Sleep Medicine Reviews 35 (2017) 85e100

Contents lists available at ScienceDirect

Sleep Medicine Reviews

journal homepage: www.elsevier.com/locate/smrv

CLINICAL REVIEW

Napping: A public health issue. From epidemiological to laboratory

studies
Brice Faraut a, *, Thomas Andrillon b, Marie-Françoise Vecchierini a, Damien Leger a, **
a
Universit

e Paris Descartes, Sorbonne Paris Cit
^tel Dieu de Paris, Centre du Sommeil et de la Vigilance, EA 7330 VIFASOM, Paris, France
e, APHP, Ho
b

Ecole Normale Sup
erieure-PSL Research University, Laboratoire de Sciences Cognitives et Psycholinguistique (UMR8554, ENS, EHESS, CNRS), Paris, France

a r t i c l e i n f o s u m m a r y

Article history: Sleep specialists have proposed measures to counteract the negative short- and long-term consequences
Received 4 March 2016 of sleep debt, and some have suggested the nap as a potential and powerful “public health tool”. Here, we
Received in revised form address this countermeasure aspect of napping viewed as an action against sleep deprivation rather than
5 September 2016
an action associated with poor health. We review the physiological functions that have been associated
Accepted 5 September 2016
Available online 13 September 2016
positively with napping in both public health and clinical settings (sleep-related accidents, work and
school, and cardiovascular risk) and in laboratory-based studies with potential public health issues
(cognitive performance, stress, immune function and pain sensitivity). We also discuss the circumstances
Keywords:
Napping
in which nappingddepending on several factors, including nap duration, frequency, and agedcould be a
Sleep debt potential public health tool and a countermeasure for sleep loss in terms of reducing accidents and
Public health cardiovascular events and improving sleep-restriction-sensitive working performance. However, the
Sleepiness impact of napping and the nature of the sleep stage(s) involved still need to be evaluated, especially from
Cognitive functions the perspective of coping strategies in populations with chronic sleep debt, such as night and shift
Stress workers.
Immunity © 2016 Elsevier Ltd. All rights reserved.
Cardiovascular risk
Night-work

Introduction determinant negatively impacting sleep is the use of mobile elec-

tronic devices (phones, computers) and the increasing amounts of
Over the last few decades, epidemiological studies have pro- leisure time spent on the internet. This activity affects many young
gressively reported that sleep loss is a clear independent risk factor adults, drastically reducing TST [16].
associated with obesity, type 2 diabetes, cardiovascular disease To counteract the negative short- and long-term consequences
(CVD), and accidents [1e4]. In laboratory research, it has also been of sleep debt, napping has often been proposed as a potential and
clearly shown that sleep restriction is associated with immune, powerful “public health tool”. In his book “The promise of sleep”,
endocrine, and vascular dysfunction [5e9]. It is now well estab- William C Dement wrote, “My fellow sleep specialists and I are
lished that, on average, 10e35% of adults suffer from sleep loss campaigning to rehabilitate napping and demonstrate that taking
during weekdays, sleeping less than 6 h per 24 h [10e13]. One naps is an excellent and respectable strategy for sleep manage-
major determinant of sleep loss is work: in particular, 20% of the ment. Naps can make you smarter, faster, and safer than you would
working population work at night or in shifts, and they sleep an be without them. They should be widely recognized as a powerful
average of one hour less than day workers [11,14]. Moreover, the tool in battling fatigue, and the person who chooses to nap should
time taken to travel from home to work and back has increased in be regarded as heroic” [17]. However, napping is not at all a ho-
most cities, directly impacting total sleep time (TST) [15]. Another mogeneous habit around the world, and this heterogeneity has to
be taken into consideration from the public health point of view. It
is indeed not the same to have a nap once a week on weekends and
* Corresponding author. Ho ^ tel Dieu de Paris, Centre du Sommeil et de la Vigi- to nap on a daily basis due to shift work. While the short-term

Paris Descartes, EA 7330 VIFASOM 1 place du Parvis Notre-Dame,
lance, Universite effects of napping on attention, concentration, and reaction time
75181 Paris Cedex 04, France.
^tel Dieu de Paris, Centre du Sommeil et de la Vigi-
may take effect with a single nap, the mid- or long-term benefits of
** Corresponding author. Ho

Paris Descartes, EA 7330 VIFASOM 1 place du Parvis Notre-Dame,
lance, Universite napping may only be considered in regular nappers (i.e., napping
75181 Paris Cedex 04, France. several times a week). Thus, different types of naps, depending on
E-mail addresses: [email protected] (B. Faraut), [email protected] the length, the circadian position, and the sleep architecture, have
(D. Leger).

http://dx.doi.org/10.1016/j.smrv.2016.09.002
1087-0792/© 2016 Elsevier Ltd. All rights reserved.
86 B. Faraut et al. / Sleep Medicine Reviews 35 (2017) 85e100

conclusions. Objective recordings of sleep, such as at-home actig-

Abbreviations raphy, have shown that napping an average of 28.0 min/d between
12:00 h and 18:00 h in young subjects (mean age 23.8 ± 3.8 y old)
CAR cortisol awakening response does not influence nocturnal sleep [25]. In the elderly, however,
CHD coronary heart disease napping from 30 min to 90 min during the afternoon and early
CRP C-reactive protein evening seems more controversial in terms of its effects on night-
CVD cardiovascular disease time sleep. Yoon et al. reported in this same ecological study that
CVR cardiovascular risk “young elderly” nappers (mean age 66.2 ± 4.9 y old napping for an
EEG electroencephalogram average of 30.4 min/d) had shorter time in bed and an earlier wake-
HPA hypothalamic-pituitary adrenal up time but no significant differences in TST or sleep efficiency. In
IL interleukin older nappers (mean age 78.6 y old, napping for 57 ± 18 min at the
NREM non-rapid eye movement beginning of the afternoon), Monk et al. [26] measured lower sleep
OR odds ratio efficiency during night-time sleep using actigraphy and poly-
PSG polysomnography somnography (PSG) but found no change in SWS or wake time after
REM rapid eye movement sleep onset (WASO) and better objective evening vigilance perfor-
RR relative risk mance. Finally, in the elderly, as discussed below, a long and
SOREMP sleep onset REM period potentially unplanned nap during daytime could be a contributing
SPA sympatho-adrenal system factor to increased cardiovascular risk (CVR).
SWS slow-wave sleep Therefore, we will consider another important issue on how to
TNF tumour necrosis factor objectively assess napping: not only the duration but also the quality
TST total sleep time of sleep in terms of non-REM (NREM) or rapid eye movement (REM)
WASO wake time after sleep onset sleep. Several recommendations have been made, mostly by the
American Academy of Sleep Medicine, regarding the use of PSG and
actigraphy [27]. However, the lack of consensus on some methodo-
to be defined [18]. Napping habits also change during an in- logical and theoretical points may impact the objective evaluation of
dividual's lifespan, from a progressive decrease in nap length and naps: i) Do studies have to recruit habitual or non-habitual nappers?
nap episodes during early childhood to the midday napping habits ii) Do scorers have to use specific classifications when scoring naps
practiced during adulthood [19]. Napping is also a culturally driven (sleep latency, first stage 1, SOREMs, awakenings)? iii) Do studies
behaviour: afternoon/midday sleep or a siesta is a common habit in have to test naps at different times of the day or at midday? Inter-
Mediterranean culture, mainly for climatic reasons, and in China, estingly, Kanady et al. tried to validate actigraphy versus PSG in the
Taiwan, and Japan as a countermeasure to excessive working hours. assessment of daytime naps and no-nap rest periods [28]. They
In China, the right to nap at work has been written into the tested the sensitivity levels (high, medium, low) of three actigraphy
constitution since 1948 in order to ensure better working condi- monitors (Actiwatch-64-Respironics) and compared sleep latency,
tions and productivity. To embrace the diversity of napping while TST, WASO, and sleep efficiency in 30 and 27 subjects in the nap and
maintaining perspective on this rather universal and homogenous no-nap groups, respectively. They found that actigraphy was able to
biological phenomenon, we will mostly consider, in this review, predict TST, sleep latency, and sleep efficiency during a nap, but with
napping as a voluntary episode of sleep ranging from several mi- optimal levels depending on the variables of interest. A medium level
nutes to nearly 90 min of sleep. Importantly, this review will not of actigraphy monitor sensitivity showed significant correlations
address naps that are taken as a result of sleep disorders, such as with TST and sleep efficiency, while high levels predicted sleep la-
sleep apnoea. tency. Low-sensitivity levels were best for determining WASO.
At the beginning of the epidemiology section, we will present Actigraphy also accurately distinguished nap from rest in no-nap
napping data during childhood as well as in the elderly, but we will subjects, indicating that it is a reliable tool for the assessment of
focus mainly on young and middle-aged adults, as the need for napping.
efficient countermeasures to sleep-debt seems greatest in this Finally, in the first section dealing with the epidemiology of
latter population. Indeed, young people are more sensitive to sleep napping, we will review the following: 1) napping across the life-
loss and are expected to have greater homeostatic pressure, so span; 2) sleep debt and napping habits; 3) napping in practical
napping is a particularly effective countermeasure in younger settings (sleep-related accidents, work and school); and 4) napping
adults [20]. We will also not forget napping issues related to pro- and cardiovascular risk. The second section will focus on the
fessional life (night and shift work schedules). cognitive and physiological effects of napping, and we will review
The present review may be criticised for focusing predominantly napping effects on 1) alertness; 2) memory; 3) stress and cardio-
on the beneficial effects of napping, but we also briefly describe how vascular systems; 4) immune functions; and 5) pain sensitivity.
napping may have deleterious effects. One frequently claimed
deleterious effect is sleep inertia, which is generally defined as a Epidemiology of napping
sensation of disorientation and a transient reduction in cognitive
performance following long naps exceeding 30 min [21]. Usually, the In the present section, we will fist describe napping across the
longer the nap, the higher the percentage of slow-wave sleep (SWS) lifespan and then discuss the circumstances in which napping
and the greater the occurrence of sleep inertia. These effects may be could be a potential public health tool counteracting the conse-
cancelled out by caffeine when taken right after the nap [22e24]. quences of sleep debt in real-life and clinical settings (Fig. 1).
Another deleterious effect is associated with long naps during
the afternoon or evening. These naps have been described to Napping patterns during lifetime
disturb sleep latency and both the quality and quantity of the
subsequent night-time sleep. Accordingly, the usual recommen- Toddlers and children
dation is to restrict daytime napping for patients with insomnia Total sleep duration decreases rapidly during the first years of
(especially sleep onset insomnia) or delayed sleep phase syndrome. life, from an average of 16e17 h at birth to a mean of 13.9 h at one
Studies in healthy subjects, in contrast, have led to contradictory year of age and 9 h at 10 y of age [29].
 B. Faraut et al. / Sleep Medicine Reviews 35 (2017) 85e100 87

