The recent post on the research showing a greater risk of harm than good for early sleep training (under six months of age) sparked a lot of defensiveness and anger by some people on the site and on places where the piece was shared. The most popular argument was that they had done early (presumably) sleep training and their child was fine so who was I to write up research that would suggest otherwise. Add in some bits of “Can’t we just support one another’s choices?” and the accusations that I don’t know a specific person’s situation so how can I write or say anything and you’d think I’d written that parents who sleep trained deserved to be locked up despite nothing of the sort being said.
With respect to this exact piece, I think some people just clearly either don’t want to read what’s there or didn’t as it was pretty clear this was all about the promotion of sleep training as opposed to parents who have done sleep training. However, that fact is something that is often lost in the discourse on sleep training at any age and I think it’s time we talk about it.
I can only speak for myself and my site here (but I know from many discussions with many others who write about sleep training, they feel the same as what I am about to describe). I write about sleep training and the problems with it because there are a lot of “experts” out there who don’t take one tiny glance at the research on it but tell parents they must do it. There’s also a lot of crappy research that gets picked up in the mainstream media – last year’s Price et al. article in Pediatrics which claimed to find no long-term effects of controlled crying, for example (their methodology didn’t allow them to even test this) – while others that counter sleep training are ignored. So I write. Do I have an opinion? Yes, after doing the research, I do, just as those who write other pieces have their opinion that sleep training is fine. No one writes on this completely unbiased, so let’s get that out of the way. But unlike many “experts”, I do make sure to cite my sources so people can read them themselves and form their own opinion, something I hope parents take the time to do.
However, the writing I do isn’t about parents, it’s about the promotion of sleep training. When we as a society promote something, it is done under the assumption that it will provide more benefits than harm. It also assumes we know nothing about individual circumstances, and that is why it has to be based on research. This leads to a very important fact: There may – in fact, probably will – be select individuals for whom whatever is being promoted does not help. They will have unique circumstances that dictate a different course of action is needed. BUT, and this is important, it doesn’t mean the original promotion is wrong.
When we talk about sleep training – especially early sleep training – we’re talking about people telling families to do it. And what the most recent research found was that people are being told to schedule their children, to put them down off the breast when breastfeeding, to leave them to learn to “self-settle”, all when there’s no evidence for it and never was. Worse still, they were telling families who had no sleep issues to start engaging in these practices, a type of promotion that takes things even further than providing interventions. What we now know, based on 20 years of research nicely reviewed and summarized, is that from a population or promotion point of view, early sleep training (whether intervention is needed or not) not only doesn’t work, but increases the risk of harm to infant and mother. This does not speak to any individual person’s situation or case. It speaks to how we want to promote matters of safety and well-being in our society, something we do on a regular basis over all kinds of activities.
For example, we don’t promote smoking because we know it leads to higher risks of very serious health outcomes. It doesn’t mean there aren’t individuals who smoked and never had a bad outcome. We don’t promote heavy drinking in pregnancy because we know it can lead to FASD. It doesn’t mean there aren’t individuals who drank heavily and their child did not have FASD. We promote a balanced diet in children and adults because we know it’s linked with better health outcomes, but it doesn’t mean there aren’t people who ate a balanced diet and caught any number of diseases. With early sleep training, there is no reason to promote it when we now know that it is more likely to cause harm than to help the average family. We can no longer say that anyone promoting early sleep training is looking out for the well-being of babies and families. Regardless of what has happened in individual families.
This brings us to the issue of the individual parents and there are two parts to discuss here: Supporting choices and individual circumstances. Starting with supporting choices, parents are getting very upset over people not supporting what they see as their choice. This is the whole “whatever you choose is fine” attitude that accompanies the push to end “mommy wars”. It’s something I feel great disdain for, though, not because I don’t want to support parents (I do and spend a lot of time each day answering questions from individual families and trying to help their individual circumstance), but because supporting a parent doesn’t mean agreeing with all of their choices. In fact, I firmly believe blindly telling a parent what they want to hear isn’t actually supporting them at all. And any parent who needs universal agreement is lacking in the conviction of their initial choice.
