Article Appraisal: Hiscock et al. (2014) Study - Healthcare

This report critically appraises the article by Hiscock et al. (2014) titled "Preventing Early Infant Sleep and Crying Problems and Postnatal Depression: A Randomized Trial." The appraisal employs the CASP (Critical Appraisal Skills Program) tool to evaluate the study's methodology, findings, and overall quality. The report examines the study's objectives, which aimed to determine the effectiveness of interventions, such as providing parents with information about infant sleep patterns and offering support, in reducing infant sleep disturbances, crying, and parental depression. The appraisal assesses key criteria, including the clarity of the research question, randomization of participants, accounting for participants, blinding procedures, similarity of groups at the start of the trial, equal treatment of groups, and the magnitude of the treatment effect. The study found that the intervention group showed fewer crying issues, less daytime sleep, and a reduced risk of parental depression. The report concludes with an assessment of the study's strengths and limitations, providing insights into the implications of the research for healthcare practice and further research directions.

Running head: ARTICLE APPRAISAL
ARTICLE APPRAISAL
Name of the student:
Name of the university:
Author note:

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Introduction
There is an increasing volume of published research accessible to health professionals. With
ever changing developments and new evidence it is also important to have strategies to access
and interpret this material so that you can provide the best care to your patients. To ensure
you that you can safely use evidence to influence your clinical decision making, you need to
have skills in assessing the quality and relevance of the research you find, these skills are
described as critical appraisal. The tool that would be used in the study is called CASP or the
Critical Appraisal Skills program tool. The paper selected is by author Hiscock et al. (2014)
namely Preventing Early Infant Sleep and Crying Problems and Postnatal Depression: A
Randomized Trial.
Background:
Modern day parents are complaining about their incapability to handle their infants well.
They state that they are often unable to understand the reason of their babies crying and
therefore feel helpless about how to make the baby calm (Kettunen, Koistinen & Hintikka,
2014). Such activities make them spend sleepless nights where they wake up in a tired state
and feel physically weak. Often such symptoms are often making them depressed and hence
they are not being able to provide as much care to the baby as they should get (Gorman,
2017). Moreover, the babies are having sleepless nights when they frequently wake up and
cry, have day sleeps and cry a lot (DeChowdhury et al., 2014). Hence, interventions for the
betterment of health for both the parents and the babies are extremely necessary.

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Pico question:
population intervention comparison outcome Time
Parents of new
born who undergo
interventions
Proper trainings
about handling
babies, information
about their crying
patterns, reasons of
crying, and similar
others
Control group Results in
lessening of babies
lack of sleep at
night (primary
outcome),
reduction in crying
and ay time sleep.
Results in
lessening
depression and
stress and anxiety
among parents or
caregivers.
Within 4 to 6
months of the
new born
Pico question:
Do Parents who are properly trained about different information about sleeping and crying
pattern for babies as well as get support and undertake discussion about sleeping and crying
issues of babies suffer from less depression, stress and anxiety than parents who do not get
the intervention in the first four to six months?
In order to appraise the article CASP tool is used as follows:
The first criteria that the article needs to fulfil is the question that whether the article
is addressing a clearly focused issue (Nadelson &Nadelson, 2014) . These criteria were

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correctly fulfilled as the researchers have rightly chosen the participants and have mentioned
their process of choosing such participants clearly. They have given a proper diagram of the
choosing procedure of the participant making it easier for the reader to develop an
understanding if the participants at a glance. The trail consisted of consulting caregivers for
781 infants who were born at 32 weeks or local in 42 child centres over Melbourne,
Australia. The interventions were also rightly discussed. They included the supply of
information about normal infant sleep and their crying patterns, medical causes of crying, and
information about parent self care within a DVD which was handed to caregivers and also via
booklet. They also discussed how they changed the mode of information with gradual passing
of weeks like form booklets to telephone conversation to discussion of parents group and
child care group. In case of the comparator, one can suggest that such interventions neither
were nor provided to the control group and they were only assisted b y regular support of
nurses which were only provided through MCH service. Outcomes were also thoroughly
discussed in the form of infant measures with the help of likert scale where the caregivers
provided answers to close ended to measure severity of each issues and also completed a 72
hour infant behaviour questions diary. The outcome was also measured for caregiver
measures with help of Edinburgh Postnatal Depression Scale (EPDS), Pittsburgh Sleep
Quality Index which was measured by 4 subscales of the MCISQ which helped them to reach
to a definite conclusion about the effectivity of the interventions.
The second criterion that was to be analysed is whether the participants who were
assigned to the interventions properly randomised. The second criterion was also properly
conducted by the researchers. This is said so because the researchers have discussed the
details of how caregivers were invited participant allotment in details. The participants were
caregivers who were cared by the MCH services from over 4 government hospitals. They had
mailed the participants entire information statements, their consent forms and baseline