Fig. 1. Physiological, cognitive, and public health prophylactic effects of napping as a countermeasure for sleep debt. Experimental sleep deprivation studies have reported
that napping leads to stress-release effects (blunted cortisol and noradrenaline responses [159,91] and reduced blood pressure [92]), normalizes immune components altered by
sleep deprivation (neutrophil counts and IL-6) [7,159], and reduces pain sensitivity enhanced by sleep deprivation [188]. Napping also facilitates the recovery of alertness reduced by
sleep loss [105,109] and has a beneficial impact on memory consolidation [127,133,134]. Prophylactic naps could correct some neuroendocrine stress and immune effects
consecutive to sleep restriction, thus decreasing the cardiovascular risk in healthy young and middle-aged adults [89]. Conversely, an increased prevalence of cardiovascular disease
in elderly subjects who take long (>60 min) and regular naps has been reported [94,96]. The practice of napping has also been associated with improvements in sleep-restriction-
sensitive working performance and reduced accidents [20,63,73].

Between 6 and 9 mo of age, daytime sleep habits stabilize to a sleepiness and reduced night-time sleep duration [39]. However,
three-nap pattern: morning naps and early and late afternoon naps. this investigation used sleep diaries and sleep questionnaires;
Then, between 9 and 12 mo, these naps are reduced to two further studies should assess objective sleep across a sufficient
(morning and early afternoon) and, finally, after 12 mo, to a single period in order to better define nap habits and frequencies during
nap in the afternoon [30,31]. This single nap disappears between 3 adolescence.
and 7 y of age, depending on genetic, biological, and environmental In adults, even after a normal night's sleep, circadian sleep-wake
conditions, giving rise to a consolidated sleep period at night. At 3 y regulation mechanisms explain a mid-afternoon sleepiness peak at
of age, according to parent reports and/or actigraphy recordings, approximately 14:00 h, which is usually seen as an ideal time-
50%e80% of children take a nap, but only 9% take a nap at 5 y of age, window for sleep [40]. This post-lunch dip is enhanced by prior
with nap duration decreasing with age in parallel [30,32]. sleep deprivation and is partly influenced by diet quality [41]. In
There is considerable individual variation in total sleep duration sleepy subjects, a short nap of approximately 20 mindwithout
and in napping among toddlers and children of the same age. SWS to avoid sleep inertiadsoon after lunch has several immediate
Napping, and especially nap duration, seem to be predominantly beneficial effects (see napping and alertness section) and does not
influenced by the environment (shared sleeping environment, disrupt night sleep.
socio-economic, familial, and educational influences, and sleep
hygiene), with a lesser effect from genetic factors and without Elderly
gender differences [33e36]. Cultural influences appear to be In older adults, napping is frequent, being observed in 39% of
weaker than environmental ones, at least in children of less than 2 subjects older than 60 y of age. Fifty-four per cent of these in-
y of age. Recently, Mindell et al. characterised cross-cultural sleep dividuals take a nap more than twice a week (mean 4.2 per week),
patterns in 2590 3e6-year-old preschool children across 13 regions according to a cross-sectional epidemiological study in France [42].
from Asian and Caucasian countries [37]. A majority of the children In another study, naps lasting an average of 38 mindwith 25 min of
in the Asian countries took naps but had later bedtimes and shorter sleepdhad no consequences for nocturnal sleep variables, in
night-time sleep compared to the Caucasian children, resulting in contrast to longer naps that disrupted the subsequent night's sleep
no differences in 24-hour TST between the two cultures. However, [43]. In community-living sedentary elderly subjects (70e89 y)
the relationship between the timing of naps within the circadian without severe co-morbidities, 54% of the subjects reported nap-
rhythm and night sleep is not well documented, and its conse- ping, with an average nap duration of 55 min (SD 41 min) [44]. In a
quences are still unknown [38]. study by dos Santos et al., 61.7% of the elderly subjects reported
napping, on average, 6 d/wk, with an average nap duration of
Adolescents and adults 53.5 ± 42.7 min [45]. These results are similar to those of other
During adolescence, a delayed sleep-wake rhythm is observed studies that have reported prevalence of napping rates of 22e61%
that conflicts with early wake-up times on scheduled school days, depending on the study location (habitual napping in warm
resulting in a significant diminution in sleep duration. As reported countries), the studied population, and the definition of nap. Nap-
in a longitudinal study (n ¼ 668, 10-year-period follow-up), nap- ping is significantly more frequent in men than in women in some
ping frequency increased to 40% in 14e19-year-old teenagers on studies, but not in all [45], and in subjects with diabetes mellitus
weekdays as a result of an increased incidence of daytime than in those without [44,46]. Napping subjects had a non-
88 B. Faraut et al. / Sleep Medicine Reviews 35 (2017) 85e100

