UNIVERSITATIS OULUENSIS MEDICA ACTA D D 1137 ACTA Marjo Tourula OULU 2011 D 1137 Marjo Tourula THE CHILDCARE PRACTICE OF CHILDREN’S DAYTIME SLEEPING OUTDOORS IN THE CONTEXT OF NORTHERN FINNISH WINTER UNIVERSITY OF OULU, FACULTY OF MEDICINE, INSTITUTE OF HEALTH SCIENCES, NURSING SCIENCE, INSTITUTE OF BIOMEDICINE, DEPARTMENT OF PHYSIOLOGY; FINNISH INSTITUTE OF OCCUPATIONAL HEALTH, OULU; NORTHERN OSTROBOTHNIA HOSPITAL DISTRICT; KYUSHU UNIVERSITY, FACULTY OF DESIGN, DEPARTMENT OF HUMAN SCIENCE
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UNIVERS ITY OF OULU P.O.B . 7500 F I -90014 UNIVERS ITY OF OULU F INLAND
A C T A U N I V E R S I T A T I S O U L U E N S I S
S E R I E S E D I T O R S
SCIENTIAE RERUM NATURALIUM
HUMANIORA
TECHNICA
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SCIENTIAE RERUM SOCIALIUM
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EDITOR IN CHIEF
PUBLICATIONS EDITOR
Senior Assistant Jorma Arhippainen
Lecturer Santeri Palviainen
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Director Sinikka Eskelinen
Professor Jari Juga
Professor Olli Vuolteenaho
Publications Editor Kirsti Nurkkala
ISBN 978-951-42-9666-6 (Paperback)ISBN 978-951-42-9667-3 (PDF)ISSN 0355-3221 (Print)ISSN 1796-2234 (Online)
U N I V E R S I TAT I S O U L U E N S I S
MEDICA
ACTAD
D 1137
ACTA
Marjo Tourula
OULU 2011
D 1137
Marjo Tourula
THE CHILDCARE PRACTICE OF CHILDREN’S DAYTIME SLEEPING OUTDOORSIN THE CONTEXT OF NORTHERN FINNISH WINTER
UNIVERSITY OF OULU,FACULTY OF MEDICINE,INSTITUTE OF HEALTH SCIENCES, NURSING SCIENCE,INSTITUTE OF BIOMEDICINE, DEPARTMENT OF PHYSIOLOGY;FINNISH INSTITUTE OF OCCUPATIONAL HEALTH, OULU;NORTHERN OSTROBOTHNIA HOSPITAL DISTRICT;KYUSHU UNIVERSITY, FACULTY OF DESIGN, DEPARTMENT OF HUMAN SCIENCE
A C T A U N I V E R S I T A T I S O U L U E N S I SD M e d i c a 1 1 3 7
MARJO TOURULA
THE CHILDCARE PRACTICE OF CHILDREN’S DAYTIME SLEEPING OUTDOORS IN THE CONTEXT OF NORTHERN FINNISH WINTER
Academic dissertation to be presented with the assent ofthe Faculty of Medicine of the University of Oulu forpublic defence in Auditorium 101 A of the Faculty ofMedicine (Aapistie 5 A), on 2 December 2011, at 12 noon
ISBN 978-951-42-9666-6 (Paperback)ISBN 978-951-42-9667-3 (PDF)
ISSN 0355-3221 (Printed)ISSN 1796-2234 (Online)
Cover DesignRaimo Ahonen
JUVENES PRINTTAMPERE 2011
Tourula, Marjo, The childcare practice of children’s daytime sleeping outdoors inthe context of Northern Finnish winterUniversity of Oulu, Faculty of Medicine, Institute of Health Sciences, Nursing Science; Instituteof Biomedicine, Department of Physiology, P.O. Box 5000, FI-90014 University of Oulu,Finland; Finnish Institute of Occupational Health, Oulu, Aapistie 1, FI-90220 Oulu, Finland;Northern Ostrobothnia Hospital District, P.O.Box 10, FI-90029 OYS, Finland; KyushuUniversity, Faculty of Design, Department of Human Science, 4-9-1 Shiobaru, Minami-ku,Fukuoka 815-8540, JapanActa Univ. Oul. D 1137, 2011Oulu, Finland
AbstractThe purpose of the study was to create a comprehensive view and add understanding about thechildcare practice of children sleeping outdoors in the context of Northern Finnish winter. Ageneral view of the topic was described, the thermal insulation of clothing of infants sleepingoutdoors in northern winter climate was evaluated and the relationships among thermalenvironment, infants’ skin temperatures and daytime outdoor sleep duration were described.
Mixed methods research design was used. A questionnaire was distributed to the parents(n=116) of children under 2 years of age in the city of Oulu. Skin temperatures of about three-month-old infants were recorded from seven skin sites throughout a daytime sleep outdoors (n=34)and indoors (n=33) in the families’ homes. The duration of the infant’s sleep was observed and airtemperature and velocity of the outdoor environment were recorded. Clothing data of infants werecollected and microclimate temperatures and humidity inside middle wear measured. Theinsulation of clothing ensembles was measured by using a baby-size thermal manikin. Therequired clothing insulation was estimated according to ISO 11079. Mothers (n=21) fromNorthern Finland were interviewed.