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questionnaires to those who were interested. Those families who expressed their interest in
written informed consent and completed questionnaire were only considered for the research.
Randomisation was done for the families to either the control group or the intervention group
by computer generated random sequencing which were actually created by independent
statistician. The randomisation was also stratified by the reference of the nurse’s MCH
centre. Both the research ream and the families were properly blinded before allocation after
which it was not possible to carry so. This was not possible as the method of providing
intervention could not be carried on in the blindfolded manner and therefore the intervention
group people were e aware of the fact that they were of the particular intervention group.
The third criteria that needs to be fulfilled by a proper RCT paper is that whether the
participants who entered the trial were properly accounted for at its conclusion. The step was
also maintained properly by the researchers. The intervention group were properly guided
and the application of the intervention was correctly carried on. After the provision of the
resources and the information to the intervention groups at the interval of four weeks firstly
by booklet and DVD at fourth week, telephonic conversation up to 8th week and parental
discussion at 12 week, assessments were made about their affectivity by closed questionnaire
surveys that yielded statistical results. Therefore the trial was not stopped but carried on
successfully. Moreover the participants in the two groups were rightly handled and analysed
with correct statistical analysis so that the results obtained of the two groups can be found out
and the differences in their result was also pointed out clearly. The outcomes were analysed
and the results for both the groups were mentioned and there was no discrepancy found from
the work of the researchers.

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The fourth criterion that needs to be governed properly is whether the participants,
health care and the study personnel were blinded for the treatment. In the case study, it has
been clearly described how randomisation was conducted of the participants into two groups:
one being the control group and the other the intervention group with the help of computer
generated random sequence. Through the entire procedure starting from the time of taking of
the consent as well as up to the time of allocation of the participants to the different groups,
both the researchers as well as the participants were blinded. However, the blinding could not
be conducted during the time of intervention as the nature of the intervention which was
selected could not support the blinding procedure. Here the intervention group had to go
through the resources, have telephonic conversation and meeting thereafter. Hence, it was
evident for them to understand that they were the intervention group and therefore blinding
could not be done.
The fifth criterion that any reader should try to judge from the paper is to look for that
the groups were similar at the start of the trials or not. The participants who were selected
were visitors of the government hospitals whose infants were about 7 days old or older than
that. No discrimination was made and no characteristics or features were selected by the
researchers. The age of the primary caregivers like the mothers were seen with mean age of
33 and infant mean age was 4. Some of the excluding criteria taken into consideration were
parents who could not speak English or whose babies were born before 32 weeks gestation or
with a serious health issue. Other than this, no specific factors like sex were utilised. Other
than this, no other factors were determined to be present in the participants irrespective of the
control and intervention groups.
The sixth criterion that needs to be assessed is that whether other than the
experimental intervention, the groups were treated equally of not. In the paper, it is seen that
the researchers have mentioned very less about the control groups and were discussing more

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about the intervention groups. However, other than the application of the intervention, no
other special benefits or treatment were provided by the researchers. The nurses of the MHC
were seen to be equally attending all the participants irrespective of the control as well as the
intervention groups showing that no extra preferences were given to the intervention group
and therefore any sort of doubts on the researchers biasness could not be captured.’
The seventh criteria which is one of the most important criteria that the reader needs
to assess is that how large was the treatment effect. In that case, one must first try to
understand the outcomes that were measured. The infant measures in the paper were
measured mainly by the postal survey which was conducted at 4 to 6 months of age. The
primary outcomes that the researchers wanted to measure were the effect of the interventions
ion the infants’ night time sleep problem. The other outcomes they wanted to measure were
that the whether the infants had day time sleeping habits, crying and feeding issues. These
were mostly known by the 72 hour infant behaviour diary for measuring sleeping, feeding
and crying and it was complete with the help of likert scale to analyse whether the rate of
severity of the issues. The caregiver outcomes were mainly measured with the help of post
natal depression scale with score values greater than 8 indicative of the postnatal depression
in the caregivers. The sleep quality and quantity of them were measured by 2 items taken
from Pittsburgh Sleep Quality Index. Caregiver cognitions about infant sleep were measured
by 4 subdivisions scales of MCISQ. Reports by the caregivers were given in the number of
visits they made o the health care centres, usefulness of the intervention and also ion their
breastfeeding duration as well as their changing of the infant’s formal. When the follow up
was conducted at the 4 month interval, no differences were found between the reports made
by the caregivers in the domains of infant sleeping, crying as well as feeding problems.
However, an interesting feature was seen that infants in the intervention groups who were
frequently fed had 87% lower odds of having daytime sleep and 75% of lower crying issues

