Protecting sleep


López Maestro M, Camba F, Oude-Reimer M, Frauenfelder O, Hankes-Drielsma I, Kalbér A, Kühn T, Silva E

© Foto Video Sessner GmbH

User group

Healthcare professionals, neonatal units, hospitals, and health services

Statement of standard

Sleep of all infants is respected.


Fetuses and infants spend most of their time sleeping. Sleep is crucial to early neurosensory and motor development. (1,2) Therefore, sleep protection for infants during neonatal care is a goal for parents and healthcare professionals. Sleep is a regulated process. Sleep-wake states can be observed only after the neuronal structures involved have developed sufficiently.

Sleep state identification and respecting the period of sleeping in preterm infants become essential because good sleep organisation in the infant is related to better developmental outcomes. Protecting sleep cycles is critical to preserve the brain’s ability to change, adapt and learn in response to experiences. (1) During sleep preterm infants are building their brain.

The neonatal unit environment has the potential to affect the quality and quantity of sleep (3) with disruption of brain development. (4)
It is important to encourage caregiving practices that preserve sleep, a non-invasive environment (5) focused on the infant’s individual needs and behavioural patterns, and help with the transition between the states. Kangaroo mother care has shown to be an important strategy, increasing sleep time and the amount of quiet sleep (6), and improving sleep-wake cycles. (7–9)


Short-term benefits

  • Improved growth (4)
  • Improved neuronal development (1,2,10)
  • Improved behavioural organisation (1,2,10)
  • Improved temperature regulation (11)

Long-term benefits

  • Improved development of motor and neurosensory systems (12)


Components of the standard

Component Grading of evidence Indicator of meeting the standard
For parents and family    
1. Parents are informed by healthcare professionals about the importance and benefits of sleep during the neonatal period. (13,14) A (Moderate quality)
B (High quality)
Patient information sheet
2. Parents are trained and supported to recognise sleep signals in their infant and how to comfort the baby. (14) A (Moderate quality)
B (High quality)
Training documentation
3. Parents are encouraged and supported in skin-to-skin contact with their infant, and know the benefits regarding their infant’s sleep. (6–8,14) (see TEG Infant- and family-centred developmental care) A (Moderate quality)
B (High quality)
Guideline, parent feedback
4. Parents are trained to facilitate self-calming behaviours and to use strategies to support infants sleep, restful period between caregiving and quiet alert periods. (14) A (Moderate quality)
B (High quality)
Training documentation
For healthcare professionals    
5. A unit guideline on sleep protection is adhered to by all healthcare professionals. B (High quality) Guideline
6. Training on the importance of sleep during the neonatal period, sleep-wake cycles in term and preterm infants and self-calming behaviours is attended by all responsible healthcare professionals. (4,5,13) A (Moderate quality)
B (High quality)
Training documentation
7. Environmental conditions that protect sleep cycles, individual needs and family participation and respect the individual behavioural states are assured. (15,16) A (Moderate quality)
B (Moderate quality)
For neonatal unit    
8. A unit guideline on sleep protection, including the maintenance of comfort, quiet environment and light control is available and regularly updated. (15). A (Moderate quality)
B (High quality)
9. Individualised care planning, including skin-to-skin care, to protect the infant’s sleep is implemented. (4,6–8,11,14) A (Moderate quality)
B (Moderate quality)
Audit report, clinical records
For hospital    
10. Training, recommendations and strategies to respect sleep and provide education and resources about sleep and sleep protection are ensured. (15) (see TEG NICU Design) A (Moderate quality)
B (High quality)
Guideline, training documentation
11. Appropriate comfortable chairs for skin-to-skin care are available. (see TEG Infant- & family-centred developmental care, see TEG NICU Design) A (Moderate quality)
B (High quality)
Audit report
For health service    
12. A national guideline on sleep protection is available and regularly updated. (17) B (High quality) Guideline

Where to go

Further development Grading of evidence
For parents and family  
For healthcare professionals  
For neonatal unit  
For hospital  
  • Provide equipment that is low in sounds and fitting the development of the infants in the NICU to protect sleep.
B (Moderate quality)
For health service  
  • Promote research into sleep to improve the quality of care.
B (Moderate quality)

Getting started

Initial steps
For parents and family
  • Parents are verbally informed by healthcare professionals about the importance of sleep during care.
  • Adjust care to the sleep-wake rhythm of the child.
For healthcare professionals
  • Attend training on the importance of sleeping during infancy and recognise sleep-wake cycles in term and preterm infants.
  • Coordinate between different healthcare professionals of different specialties in order to protect the infant’s sleep.
  • Adjust care to the sleep-wake rhythm of the child.
For neonatal unit
  • Develop and implement a unit guideline on sleep protection.
  • Develop information material on the importance of sleep during care for parents.
  • Organise training sessions for caregivers explaining the importance of respecting sleeping period for the infant brain development and the unit policy or guidelines.
  • Provide protocols within meetings between all hospital specialities related to care in order to protect sleep to evaluate cooperation.
For hospital
  • Support healthcare professionals to participate in training on the importance of sleeping during infancy and recognise sleep-wake cycles in term and preterm infants.
For health service
  • Develop and implement a national guideline on sleep protection.