A fit can be found between family – cultural outdoor sleeping childcare practice – and NorthernFinnish winter environment, but also factors that decreased the fit existed. Winter environmentwas seen as an affordance for the child to sleep outdoors. Infants usually slept outdoors in thedaytime once a day in different kinds of environments, the best temperature being -5 °C. Outdoorsleeping was a self-evident and common culturally bound custom. Guidelines and encouragementwere given to mothers from different sources, and by sharing their own experiences, mothersparticipated in the cultural knowledge-building processes. The outdoor sleeping practice wascommonly accepted collective behavior. Many risk factors also existed, but when all securityperspectives were first taken into account it promoted family well-being by creating rhythm andstrengthening the fluency of everyday life. The optimal thermal insulation was difficult to adjustsystematically and both cooling and sweating existed. When ambient temperature decreased, thecooling rate of Tsk increased. Children slept longest outdoors when the cooling rate of Tsk wasminimal. The basic idea was that outdoor sleeping promoted children’s health.
A comprehensive view of the phenomenon was gathered into the evaluation model, which canbe utilized in nursing practice. The findings give detailed information that is utilized whenupdating guidelines. This study also creates ground for international comparative studies.
Keywords: child, child care, culture, mixed methods, Northern Finland, skintemperature, sleep, thermal insulation of clothing, winter
Tourula, Marjo, Lasten ulkona nukuttaminen talvella lastenhoitokäytäntönäpohjoissuomalaisessa kontekstissa Oulun yliopisto, Lääketieteellinen tiedekunta, Terveystieteiden laitos, Hoitotiede; Biolääke-tieteen laitos, Fysiologia, PL 5000, 90014 Oulun yliopisto; Työterveyslaitos, Oulu, Aapistie 1,90220 Oulu; Pohjois-Pohjanmaan sairaanhoitopiiri, PL 10, 90029 OYS; Kyushun yliopisto,Suunnittelun tiedekunta, Ihmistieeteet, 4-9-1 Shiobaru, Minami-ku, Fukuoka 815-8540, JapaniActa Univ. Oul. D 1137, 2011Oulu
TiivistelmäTutkimuksen tavoitteena oli muodostaa kokonaiskuva ja lisätä ymmärrystä lasten ulkona nukut-tamiskäytännöstä pohjoissuomalaisessa talvikontekstissa lasten ja perheiden hyvinvoinninlisäämiseksi. Tarkoituksena oli kuvata lasten ulkona nukuttamiskäytäntöä, ympäristön ja ihonlämpötilojen sekä unen pituuden yhteyttä ja arvioida vaatetuksen lämmöneristävyyttä.
Tutkimuksessa käytettiin mixed methods -lähestymistapaa monipuolisen kokonaiskuvantavoittamiseksi. Pilottikysely tehtiin alle 2-vuotiaiden lasten vanhemmille (n=116) Oulun alueel-la. Ihon lämpötiloja mitattiin seitsemästä eri kehon osasta noin kolmen kuukauden ikäisiltä lap-silta (n=34) heidän nukkuessaan kotona päiväuniaan sisällä ja ulkona Pohjois-Suomessa talvel-la. Unen pituutta havainnoitiin ja ympäristön lämpötilaa ja tuulen nopeutta mitattiin. Lasten tal-vivaatetuksesta kerättiin tietoa ja lämpötiloja mitattiin vaatetuksen eri kerroksista sekä kosteuttavälivaatetuksen alta. Vaatetuksen lämmöneristävyyksiä mitattiin lasten kokoa vastaavalla lämp-önukella. Vaadittava lämmöneristävyys arvioitiin ISO 11079 – standardin mukaisesti. Pohjois-suomalaisia lapsiperheiden äitejä (n=21) haastateltiin kulttuurisen tiedon esille tuomiseksi.
Yhteensopivuus perheen, kulttuurisen ulkona nukuttamiskäytännön ja pohjoisen talviympär-istön välillä voidaan saavuttaa, mutta toisaalta myös tasapainoa vähentäviä tekijöitä löytyi. Tal-viympäristö nähtiin tarjoumana lapsen rauhalliselle nukkumiselle sen puhtaan ja raikkaan ilmanja luonnon sekä hiljaisuuden ja rauhallisuuden takia. Talvinen sää vaihteli auringon paisteestakovaan lumipyryyn ja lämpötila muutamista lämpöasteista lähes kolmenkymmenen asteen pak-kaseen lasten nukkuessa vaunuissaan. Paras lämpötila ulkona nukkumiselle oli -5 °C. Ulkonanukuttamista pidettiin itsestään selvänä kulttuurisena tapana. Äidit saivat ohjeita ja kannustustalasten ulkona nukuttamiseen eri lähteistä. Vertailemalla ja jakamalla kokemuksiaan he osallistui-vat myös itse kulttuurisen tiedon rakenteluun. Lasten ulkona nukuttaminen talvella osoittautuiyleisesti hyväksytyksi kollektiiviseksi käyttäytymiseksi, joka toisinaan aiheutti paineita äideille.Lapsen ulkona nukkumiseen liittyi monia riskitekijöitä, mutta kaikki turvallisuusnäkökohdatensin huomioon ottamalla se edisti perheen hyvinvointia luomalla säännöllistä rytmiä ja vahvis-tamalla arjen sujuvuutta. Optimaalisen vaatetuksen lämmöneristävyyden löytäminen systemaat-tisesti eri lämpötiloissa oli vaikeaa; sekä jäähtymistä että hikoilua esiintyi. Ympäristön lämpöti-lan laskiessa keskimääräisen ihon lämpötilan jäähtymisnopeus lisääntyi. Lapset nukkuivat ulko-na pisimpään silloin, kun ihon lämpötilan jäähtyminen oli hitainta. Ensisijaisesti ulkona nukku-misen ajateltiin edistävän lapsen terveyttä.
