a factor of 1.55 for each elevation of 1 on an 11-point
scale. Moreover, postpartum depressed mood was associated with fewer consecutive
hours of nocturnal sleep. That the mother’s postnatal anxiety and stress did not
contribute to this effect is in line with literature that emphasises the deleterious effects
of maternal depressive mood on the child’s sleep and with evidence that maternal
stress does not predict the persistence of sleep difficulties in children at the age of
three years beyond what is predicted by depression (Zuckerman et al., 1987).
Researchers have noted difficulties in clarifying the causal nature of associations
between maternal depression and infant sleep difficulties (Armstrong et al., 1998;
Hiscock & Wake, 2001; Ross, Murray, & Steiner, 2005) but two main pathways have
been proposed. The first is that the child’s sleep disruption contributes to maternal
depression by augmenting sleep deprivation in the mother (Ross et al., 2005; Warren,
Howe, Simmens, & Dahl, 2006). This explanation is consistent with evidence that:
(1) chronic sleep deprivation is a risk factor for the onset of depression in the general
population (Boivin et al., 1997) and in new mothers in particular (Dennis & Ross,
2005; Goyal, Gay, & Lee, 2007), and (2) reducing an infant’s sleep problems
improves maternal mood (Armstrong et al., 1998; Hiscock & Wake, 2002). The
second suggested pathway is that maternal depressive symptoms contribute to infant
sleep problems through maladaptive parenting behaviours that negatively affect the
infant’s sleep. Thus, children of depressed mothers may be more prone to sleep disor-
ders as a reaction to their mothers’ inappropriate practices in situations of bedtime
resistance or night waking (Stoleru, Nottelmann, Belmont, & Ronsaville, 1997).
Results from two longitudinal studies support this notion by showing that maternal
depressive symptoms predicted persistence (Zuckerman et al., 1987) and even
worsening (Warren et al., 2006) sleep problems among children up to three years of
age, while children’s sleep disturbances were unlikely to contribute to maternal
depressive symptoms.
Finally, Karraker and Young (2007) proposed a model in which the two suggested
causal pathways between child sleep disruption and mother depressive symptoms
operate simultaneously. Tired and depressed mothers of wakeful infants purportedly
engage in parenting practices that prolong or increase the child’s night waking,
thereby increasing their own exhaustion and depression, and so on cyclically. In line
with this model, a greater frequency of night wakings in the infants of depressed moth-
ers could be an indicator of less sensitive caregiving (Mills-Koonce, Gariepy, Sutton,
& Cox, 2008) and an early marker for the development of insecure child–mother
attachment (De Wolff & van IJzendoorn, 1997). However, since depressed mothers
underestimate their own sleep quality (Dorheim, Bondevik, Eberhard-Gran, &
Bjorvatn, 2009), they may also overemphasise sleep difficulties in their child. For
instance, mothers experiencing depressive affects retrospectively report difficulties
with their infant learning to sleep through the night (Germo, Goldberg, & Keller,
2009). Alternatively, by sleeping less during the night, they may be more aware of
their infant’s night awakenings than are non-depressed mothers (Hiscock & Wake,
2001; Karraker & Young, 2007).
Prenatal maternal factors

Contrary to our hypotheses, neither maternal prenatal psychopathology nor maternal
history of insomnia before pregnancy predicted disrupted sleep consolidation in the
child. One explanation for these unexpected findings is that completion of the ques-
tionnaires measuring psychopathology and insomnia within 48 hours of giving birth
distanced mothers psychologically from their past difficulties and led to underestima-
tion of them. Childbirth is a landmark event that evokes both positive and negative
psychological reactions, and for some women transition to motherhood may be a
period of heightened cognitive–emotional sensitivity during which they are totally