statistically significant higher body mass index and more depres- countries (Mexico City, Montevideo, Santiago, and Caracas), one-
sion symptoms (using the Center for Epidemiologic Studies- third of the studied population reported daytime napping at least
depression scale), but there were no differences in night-time 3 d/wk with the highest frequency of daytime napping reported in
sleep parameters or in the prevalence of CVD in nappers and Caracas (35.2%) [52]. Another investigation reported that Mexican
non-nappers [44]. In post-menopausal women, a relationship be- college students (n ¼ 577) took more naps during the week (34.5%,
tween daytime napping duration and diabetes type 2 has been mean sleep duration 1.25 ± 0.64 h) than during the week-end
reported, and napping for more than 30 min/d was associated with (20.2%; mean sleep duration 1.51 ± 0.77 h) [53]. These subjective
a 74% higher chance of diabetes compared to non-nappers in cross- urban investigations in Latin American countries indicated a similar
sectional and self-reported data obtained between 1992 and 1999 proportion of nappers than other countries described here, sug-
[47]. gesting that further studies with larger representative samples are
Compared to young adults, napping episodes are generally more required to better understand the effect of the photoperiod,
frequent in the elderly [48,49]. This could be explained by age- climate, and latitude on siesta habits. In France, a third of working
related differences in biological factors, comorbidities, and quality people indicate that they have a minimum of one nap during the
of night sleep [45,48]. An evening nap is more frequent in old week [54]. A poll previously conducted by the French National
subjects and can be explained by a phase-advanced rhythm, but it Institute for Sleep and Vigilance in a representative French sample
may lead to disrupted sleep and decreased nocturnal sleep [48]. of 1010 adults aged 18e65 y old showed that the mean daily sleep
Studies on napping in older adults have reported beneficial out- debt during the week (defined here as the difference between
comes but also risk factors for mortality depending on the health of night-time sleep during the week-end and the week) reached
the subject (organic and psychiatric comorbidities), the quality of nearly 2 h in the third of adults sleeping less than 6 h per night [55].
night sleep, and the duration of the nap.
Most of these studies are cross-sectional, and only few are Napping in practical settings
longitudinal, so it is not yet possible to come to conclusions on the
causal relationships between napping and morbidity/mortality. Napping and sleep-related accidents
We will not review the links among poor sleep, sleepiness, and
Sleep debt and napping habits accidents, which have been widely debated [4,56,57]. The public
health consequences of sleep-related accidents are severe, with an
As will be described below, several methods have been used to estimated 30% of fatal motor vehicle accidents partially attributed
assess sleep debt. These take into account the inter-individual dif- to sleepiness at the wheel on highways and a lower but significant
ferences in the number of hours of sleep required by each person, risk on other roadways [58e60].
determined in part by genetic and epigenetic backgrounds. Simi- Because napping is a recognized means of fighting sleepiness,
larly, there is inter-individual variability in the ability to efficiently and sleepiness at the wheel is one of the most potentially
nap (short sleep latency and sleep continuity). Although we still do dangerous situations in daily life, it is easy to understand why
not have consensual and objectively measured data comparing napping has been one of the main expert recommendations to
sleep debt across countries, a recent survey published by the Na- prevent sleepiness at the wheel. Many “advertising campaigns”
tional Sleep Foundation compared napping habits in a represen- have, at national and international levels, urged drivers to “take a
tative sample of 250 subjects between 25 and 55 y old in six nap” every 2 h while driving long distances [58,59,61]. In 2013, the
different countries (the USA, Canada, Mexico, the United Kingdom, European Sleep Research Society developed a European campaign,
Germany, and Japan) [50]. Among the subjects who had taken a nap “the European Sleep Research Society waking bus”, with a bus
in the two weeks before the study, the average number of naps crossing nine European countries to a meeting with the European
taken ranged from 2.8 in Canada, to 3.6 in Mexico, to 4.4 in Ger- Parliament [61]. One of the messages was on the need for breaks
many, with a mean nap duration ranging from 33.8 min in Ger- and naps while driving.
many, to 36.7 min in Mexico, to 45.2 min in the USA. The USA and However, scientific data are lacking to evaluate what this
Japan had the highest percentage of nappers, with half of the recommendation is founded on and whether it really prevents
subjects reporting having taken a nap in the two weeks prior to the accidents and sleepiness at the wheel in ordinary traffic conditions.
survey. It is interesting to note that these two countries, with the Several studies in small groups of subjects on driving simulators
highest percentages of nappers, are also the two countries where have shown that napping may or may not prevent accidents,
the highest sleep debt rate has been reported (assessed qualita- depending on the amount of sleep deficit [20,62e64]. Napping for
tively as the difference between the number of hours of sleep 20 min, combined with caffeine, was the most effective method
needed to function at one's best during the day and the number of (versus caffeine alone and placebo) to reduce the sleepiness of
hours slept on workdays): 69% in the USA and 70% in Japan. In sleepy drivers during 1 h of simulation [62]. However, napping
Mexico, the survey also indicated a high sleep debt rate (69%) on opportunities during three periods of 1 h each had no significant
workdays, but surprisingly, this debt was less reduced (still 54%) benefits on the driving performance of eight drivers following a
than in the other countries analysed during non-workdays. Also, night of sleep loss [63]. Levels of subjective sleepiness were also not
39% had taken naps in the last two weeks, a significantly lower rate affected by the nap opportunity condition. More recently, 31 sub-
than in the USA and Japan (both 51%). In an earlier poll in the USA, jects were kept awake for one night with random assignment to a
46% of 1000 individuals had taken at least two naps in the past 10-min nap ending at 04:00 h plus a 10-min nap at 07:00 h, a 30-
month, and 43.5% of these nappers took five or more naps per min nap ending at 04:00 h, or a no-nap control. The subjects per-
month. The nap durations were 15e44 min for 36% of the nappers, formed a 40-min driving simulator task at 07:00 h and 18:30 h
45 min to 1 h 14 min for 38%, more than 1 h 14 min for 22% and less post-recovery sleep [64]. Compared to the control conditions, the
than 15 min for 1% [51]. napping conditions did not significantly impact simulated driving
However, these values were measured using questionnaires and lane variability, percentage of time in a safe zone, or time to first
were not assessed with objective measurements (actigraphy, PSG). crash on morning or evening drives. However, these latter two
The survey also did not specify whether the nap episodes occurred investigations were tested in the context of one night of total sleep
during the week/working day or during the week-end/non- deprivation, which is an infrequent situation for most drivers. On
working day. In the metropolitan areas of four Latin American driving simulator and real highway settings, Sagaspe et al. [20]
 B. Faraut et al. / Sleep Medicine Reviews 35 (2017) 85e100 89

tested the effects of napping (30 min) or caffeine (200 mg) on total of 19% of shift and night workers were classified as regular
inappropriate line crossings, self-perceived fatigue, and sleepiness nappers vs. 8% of the total sample. Napping habits and frequency
in 12 young and 12 middle-aged subjects. They found that both were investigated as a function of exposure to natural light in
coffee and napping reduced the risk of inappropriate line crossings, 13,296 workers of one transportation company (78.9% men; mean
compared with placebo, but this reduction was found in a higher age 39.9 ± 9.2 y; 63.9% working irregular shifts). Interestingly, the
proportion of the younger participants than of the middle-aged subjects (34.9% of the sample) who were not exposed to natural
ones. light during working hours felt more sleep deprived, complained
From an epidemiological point of view, a Japanese survey more about poor sleep and sleepiness, and napped at least five
comparing 716 professional drivers to 3365 non-professional times a week significantly more (19.5% vs. 14.8%) than the workers
drivers showed that among professional drivers, being male and exposed to natural light [68].
having experienced a traffic accident due to drowsy driving were In the last few decades, napping has indeed found a new place at
associated with a preference for napping, whereas longer annual the workplace due to prevention strategies to fight sleep depriva-
driving distances and shorter periods after obtaining the driving tion in shift and night workers and to address jet-lag.
license were associated with drinking coffee [65]. More conceptu-
ally, based on Italian accidents and analysis, Garbarino et al. [66]
showed on retrospective data that drivers who did not nap had Napping and shift/night work. Approximately one in five workers in
approximately 38% more accidents than drivers who did nap. Based industrialised countries work at night, and this percentage con-
on prospective data, these authors suggested that the theoretical tinues to increase with the evolution of 24/7 services in trans-
efficacy of napping was quantified by a 48% decrease in the portation, safety, health, and media around the world. Night work
occurrence of accidents. impacts both sleep quality and sleep length, with a one-hour
To our knowledge, there are no other studies based on inter- deficit, on average, per 24 h compared to day workers [69,70].
ventional epidemiology that compare sleepiness at the wheel The consensually recognized consequences of night work on health
before and after the use of prophylactic naps in regular long- are probably linked not only to circadian misalignment due to night
distance professional or nonprofessional drivers. work but to the sleep debt itself. Obesity, diabetes, and CVD are the
Another important issue is that many road traffic authorities most frequent associated disorders, and in females, there is a
have often been confused by the terms fatigue and sleepiness, significantly higher risk of breast cancer [71,72]. Sleepiness is also
which are frequently associated. Thinking that the word “fatigue” frequently reported by night workers and might also be explained
may be better recognized by “users” than the more scientific word by circadian and homeostatic factors [69]. This is why it seems
“sleepiness”, many of these authorities recommended that drivers important to propose napping as a global strategy to increase 24-
“take a break” rather than “have a nap” [62]. Except for the USA, hour sleep duration in night workers.
where “driving sleepy” was one of the main messages of the initial The effects of napping on sleepiness and sleep-related perfor-
public health campaign made by the National Sleep Commission mance in night workers have been reviewed recently by Rugiero
[67], most of the other parts of the world have only recently and Redecker based on a systematic literature analysis that retained
changed their message from fatigue to sleepiness, and statistics on 13 heterogeneous but relevant studies from the 2775 abstracts
accidents still confuse the two terms [61]. identified [73]. One limitation of this review was that these 13
studies included very small samples of mostly young adults, from
six to a maximum of 49 subjects (mostly healthy volunteers rather
Napping and work than real workers). Another limitation was that nap time oppor-
Napping at the workplace has long been considered a provoc- tunities varied markedly, from 20 min in one study to 120 min in
ative issue. In the past, there was no place for sleeping at work, as four others. Similarly, the test times varied among the 24-hour
napping was a sign of laziness rather than a strategy now evoked by cycles, with two studies testing a nap before night work and the
the “power nap” defenders. Sleeping was also considered a private others a nap during night work. Globally, the findings of this review
issue for vulnerable individuals, and employers did not want to face indicated, based on well-admitted objective and subjective mea-
legal issues with employees sleeping at work. Numerous workers surements, that planned naps during night shifts reduced
have, however, decided to nap inside or outside the workplace nocturnal sleepiness and improved sleep-related performance
when they are shift working. A National Sleep Foundation poll deficits. However, given the usual sleep deficit of shift workers, it
(2008) reported that 55% of shift workers (vs. 35% of non-shift would be interesting to test whether a single nap is enough to
workers) had taken at least one nap during the month prior to compensate for sleep debt or if multiple napping is the best way to
the poll [51]. However, 89% did not nap at work, and blue collar cope with sleepiness.
workers were more likely to nap at work than white collar workers Interestingly, some recent studies have tried to assess the con-
(15% vs. 9%). Approximately one-third of the respondents (34%) sequences of napping not only in simulated night work conditions
reported that their employers allowed them to nap during breaks, in the laboratory but also on real subjects at the work place. Chang
and 16% mentioned that they had dedicated places for napping et al. [74] tested napping in 36 nurses (with 15 ± 11 y of work
(24% for those working in public services, safety, and health). experience in the same type of job). They proposed a nap between
Twenty-six per cent of those who were not allowed to nap would 02:00 h and 02:15 h and took measurements between 03:00 h and
have liked to have been able to nap at work if possible. In France, 04:00 h. The authors showed that subjective fatigue did not change
the French National Institute for Sleep and Vigilance survey, in a before and after the nap. There was also no difference in the per-
representative sample of 1032 active adults, found that 32% re- formance of visual attentive tasks between nurses who napped and
ported taking at least one nap per week, with an average of 2.2 naps those who did not. This is not the only negative study on napping at
per subject [54]. Regular nappers (at least three naps per week) work, as was underlined by Rugiero and Redecker [73], and it
constituted 8% of the sample. Regular nappers were significantly demonstrates that the positive effects of napping are difficult to
more sleepy (15% with ESS > 15) and more likely to be short capture at the workplace, as with real traffic data, especially in
sleepers (11% for TST <6 h vs. 8% for TST >/8 h). The average nap shift/night workers who have been sleep deprived for years. By
length was 47 min on weekdays and 61 min over the weekend. A contrast, we demonstrated the positive effects of a short nap plus
90 B. Faraut et al. / Sleep Medicine Reviews 35 (2017) 85e100