Lasten ulkona nukuttamisen arviointimallia voidaan hyödyntää käytännössä ohjauksen yhte-ydessä ja tutkimuksen tuottamaa yksityiskohtaista tietoa ohjeistusten päivittämisessä. Tutkimusantaa lähtökohtia kansainväliselle vertailevalle tutkimukselle.
Asiasanat: ihon lämpötila, kulttuuri, lapsi, lastenhoito, mixed methods -lähestymistapa,Pohjois-Suomi, talvi, uni, vaatetuksen lämmöneristävyys
To Tuomo, Eetu, Olli, and Aaro
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Acknowledgements
This study was carried in co-operation with the Institute of Health Sciences and
the Institute of Biomedicine at the University of Oulu as well as Finnish Institute
of Occupational Health, Oulu, Northern Ostrobothnia Hospital District and the
Department of Human Science at the Kyushu University.
Most importantly, I would like to thank all families for your participation. I
appreciate your interest in my study and your contribution to it making this thesis
possible. I want to thank those public health nurses and other persons who helped
me to contact the study families.
My warmest appreciation and the most grateful acknowledgements go to my
supervisors Professor Arja Isola, Professor Hannu Rintamäki and Emeritus
Professor Juhani Hassi. I want to express my deepest gratitude to Arja for your
encouragement, support and advice during my academic studies, especially
during these five years when I have been privileged to work as a doctoral
candidate at the Institute of Health Sciences. I am very grateful for your
enthusiasm when I presented the idea of my research, your trust and that you have
encouraged me to continue until the doctoral thesis. I want to express my special
gratitude to Hannu for inspiring me in the field of thermophysiology. I am very
grateful to you for helpful discussions and valuable support. I highly appreciate
that you always gave me time when I needed to reflect many kinds of issues. I
want to thank Juhani for introducing me to the field of cold research. You had a
significant role in encouraging me to do research in this field.
I would like to express my grateful acknowledgements to The Vice-President,
Professor, Yutaka Tochihara, at the Kyushu University. I highly appreciate that
you gave me the possibility to do the clothing insulation measurements at the
Faculty of Design. I am grateful to Takako Fukazawa, PhD, for your guidance,
valuable comments and patience when introducing me to the field of clothing
insulation measurements. I highly appreciate our cooperation. I wish to express
my gratitude to Koji Tabata as well as the students and the staff at the Research
center for human environmental adaptation for your help with thermal manikin
measurements. My family and I want to express our gratitude to Hitoshi
Wakabayashi, PhD, for sharing with us many unforgettable moments in Japan and
in Finland. I have been privileged to meet all of you.
I want to express my gratitude to Professor Leena Paasivaara and Docent
Sirkka Rissanen, members of the follow-up group, for your valuable comments. I
am grateful to the official referees of the dissertation, Professor Randi Eidsmo
10
Reinertsen and Docent Päivi Kankkunen, for your careful review and valuable
advice to improve this thesis.
I want to express gratitude to Risto Bloigu, MSc, for your statistical guidance,
Anna Vuolteenaho, MSc, for revising the language of my manuscripts and this
thesis, Pertti Tuhkanen, specialized occupational hygienist, for helping with the
measurement of relative humidity, Raija Heino, information specialist, for helping
me in literature searches and Aino-Maria Vuoti, senior in visual communication,
for graphic designing of figure 5.
I am grateful to the staff at the Institute of health sciences, department of
nursing science and health administration for all the support I got during these
years. Working with you and our fruitful discussions have been important to me. I
want to thank docent Tarja Pölkki for inspiring discussions about research among
children.
I warmly thank my fellow students and friends especially Hanna, Maire,
Eeva-Leena, Merja, Outi, Leena, Ulla, Pirjo and Jaana for our conversations that
have been very helpful for me, your support and sharing experiences with me. I
also express my gratitude to all doctoral candidates at the Finnish Post-Graduate
School in Nursing Science.
I would like to thank my friends, Helinä and Minna, for offering refreshing
company and support.
I want to thank my parents, Anni and Paavo, for your encouragement, support
and help throughout my life. Moreover, I want to thank my siblings, Kirsi, Satu,
Marko and Heli for everything. You and your families will always have a special
place in my life. I also thank Leena, Pentti, Tapio, Ilkka, Outi and your families
for your support.
My dearest gratitude is expressed to my husband, Tuomo. We have shared our
lives; thank you for your love and patience. Our sons, Eetu, Olli and Aaro are the
most important persons in my life. Thank you for richening my life in so many
ways.
This study was financially supported by the Finnish Post-Graduate School in
Nursing Science, the Graduate School of Circumpolar Wellbeing, Health and
Adaptation, Northern Ostrobothnia Hospital District and Health Science
Academic Leaders and Experts.
