The Interventional Effect of Quiet Time Protocol on the Sleep Status of Premature Neonates Admitted to the NICU

Document Type : Original Article


1 Department of Pediatric Nursing, School of Nursing and Midwifery, Zahedan University of Medical Sciences , Zahedan, Iran

2 Community Nursing Research Center and Pediatric Department, Faculty of Nursing and Midwifery, Zahedan University of Medical Sciences, Zahedan, Iran



Background: Most infants born prematurely are admitted to the NICU for their survival, an environment that is rich in stressors that has non positive effect on the sleep and wakefulness condition. The goal of this study was evaluating the effect of the QTP intervention on the sleep status of premature neonates admitted to the NICU.
Methods: This study was semi-experimental and 62 premature babies hospitalized in NICU, who were selected by available sampling method. The tools used included demographic information questionnaire and Als sleep and wakefulness tool. Infants in two groups were evaluated in 3 stages. before, during and after the intervention in the evening shift from 15:00 to 17:00 for 60 minutes. The data was analyzed using SPSS software (version 22). A  p value of less than 0.05 was considered statistically significant. The validity of the mentioned tool was investigated according to the content method according to the study of Rajaei in 2013 under the title of investigating the sleep-wakefulness of premature infants and its relationship with demographic characteristics, and the reliability of the tool was also investigated according to the same study.
Results: The chi-square test showed that the variable frequency of deep sleep (type A) before (P=1)and after (P=0.05) the intervention in the two groups did not have a statistically significant difference and just during the intervention has a statistically significant difference (P<0.001). Comparison of the distribution of the frequency of deep sleep (type B) before, during and after the intervention in 2 groups shows that before the intervention, deep sleep (type B)  was not observed in the two groups. However, in the intervention group, 58.1% had deep sleep during the intervention and 6.5% after the intervention. The control group did not have deep sleep (type B) in these three time periods.
Conclusion: Considering the effectiveness of QTP in reducing environmental stimuli and improving sleep status, implementation of these items is recommended as a standard care to reduce stress, improve growth and development of preterm infants in the nicu.


  1. Khanjari S, Bordbar A, Haghani S, Khani M. Effect of training nurses in the process of weaning premature infants from mechanical ventilation on infection incidence in neonatal intensive care units. Iran J Neonatal. 2022;13(3):37-43.