Infants have a different sleep pattern to older individual. During infancy, there are three types of sleep: (3)

Active sleep (AS)
Irregular sleep in which the electrical activity is like the waking state. Rapid eye movement under the eyelids, irregular heartbeat and breathing are present. This type of sleeping represents 50% of newborn at term.

Quiet sleep
The body is relaxed, there is no eye movement, and the heartbeat and breathing are regular, the parasympathetic system predominates. The muscles are relaxed but there may be movement.

Undetermined sleep
It is difficult to identify, as it is neither one nor the other: characteristic of preterm infants, who have their brain in continuous development.

During active sleep there is an endogenous intense and generalised stimulation, AS might play the role of stimulation to the brain in a period when waking life is limited. Mainly, AS is associated with the development of the sensory systems and it is necessary to form long-term circuits related with memory and learning. Quiet sleep plays an important role in the synaptic remodelling, in tissue repair and recovering from illness, as well as growth. (4)


  1. Peirano P, Algarín C, Uauy R. Sleep-wake states and their regulatory mechanisms throughout early human development. J Pediatr. 2003 Oct;143(4 Suppl):S70-79.
  2. Graven SN, Browne JV. Sleep and Brain Development: The Critical Role of Sleep in Fetal and Early Neonatal Brain Development. Newborn Infant Nurs Rev. 2008 Dec 1;8(4):173–9.
  3. Mirmiran M, Maas YGH, Ariagno RL. Development of fetal and neonatal sleep and circadian rhythms. Sleep Med Rev. 2003 Aug;7(4):321–34.
  4. Laudert S, Liu WF, Blackington S, Perkins B, Martin S, Macmillan-York E, et al. Implementing potentially better practices to support the neurodevelopment of infants in the NICU. J Perinatol Off J Calif Perinat Assoc. 2007 Dec;27 Suppl 2:S75-93.
  5. Mahmoodi N, Arbabisarjou A, Rezaeipoor M, Pishkar Mofrad Z. Nurses’ Awareness of Preterm Neonates’ Sleep in the NICU. Glob J Health Sci. 2015 Nov 17;8(6):226–33.
  6. Bastani F, Rajai N, Farsi Z, Als H. The Effects of Kangaroo Care on the Sleep and Wake States of Preterm Infants. J Nurs Res JNR. 2017 Jun;25(3):231–9.
  7. Smith KM. Sleep and kangaroo care: clinical practice in the newborn intensive care unit: where the baby sleeps.. J Perinat Neonatal Nurs. 2007 Jun;21(2):151–7.
  8. Messmer PR, Rodriguez S, Adams J, Wells-Gentry J, Washburn K, Zabaleta I, et al. Effect of kangaroo care on sleep time for neonates. Pediatr Nurs. 1997 Aug;23(4):408–14.
  9. Levy J, Hassan F, Plegue MA, Sokoloff MD, Kushwaha JS, Chervin RD, et al. Impact of hands-on care on infant sleep in the neonatal intensive care unit. Pediatr Pulmonol. 2017;52(1):84–90.
  10. Graven S. Sleep and brain development. Clin Perinatol. 2006 Sep;33(3):693–706, vii.
  11. Chwo M-J, Anderson GC, Good M, Dowling DA, Shiau S-HH, Chu D-M. A randomized controlled trial of early kangaroo care for preterm infants: effects on temperature, weight, behavior, and acuity. J Nurs Res JNR. 2002 Jun;10(2):129–42.
  12. Kreutzmann JC, Havekes R, Abel T, Meerlo P. Sleep deprivation and hippocampal vulnerability: changes in neuronal plasticity, neurogenesis and cognitive function. Neuroscience. 2015 Nov 19;309:173–90.
  13. Weisman O, Magori-Cohen R, Louzoun Y, Eidelman AI, Feldman R. Sleep-wake transitions in premature neonates predict early development. Pediatrics. 2011 Oct;128(4):706–14.
  14. Davidson J, Aslakson R, Long A, et. al. Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU. Crit Care Med. 2017;45(1):103–28.
  15. White RD. Recommended standards for the newborn ICU. J Perinatol. 2007;27:S4–S19.
  16. Graven SN. Early neurosensory visual development of the fetus and newborn. Clin Perinatol. 2004 Jun;31(2):199–216, v.
  17. NCJ | 1. Introductie gezonde slaap [Internet]. [cited 2018 Jun 11]. Available from:

November 2018 / 1st edition / next revision: 2023

Recommended citation

EFCNI, López Maestro M, Camba F et al., European Standards of Care for Newborn Health: Protecting sleep. 2018.

Farmaco di marca Viagra nello store Viagra. Felice di ogni cliente! Garantiamo la qualità del servizio.

    For the purpose of evaluation, we would be grateful if you could send us details on your profession and country. This information is optional, anonymous and the data processed will exclusively be used for the aforementioned purpose, in line with Article 6, Para. 1 lit. a GDPR (General Data Protection Regulation).

    Thank you for your support!