Oulu, October 2011 Marjo Tourula
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List of abbreviations and definitions
BAT brown adipose tissue
°C Celsius
CI confidence interval
CIS cold injury syndrome
CLO thermal insulation of clothing, 0.155 m2 °C/W
CV coefficient of variation
Icl basic thermal insulation, m2 · K · W–1
Icle effective clothing insulation, m2 · K · W–1
IREQ required clothing insulation, m2 · K · W–1
ISO International Organization for Standardization
It total thermal insulation, m2 · K · W–1
M metabolic rate (W/m2)
REM rapid eye movement sleep
RH% relative humidity
rs Spearman’s rank correlation coefficient
SD standard deviation
SIDS sudden infant death syndrome
Tsk mean skin temperature (°C)
VO2 oxygen consumption
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List of original publications
This thesis is based on the following articles, which are referred to in the text by
their Roman numerals:
I Tourula M, Isola A & Hassi J (2008) Children sleeping outdoors in winter: Parents’ experiences of a culturally bound childcare practice. International Journal of Circumpolar Health 67(2–3): 269–278.
II Tourula M, Isola A, Hassi J, Bloigu R & Rintamäki H (2010) Infants sleeping outdoors in a northern winter climate: skin temperature and duration of sleep. Acta Paediatrica 99(9): 1411–1417.
III Tourula M, Fukazawa T, Isola A, Hassi J, Tochihara Y & Rintamäki H (2011) Evaluation of the thermal insulation of clothing of infants sleeping outdoors in Northern winter. European Journal of Applied Physiology 111(4): 633–640.
IV Tourula M, Pölkki T & Isola A (2011) The cultural meaning of children sleeping outdoors in Finnish winter: A qualitative study from the viewpoint of mothers. Manuscript.
In addition, some unpublished data are presented in the thesis.
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Table of contents
Abstract
Tiivistelmä
Acknowledgements 9
List of abbreviations and definitions 11
List of original publications 13
Table of contents 15
1 Introduction 17
2 Review of the literature 19
2.1 The concept of environment .................................................................... 19
2.2 Winter environment in Northern Finland ................................................ 21
2.3 Families’ cultural childcare ..................................................................... 22
2.4 Cultural clothing practice and thermal resistance ................................... 25
2.5 The well-being of children in the north ................................................... 27
2.6 Sleep of children ..................................................................................... 29
2.7 Thermal environment of children ............................................................ 34
2.7.1 Thermal balance and thermoregulation ........................................ 34
2.7.2 Interaction between sleep and thermoregulation .......................... 37
2.7.3 Symptoms of thermal stress .......................................................... 39
2.8 Summary of the literature........................................................................ 40
3 Aims and hypotheses of the study 43
4 Methodology 45
4.1 Mixed methods research design .............................................................. 45
4.2 Subjects and settings ............................................................................... 48
4.3 Procedures, data collection and analysis ................................................. 49
4.3.1 Children sleeping outdoors in winter from the viewpoint
of parents ...................................................................................... 49
4.3.2 Observation and physiological measurement of infants ............... 51
4.3.3 Microclimate and clothing insulation measurements ................... 54
Bacon et al. 1991). All these studies were implemented indoors in quite stabile
thermal condition while mothers in northern winter encountered more challenges
in varying weather conditions.
The infants were like swaddled during outdoor sleeping when mothers
bundled them up in layered clothing and sleeping bags, restraining their
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movements when they slept in the pram. Cold environment makes it possible to
use this kind of swaddling without overheating of the infants.
Mothers found the most appropriate thermal insulation of clothing at around
−5°C when the observed and required insulation values were equal. The Finnish
maternity package and pram gives appropriate insulation at −5°C, providing
explanation for this. Our findings in the questionnaire study (Study I) also support
the notion that the best temperature for letting the child sleep outdoors is about
−5°C. There is a bigger risk that infants do not reach thermal balance when it is
colder or warmer than −5°C. Fine adjustment is needed in the selection of thermal
insulation of clothing in other outdoor temperatures than −5°C.
The maximum amount of clothes gave appropriate insulation in ambient
temperature of about −17°C, but it should be noticed that by limiting the duration
of cold exposure, letting the child be outdoors is possible, but not desirable, in
colder weather. When the insulation of infant’s clothing is less than the required
insulation, the body cannot maintain thermal balance during a long nap outdoors,
which is why sleeping time has to be limited to prevent progressive cooling (ISO
11079 2007).
Our study shows that the thermal insulation of the clothing of infants sleeping
outdoors has important significance in terms of reaching goodness of fit between
the child, family and northern winter environment. The cooling rate of Tsk.
increased when the deficiency in thermal insulation increased, and in this kind of
situation, infants slept for a shorter time. This is in line with the study of Eiser et
al. (1985), in which mothers reported that the infants became irritable when too
cold.
A slow cooling of Tsk was observed even when the difference between
observed and required thermal insulation was ≥ 0 clo caused by either diurnal
variation, a sleep-induced decrease in body temperature or return to normal
temperature after initial overheating due to dressing procedures indoors. Before
going outdoors, infants were dressed in layered winter clothes and put in prams
indoors, causing heat accumulation and higher skin temperature at sleep onset
when compared to indoor sleeping.
Vasoconstriction showed that infants were not always sleeping at
thermoneutral temperature and their thermoregulation processes were activated.
