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A new review paper out in the Journal of Developmental and Behavioural Pediatrics[1] has me hearing choirs, seeing the clouds part, and sun shining down (and I live in Vancouver, BC so it’s not something I see very often) over finally seeing someone address the issue of sleep training in young children by summarizing ALL the research (albeit only until six months of age).  For so long, so much of the discussion has been based on us not actually knowing what the summary is of the research.  What do all the pieces of research say when looked at together?  Well, this new review paper systematically examines all articles from 1993 to August 2013 that examined the effects of sleep training on infants younger than six months of age.

Just a reminder, in case people didn’t know, many doctors, sleep experts, sleep trainers, and clinics start to promote sleep training at month 3 or 4.  Some parents start even earlier.  And when those of us speak out against it’s promotion, arguing infants are in a sensitive period at that point (the fourth trimester so to speak) or have naturally developing circadian rhythms we don’t want to mess with, or that this type of training can harm breastfeeding success, we’re told it’s up to us to prove the risk of harm if we don’t want it *promoted*.  Well… here is that proof.  (Remember we’re talking about promoting something here, not speaking to parents who used methods without knowing anything or who were told by doctors, sleep experts, etc. to use these methods early.  We have to differentiate between speaking to parents who are trying anything that will work and the people who should know what to promote and what not to promote.)

Drs. Pamela Douglas and Peter Hill out of the University of Queensland in Australia (both of whom I’d like to buy drinks for) performed the review.  A total of 43 articles met the criterion for inclusion.  There were various sleep training techniques included in the review.  The usual suspects, as well as decoupling feeding from sleep and touch (i.e., never letting the baby fall asleep at the boob or in arms, teaching the child to “self-settle” without touch or food), scheduling the baby’s sleep whether tired or not, and decreasing daytime stimulation.  They looked at all of these for the outcomes associated with them on infants and mothers.

One of the most disturbing revelations is that articles promoting sleep training in the early months don’t actually have scientific backing for it.  What many of them found was simply that sleep consolidates rapidly during the first four months postpartum and that because it does this, it is assumed to be evidence that sleep training will prevent later problems in sleep-wake cycles for infants.  But when they actually looked at outcomes for infant and mother (as this is who has primarily done the sleep training in the research they found), they find the following:

  • Sleep training in the first 12 weeks does result in longer sleep durations but does not reduce infant crying, which is the main concern for parents seeking sleep training.
  • Increased night wakings in breastfed babies was not associated with any long-term sleep or behavioural problems despite many suggesting long-term problems associated with infant night wakings.
  • Infants who show night wakings or other sleep disturbances at six months (without intervention) have completely normal mental health in young adulthood, meaning those who suggest a link to later problems don’t have a leg to stand on.
  • For those who worry about moms with depression, sleep training prior to six months was not found to decrease maternal depression at all.  And in fact, mom’s sleep problems do not correlate with infant sleep but rather are due to the depression, not the infant.
  • In fact, it was maternal depression that predicted longer infant awakenings at night (though not frequency), not the other way around.
  • Mothers who breastfeed wake more to feed babies but report better sleep quality and lower rates of postpartum depression.
  • The few studies that reported a decrease in maternal depression due to interventions were incredibly complex interventions with many elements (including support for mother) and the lowered depression cannot be said to be due to sleep training.
  • Decoupling feeding from sleep in infants younger than six months was associated with increased breastfeeding failure.
  • Rigid, scheduled sleep and care in the early months is associated with three times the risk of behavioural problems at six months and twice the amount of crying as infants with cue-based care.
  • Placing an infant in a dark room during the day under the guise of them needing sleep or crying from being “overstimulated” or “overtired” actually inhibits the consolidation of night sleep (meaning more night wakings) and increases the risk for SIDS.  It also reduces the ability of mom to develop a good daytime biorhythm with the baby which reduces maternal mental health.
  • The focus of sleep interventions – namely the amount the baby has slept, how long between sleeps, number of wakings, etc. – actually increases parental anxiety.  It can also result in worse sleep for baby.

Perhaps most interesting of all, though not an outcome, most families don’t report any issues with infant sleep in the first six months.  Most people are being told to use behavioural techniques as preventative measures for later problems.  Only there’s no evidence that this works and as we’ve just read, actually can pose more problems for the family both in the short- and medium-term.  And none of these studies even looked at any longer-term social or emotional issues that can arise from sleep training so young, thus the question of what the risk of long-term harm is still remains.

What to do?  As the authors here suggest, treatments need to be holistic.  In the minds of these authors and researchers, early treatment of any problem should avoid sleep training and all behavioural techniques in favour of education about cue-based care, parent-child synchrony, healthy daytime biorhythms, and addressing parental anxiety about sleep and normal crying.  Further, feeding difficulties should be examined as one of the potential causes of unsettled infant behaviour, thus parents should be given all the assistance they need to address any feeding issues.

Isn’t it sad that we needed 20 years of studies to prove the risk of harm?  Couldn’t we have not promoted this and saved these families the anxiety, stress, and problems that came with promotion of something that hadn’t been proved to do no harm despite countering all biological norms?

So… sleep trainers, baby “experts”, doctors, and anyone else promoting sleep training in young infants:  What are you going to do now?

Update:  Here is a video with the authors of the review talking about the research and sleep in the first six months!  (Thank you to Natalie for this.)

Click here for a follow-up opinion piece.

[Image Credit:  Unknown]

 


[1] Douglas PS, Hill PS.  Behavioral sleep interventions in the first six months of life do not improve outcomes for mothers or infants: a systematic review.  J Dev Behav Pediatr 2013; 34: 497-507.