exposure to a bright light in professional shift and night drivers start of kindergarten. The main results were that the percentage of
driving prototypes on a road circuit [75]. We registered PSG in nine nappers did not change, but the number of weekdays with a nap
prototype drivers for 8 h on the same circuit in two different set- dropped from 3.6 ± 1.1 to 2.7 ± 1.4 and the nap duration decreased
tings: a reference setting with a pause and no-nap and a second from 82 ± 24.2 min to 34.2 ± 30.5 at day 15, while no changes were
setting with a 20-min napping opportunity in the middle of the measured in weekend naps [81]. In 2482 Brazilian children aged
shift followed by 10-min exposure to a bright light (5000 lux). 7e10-year-old, 54% started school in the morning vs. 44% in the
Subjects showed significantly reduced sleepiness at the wheel, with afternoon. Napping was more frequent (81%) in children who
an average of 10.7 ± 6.7 episodes of theta sleep during the baseline studied in the morning than children attending school in the af-
(766 ± 425 s) vs. 1.0 ± 1.0 episodes lasting 166 ± 96 s in the period ternoon (19%). The authors suggested that it is probably a
with nap and light (p ¼ 0.016). The percentage of time driving compensation for sleep deprivation, as these children had a shorter
asleep at the wheel was also significantly reduced 3.7 ± 1.9% vs. TST vs. children studying the afternoon [82]. Moreover, in children
0.9 ± 0.6% (p ¼ 0.0077). In this study, a combination of napping and aged 5e9 y, a significant increase in subjective sleepiness level and
bright light pulses had a powerful effect on decreasing sleepiness at decreased performance at complex tasks (Go/No GO tasks) were
the wheel of shift work drivers. reported in the beginning of the afternoon (14:00 he16:00 h) [83].
Wang et al. [76] explored the impact of daytime napping asso- Nap deprivation studies have mostly concerned children older
ciated with the risk of breast cancer in women in China. They re- than 2 y of age. The benefits of napping have been more widely
ported face-to-face interviews with 712 women (including 33% studied in young children due to the possible neurocognitive
night workers) who had been followed for metastatic breast cancer impact (vocabulary and auditory attention span) in pre-schoolers
and with 742 controls (26.2% night workers) followed for routine [78,79]. In this context, night-time sleep appears to be more
check-ups in the same hospitals. Short and long sleep durations crucial for the development of cognitive function than daytime
were significantly associated with breast cancer. Interestingly, napping (see also Cognitive and physiological effects of napping
daytime napping was associated with a reduced risk of breast section).
cancer among night-shift workers (odds ratio (OR) : 0.57 In addition, some cognitive studies in 3-year-olds have assessed
(0.36e0.90)), but no association was observed in women who had the effects of napping on attention control and mature self-
never performed night-shift work. Moreover, among women who regulation strategies in nap deprivation paradigms. Nap depriva-
reported never napping, short sleep (OR: 1.71 (1.10e2.68)) but not tion during a 5-day period was associated with a longer night-time
long sleep (OR: 1.49 (0.79e2.81)) was associated with an increased sleep duration (assessed by actigraphy and sleep diaries by parents)
risk of breast cancer. However, this result was in contrast to that of and improvement in attention control [84]. In another study, nap
the “The Million Women Study, a population-based prospective deprivation during an 11-day period (resulting in z90 min of loss
cohort study” [77], which concluded that napping was associated of sleep/24 h) led to moderate to large effects on self-regulation
with a short-term increased risk of breast cancer. During an average strategy in response to challenging events in the children's daily
of 7.4 y of follow-up, 20,058 breast cancers and 31,856 other cancers life, suggesting a risk for school adaptation [85]. The reported
were diagnosed. Over the first 4 y of follow-up, daytime napping behavioural consequences of napping differ according to the type of
(sometimes/usually vs. rarely/never) was associated with a slightly study (experimental or non-experimental), the developmental
increased risk of breast cancer (relative risk (RR) ¼ 1.10, 95% CI stage, and the environmental context.
1.06e1.15) and of other cancers (RR ¼ 1.12, 1.08e1.15), but the RRs A better understanding of the short- and long-term conse-
decreased significantly with increasing follow-up time (P ¼ 0.001 quences of nap schedules on behaviour and study outcomes in a
and P ¼ 0.01, respectively, for trend). Four or more years after larger range of child development stages is necessary [38].
baseline, there was no elevated risk of breast cancer (RR ¼ 1.00,
0.96e1.05) and only a marginally greater risk of other cancers Napping associated with clinical settings
(RR ¼ 1.04, 1.01e1.07). However, no details on shift work were
provided in this study. The authors concluded that napping may Napping and cardiovascular risk: protective effects?
reflect a “pre-clinical state of disease with fatigue and sleep Short sleep duration and prolonged sleep restriction over many
disorders”. years are now clearly associated with a greater risk of obesity, hy-
pertension, and diabetes and a higher incidence of cardiovascular
Napping and school events [2,3,86,87]. In a pioneering case-control study on napping
A critical issue in child development is whether daytime nap- and cardiovascular health, 97 men with an acute episode of coro-
ping needs to be encouraged at 3 y of age, when children attend nary heart disease (CHD) were investigated and compared to 90
school for the first time. What are the consequences of scheduling a control subjects [88]. This study, performed in a relatively small
long period in the beginning of the afternoon that allows children sample, indicated that a 30-min afternoon siesta was associated
to take a long nap at school? Investigations were mainly performed with a 30% reduction in the incidence of CHD after adjustments for
by actimetry or parental diaries reporting sleep quality, TST/24 h, the usual potential confounding factors. In a prospective cohort of
and circadian rhythms. more than 23,000 subjects, taking a midday nap occasionally
It has been shown that the longer the nap durations, the later (defined as once or twice a week or a midday nap < 30 min irre-
the toddlers (2e5 y old) went to bed on the corresponding night spective of the frequency) or at least three times per week (with an
[32]. TST per 24-hour period does not differ in toddlers who nap average duration of at least 30 min) was reported to be inversely
and who do not, but napping reduces time in bed at night and night associated with coronary mortality among healthy working men
sleep duration and increases sleep onset latency together with [89]. This protective effect of napping on coronary mortality was
delayed melatonin onset (38 ± min later) in napping toddlers as obtained after controlling for potential confounders, including
compared to non-napping toddlers [78e80]. Napping therefore smoking status, age, body mass index, physical activity, education,
changes the distribution rather than the duration of sleep. How- and Mediterranean diet score. In a very recent original dose-
ever, a study (using actigraphy and sleep diaries) investigated the response model, a meta-analysis investigated the link between
effect of going to school for the first time at 5 y old. The studied nap duration and the incidence rate of CVD [90]. The authors
parameters were measured both before and 15 and 30 d after the identified 11 prospective cohort studies with 151,588 participants
 B. Faraut et al. / Sleep Medicine Reviews 35 (2017) 85e100 91