Sometimes infants were also too heavily clothed, which was seen as higher level
of Tsk and relative humidity inside the clothing. This is consistent with the
findings of Grover et al. (1994), where bundling a healthy infant in a temperate
environment caused an increase in skin temperature. Of the different skin sites,
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cheek temperature showed the biggest positive correlation with microclimate
humidity measured on the chest. This suggests that the head plays an important
role in heat loss, as also shown by previous studies where most of the heat loss in
dressed infants has occurred via the head (Stothers 1981, Elabbassi et al. 2002),
especially via the face (Nelson et al. 1989). Elabbassi et al. (2002) have cautioned
against reducing heat loss from the head of heavily dressed newborns, which was
suggested to contribute to overheating of the brain, and Mitchell et al. (2008)
have recommended avoiding head covering as part of SIDS prevention strategies.
Special attention should therefore be given therefore to cold protection of the
head of outdoor sleeping infants to avoid overheating and cooling alike.
Excessive bedding and clothing causes overheating, and its relevance to SIDS
has been widely studied (Nelson et al. 1989, Fleming et al. 1990, Ponsonby et al.
1992, Wigfield et al. 1993, Wilson et al. 1994, Watson et al. 1998, Baddock et al.
2004, Wilson & Chu 2005), but hardly any studies were found related to the
association between SIDS and too little thermal insulation (Williams et al. 1996).
It should be taken into account in interpretations that children are individuals,
as pointed out by one of the interviewed mothers who had noticed that her child
who had Down’s syndrome reacted differently to cold. The type and intensity of
cold exposure and many individual factors interact with cold-related symptoms
(Stocks et al. 2004). Special attention should be paid to thermal insulation of
clothing in the case of children with neurological disorders with cold extremities
(Svedberg et al. 2005) and Raynaud’s phenomenon (Nigrovic et al. 2003) because
of their increased risk of frostbite and higher level of stress reaction if they are
allowed to sleep outdoors. Moreover, facial cooling alone with inhalation of warm
air can increase bronchoconstriction in children with mild asthma (Zeitoun et al.
2004).
Scientifically based guidelines of children’s cold protection and sleeping in
varying weather conditions should still be considered. Hull et al. (1996a,b) have
suggested to giving general advice and reinforcing parents’ awareness of infants’
sweatiness and coldness and adjusting the amount of clothing insulation in
accordance with ambient air temperature, rather than giving more specific advice,
due to the individuality of infants and wide variation in their sleeping metabolic
rates.
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6.3.5 Well-being of the children
Sleep. The findings of both the questionnaire and the observational study show
that among well-clothed children, the duration of outdoor sleep is longer
compared to indoor sleep. The average duration of outdoor sleep episode was
longer and that of indoor sleep shorter when compared to other studies of children
at the age of about three months sleeping indoors (Iglowstein et al. 2003, Sadeh
2004, Sadeh et al. 2009). Morgan (2006) has brought out the thought that long
sleep duration would not be the best practice nutritionally. It would also be a new
viewpoint in terms of SIDS research in Scandinavia that if long outdoor sleep
duration were taken into account the SIDS risk per slept hour might in many cases
be greater outdoors than indoors.
One suggestion for the long duration of outdoor sleeping could be restriction
of movements by winter clothing and sleeping bag, as swaddling has been shown
to increase duration of sleep (Gerard et al. 2002, Franco et al. 2005) and may help
infants return to sleep spontaneously, limiting parental intervention (Gerard et al.
2002). During outdoor sleeping auditory stimuli are reduced by hats, sleeping
bags and prams, preventing the effect of less intense auditory stimuli needed to
incur arousal when swaddled (Franco et al. 2005).
Soothing techniques and the location of sleep have been shown to affect
infant sleep (Sadeh 2004). Sleeping in a pram outdoors could be the same kind of
situation as falling asleep and sleeping alone in a crib in a separate room, which
has been shown to improve the possibilities of infants to sleep through the night,
with fewer night awakenings. It has been suggested that parents of such infants
are less likely to notice when their infant wakes up because of the distance and
visual separation (Sadeh 2004). Outdoor sleeping could promote infants’ own
self-regulation and self-soothing skills, the lack of which could cause shorter
sleep (Sadeh et al. 2010).
Parents familiarized their children with outdoor sleeping by starting with a
short duration. Children may learn to sleep outdoors so well that it is difficult to
try to have them sleep indoors. An antecedent stimulus may encourage the
behavior that has been linked with the stimulus. The stimulus serves as a trigger
for the desired behavior. Over time, bedtime routines in a familiar environment
become associated with the onset of sleep. (Wiggs 2009.) In the same way,
dressing the child in winter clothing and putting the child out serve as an
antecedent stimulus and help the child fall asleep.
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Interaction between sleep and thermoregulation. Cold exposure was not the
factor that made children sleep longer. This study showed infants’ high sensitivity
to cold, when a slight cooling rate caused awakening and decreased the total sleep
time in a cool environment. Previous studies confirm this, as findings show a
decrease in total sleep time in unclothed neonates due to cold exposure (Bach et
al. 1994, Telliez et al. 1997). However, Hey and O’Connell (1970) have presented
a contrasting finding: well-clothed infants who were exposed to a cold
environment slept quietly even when heat production was increased, suggesting
that swaddled infants may not cry or call for attention even if they are under
severe cold stress. It could be hypothesized that a slow enough cooling rate due to
good clothing is under the infants’ threshold and during long duration of sleep
skin temperature can decrease without awakening the child. The skin is quite
insensitive to slow rates of temperature changes that cause adaptation (Parsons
2003). The thresholds for warm and cold stimuli increase when the rate of
temperature change becomes small (Kenshalo 1990). In previous studies on
infants’ sleep in cool exposure (Azaz et al. 1992, Telliez et al. 1997, Bach et al.
