Background
Crying and sleep problems in infancy are common concerns for parents [
1,
2], often resulting in increased use of multiple health services [
3‐
5]. Sleep problems have different presentations and rates at different ages [
2], and the prevalence varies depending on the criteria used. Between 10 and 35% of parents report problems with their infant’s sleep, including both sleep duration and nighttime awakenings [
1,
6‐
8]. A crying duration exceeding 3 h/24 h for at least 3 days of at least 3 weeks is typically known as ‘colic’ [
9]. Infantile colic affects between 17 and 25% of infants during the first months of life, with a reported peak of excessive crying somewhere between 3 and 6 weeks of age [
10,
11].
Although infant crying and sleep problems are usually regarded as self-resolving [
10], there is conflicting evidence on their association with adverse medium to long-term outcomes. In a meta-analysis [
12], both excessive crying and sleep problems during the first year of life were linked to internalizing and general behavioral problems in children aged 2 to 10 years, particularly in multi-problem families. These findings were confirmed in a recent systematic review that found that sleep duration among healthy children aged 0–4 years, based on parents’ reports, is prospectively associated with mental health problems such as anxiety, depression, and poor emotion regulation. The evidence related to cognitive and motor development was not clear [
13]. Two previous Norwegian birth cohort studies have examined sleep in young children [
14,
15], and found that total sleep, prolonged sleep onset, and frequent nighttime awakening among 24-month-old children was associated with a greater risk of concurrent social-emotional problems in toddlerhood [
14]. Children who sleep less than 11 h or awaken three or more times per night at 18 months have more emotional regulation difficulties at 5 years [
15].
Although previous research represents important steps toward identifying the long-term outcome of colic and sleep problems in children, these studies have limitations. Most previous studies have examined the associations in preschool children rather than in the first years of life. Due to high neuroplasticity and rapid brain development in the first years of life, early experiences can modify the organization of cortical structures and strengthen the brain connections [
16]. Hence, understanding the relationship between difficulties already in infancy will enable researchers and clinicians to identify, prevent, and treat sleep and crying problems.
The Norwegian Mother and Child Cohort Study (MoBa) contains valuable information on infant crying and sleep behavior and children’s health and development from birth to toddlerhood. Thus, the aim of the present study was to examine whether there is an associations between infants’ crying and sleep problems at 6 months and behavioral and development problems at 18 months, 3 and 5 years.
Statistical analyses
Continuous variables were described with mean and standard deviation (SD), categorical variables with counts and percentages. Both main outcomes were assessed using a questionnaire administered at four time points. The number of included items varied among assessment points so we used z-scores to be able to assess differences between groups of children both at given time points and across the whole follow-up. The z-scores were constructed as follows: at each assessment point the dataset was divided into two groups based on the exposure variable (e.g. having colic or not, having a sleep problem or not). Those who did not report such an event (no colic, no sleep problems) served as the normal population for a given outcome (event). Thus z-scores equal to zero represent the mean for the normal population, scores over zero indicate higher values of the outcome compared to the norm, and scores below zero indicate values lower than 50% of the norm (Supplementary file
1).
To model changes at given time points and across the follow-up trajectories, we used linear mixed models for repeated measures with an unstructured covariance matrix to account for dependencies within the included individuals (children), as the same child was assessed at several time points. The results are expressed as estimates of beta (B) with 95% confidence intervals (CI). P-values < 0.05 were considered statistically significant. As the study is considered exploratory, no correction for multiple testing was done. All analyses were performed using SPSS, version 24.
Discussion
This large population-based study revealed that infants with colic scored significantly lower on general development at 5 years and higher on internalizing problems both at 3 and 5 years than the reference population. Children who awoke frequently and were more difficult to put to bed at 6 months scored significantly lower on general development at 18 months and 3 and 5 years, and higher on internalizing behavior problems at 3 and 5 years than the reference population. Children with shorter sleep duration at 6 months had more internalizing behavior problems at 3 and 5 years.