focused on the infant’s needs, a state designated by Winnicott (1965) as ‘primary
maternal preoccupation’. Such a change may render women psychologically unavail-
able to respond accurately to questions about former internal states.
The quality of a mother’s bonding with her own parental figures also did not
predict sleep fragmentation at the age of 12 weeks as expected. This hypothesis
(Jefferis & Oliver, 2006) was based on the notion of transgenerational transmission of
anxiety (DiBartolo & Helt, 2007), as expressed here in the child’s difficulty in sepa-
rating from the caregiver at night. Given the complexity of these concepts and the lack
of studies on the topic, it is possible that the instrument used in the present study (PBI)
does not adequately capture the type of maternal relational insecurity that interferes
with the child’s sleep.
Clinical implications
Our finding of a time window from 6 to 12 weeks of age that is critical to sleep consol-
idation may inform the development and evaluation of much-needed intervention
programmes. Because it is still not known definitively if sleep fragmentation has detri-
mental or beneficial effects on infant development, sleep interventions should for the
time being be applied only in families where the infant’s sleep fragmentation is a
burden, interfering with the quality of parent–child interactions. Until this issue is
resolved, findings from the present study suggest that intervention programmes could
target the factors of room sharing, breastfeeding and depressive mood among families
with infant sleep problems. Nonetheless, caution should be exercised with respect to
room sharing and breastfeeding in particular. Both factors are associated with sleep
difficulties, but both have also been reported to impart benefits to the child’s health
and development. Breastfeeding should clearly not be avoided, but provided to the
child in a way that is minimally disruptive to the infant’s sleep (for a discussion, see
Pinilla & Birch, 1993 and St James-Roberts et al., 2001). With respect to cosleeping,
the latter has been reported repeatedly to predict poor sleep during childhood and the
same may be true for the very first weeks of life. However, cosleeping could also be
a protective factor against SIDS (McKenna & McDade, 2005). Also, as previously
suggested (Germo et al., 2009), some families may hold personal or cultural beliefs
that emphasise a later onset of sleeping through the night and which may thereby be
associated with less distress and less need for professional help.
12 V. Simard et al.
Acknowledgements
This research was supported by grants received from the Social Sciences and Humanities
Research Council of Canada (SSHRC), the Canadian Institutes of Health Research (CIHR) and
the Natural Sciences and Engineering Research Council of Canada (NSERC).
Notes on contributors
Valerie Simard is a clinical child psychologist and a professor in the Department of Psychology
at the Université de Sherbrooke. Her research interests include child development, sleep,
parent–child relationships and attachment.
Jessica Lara-Carrasco is a doctoral student in the Department of Psychology at the Université

de Montréal who is currently conducting research in the Dream and Nightmare Laboratory at
the Sleep Research Center of Hôpital du Sacré-Coeur de Montréal. Her research interests
include functions of dreams, sleep and maternal adjustment.
Tyna Paquette is the research coordinator of the Dream and Nightmare Laboratory at the Sleep
Research Center of Hôpital du Sacré-Coeur de Montréal. Her research interests include
physiology of normal and disordered dreaming.
Tore Nielsen is a psychologist, professor of psychiatry at the Université de Montréal, and

director of the Dream & Nightmare Laboratory at the Hôpital du Sacré-Coeur de Montréal
where he conducts research on nightmare physiology and the neuroscience of dreaming.
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Early Child Development and Care

Breastfeeding, maternal depressive mood and room sharing as predictors of

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Breastfeeding, maternal depressive mood and room sharing as

Psychiatry, Université de Montréal, Montreal, Quebec, Canada

*Corresponding author. Email: valerie.simard@usherbrooke.ca

ISSN 0300-4430 print/ISSN 1476-8275 online

Maternal psychological factors

infant sleep fragmentation, which might be considered a sign of protodyssomnia, an

Sleep Disorders Questionnaire – Abbreviated (SDQ-A). This 81-item instrument was

Symptom Checklist-90-Revised (SCL-90-R). This 90-item instrument assesses psycho-

identified as a possible confounder, and was therefore included as a covariate in subse-

Longitudinal progression of sleep consolidation from the age of three to 12 weeks

Predictors of sleeping less than six hours in a row at 12 weeks

*p < .05; **p < .01.

Predictors of number of consecutive hours of nocturnal sleep at 12 weeks

Post-hoc analyses: association between room sharing and breastfeeding

bottle-feeding (76.9%) than among breastfeeding (54.4%) mothers (χ2[1, n = 105] =

Maternal practices: breastfeeding and room sharing

Depressive affect of the mother

Prenatal maternal factors

period of heightened cognitive–emotional sensitivity during which they are totally

Jessica Lara-Carrasco is a doctoral student in the Department of Psychology at the Université

Tore Nielsen is a psychologist, professor of psychiatry at the Université de Montréal, and

aggregation. Sleep Medicine, 9, 297–302.

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