2000a, Bach et al. 2001, Telliez et al. 2004), the correlation between cooling rate
of Tsk and sleep duration has been ignored, although it is essential in relation to
sensations in a cold environment.
A correlation was not found between the rate of rise of Tsk and sleep duration
indoors. This is in line with the findings of Bach et al. (1994), where neonates’
sleep was not disturbed by exposure to warm temperatures. The threshold is
higher for the rate of rise than the rate of fall in skin temperature (Libert et al.
1979), and there is stronger sensitiveness to cold than to warm in all body sites
(Stevens & Choo 1998). During outdoor sleeping sweating of infants was
observed, and humidity increased quite evenly when Tsk increased. In the study of
Werner and Reents (1980), evaporation started to increase rapidly when the
ambient air temperature rose above 30°C.
Central-peripheral temperature difference has been shown to be a better
indicator of the thermal state of the child than a single skin temperature
measurement alone (Lyon et al. 1997). Those infants who had a slow cooling rate
and were outdoors for about 200 min or more (n = 10) had an increase of more
than 2°C in central-peripheral temperature difference. A difference of more than
2°C may have an effect on heart rate and blood pressure of very low birth weight
infants (Lyon et al. 1997). For this reason it would be better to limit the duration
of outdoor sleep to less than 200 min, especially if it is colder than −5°C. The
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cooling-induced awakening of infants may interrupt the cold exposure before
cooling appears if the cooling rate crosses the threshold.
The findings indicate that the infants had in some cases cold stress; peripheral
vasoconstriction was found as there was a significant increase in the central-
peripheral skin temperature difference during outdoor sleeping and significantly
lower temperatures of the extremities at the end of outdoor sleeping compared to
indoor sleeping. Coldness of hands and feet was also observed by palpation.
Thermoneutrality was not maintained in 85% of the infants sleeping outdoors, as
Tsk fell more than 0.3°C/hour, if the definition of thermoneutrality is viewed
according to Sauer et al. (1984). However, the proportion of infants who reached
thermoneutrality could be higher because study infants were older and body
weight greater than in the study of Sauer et al. (1984). Skin temperature of the
chest at the end of outdoor and indoor sleep did not differ significantly, which
shows that cooling-induced vasoconstriction had first taken place in peripheral
vessels, but cooling had not proceeded to hyporthermia. The interviewed mothers
described how they checked their outdoor sleeping infants’ temperature by
palpating the cheeks and nape. It is possible to feel sweatiness by palpating the
nape, but it is not the right place to feel coldness, because nape temperature
remains warm during cold exposure due to the action of brown adipose tissue
(Silverman et al. 1964, Rylander et al. 1972).
It was interesting to find that mothers tried to protect their children from
cooling as they had noticed a correlation between cooling and the common cold.
An association was found between cold outdoor temperature and humidity and
respiratory tract infections among adults in the study of Mäkinen et al. (2009). On
the other hand, some mothers saw sleeping in a cold environment as toughening
the child, which is line with findings among Swedish mothers (Welles-Nyström et
al. 1994).
A white and bluish area on the child’s cheek was reported by some parents. A
white area seems to be frostnip, which is superficial cooling of tissues without
cellular destruction (Marx et al. 2010), whereas a bluish area might be a chilblain,
a form of cold injury representing the next stage of severity (Giusti & Tunnessen
1997). The low amount of frostbite injuries reported in previous studies in
Finland (Juopperi et al. 2002, Koljonen et al. 2004) was confirmed in this study,
as no other frostbite injuries came up.
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6.4 Summary of the findings and conclusions
1. The winter environment in Northern Finland with pure air and peaceful, fresh
and clean nature can be seen as an affordance for the child sleeping outdoors.
2. During daytime, infants usually sleep outdoors once a day in different kinds
of conditions, from sunshine to heavy snowfall, with ambient air temperature
decreasing almost to −30°C.
3. The best temperature for outdoor sleeping was shown to be −5°C.
4. Outdoor sleeping is a self-evident and common culturally bound custom in
Northern Finland.
5. Guidelines, advice and encouragement about having children sleep outdoors
were given to mothers from different sources. Mothers built their own
personal knowledge through their experiences and shared it with others, at the
same time participating in the cultural knowledge-building processes. The
outdoor sleeping childcare practice is a commonly accepted collective, a type
of behavior that is sometimes felt to be compulsory.
6. There are many risk factors involved with the outdoor sleeping practice, but
when all security perspectives are taken into account it can promote family
well-being by creating a rhythm and strengthening the fluency of everyday
life.
7. It was difficult to adjust systematically the optimal thermal insulation for
outdoor sleeping infants during northern winter. When ambient temperature
decreased, the cooling rate of Tsk increased, suggesting that the cold
protection of the clothing compensated only partly for the increased heat loss.
Both cooling and sweating existed.
8. Specific guidelines on clothing are needed for parents.
9. Maximum amount of clothes combined with a pram can provide appropriate
insulation in ambient temperature of about −17°C.