    1. Dehghani K, Kargar Z, Mirjalili SR, Fallahzade H. The Effect of infant massage on attachment behaviors in mothers of premature infants. J Babol Univ Med Sci. 22020;22(1):412-4
    2. Zahadatpour Z, Edraki M, Razavinejad Ardekani S. The effect of lullaby on sleep patterns changes in premature neonates after endotracheal suctioning in neonatal intensive care unit. Journal of Clinical Nursing and Midwifery. 2019;8(3):482-890.
    3. Tavasoli A, Akhoundzadeh G, Hojjati H. The effect of narrative writing of mothers on their stress with care in the neonatal intensive care unit. J Complement Med. 2020;10(3):196-205.
    4. Lan HY, Yin T, Chen JL, Chang YC, Liaw JJ. Factors Associated With Preterm Infants' Circadian Sleep/Wake Patterns at the Hospital. Clin Nurs Res. 2019;28(4):456-472.
    5. Mihaylova A, Parahuleva N, Petkova-Gueorguieva E, Gueorguiev S. Epidemiology and risk factors for premature birth. Knowledge-International Journal. 2018;28(2):629-36.
    6. Momeni F, Javadi MH, Lavassani MGA, Haghshenas M. The effect of music therapy (lullabies) on infants' physiological and growth parameters. Med JD S. 2015;5(11):242-2
    7. Eshgizadeh M, Moshki M, Mojtabavi J, Derakhshan N. Effect of Foot Reflexology on Milk Production in Mothers with Premature Infants. Intern Med 2017;23(4):319-24.
    8. Eshghi F, Bostani S. The effect of gentle human touch on behavioral states in preterm infants. Journal of Preventive Medicine. 2019;6(1):9-3.
    9. Mahmoodi N, Knoll BL, Keykha R, Jalalodini A, Ghaljaei F. The effect of oral motor intervention on oral feeding readiness and feeding progression in preterm infants. Iran J Neonatal. 2019;10(3):58-63.
    10. Hee Chung E, Chou J, Brown KA. Neurodevelo-pmental outcomes of preterm infants: a recent literature review. Transl Pediatr. 2020;9(Suppl 1):S3-S8.
    11. Amini Z. A review of telemedicine in preterm infants in the corona pandemic. Razi Journal of Medical Sciences. 2021;28(9):135-1
    12. Lien R. Neurocritical care of premature infants. Biomed J. 2020;43(3):259-267.
    13. Valizadeh L, Sanaeefar M, Hosseini MB, Asgari Jafarabadi M, Shamili A. Effect of Early Physical Activity Programs on Motor Performance and Neuromuscular Development in Infants Born Preterm: A Randomized Clinical Trial. J Caring Sci. 2017;6(1):67-79.
    14. Park J. Sleep Promotion for Preterm Infants in the NICU. Nurs Womens Health. 2020;24(1):24-35.
    15. Lacina L, Roux M, Kessler C, Jain V. Using Newborn Individualized Developmental Care and Assessment Program (NIDCAP) Philosophy and Principles in the Implementation of a NICU Book Sharing Program. Developmental Observer. 2020;13(1):5.
    16. Uchitel J, Vanhatalo S, Austin T. Early development of sleep and brain functional connectivity in term-born and preterm infants. Pediatr Res. 2022;91(4):771-786.
    17. Graven S. Sleep and brain development. Clinics in perinatology. 2006;33(3):693-706.
    18. Kuhn P, Zores C, Langlet C, Escande B, Astruc D, Dufour A. Moderate acoustic changes can disrupt the sleep of very preterm infants in their incubators. Acta Paediatr. 2013;102(10):949-954.
    19. Bennet L, Walker DW, Horne RSC. Waking up too early - the consequences of preterm birth on sleep development. J Physiol. 2018;596(23):5687-5708.
    20. Kozier B. Glenora Erb BScN R, Berman AT, Snyder S, Madeleine Buck R, Ferguson L, et al. Fundamentals of canadian nursing: Concepts, process, and practice: Pearson Canada 4th ed Plus NEW MyLab Nursing: Pearson. 2017:21-4.
    21. Borji M, Otaghi M, Salimi E, Sanei P. Investigating the effect of performing the quiet time protocol on the sleep quality of cardiac patients. Biomedical Research-India. 2017;28(16):7076-70
    22. Cailleau L, Weber R, Cabon S, Flamant C, Roué JM, Favrais G, et al. Quiet sleep organization of very preterm infants is correlated with postnatal maturation. Front Pediatr. 2020;8:559658.
    23. Lim R. Benefits of quiet time interventions in the intensive care unit: a literature review. Nurs Stand. 2018;32(30):41-48. 
    24. Calikusu Incekar M, Balci The effect of training on noise reduction in neonatal intensive care units. J Spec Pediatr Nurs. 2017;22(3):e12181.
    25. Zauche LH, Zauche MS, Williams BL. Influence of Quiet Time on the Auditory Environment of Infants in the NICU. J Obstet Gynecol Neonatal Nurs. 2021;50(1):68-77.
    26. Payida-Ansah D. Implementation of a Quiet Time Protocol in the Neurosurgical Intensive Care Unit. 2021. Available from: https://archive.hshsl.umary edu/handle/10713/15773
    27. Ameri Z, Ghaljaeiz F, Navidian A, Imani M. Investigating the effect of fetal position on the sleep-wake state of premature neonates in the neonatal intensive care unit: A clinical trial study. Med Sci. 2018;22(94):533-5
    28. Als H. Manual for the naturalistic observation of newborn behavior: Newborn Individualized Developmental Care and Assessment Program (NIDCAP). Boston: Harvard Medical School. 1995.
    29. Als H. Reading the premature infant. Developmental interventions in the neonatal intensive care nursery. 1999:18-85.
    30. 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. 2017;25(3):231-239.
    31. Bastani F, Rajai N, Amini E, Haghani H, Janmohammadi S. The Assessment of sleep and wake state of premature infants hospitalized in neonatal intensive care unit (NICU) and it's relation with demographic variables. Alborz University Medical Journal. 2013;2(1):1-6.
    32. Goeren D, John S, Meskill K, Iacono L, Wahl S, Scanlon K. Quiet time: a noise reduction initiative in a neurosurgical intensive care unit. Care Unit. Crit Care Nurse. 2018;38(4):38-44.
    33. Chamanzari H, Hesari MM, Malekzadeh J, Shakeri MT, Hojat SK, Hosseini SM, et al. Effect of implementation of Quiet Time Protocol on sleep quality of patients in Intensive Care Unit. 2016.
    34. Abdeyazdan Z, Mohammadian-Ghahfarokhi M, Ghazavi Z, Mohammadizadeh Effects of nesting and swaddling on the sleep duration of premature infants hospitalized in neonatal intensive care units. Iran J Nurs Midwifery Res. 2016;21(5):552-556.
    35. Pugliesi RR, Campillos MS, Orsi KCSC, Avena MJ, de Cacia Pradella-Hallinan ML, Tsunemi MH, et al. Correlation of premature infant sleep/wakefulness and noise levels in the presence or absence of “quiet time”. Advances in Neonatal Care. 2018;18(5):393-39
    36. Orsi KCSC, Avena MJ, de Cacia Pradella-Hallinan ML, Pedreira MdLG, Tsunemi MH, Avelar AFM, et al. Effects of handling and environment on preterm newborns sleeping in incubators. J Obstet Gynecol Neonatal Nurs. 2017;46(2):238-247.