BALTIMORE 鈥� At home, parents try to keep their children on a regular sleep schedule, with the evening bedtime transition marked by rituals like reading stories, flipping on night-lights and getting tucked in with favorite stuffed animals.
But that difference between night and day blurs in hospitals 鈥� making it more difficult for young patients to rest when they need it the most.
Between the fluorescent lights, the chatter of on-duty doctors and nurses, and being roused for things like baths and vitals checks, getting eight hours of shut-eye is challenging. So now, with research increasingly highlighting the link between sleep and good health, children鈥檚 hospitals are rethinking just how they work at night.
鈥淚f we鈥檙e going to try to heal kids, we need to try to have them do the one thing that鈥檚 so important for their brain development. And that鈥檚 optimizing their sleep,鈥� said Sapna Kudchadkar, an assistant professor of anesthesiology, critical care and pediatrics at Johns Hopkins Children鈥檚 Center in Baltimore. She launched an initiative to improve sleep in the hospital鈥檚 pediatric intensive care unit a year ago.
Children鈥檚 hospitals are now adopting some of the used to foster better sleep at hospitals serving adults. For example, some are enforcing quiet hours after dark, clustering things like overnight blood draws and medication doses to minimize interruptions, and bringing in tools like white noise machines to promote a soothing environment.
Activities such as bathing children are shifted to daylight hours. Also, playtime is promoted in the afternoon to help maintain a sense of normalcy and contrast nighttime rest. The hope is that children will sleep better and heal faster.
Physicians and hospital administrators are starting to recognize that 鈥渨e鈥檙e doing some stuff in our hospitals that doesn鈥檛 really reflect what we鈥檙e telling people to do at home,鈥� said Jennifer Jewell, a pediatric hospitalist at the Barbara Bush Children鈥檚 Hospital in Portland, Maine, who chairs the American Academy of Pediatrics鈥� Committee on Hospital Care.
Improving children鈥檚 sleep at night sometimes means enabling physical activity in the daytime. (Courtesy of Claire Burdette)
Children鈥檚 hospitals aren鈥檛 yet held to the same patient satisfaction standards as other facilities. But there is growing interest in better catering to both children and their parents, doctors said. There鈥檚 the competitive element, noted Heather Walsh, a registered nurse who coordinates some of the quality improvement trainings undergone by clinical staff at Children鈥檚 National Health System in Washington, D.C. If families don鈥檛 like the care they get, they can go elsewhere.
And doctors are starting to realize that poor sleep isn鈥檛 just inconvenient. It can make children sicker.
In the intensive care unit, for instance, children who aren鈥檛 disturbed at night don鈥檛 need as much sedation or anesthesia, Kudchadkar said. That matters, she noted, since some of those drugs 鈥� benzodiazepines and prescription opioids 鈥� can be more dangerous for young patients to take. Kids who rest well at night are also more likely to get up and move around in the daytime.
In addition, because many children鈥檚 hospitals encourage parents to spend the night in their child鈥檚 room, late-night interruptions 鈥� whether a temperature check or the cleaning Zamboni in the hallway 鈥� wake them, too. As a result, parents aren鈥檛 rested when getting instructions for kids鈥� follow-up care. It鈥檚 easier to mishear or misremember a complicated medication instruction, said Lisa Meltzer, associate professor of pediatrics at National Jewish Health in Denver. Meltzer has also researched sleep quality in children鈥檚 hospitals.
鈥淭here鈥檚 more evidence really showing a direct link between insufficient and poor quality sleep and negative outcomes,鈥� she said.
When children can鈥檛 get out of bed, nurses in the Johns Hopkins pediatric ICU bring them toys from the unit鈥檚 playroom. It鈥檚 part of an effort to foster wake-sleep cycles better aligned with how children naturally function. (Courtesy of Sapna Kudchadkar)
The changes can seem small. At Hopkins, blinds are typically lowered between 8 p.m. and 8 a.m., though nurses might adjust that based on a particular family鈥檚 needs and habits. Parents are asked their children鈥檚 favorite music to sleep to. The ICU鈥檚 will find those songs to play on portable radios. One teenager requested Tupac, while some patients might bring in the soundtracks from their favorite video games. In a number of rooms, many alerts no longer trigger loud beeps blasted from overhead speakers. Instead, they鈥檙e sent straight to the relevant nurse鈥檚 phone. He or she can see to the child鈥檚 need, but the noise doesn鈥檛 disturb the whole unit.
Finding a balance, though, is tough. With very sick children, doctors and nurses do need to wake them more often at night. Some tests and medications can鈥檛 wait, especially in the ICU, said Patricia Hickey, vice president of cardiovascular and critical care services at Boston Children鈥檚 Hospital. Plus it鈥檚 hard to accommodate what patients need at different ages. Think of the habits of a 2-year-old versus a teenager. One goes to sleep聽and wakes early. The other may be unable to sleep before 11 p.m. Hospitals need to accommodate both.
The jury鈥檚 still out on how effective these strategies are. It鈥檚 difficult to prove reduced chatter leads to shorter hospital stays for kids. But there鈥檚 anecdotal support. At Boston Children鈥檚, which launched its sleep-promotion campaign last summer, hallways are markedly quieter, and families have said they appreciate the attention, Hickey said. The hospital鈥檚 conducting a survey this fall to better assess that, she added.
But challenges remain. Foremost is teaching doctors and nurses to be quiet and considerate.
鈥淔or some people, the night is no different than the day 鈥� that鈥檚 when they work,鈥� said Myke Federman, a critical care pediatrician who started a sleep initiative at Mattel Children鈥檚 Hospital UCLA in Los Angeles.
Many nighttime interruptions 鈥� like bathing a child at 3 a.m. 鈥� happen because they suit the staff鈥檚 schedule, Kudchadkar said. Getting away from that required a major recalibration of the ICU鈥檚 workflow and culture. At Hopkins, it took about a year, Kudchadkar added. The ICU used to be as loud as an emergency department. Now, the staff speaks in hushed whispers, even by day.
Meanwhile, for Mattel Children鈥檚 Hospital, curbing the nighttime ruckus requires continued attention, Federman said. Mattel, which launched its program in 2015, is trying to bring its noise levels down. So far, they haven鈥檛 budged significantly from 50 decibels at night. That鈥檚 north of their goal: 30 to 40 decibels, the sound of a quiet library.
Changes have not been easy, Kudchadkar agreed, but they are taking root.
鈥淭he bottom line is, 鈥楬ow do you create a peaceful, healing environment?鈥欌�� she said. 鈥淲e鈥檙e getting there.鈥