and a mean follow-up period of 11 y (60% women, 5276 cardio- studies, confounding factors on the relationships between nap
vascular events). Napping for less than 1 h was not associated with duration and CVR are adjusted for age, sex, BMI, sleep disturbances
CVD, while longer naps (>1 h) were associated with higher car- and diagnosed diseases as a surrogate of information for sleep
diovascular risk. Interestingly, a significant J-curve dose-response apnoea. These studies do not specifically detect OSA. Hence, snor-
relationship between the length of the nap and CVD was ing and detection of OSA could affect sleep patterns and could be
observed, with the relative risk ratio decreasing from a 0- to 30-min potential biases in the strength of the results. Daytime napping, in
nap duration per day, indicating a protective effect against cardio- such cases, may only be a marker of the illness, and the association
vascular risk of naps 30 min, irrespective of age. of day-time napping with all-cause mortality may be explained by
Again, the reduced release of sympathetic system mediators, reverse causation. However, no proof for such a hypothesis has
such as catecholamines, together with the reduced systolic and been established. The association between napping and all-cause
diastolic blood pressure and heart rates during naps of no longer mortality was reported to persist in subjects without pre-existing
than 30 min are potential mechanisms that partially explain the illness [93].
beneficial effects of short naps on cardiovascular health [91,92]. To conclude, whether a spontaneous short nap has a beneficial
cardiovascular effect in older subjects remains an open question.

Napping and cardiovascular risk: controversial effects in the elderly?

By contrast with what has been found in younger adults, it re- Cognitive and physiological effects of napping
mains unclear whether regular and rather long daytime naps could
be a risk factor in the elderly. Several studies have investigated the Here, we will review the beneficial physiological effects that
association between napping and CVD or all-cause mortality in the have been reported to be associated with napping, with most of the
elderly. Usually, these studies consider naps as short when the data coming from healthy young adults or middle-aged adults in
duration is less than 60 min and as long when lasting more than laboratory studies (Fig. 1).
60 min.
A meta-analysis of 11 prospective cohort studies reporting the Napping and alertness
influence of napping on CVD or all-cause mortality was recently
published [90]. Patients with a history of CVD, with CVD at baseline, Effect of sleep deprivation on alertness and cognitive performance
or with excessive daytime sleepiness were excluded. In the elderly Prolonged wakefulness generally leads to the impairment of
(>65 y of age), a long nap (>60 min) was closely associated with various cognitive abilities, which has been thoroughly reviewed
increased cardiovascular risk and other risks of mortality [90]. In elsewhere [101,102]. The consequences can range from tragic
another meta-analysis (n ¼ 130,068 individuals, 60.5% women, events (road accidents, occupational errors in dangerous settings)
majority of participants >65 y old), napping, especially for longer to milder impairment in everyday performance. The extent of the
than 1 h, was significantly associated with all-cause mortality but cognitive processes affected is broad: simple reactivity to unpre-
not with CVD or cancer mortality [93]. This meta-analysis included dicted stimuli is impaired, as are more complex processes, such as
a limited number of studies that assessed cardiovascular risk, attention allocation, working memory, cognitive control, reasoning,
which may explain the non-significant association between nap- and creativity. According to the influential “two-process model” of
ping and CVD. In the German Heinz Nixdorf Recall Study (n ¼ 4123, sleep regulation [103], sleepiness is influenced by, on the one hand,
aged 45e75 y), regular (at least 5 d/wk) and long (>60 min) midday a homeostatic process increasing exponentially in the course of
naps were associated with a hazard ratio for cardiac events of more wakefulness and, on the other hand, by a circadian process
than two in both men and women. In a case-control Costa-Rican synchronised with light exposure. Interestingly, homeostatic
study (n ¼ 1027, mean age þ sem 57 ± 11 y old), napping longer pressure is dissipated during sleep at a faster rate than it accu-
than 1 h at least once per week was associated with higher mulates when awake [104]. Thus, short bouts of sleep can allow for
myocardial infarction risk [94,95]. However, napping and resting the recovery of alertness, and napping has been extensively studied
were not differentiated in the study, which represents an important as a countermeasure to sleep need.
limitation.
Interestingly, two Chinese epidemiological studies (n > 18,000
in both studies; mean age 62.8 y old at inclusion) with a 3e5 y Napping and cognitive recovery
follow-up found that, compared to short naps (30 min), long naps Short sleep episodes (approximately 10e15 min) can restore
(60 min or  90 min) were associated with a higher risk of inci- cognitive impairments developed over a much longer timeline
dent CHD [96,97], hypertension [98], type-2 diabetes [99], and (typically more than 16 h) [105]. In addition to cognitive recovery,
metabolic syndrome [100] were also found significantly associated short naps also affect brain activity, as recorded through EEG.
with long naps, after adjusting for potential confounders. In a study Indeed, the behavioural impairments associated with sleep loss are
by Wu et al., longer daytime napping (90 min), and not night-time associated with changes in neural activity characterised by an in-
sleep duration, was associated with a greater risk of metabolic crease in cortical excitability [106] and fatigue-related oscillations
syndrome in women [100]. In a study by Cao et al., long midday (e.g., gradual replacement of alpha (8e11 Hz) by theta (5e8 Hz)
naps of >60 min, but not shorter naps (<60 min and <30 min), were oscillations) [107,108]. Naps can revert these changes [109,110].
associated with a greater risk of hypertension [98]. In a study by Moreover, these changes are predictive of behavioural recovery
Fang et al., a nap duration of >60 min was significantly associated [111] and seem to be mediated predominantly by NREM sleep and
with an increased risk of impaired fasting glucose, and a nap slow-oscillations in particular. Indeed, naps containing only stage 1
>30 min was significantly associated with a moderate increased NREM show no or weak recovery of cognitive performance in
risk of type 2 diabetes [100]. All of these factors are well-known risk contrast to naps containing stage 2 NREM and, thus, slow-
factors for CVD and may explain the relationship between long oscillations [112]. In addition, greater sleep pressure leads to
sleep time and long naps and the incidence of CHD. higher amplitude and denser slow-waves [113,114]. Finally, dis-
Some participants of these population-based studies may have turbing slow-oscillations with cross-hemispheric alternating cur-
had undetected or unknown pre-existing disease. In these elderly rent affects subsequent cognitive performance [115].
92 B. Faraut et al. / Sleep Medicine Reviews 35 (2017) 85e100