When it comes to sleep training methods like cry-it-out, I will not say it is a “good” method, but I can still call a given mother “good”. I will acknowledge that we live in a world that is not family-friendly and that sometimes families may feel they need to do that, but I view that as the lesser of two evils. Still evil, but families with little choice don’t get to always pick. And as such, I don’t harbour ill-will towards parents. Even if it wasn’t the lesser of two evils but rather because a doctor or family member said they must. People work with the information they have at a given time and you cannot judge a person for acting in accordance with the information they have. You can just hope they can learn more and make more informed decisions (whatever they are) going forward. And you still don’t have to agree with all of them. For example, I have friends that smoke and although I find the act of smoking disgusting, I don’t find my friends disgusting. The same can go for any parenting choice and any individual parent.
The second part here is about the individual circumstances families find themselves in. In our society as it is today, there are lots of reasons families find themselves pitted against their children. It’s one of the things that bothers me the most as families should be bonding and feeling supported from the start, and sadly that is a bit of a pipe dream these days. So I do understand where parents are coming from – sleep deprived, back at work early, etc. – but this has nothing to do with promotion and everything to do with building up your toolbelt and finding what works for your family while minimizing the harm done to each and every member of your family.
As I write for the site, I can only speak in generalities which means I cannot, nor should I be expected to, know your individual circumstance. That does not mean I cannot talk about the methods we promote as a society. It means I talk about the methods not the people that use them. And when people contact me for help, then we can start to look at the individual circumstances and try to find more tools for them to try out that can help their individual circumstance.
If reading that someone disagrees with some aspect of your parenting or that there’s research suggesting it does more harm than good generally bothers you or angers you, it’s not the problem of the person who is sharing that information. It’s your problem. Information should never be hidden because someone doesn’t like it. And when that information has important implications for policy and what caregivers should be promoting? Even less reason to hide it, no matter how many people may be upset by the findings. I hope those who are in the position of power to promote various techniques for infant sleep take heed of the research. Especially when there are techniques that are gentler and don’t pit mom and/or dad against their child. Those are what we should be promoting. Will these gentle methods work for everyone? Honestly, probably not, but they should remain your first line, or key players, so to speak, and then work with individual cases when those key players fail.
Parenting isn’t always easy. For that reason alone parents should be able to come to the table armed with the best information possible, including a variety of tools and the risks associated with each, and then make their decision. And that requires us to disseminate the research and make sure that when we promote techniques, we do so focusing on minimizing harm, not winning popularity contests.
I absolutely, whole-heartedly agree with this post! The research is NOT equivocal, ignoring your baby’s cries will NOT promote wellbeing. Parents deserve the truth. They also deserve much more support than they currently get (maternity leave, doula support, lactation support, etc.), but they will never demand this support if we hide the truth about our current practices like sleep training if they think that these methods are safe/effective.
It is hard to be the unpopular messenger, but we must each stick to the truth and eventually parents (and children!!) will be very grateful that we did!. Carry on!
