Introduction: Culture and Sleep in Children

At some fundamental level, sleep-related behaviors and sleep problems in children represent a complex interpolation of biological, psychologic/developmental/environmental, and social influences, the relative contributions of which are oftentimes difficult, if not impossible, to separate out. Biological determinants of sleep, including sleep homeostatic mechanisms and chronobiological principles,1,2 and the ways in which culture and biology interact both play a major role in the establishment of sleep patterns.3,4 In addition, children are also active participants in shaping sleep practices through such individual characteristics as temperament and social relatedness5 as well as an emerging understanding of their own individual cultures.6 As an inherently biopsychosocial phenomenon, sleep is embedded in its sociocultural context and thus is impacted on by such variables as cultural beliefs about the perceived function and meaning of sleep, cultural norms for sleep practices, and social interactions, networks, and relationships, to name a few. The biology of sleep architecture and regulation notwithstanding, there is unlikely to be one universally applicable “right way” (or time or place) to sleep. Ultimately, cross-cultural comparisons among societies of different political, economic, ideological, and historical backgrounds are invaluable in providing the opportunity to better understand the neurobiology and chronobiology of sleep itself, as well as to delineate the respective roles of culture and biology on sleep behavior and its interpretation.7Sleep disorders and sleep practices in children are uniquely suited to serve as the focus for an examination of the interplay between the biological and the sociocultural, because so many of the variables that affect sleep problems, patterns, and practices are highly culturally based. Furthermore, because sleep problems are almost universally present in childhood and have negative health and well-being effects common to all children, the impact of sleep problems on children and families transcends all cultures. In addition, the evolution of sleep practices and behaviors across childhood is particularly sensitive to the important interplay between culture and child development. On a practical level, in recent years, pediatric providers have increasingly been expected to work with families of widely differing cultural origins. Thus, the ability and willingness of health care practitioners to appreciate the family, ethnic/racial, socioeconomic, and cultural context of pediatric sleep disorders and to incorporate that sensitivity to these issues in evaluating etiologic factors and in planning interventions for the individual child and family have a highly significant impact on the quality of care in clinical practice. Finally, the opportunity for disease prevention and health promotion in pediatric sleep is substantial and must also be informed by awareness and incorporation of the cultural issues that impact sleep practices and sleep health in children.To begin to examine the cultural variables that impact on children's sleep in a more comprehensive and systematic way, a group of pediatric sleep experts from around the world (including Israel, China, India, Australia, Spain, Switzerland, Sweden, Italy, and Canada) came together at the first meeting of the International Pediatric Sleep Education (IPSE) Task Force in the spring of 2003 in Chicago, Illinois. This exploratory venture, sponsored by Johnson & Johnson, was initiated to galvanize a dialogue on 2 fronts: addressing educational gaps that exist for both parents and professionals regarding healthy sleep in children and exploring the cultural differences (and similarities) that impact on a host of issues related to children's sleep. It was felt that the IPSE project would represent a unique opportunity to benefit physicians, children, and families worldwide in an important and long-lasting way. A focus on physician education would also enable the program to include components on identification and management of specific sleep disorders and also to incorporate patient education and anticipatory guidance, thus having a potentially long-term impact on the prevention of sleep problems as well.The task force's mission was to (1) begin to examine cultural similarities and differences potentially impacting sleep practices in infants, children, and adolescents, (2) identify and support a core group of individuals dedicated to developing pediatric sleep medicine education programs in a variety of cultures, and (3) set parameters for developing culturally relevant pediatric sleep medicine educational materials for pediatric practitioners and for parents and patients. In addition, the fostering of cross-cultural pediatric sleep research was included as another important objective.During the day-long meeting of the IPSE Task Force, each member gave 2 formal background presentations to the group: one on the unique cultural issues that impact on sleep practices in their respective countries and the other on the “state of the science” in pediatric sleep medicine and pediatric sleep education in their nation. The following key points emerged from these presentations and the discussions that followed: A final important short-term goal identified at the meeting by the IPSE was to develop the following supplement to the journal Pediatrics on cultural issues impacting on children's sleep. It was the intent of the task force that such a collection of review and original articles on the topic from contributors around the world would be seen as a resource for future work in what is a relatively new field in pediatrics. To that end, original research articles were solicited both from the IPSE Task Force members and from the international pediatric sleep community. The final articles presented in this supplement represent a broad range of cultures, age groups, and subtopics and include several cross-cultural comparison studies (LeBourgeois et al and Liu et al), a longitudinal study conducted over a 10-year period (Jenni et al), and a comprehensive review of the literature (Jenni and O'Connor). They explore a number of the most important cultural issues in the pediatric sleep field including cosleeping (Fukumizu et al and Valentin), adolescent sleep patterns (Lebourgeois et al and Yang et al), and napping (Crosby et al) and together comprise a body of work that is both unique and exciting. It is the hope of the task force that the scientific work presented here will provide inspiration and an impetus for more cross-cultural pediatric sleep research and collaboration in the future.