However, naps can also lead to sleep inertia, i.e., a state of approach are multiple, including the effect of sleep inertia [129],
impaired alertness following awakening [21], which will suppress which makes it unpractical in some situations, such as on-duty
the cognitive advantage of taking a nap. Sleep inertia is usually naps. More recently, stimulation techniques have been developed
observed following naps of more than 20 min, i.e., whenever to directly act on the brain's electrical activity to either generate
sleepers enter NREM stage 3 or 4 [116]. What is the neurobiological slow-waves or enhance them [130,131]. Further studies are needed
basis of sleep inertia? The appearance of slow-wave trains on scalp to quantify the behavioural impact of these techniques [132],
EEG readings reflects profound changes in the dynamics of especially for chronic use, but initial results are encouraging [128].
thalamo-cortical loops, which take time to instate and to revert. It
has been shown, for example, that sleep onset is delayed by up to Napping and memory
10 min in different brain regions [117,118]. If similar regional dif-
ferences occur upon awakening, the individual could be in a The memory function of sleep
dissociated state, impairing his/her performance. There is an abundant literature on the link between sleep and
The timing of the nap is also important [105]. Early-afternoon memory [127,133]. Sleep, even for short durations [134], has been
naps show shorter sleep latency and increased sleep efficiency shown to help the consolidation of memory, i.e., the increase in
and slow-wave activity compared to late afternoon naps [119]. By memory strength after sleep compared to an equivalent period of
contrast, taking a nap at the wrong time can diminish its recovery wakefulness. Indeed, not only can sleep prevent the degradation of
power [120], although this relationship between the benefit of naps memory usually associated with wakefulness [135], but it can also
and their circadian position is debated [121]. This circadian influ- allow for off-line improvement of memory compared to the pre-
ence on nap efficiency could be linked both to sleep pressure (i.e., sleep level without additional practice [136]. Sleep can also be
the amount of time spent awake before the nap) and to the circa- associated with insights [137] or the generalization of learnt rules
dian clock, independently of sleep pressure. Ultimately, both of [138], suggesting that mnesic traces can also be re-arranged during
these effects could be directly related to a sleeper's ability to pro- sleep. Finally, sleep potentiates future learning by preserving the
duce slow-waves, which also depends on sleep pressure and cognitive functions instrumental in learning. The beneficial influ-
circadian position. ence of naps has been especially studied in children, highlighting
Thus, because the proportion of light sleep (NREM stage 2, the importance of napping in educational settings [138,139].
promoting vigilance) vs. deep sleep (NREM stages 3 and 4, pro-
voking sleep inertia) during a nap depends on various factors, such Napping and memory functions in children
as age, timing of the nap, or individual differences. This variability In the first years of life, the nervous system undergoes drastic
could partly explain the sometimes-contradictory effects of naps on changes leading to the development of key cognitive functions. This
cognitive performance presented in the previous sections. Naps, ontogeny is associated with the formation and consolidation of
therefore, need to be finely (and perhaps individually) calibrated to countless memories. Sleep and naps appear to have a strong
maximise their advantage. beneficial effect on these processes [19]. Indeed, in 6- and 12-
month-old infants, Seehagen et al. demonstrated that napping
Napping: the ultimate countermeasure? (>30 min) within 4 h after a learning session consolidated mem-
Other countermeasures to sleep loss, such as caffeine [122] and ories for new behaviours and facilitated the formation of long-term
exposure to light [123], have been extensively investigated and can non-verbal declarative memory [140]. By contrast, infants who did
be used to restore alertness. However, naps seem more efficient, not nap within 4 h after learning failed to remember the items of
especially considering their long-term effects [124]. A more drastic the test. The protective influence of sleeping immediately after
view considers sleep as the ultimate countermeasure. Indeed, learning was also demonstrated using EEG markers. These markers
extended periods of wakefulness have a crucial impact on neural suggest that napping can improve both memory retention and
activity. In particular, sleep-like patterns can be observed while generalization in preverbal 9- to 16-month-old infants [141].
individuals are still awake. In rodents, it has been shown that sleep In another study, Horvath et al. studied word learning in 34
deprivation is associated with the appearance of instances of infants 16 mo old using object-word associations [142]. After a 2-
neuronal silencing similar to the off states accompanying sleep hour delay, memory performance increased for the nap group but
slow-waves [107]. In humans, several studies have shown that not for the wake group. In addition, the gain in performance
sleep is a local, use-dependent process: performing a given task correlated positively with the expressive vocabulary in the nap
extensively translates into an increase in sleep-like activity (in- group, suggesting that sleep interacts both with new and pre-
crease in slow and theta power), more predominantly in the re- existing memories. Overall, naps seem to play an important role
gions involved in the task [108,125]. Such regional effects are also in language acquisition, and it seems of great importance to pre-
seen during sleep: slow-waves increase locally in a use-dependent serve a healthy sleep-nap pattern.
manner, and this increase is predictive of subsequent cognitive The beneficial effect of napping on explicit memory has also
performance [126]. It has therefore been proposed that sleep, and been reported in children between 3 and 6 y old [143]. In this age
slow oscillations in particular, are necessary for the brain to “pay group, the mean nap duration was documented as 77 ± 18.7 min,
the price” of being awake [127]. According to this view, naps would and napping had a clear benefit on memory retention, with chil-
not only be the most efficient but also the only absolute counter- dren forgetting significantly more items after staying awake than
measure to dissipate the homeostatic pressure for sleep. following a nap. Moreover, the benefit of the nap was greatest for
children who regularly napped [144]. Finally, the decrease in per-
Boosting the power of naps formance observed in nap-deprived children was not recovered
Given the importance of napping for the recovery of alertness, during subsequent overnight sleep. Motor learning also appeared
there is increasing interest in the optimisation of naps commonly to benefit from napping, but only after an extended period of sleep,
called “power naps”. Early studies have focused on the use of including night sleep [145]. In older children, 6e12 y old, a period of
medication to increase sleep onset latency and increase sleep effi- sleep was also associated with the improvement of a non-word
ciency [128], with positive outcomes. However, the risks of this learning task and a cognitive puzzle [146]. However, the
 B. Faraut et al. / Sleep Medicine Reviews 35 (2017) 85e100 93

relationship between napping habits and cognitive development studies have been conducted exclusively on small samples, and the
may be complex, and one study described an association between long-term effects are unknown and must be monitored before
language delay at 60 mo with the fact of still having naps at 3e6 y of expanding these techniques to the general population.
age [79].
Napping and neuroendocrine stress and cardiovascular systems
Associated mechanisms and their importance for napping
The mechanisms of sleep-related memory consolidation have The effects of napping on neuroendocrine stress systems are still
been intensely investigated. First, NREM- and REM-sleep do not not sufficiently described. However, the data reported below sug-
have the same impact: REM-sleep seems particularly important for gest a slowdown of the activity of the two major neuroendocrine
emotional and procedural memory, whereas NREM-sleep (pre- stress pathways, i.e., the hypothalamic-pituitary adrenal (HPA) axis
dominant in naps) is particularly important for declarative and the sympatho-adrenal system (SPA). The activity of these two
hippocampus-dependent memories [133,136]. stress pathways can be assessed by measuring the release of
From a mechanistic point of view, the replay of previously cortisol (HPA axis) and catecholamines (SPA system). In addition to
learned information has been observed during NREM-sleep (and, to the stress effects, cortisol levels display circadian rhythms with
a lesser extent, REM-sleep) [147], suggesting that the consolidation increasing levels from the early morning to maximum values at
of memories occurs through active consolidation. Slow-waves and approximately 08:00 h followed by a decrease reaching a minimum
sleep-spindles could organise this replay and the transfer of the during the night [155,156]. Interestingly, a small increase can be
hippocampal mnesic traces to the neocortex for long-term storage observed at the end of the afternoon. The catecholamines
(active consolidation hypothesis) [133]. For example, the suppres- (noradrenaline and adrenaline) also display a circadian rhythmicity,
sion of sleep spindles impairs consolidation [148], while sleep- with maximum release during the day and reduced levels at night
related memory improvements are often correlated with sleep [157].
spindle density. Another proposal stipulates that memory consol- Regarding the HPA axis, it has been previously described that
idation could be achieved by a general downscaling of synaptic cortisol and SWS have two independent but synchronized gener-
connections during SWS (synaptic homeostasis hypothesis) [127]. ators, both during night sleep and daytime sleep. An increase in
Such synaptic normalization would be necessary for the brain to slow-wave activity can happen in the absence of cortisol pulses
limit the number and strength of synapses, which incur metabolic (especially at the beginning of the night), but when cortisol
and computational costs in the brain. To conciliate these seemingly secretion and slow-wave activity occur at the same time, they
contrasting views, a recent framework proposed that both active oscillate in phase opposition [156]. Moreover, during recovery sleep
consolidation and general downscaling occur during sleep but at at night after total sleep deprivation, there was a significant nega-
different sleep stages [149]: active consolidation could occur in tive correlation between the amount of SWS and plasma cortisol
light NREM-sleep (stages 1 and 2), whereas downscaling would levels. This observation suggests a link between the amount and
predominate in deep NREM-sleep (stages 3 and 4). Such a activity of SWS and the slowing of the stress HPA axis during sleep.
distinction between NREM-sleep stages lacks direct empirical In addition, cortisol has been reported to be significantly
support but could be of importance for napping, during which light increased after sleep loss in different studies: only during the
NREM usually dominates. evening following a night of total sleep deprivation in one study
[155] and, interestingly, during the immediate first hours of the
Learning while napping sleep deprived night (but not in the second part of the night) and
Given the accumulating evidence showing that sleep promotes the morning hours following a night of sleep deprivation in another
the active consolidation of memories, several attempts have been [158]. Supporting the use of naps as a countermeasure to the stress
made to target these processes [150]. The entrainment of slow effects of acute sleep deprivation, it has been shown that a long 2-
oscillations through acoustic stimulation has an impact on memory hour midday nap following a night of total sleep deprivation or a
retention [131]. The consolidation of a given memory may even be shorter 30-min nap following a night of sleep restricted to 2 h of
favoured by pairing it with an acoustic cue that is replayed during sleep (both nap consisting of about 50% of SWS) were associated
sleep (Targeted Memory Reactivation) [151]. Naps appear to be an with a decrease in plasma and salivary cortisol levels during the nap
ideal situation for such an approach, with the possibility of episodes [7,159]. Hence, a 30-min nap in the first half of the night
strengthening memories in light NREM-sleep right after encoding and in the morningdperiods of cortisol increases enhanced by a
and without interfering with nocturnal sleep or inducing subse- night of sleep deprivationdcould be an efficient tool to re-
quent sleep inertia. equilibrate cortisol values in the context of sleep loss.
Recently, it has also been shown that memories can be created The cortisol awakening response (CAR) consists of a marked
during NREM and REM-sleep. In rodents, place-cells can be paired increase in cortisol level associated with the process of morning
with rewarding intracranial stimulation, triggering spontaneous awakening after night-time sleep [160]. In addition to the stress-
preferences for the associated spatial position upon awakening releasing effects during the nap we reported above, some studies
[152]. In humans, sounds or odours can be paired with aversive have investigated whether such a CAR is observed after episodes of
odours [153]. However, such forms of sleep-learning are usually napping. A CAR has indeed been observed during the hour after
quite difficult to demonstrate and are extremely weak compared to awakening from a long nap. A 90-min nap during the morning at
our awake abilities. Nevertheless, a recent study showed that sleep- 09:00 h and the afternoon at 13:00 h triggered a CAR [161]. How-
learning could influence behaviour where similar procedures in ever, a 50-min nap starting at 13:00 h did not elicit such a cortisol
wakefulness failed [154]. In this study, cigarette-smoking habits response. This study's authors indicated that the level of the CAR
were reduced after the pairing of tobacco odour with an aversive depended mainly on the time spent in stage 2 sleep and that more
odour during sleep but not with similar conditioning in SWS was associated with higher waking cortisol levels. Vgontzas
wakefulness. et al. [159] also noticed a CAR after a 2-hour nap starting at 14:00 h
Although this field of research is at its beginnings, initial results following a night of total sleep deprivation. Cortisol levels increased
are encouraging in showing that naps could be used to enhance markedly during the first hour after nap awakening and then
learning or to allow a different form of learning. However, these remained slightly higher during the five subsequent hours
94 B. Faraut et al. / Sleep Medicine Reviews 35 (2017) 85e100