Our results are consistent with the findings of previous research [
12,
13,
15,
23], which concluded that colic and sleep problems early in life may predict later development and behavioral difficulties. In accordance with previous studies [
15,
24‐
26], our findings revealed that internalizing behavioral problems are most frequently reported in association with sleep problems in young children. In a previous Norwegian cohort study, Sivertsen and colleagues (2015) found that shorter sleep duration at 18 months was predictive of developing emotional regulation difficulties utilizing the CBCL both concurrently and at 5 years of age, especially in relation to internalizing problems. However, our study extends previous findings by showing that children with shorter sleep duration already from 6 months of age had more internalizing behavior problems at later ages than their peers. Behaviour difficulties identified in young children can persist and increase a child’s risk of later adverse outcomes, although stability and pathways of behavior problems seems to vary according to the types of problem that are studied [
27,
28].
Our results also revealed that children in the group with frequent awakenings or difficulty with putting to bed had poorer general developmental outcomes at preschool ages than children with no such problems. One explanation for our findings may be that frequent awakenings predict poorer attention regulation [
29,
30] and affect executive task performance that is important for the ability to learn new skills and solve problems in everyday life [
31,
32]. Although difficulties falling asleep or frequent awakenings in children are often followed by longer sleeps on subsequent days or nights, these results highlight the importance of nighttime sleep as a component of total sleep duration and are consistent with the literature supporting a positive association between nighttime sleep duration and development outcome in preschool children [
23].
Current empirical knowledge on the development of excessive criers after the end of the difficult colic period is inconclusive. Our results showed that infants with colic reported at 6 months of age scored significantly lower on general development and higher on internalizing problems then the reference population. These findings are confirmed by previous studies, which reported an association between infant crying and subsequent child behavioral problems [
12,
33], especially in externalizing behaviors and lower motor scores [
34]. Conversely, Bell et al. (2018) did not find any associations in an Australian study between infants with colic whose crying self-resolved and internalizing and externalizing behavior problems measured by caregiver reports [
35]. However, some of the infants with colic in our study may have had multiple regulatory problems (crying combined with sleep problems) and thus may have been at greater risk of developmental deficits later in life compared with infants with isolated crying problems [
12]. In addition, we did not have any information about crying after 6 months which may affect long-term development.
Different underlying mechanisms have been proposed to explain the predictive links between early regulation problems and subsequent development problems, including overlapping genetic and biomedical features [
36] and parenting factors [
37]. Sleep disturbance may influence the brain circuits that underlie emotional processing that are key characteristics of emotional and behavioral problems [
38,
39]. Children with individual differences in personality, temperament, behavior, and social competence trigger positive or negative reactions from parents. When parents are affected by their infants’ fragmented sleep or crying, they may provide less optimal stimulation overall, inadequate parental practices or limit-setting behavior that may negatively affect development and behavior [
37].
This study showed that infants with colic and sleep problems at 6 months scored significantly lower on general development, and higher on behavior problems than the comparison group, for example, children with colic at 6 months scored 10% lower on developmental problems at 5 years compared to the mean scores of children without colic, and children with shorter sleep duration scored 15% higher on internalizing problems at 3 years compared to the mean scores of children with longer sleep duration. The clinical relevance of this findings should be further investigated in later research. However, previous research revealed that crying and sleeping problems in infancy predict later development and behavior difficulties [
12,
33,
40].
Our findings extend the outcomes to a younger age group and underscore the importance of preventive measures and supporting families with infants with colic and sleep problems. Several risk and protective factors for sleep problems have been identified [
41], and identification of problems and support for families and appropriate referral are needed throughout infancy and early childhood.
Although the present study has many strengths, including the large prospective longitudinal sample with repeated follow-ups, the results must be interpreted in light of several methodological limitations. Firstly, the assessment of sleep or colic did not include validated or objective measures and mother-reported sleep duration was assessed in predefined categories. Secondly, we did not include all the items in the ASQ or CBCL instrument, and thus the use of abbreviated versions instead of the original scales may have affected the results. Thirdly, some confounders were controlled for in this study, while other variables that could have impacted the analyzed associations, such as maternal psychopathology or maternal burden of care were left unexplored. Lastly, the results may also be affected by a selection bias due to high attrition rates in the MoBa study [
17]. When comparing MoBa participants with the data from the Medical Birth Registry in Norway (including all women giving birth in Norway) on key parameters, a lower rate on predictor variables was found, with higher maternal age and fewer health related risks, than children of those not participating. Still, we would advise caution when interpreting our findings.
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