Good post, get so tired of the whole “support everyone in everything they do” rubbish. If the research is there, then you can’t really refute it…
Hi Tracy, first off I just want to say that as an academic researcher and mom of two little ones (2 yrs and 9 months), I really enjoy your posts! The comments and critiques of your most recent sleep posts are very interesting and informative, as I feel they really underline what the main issue is: misinformation on realistic expectations. Our happiness and satisfaction is often a product of our expectations in life. If you believe you are meant to be a millionaire and not work a day, then you will be pretty bummed if you need to spend 40 hours at a desk to only earn a mid-level income. However, if you grew up in a family of hard workers who earned meager hourly wages, then a desk job with salary and benefits probably feels like you have really achieved a better life and for it you feel internal satisfaction. Within the first night of becoming a new parent, we are often intimately introduced and initiated into the land of sleep deprivation. We knew it was coming. We read about it. We were warned about it. Our friends with kids laughed about it. But none of that could prepare you for how hard that would really feel and how much it just plain sucks! Our thoughts very quickly turn to ‘when will we get to sleep again’ and now, with all the ‘information’ on the internet at hand, we google the answer. We find posts, blogs, articles, news stories, research, etc… all discussing when infants will sleep through the night (or STTN as many online sources call it). We start waiting for our kid to STTN and start believing something is wrong when they don’t. We are then told that if it doesn’t happen on its own by x months (and by my pediatrician, x=4), then we need to do something about it or face waking in the middle of the night for possibly ever (yikes!!!). The unknown is scary, but the thought of never sleeping again is scarier. So we get desperate, scared we are not doing the right thing, and start researching techniques to make our kid STTN. Some of us CIO, some of us don’t, some of us make up our own strategy. But again, we do this for two primary reasons: 1) we think we are supposed to have a kid STTN by a certain age, and 2) we are scared that if we don’t, we will set up bad and irreparable habits. Now, I know some may say there is a 3rd reason and that is because mom needs sleep (the popular ‘happy mom=happy baby” concept), but honestly, that is just a side benefit rather than the reason we do it. I say this because clearly there are many other things about having a baby that make mom’s life harder but that we still do because we need to for the health of our baby. Now, I will say that I am not my best self after a rough night of limited sleep. My husband would agree. But again, it comes down to expectations. If I thought I would feel that way forever, then I would need a solution pronto! But if I was more accurately informed that this is typical of most kids and a phase that they will outgrow as they inevitably mature, both physically and mentally, then I could handle it knowing there is light at the end of the tunnel. Doctors need to support moms with accurate information rather than just trying to pacify moms with what they want to hear. And for those who say that doctors don’t do that, consider the issue with antibiotics. Doctors often prescribe antibiotics because they know it’s what the patient wants, as patients expect their doctors to do something about their illness. However, doctors will admit that these same patients often don’t need antibiotics since they have common viruses which can’t be helped by drugs. We now know that this is leading to microbial drug-resistance, a deadly problem. Anyhow, my point is that just because a doctor tells you something doesn’t mean it’s true.
I know this all too well for a few reason. One, I am an epidemiologist at a major U.S. institute and work with MDs who conduct research. They consult with me on how to design studies because they really have no clue how to do it properly otherwise. They are experts in individual-level health issues, but not population-level research (as Tracy often points out the differences for). Two, I am a mom of a child who, though now is doing very well, was born with many complicated medical issues. He was a mere 3lbs at birth and was just not a hungry kid (he still isn’t). Trying to get him to eat and gain precious pounds as an infant was difficult and scary. He also woke frequently at night (2-5 times) for a long time, and we welcomed those opportunities to try to feed him pumped breast milk (he could never latch due to low muscle tone). So, imagine my surprise when our well regarded pediatrician with 20 years of experience said that at 6 months old, we needed to stop feeding him at night and do extinction CIO. She told me that if we didn’t, he wouldn’t get the consolidated sleep that his brain needed to grow and develop properly. Yikes, right?! The last thing I needed was to introduce additional complications in his brain development (he was already experiencing gross motor delays and other neurological issues). Even though I research the heck out things, she scared me. I mean really scared me. So we tried. He cried for 2.5 hours I am ashamed to say. We cried too. We abandoned the plan the next night of course after 1 hour of crying and kept feeding him. My poor little guy needed his food, as his small tummy could only handle so much at once. Anyhow, at the next appointment when the doc asked how it was going, I smiled and said ‘great’ and left it at that. At 14 months, my supply completely dropped and we went to a toddler formula. He started STTN on his own that week. Breast milk is digested quickly, and I now firmly believe that breast fed babies wake up in the night more for this reason, and that given that breast feeding is completely natural, so is the night waking. My daughter, who is now 9 months, breast feeds, sleeps with me, and while she wakes to eat, never cries. I am confident that this pattern of night waking will end when she weans. and if not, we will gently work on it then.