compared to the no-nap condition. This CAR was also associated daytime naps could boost the night-time recovery process,
with a beneficial effect on objective alertness assessed by the particularly in the context of chronic sleep restriction. When
multiple sleep latency test at three time points during the 5-hour subjects were totally sleep deprived, napping for 2 h counter-
period following awakening from the 2-hour nap [159]. balanced the increased levels of serum interleukin (IL)-6 post-
This enhanced cortisol response at awakening from an after- sleep deprivation [159,170]. Indeed, lower IL-6 levels were
noon nap is also accompanied by an increase in heart ratedwhich measured for several hours following the 2-hour midday nap be-
reflects sympathetic activitydbut to a lesser amplitude than during tween 14:00 h and 16:00 h compared to the sleep-deprived values
morning awakening after a night's sleep [162,163]. without a nap [159]. Although increased serum IL-6 levels have
Regarding the SPA system, a recent study reported that sleep been linked to experimental sleep deprivation and restriction
restricted to a period of 2 h between 02:00 h and 04:00 h enhanced studies, a recent systematic review reported no significant asso-
levels of the urinary catecholamine noradrenaline during the sec- ciation between experimental short sleep duration and increased
ond part of the afternoon and that two 30-min nap episodes pre- blood IL-6 levels [171]. We reported, in continuous PSG-monitored
vented this effect [91]. A similar significant increase in serum subjects, that salivary Il-6 was reduced after one curtailed night
noradrenaline levels has been recorded during the afternoon after with only 2 h of sleep, while a 30-min daytime nap reversed this
one night of total sleep deprivation in 14 young healthy men [164]. effect [91]. Beyond the scope of the potential links between sleep
The reduced release of sympathetic system mediators, i.e., disturbances and duration and inflammation, IL-6 could also be
noradrenaline, following nap episodes reported in the previous considered a protein with antiviral properties present in the saliva.
data may be expected to increase the diameters of some blood Salivary IL-6 levels decreased after a night of restricted sleep but
vessels and decrease the heart rate, leading to a reduction in blood remained normal when the subjects were allowed to nap during
pressure. During a short afternoon nap at 14:00 h (5.9 ± 11.1 min) the day [91]. This suggests that naps may be beneficial for the oral
following a restricted 4-hour period of night-time sleep (from immune system.
02:00 h to 06:00 h), Zaregarizi et al. [92] reported an acute Interestingly, a recent paper examined the frequency of napping
reduction in blood pressure (systolic and diastolic blood pressure) in relation to night-time sleep duration and the link to the in-
and heart rate. The authors also reported that this reduced blood flammatory status, as assessed by C-reactive protein (CRP) levels, in
pressure and heart rate could not be attributed solely to the supine 2147 young adults (mean age 29.05 ± 1.8 yold). CRP has the
position, because the measurements taken during the nap were methodological advantage of displaying steady levels throughout
significantly lower than the levels observed when the subjects were the 24-hour period [172]. The authors reported that for night sleep
lying supine in relaxed wakefulness. Similarly, in young night-shift durations of between 5 and 9 h, regardless of the napping fre-
nurses (mean age 23 ± 1.8), two 15-min naps at 02:30 h and 04:30 h quency, CRP levels were relatively low [173]. However, when
during an 8-hour night shift resulted in a significantly reduced low- looking at the short sleep group (<5 h of night-time sleep), the
to-high-frequency ratio compared to the no-nap condition during subjects who reported napping every day had significantly higher
the 06:00e09:00 h period, suggesting reduced sympathetic ner- CRP levels than the group that napped almost every day or the “no
vous activity [165]. nap to a few naps/week” group. In particular, among the short sleep
group, the group that napped almost every day, possibly in order to
Napping and immune functions compensate for the curtailment of night sleep, had the lowest CRP
levels. This latter group reported significantly fewer clinical
Napping effects on immune function symptoms than the groups that napped every day and the “no nap
Increasing amounts of data have been reported showing that to a few naps/week” group, suggesting that this healthier group
total sleep deprivation or partial sleep deprivationdpossibly via used naps as an efficient countermeasure for sleep debt. By
enhanced stress pathwaysdcan change the expression patterns of contrast, the subjects who napped every day within the short sleep
several immune molecules [8]. Among the immune parameters, and long sleep (>9 h of night-time sleep) groups had elevated CRP
the main leucocyte subpopulation consists of neutrophils, which levels and more clinical symptoms. We can speculate that the
are involved in the early host innate responses to infection. Blood subjects requiring naps every day were not as healthy and that the
neutrophil levels are significantly increased the morning after one nap for these individuals was associated to a low-grade inflam-
night of total or partial sleep deprivation [7,166]. Interestingly, mation and a symptom of an increased cardiovascular risk status.
following partial or total sleep deprivation, neutrophil counts This paper was, however, limited by the absence of sleep duration
remained higher than baseline after one 8-hour night of recovery data during the nap. Moreover, the cut-off for the medium sleep
sleep [7,167]. A study even reported in nine healthy male subjects group was rather broad (from 5 to 9 h of night-time sleep), while
that after five nights of restricted sleep of 4 h sleep per night, this group is more commonly defined as having between 7 and 9 h
neutrophil counts remained elevated above baseline at the end of of night-time sleep.
a 7-day period of sleep recovery, sleeping 8 h per night [168]. It is In summary, increasing data suggest that chronic sleep restric-
therefore somewhat unexpected that a 30-min midday nap taken tion may lead to a low-grade inflammation. It is exciting to note
the day after a night restricted to 2 h of sleep restored neutrophil that napping could change and/or restore several immune param-
counts to baseline values after only a single night of 8 h of recovery eters altered by sleep loss.
sleep [7]. The same study also reported that extending the night of
recovery sleep from 8 to 10 h also restored neutrophil counts to
baseline values, similar to the 30-min nap. Given these seemingly Napping, stress, and immune interrelations
opposite results, the use of neutrophil counts as an immune sensor Napping is an interesting tool to explore the relation among
of sleep restriction and recovery must be further evaluated [7,169]. sleep (including the role of different sleep stages), stress, and im-
They also suggest that in this specific case, 30-min of a midday mune responses. We will discuss the possible physiological path-
nap þ 8 h of recovery sleep (i.e., 8 h 30 min of total sleep) had way(s) that can change the expression of immune markers after
similar effects as 10 h of continuous recovery sleep. In this sleep deprivation and recovery. Sleep deprivation counterbalanced
perspective, additional napping studies should better define how by nap episodes leads to changes in stress and immune molecules,
 B. Faraut et al. / Sleep Medicine Reviews 35 (2017) 85e100 95