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than the control group. However night time sleep reports of the infants were similar in both
the groups at the end of the 4 month follow up. However at six months, differences due to
being frequent feeders were not seen. In case of the caregiver outcomes, it was seen that there
were no differences in their reports of depression at 4 month study. However, in the 6 month
study, intervention group caregivers showed less chances of developing depression than the
control groups. The former also showed fewer doubts in their ability to manage their infants
sleep at both the tome points. Moreover, it was also seen that after 6 months, intervention
groups had to spend less than 20 minutes for managing their infant in the night. They also had
less concern regarding infant death, did not have to change formula in comparison to that of
the control groups. Therefore it helped to see that the caregivers were indeed benefited from
the interventions. However, the results regarding the primary outcomes were not clearly
mentioned as it should have been that is sleep problem reduction of the infants at night were
not clearly stated and had been clubbed with the effect of frequent feeders stating that they
helped to handle days keep issues and crying issues. Nigh time sleep problems which was the
primary outcome was analysed to be similar in both groups
The next criterion in consideration for appraising the given article is that whether the
estimate of the treatment effect was precise or not. The estimates that were made were much
precise and were at 95% confidence limits which make the article valuable to be applied in
the evidence based studies in the nursing profession. All the confidence limits in each if the
statistical analysis of the outcomes were clearly depicted and there was not scope of the
researchers to use nay hypothetical statements. Hence the estimates of the treatment effects
are indeed found to be quite precise.
The ninth criterion that a paper needs to fulfil properly in order to be considered as
valuable for different evident based researchers or even by others to gain information in the
domain is that whether the results which were obtained from the researchers were valuable or

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not. This paper really scores well in this criterion as the interventions can be definitely
applied to the participants in any scenario. There are indeed large numbers of newly formed
parents who come up with issues of depression, sleeplessness, frustration, lack of skills to
maintain a baby. There are many parents who even complain of the babies crying at night
disrupting their sleep which becomes strenuous for them. The babies tend to cry, not sleep in
the night, falls asleep in the day and many others. This is a genuine issue faced by a large
number of parents of newly born. Hence the interventions which are mentioned by the
researchers are indeed helpful. However, they are seen to be mostly helpful for babies who
feed well. They are highly beneficial for the parents as they learn to develop skills of
maintaining babies, develop ideas about their crying and sleeping patterns and make them
aware of the activities of the babies. Hence, the article is indeed helpful and will be beneficial
for nurses in evidence based practices.
The tenth criterion that needs to be verified is that whether all the clinically important
outcomes considered were not. To these, it must be said, that the research brought out very
positive effects in the behaviour of the parents as well as the health condition of the parents
also became quite well after the application of the intervention. They showed less symptoms
of depression and were also not awake in the night for more than 20 minutes. This reflected
that the parents developed themselves with the help of the intervention. However, the primary
outcome was not satisfied in the part of infant outcomes. The intervention showed no change
in the sleep patterns of the baby in both the groups both in 4 month and 6 month time.
Therefore the intervention was partly successful and further researches are required to
comment more specifically in the primary outcomes.
The eleventh and the last criterion that the reader needs to assess are to know
what the implications of the study practice are. It also should clarify that whether the benefits
worth any harms and costs. The interventions that were provided were totally harmless and

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also did not possess any threats to any stakeholders associated with the research. This
treatment had no negative short or long term impacts. They are indeed found to be extremely
helpful for a large number of parents and they indeed reported positive results with the
assessment scales of depression and other. Therefore, the research can be used by young
researchers for further carrying out researches to develop the interventions for better
outcomes or even for perform the literature revise for their own researches. Young healthcare
professionals may also use this as evidence based practices where they will use this
intervention for treating parents who come for their advice and how to manage their babies.
From the entire appraisal, it is evident that the information provided by the paper is
indeed much helpful in educating the modern day parents. The intervention s have made them
understand the systematic ways of handling the issues of infant crying, lack of night sleep,
day sleep and others. The paper has shown that good feeding babies are the ones who show
less symptoms and day sleep when the interventions are applied. Moreover, the parents were
less depressed and seemed to develop ideas about how to control their babies. Therefore,
indeed the paper was helpful as it helped to give good suggestions about how to maintain the
health of the mother and the infant at the same time and therefore a valuable paper in
maternal and childcare nursing.

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References:
De Choudhury, M., Counts, S., Horvitz, E. J., & Hoff, A. (2014, February). Characterizing and
predicting postpartum depression from shared facebook data. In Proceedings of the 17th
ACM conference on Computer supported cooperative work & social computing (pp. 626-
638). ACM.
Gorman, J. (2017). Postpartum Depression and Opinions on Screening.
Hiscock, H., Cook, F., Bayer, J., Le, H. N., Mensah, F., Cann, W., ... & St James-Roberts, I.
(2014). Preventing early infant sleep and crying problems and postnatal depression: a
randomized trial. Pediatrics, 133(2), e346-e354.
Kettunen, P., Koistinen, E., & Hintikka, J. (2014). Is postpartum depression a homogenous
disorder: time of onset, severity, symptoms and hopelessness in relation to the course of
depression. BMC pregnancy and childbirth, 14(1), 402.
Nadelson, S., & Nadelson, L. S. (2014). Evidence‐Based Practice Article Reviews Using CASP
Tools: A Method for Teaching EBP. Worldviews on Evidence
‐Based Nursing, 11(5), 344-
346.