10. Children sleep longest sleep outdoors when the cooling rate of Tsk is minimal.
11. Outdoor sleeping promotes satisfying children’s daytime sleep needs as it
increased the duration of sleep.
12. Infants should not sleep outdoors for more than three hours because a slow
cooling rate that remains under threshold could increase cold stress.
13. Outdoor sleeping was thought to promote children’s health.
14. A comprehensive view of the phenomenon was gathered in the evaluation
model of outdoor sleeping episode (Figure 5). It provides a tool for
systematic evaluation on each different level and between levels, shifting the
98
pointer of goodness of fit either to the direction of beneficial or adverse
effects.
6.5 Implementation and suggestions for future research
This study gives information about outdoor sleeping that can be applied to
practical problems encountered by parents. Families who move to Finland can
familiarize themselves with a childcare practice that they may even never have
heard of by reading this study. It also provides support to families who move
abroad, helping them describe a practice that is self-evident to them, but which
may seem peculiar to others.
The evaluation model of outdoor sleeping episode can be utilized in nursing
practice when public health nurses give counseling to families. It helps to identify
relationships between different levels and broader aspects that should be noticed
in guidelines. The model (Figure 5) can be used as a tool when giving counseling.
More specific guidelines are needed in Finland, and the study findings also
provide detailed information, for example about required clothing insulation in
different outdoor temperatures.
In nursing science, when mixed methods are used to study different kind of
phenomenon, findings can be compiled and utilized with the mixed methods
evaluation model (Figure 5), developed in this study. The questionnaire used in
Study I still needs improvements, and the evaluation model of outdoor sleeping
episode need testing.
This study prepares the ground for international comparative studies. Cultural
comparisons allow us to understand better children’s sleep in different contexts
and to evaluate the benefits and consequences of different cultural sleeping
practices (Giannotti & Cortesi 2009). Hardly any other studies addressing the
outdoor sleeping childcare practice can be found, and for that reason it would be
of great significance to add questions about outdoor sleeping into international
questionnaires, such as the Brief Infant Sleep Questionnaire (BISQ), used to study
bed sharing and room sharing (Sadeh 2004, Mindell et al. 2010a). Internationally
collaborative and broadly interdisciplinary studies are needed (Jenni & O’Connor
2005) using both qualitative and quantitative approaches in the field of SIDS
research, where there is still a lack of knowledge dealing with correlations
between outdoor sleeping, cooling and SIDS.
This study concentrated on the thermal environment, but not on the quality of
indoor and outdoor air, which are also important factors when evaluate the
99
healthfulness of the outdoor sleeping practice. Information about connections
between morbidity, such as falling ill due to infections, and cooling caused by
outdoor sleeping is still needed. In the next phase, more extensive
epidemiological studies and experimental research is needed to attain inferences
from causal relationships.
Future research is needed to find out the effects of extreme weather events on
children and to gain more knowledge about children’s environmental health.
100
101
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121
Appendix Clothing insulation tests and information about clothing
CL
OT
HIN
GIN
SU
LA
TIO
NT
ES
TS
:
B1.
AB
BR
EV
IAT
ION
S:
Type
ofcl
othe
s:L
isto
fcl
othe
s:U
1un
derc
loth
es1,
2,3
U1 UU1
2.
U2
unde
rclo
thes
1,2,
3,6
Bbl
anke
t5
M1
mid
-lay
er7,
8,12
,13,
M2
mid
-lay
er7,
8,9,
10,1
1,12
,13
U1
3.M
1
U1
M1
O1
4.
M3
mid
-lay
er7,
10,1
1,13
O1
oute
rwea
r14
a,15
b,17
O2
oute
rwea
r7,
14a,
15b
O3
oute
rwea
r14
b,15
a,16
,17
C18
U1
M1
O1
C1
5.
OC
C1
cove
rs18
C2
cove
rs19
Ssh
eeps
kin
20P
pram
21
U1
M1
O1
C1
6.P
U2
O2
C1
P7.
gabgnipeels.81
tiusydob.1ffu
mtoofretni
wdeddap.91
yppanelbasopsid.2
nikspeehs.02sgniggel
detoof.3marp.12
tiusrep
mor.4
U2
M2
O3
C2
S8.
UM
P
OC
P
5.bl
anke
tand
duve
tcov
er6.
sock
s7.
mit
tens
8.w
oole
nso
cks
9l
itt
U2
M3
9.O
3C
1P
9.w
oole
nm
itte
n10
.pla
ysui
t(s
hirt
and
pant
s)11
.ove
rall
wit
hw
addi
ng12
.woo
len
card
igan
and
pant
s13
bala
clav
aha
t13
.bal
acla
vaha
t14
a.sn
owsu
it14
b.w
arm
ersn
owsu
it15
a.in
sula
ted
hat
15b
woo
len
hat
15b.
woo
len
hat
16.i
nsul
ated
mit
tens
17.i
nsul
ated
boot
ies
122
Un
der
clot
hes
:
LIS
TO
FC
LO
TH
ES
4ro
mpe
rsu
it
1.bo
dysu
it•
wei
ght:
61.1
g•
60cm
•10
0%
cott
on
4.ro
mpe
rsu
it•
wei
ght:
78.4
g•
60cm
•10
0%
cott
on
•10
0%
cott
on
2.di
spos
able
napp
y
3.fo
oted
legg
ings
•w
eigh
t:44
.3g
•60
cm
5.bl
anke
tand
duve
tcov
er•
wei
ght:
671.