suggesting the presence of sleep-dependent interactions between 8.9 ± 0.12 h per night versus 7.14 ± 0.18 h in the control group) on
the neuroendocrine stress axis and immune functions. pain hypersensitivity, assessed by the time to finger withdrawal
Cortisol and catecholamines can both trigger the vascular following exposure to a radiant heat stimulus, were also reported
neutrophil mobilization measured after sleep deprivation, whereas [186].
the limited release of these two stress mediators during napping In patients with fibromyalgia, the more frequent and longer the
was associated with a decrease in blood neutrophil levels naps, the more severe the pain symptoms seem to be [189]. These
[7,174,175]. Noradrenaline has been shown to inhibit IL-6 and data are expected because the nap here is a symptom of poor health
tumour necrosis factor (TNF)-alpha production by human whole and a painful condition. In support of this, lower levels of pain and
blood and human monocytes in a concentration-dependent depressive syndromes were measured in intentional nappers who
manner [176,177]. The reduced noradrenaline release after nap- took short naps less regularly compared to patients reporting non-
ping episodes could account for the reduced blood IL-6 levels at the intentional naps with long duration on a daily basis. However,
end of the afternoon [159]. further investigations should better define whether napping could
Irwin et al. hypothesised that the two major stress pathways be used to decrease analgesic intake in patients with chronic pain
(HPA axis and the sympathetic nervous system) may shift the basal symptoms. In the night worker and shift fields, a pilot study eval-
gene expression profile towards increased pro-inflammatory uated musculoskeletal pain in 66 nursing home care workers (54
pathways (e.g., activation of b-adrenergic signalling activation women aged 32.6 ± 2.4 y old) in relation to nap frequency during an
leads to nuclear factor-kappa B [NF-kB]-dependant inflammatory 8-hour night shift. The care workers who napped at least once
gene expression) [171,178]. The potential beneficial effects of nap- every two night shifts (nap length during the night shift
ping on stress and immune-inflammatory parameters could have 76.1 ± 32.9 min) reported significantly less pain in the arm and leg
potential prophylactic long-term effects on cardiovascular risk than those who did not take a nap or who took a nap less than once
development in healthy middle-aged adults. every two night shifts [190].
These effects of napping and the nature of the stage(s) of sleep By which mechanisms could sleep restriction and napping
involved need to be further evaluated, especially from the modulate pain tolerance? Regarding the involvement of vigilance
perspective of napping coping strategies in populations with in the effects of napping, similar alertness levels were measured
chronic sleep debt, such as night and shift workers. after sleep restriction alone and at awakening from the nap
(because post-nap sleep inertia had not dissipated) [188], sug-
Napping and pain sensitivity gesting that altered vigilance was not the only mechanism
involved. The high proportion of SWS during napping could
Pain and reduced sleep quantity and quality are two major indicate a possible role of this sleep stage in the “analgesic” ef-
public health topics. We will discuss the relations between napping fects of napping. However, REM sleep loss has also been reported
and pain because the clinical implications of this issue are impor- to be associated with hyperalgesia using an alternative pain
tant, although there are very few data available. Epidemiological methodology to assess pain than the QST used previously, i.e.,
and experimental studies have indicated reciprocal interactions measured by the time to finger withdrawal following exposure to
between sleep deprivation or sleep quality and pain. On one side, a radiant heat stimulus [191]. Finally, because napping can change
restricted and fragmented sleep alters pain perception and toler- immuno-inflammatory mediator levels [91,159], it would be of
ance, while on the other side, pain results in fragmented and interest to measure levels of prostaglandins, released by
restricted sleep. [179e182]. numerous tissues that can stimulate nociceptors.
In a sample of 971 adults, it was shown that sleep duration
influenced pain perception and pain symptom frequency, with Conclusions
subjects reporting less than 6 h sleep per night having greater pain
the subsequent day [180]. The National Sleep Foundation 2015 report In the present review, we have attempted to discuss the cir-
on sleep and pain (1029 adults, 52% of women) indicated that an cumstances in which napping could be a potential public health
average weekly sleep debt (defined as the difference between tool as a measure to counteract sleep debt consequences in real-life
preferred sleep and actual sleep length) of more than 40 min was situations (driving, work, and school) and for cardiovascular risk
associated with chronic pain in the past week, but subjects with no outcomes. Laboratory-based studies detailed the beneficial effects
pain did not indicate a sleep debt [183]. Population-based studies of of napping on several systems (cognitive, stress, immune or pain
objective assessments of sleep together with pain are still lacking, functions). Furthermore, pilot nap-based laboratory studies have
but the available data indicate that fragmented and less-efficient reported that a midday nap of 20e30 min improved mood status
sleep seems to be associated with low back pain symptoms [184,185]. and mental states [192,193], suggesting that a proper application of
In healthy subjects, most of the sleep restriction studies devoted a short nap could positively affect the aforementioned functions.
to pain have shown that it was associated with increased pain in- The duration and the circadian position of a nap result in distinct
tensity or a decreased pain threshold [186e188]. Pain tolerance and but potentially cumulative effects. For instance, the simultaneous
perception are certainly influenced by alertness levels. Sleep loss occurrence of circadian dips with napping seems to cause the nap to
enhances hyperalgesia, probably by acting on pain-inhibiting/ have a greater recovery effect on alertness [194]. The mid-afternoon
facilitating physiological pathways, but less is known about the circadian dip could also be seen as an evolutionary opportunity to
effects of napping on these pathways. Using quantitative sensory encourage a midday nap, leading to the possibility of reducing
testing (QST), it was recently shown in a pilot study that a 30-min night-time sleep. This raises the question as to whether the midday
nap episode with approximately half SWS could restore to baseline nap could be a sleep surrogate that could explain why some subjects
levels the reduced pain tolerance to heat and mechanical pain who restrict their nocturnal sleep time and usually practice a day-
stimuli measured after a night of sleep restricted to 2 h [188]. This time nap seem to not suffer much from the consequences of sleep
study also suggested that sleep restriction induced different types debt [173]. Space study simulations, although they can hardly be
of pain hypersensitivity to pain stimuli in different body areas, extended to the general population, suggest that splitting sleep into
which were reduced by napping, suggesting complex mechanisms. several sequences (polyphasic sleep) does not strongly disrupt
In a similar setting with sleep recovery after sleep restriction, the cognitive performance, sleepiness, or inflammatory responses to
beneficial effects of four nights of extended bedtime sleep (mean sleep deprivation [170,195]. However, population-based studies
96 B. Faraut et al. / Sleep Medicine Reviews 35 (2017) 85e100

investigating the consequences of TST on health indices that

- Increasing attempts are being made to boost the recovery
compare the effects of the sum of night-time sleep þ daytime nap
function of sleep through electric or sensory stimulation.
vs. a similar sleep period strictly during night-time are still lacking.
While exciting, the long-term effects are unknown and
As a final point, further studies should investigate in an
must be carefully addressed in the future.
ecological/real-life environment over a period of weeks the po-
- Further napping studies should allow us to better define
tential benefits of a daily midday nap in subjects with chronic sleep
the respective contributing sleep stages that can improve
debt.
the recovery processes of alertness and stress and im-
mune responses as well as memory consolidation.
- Investigations of how napping could be an efficient public
health tool to fight the clinical repercussions of sleep loss
Practice points are expected.
- Epidemiological studies should better characterise
- Napping habits change across our lifetime, from the whether long and frequent unplanned naps could be a
polyphasic sleep of the newborn, through a progressive symptom of underlying disease.
decrease in the length and number of nap episodes during - Further studies of practical implementation of napping
early childhood, to the midday napping habits practiced strategies to cope with sleep debt in the work environ-
during adulthood, with an increasing prevalence with ment are awaited.
advancing age.
- A growing number of people are chronically sleep
restricted because of study and work schedules, Conflicts of interest
commuting times, or increased access to connected me-
dia, leading to a sleep debt during the week. Damien Leger has received funding or has been the main
- Sleep deprivation has a well-documented impact on investigator in studies sponsored by Sanofi aventis, Merck, Vanda,
cognitive performance, and recent studies have started to Actelion, Bioprojet, Philips, Resmed, and Vitalaire in the last 5 years.
unravel the underlying mechanisms. The intrusion of Marie-Francoise VECCHIERINI has received funding or has been an
sleep-like activity within the awakened brain after pro- investigator in studies sponsored by Sanofi aventis, Merck, Vanda,
longed periods of wakefulness could explain such cogni- Bioproject, and Resmed in the last 5 years.
tive deficits, stressing the role of naps as the ultimate The other authors do not declare any conflict of interest.
countermeasure for sleep loss.
- A growing body of evidence has stressed the importance Acknowledgements
of napping for learning, especially for children. Large-
scale studies are needed in order to better understand We would like to thank Karen Pickett for English-language
the effect of naps and their timing on memory perfor- editing and Caroline Gauriau for the figure layout in the
mance, but current evidence advocates for the use of naps manuscript.
as a pedagogic tool.
- Napping could be a countermeasure to the increased
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