3g
•bl
anke
tfi
llin
g:10
0%
•10
0%
cott
onbl
anke
tfi
llin
g:10
0%
poly
este
r,•
cove
r:52
%po
lyes
ter,
48%
cott
on•
blan
ketc
over
:100
%co
tton
123
Mid
-lay
er:
6.so
cks
•w
eigh
t:19
.7g
•si
ze:1
9-21
•78
%co
tton
,20
%po
lyam
ide,
lycr
a
7.gl
oves
•w
eigh
t:18
.7g
78%
20%
lid
l
9.w
oole
nm
itte
n•
wei
ght:
40.7
g
•78
%co
tton
,20
%po
lyam
ide,
lycr
a
8.w
oole
nso
cks
•w
eigh
t:38
.0g
124
12.w
oole
nca
rdig
anan
dg
pant
s•
wei
ght:
258.
2g
10.p
lays
uit
(shi
rtan
dpa
nts)
•w
eigh
t:14
5.9
g•
size
:70
cm•
100%
cott
on
11.o
vera
llw
ith
wad
ding
•w
eigh
t:28
6.6
g•
size
:70
cm
13.b
alac
lava
hat
•w
eigh
t:26
.1g
•si
ze:7
0cm
•10
0%
cott
on•
100
%co
tton
,w
addi
ng:1
00%
poly
este
r
125
Ou
terw
ear:
14a
snow
suit
15a.
insu
late
dha
t14
a.sn
owsu
it•
wei
ght:
470.
5g
•si
ze:6
8cm
•co
ver:
100
%po
lyes
ter,
fill
ing:
100
%po
lyes
ter
•w
eigh
t:62
.6g
•si
ze:5
0•
cove
r:10
0%
poly
este
r,fi
llin
g:10
0%
poly
este
r,fi
llin
g:10
0%
poly
este
r,li
ning
:50
%po
lyes
ter,
50%
cott
on
lini
ng:
50%
poly
este
r,50
%co
tton
bi
14b.
war
mer
snow
suit
•w
eigh
t:66
7.0
g•
size
:68
cm
15b.
woo
len
hat
•w
eigh
t:36
.1g
126
16.i
nsul
ated
mit
tens
•w
eigh
t:46
.9g
•si
ze:1
•co
ver:
100
%po
lyes
ter,
fill
ing:
100
%po
lyes
ter,
lini
ng:5
0%
poly
este
r,50
%co
tton
17in
sula
ted
boot
ies
17.i
nsul
ated
boot
ies
•w
eigh
t:58
.5g
•si
ze:1
•co
ver:
100
%po
lyes
ter,
fill
ing:
100
%po
lyes
ter,
fill
ing:
100
%po
lyes
ter,
lini
ng:5
0%
poly
este
r,50
%co
tton
127
Cov
ers:
20.s
heep
skin
ih
1152
7
18.s
leep
ing
bag
•w
eigh
t:43
8.0
g•
fabr
ic:1
00%
cott
on,
•w
eigh
t:11
52.7
g
fill
ing:
100
%po
lyes
ter
21.p
ram
19.p
adde
dw
inte
rfo
otm
uff
•w
eigh
t:90
0.3
g
128
129
Original publications
I Tourula M, Isola A & Hassi J (2008) Children sleeping outdoors in winter: Parents’ experiences of a culturally bound childcare practice. International Journal of Circumpolar Health 67(2–3): 269–278.
II Tourula M, Isola A, Hassi J, Bloigu R & Rintamäki H (2010) Infants sleeping outdoors in a northern winter climate: skin temperature and duration of sleep. Acta Paediatrica 99(9): 1411–1417.
III Tourula M, Fukazawa T, Isola A, Hassi J, Tochihara Y & Rintamäki H (2011) Evaluation of the thermal insulation of clothing of infants sleeping outdoors in Northern winter. European Journal of Applied Physiology 111(4): 633–640.
IV Tourula M, Pölkki T & Isola A (2011) The cultural meaning of children sleeping outdoors in Finnish winter: A qualitative study from the viewpoint of mothers. Manuscript.
Reprinted with permission from International Association of Circumpolar Health
Publishers (I), John Wiley and Sons (II), Springer (III).
Original publications are not included in the electronic version of the dissertation.
130
A C T A U N I V E R S I T A T I S O U L U E N S I S
Book orders:Granum: Virtual book storehttp://granum.uta.fi/granum/
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Marjo Tourula
THE CHILDCARE PRACTICE OF CHILDREN’S DAYTIME SLEEPING OUTDOORSIN THE CONTEXT OF NORTHERN FINNISH WINTER
UNIVERSITY OF OULU,FACULTY OF MEDICINE,INSTITUTE OF HEALTH SCIENCES, NURSING SCIENCE,INSTITUTE OF BIOMEDICINE, DEPARTMENT OF PHYSIOLOGY;FINNISH INSTITUTE OF OCCUPATIONAL HEALTH, OULU;NORTHERN OSTROBOTHNIA HOSPITAL DISTRICT;KYUSHU UNIVERSITY, FACULTY OF DESIGN, DEPARTMENT OF HUMAN SCIENCE