All of that said, do I believe we harm our kids permanently from CIO techniques? I don’t know. The research on the subject is not well done. Even the review you cited includes many studies that are mediocre and leave much to be desired. I’d like to think that as a human race we are stronger than a few poor parenting decisions. My own mother stopped breast feeding at 2 weeks because she didn’t like it, and wasn’t exactly the most present mother you could have, making many selfish decisions. How did this impact me? Well, quite negatively to be honest, at least until I got older and took ownership of my own life rather than being a victim. But would a loving home with completely present and selfless parents who used CIO lead to the same outcome? Again, I don’t know, but my gut feeling based on all I have read is no. Is it best? No, I also don’t think so. Again, I think we need to have realistic expectations as parents and a society that supports that rather than “quick-fix solutions”. MANY doctors over the years have tried to give us quick-fix solutions for my son’s eating problems. None of them are research-based (even at top institutes with Children’s feeding programs, I hate to say it). I believe they cause more harm than good too. I think as with most parenting issues, whether typical or related to special needs issues, slow and steady and gentle and understanding is key.
Now, I will also Tracy that while I have read fabulous critiques you have done of some research out there on topics you disagree with, you tend to be much lighter on those that support your ideas, like this review article. An example is the great review you did on the recent review on studies that found bed sharing to increase the risk for SIDS. And as an epidemiologist, that work really was well done! This review is just ‘meh’ and I think you could probably find many more holes in it if you looked.
I’m curious as to what you found “meh” about the early sleep training review. The bedsharing meta-analysis was relatively easy given the stats used and clear methodological flaws in it (which were glaring). This was seemed like it represented the original articles well from the few I’ve read both of, but am happy to be corrected. It’s not a meta-analysis but with the differing methodologies used by the original research, I’m not sure how they could do it properly. And they were clear to separate out different types of training. And of course, I didn’t find anything too overstated at all. They never claimed a child will never recover, be permanently damaged, etc., but focused on the very real risks that were found.
Edit: Just did another read through to see if I missed anything and I can’t see what’s “meh” – in fact, I’d argue they were at times overly generous with some of the research where I would have argued it showed worse outcomes they they found!
All this review did was summarize what the authors felt were the most important points from the studies that they found and which observed no or negative effects from applied interventions. It did not even attempt to objectively discuss the strengths and limitations of the compiled articles, which is the very least a review article should do. Also, it wrote off those studies finding positive outcomes with what they call 3 major methodological flaws. Of course, those same flaws are present in many other studies as well, along with others that are not discussed here. While I have not read each, I have read several and have found major issues with confounding and biases that just weren’t accounted for. Also, I think lumping together the variety of interventions that they did, particularly related to feeding along with sleep, makes it impossible to tease out specific effects related to sleep issues. That is, consultations with health professionals to provide guidance and advice is quite different from employing a particular, structured, sleep training program. Additionally, the first 6 months is a difficult period to really assess. Many of these studies focused on the first 1-3 months, which are when infants commonly experience colic and excessive crying. The kind of infant/mother support needed at that time is a very different animal from the more classis ‘when will my otherwise happy baby STTN’ issues that get most moms to consider sleep training. A 4-6 month old is very different from a 1-3 month old. Lumping them together just doesn’t make sense and makes it impossible to draw any reasonable conclusions.
This paper felt more like a light review/editorializing rather than a robust and objective scientific assessment of all relevant research. But that’s just this epidemiologist’s take on it.
But Jen, they *didn’t* get rid of those studies with the methodological flaws that supported sleep training. You can see them cited throughout the results of the study. This is part of why I was impressed because they *could* have rejected them based on the strong methodological considerations but did not. I must also admit I’ve not read reviews which have the space to talk about the strengths and limitations of all the articles included at all. Even the recent reviews on sleep training generally that have been cited did no such thing (and when I wrote about them I didn’t call them out for it either as the space that would require would be rejected by many journals, at least in this field).
The authors of the review acknowledge confounds in their main methodological limitations. Though I’m curious which ones have more because I’d be interested (like you I’ve read some but not all). The feeding issues are brought up right away as a major problem, but one for which we don’t have a solution. And they also discuss the limitation you mention of teasing out the effects of sleep interventions versus other components.
I find your comments on age interesting though. Although the authors found that many of the studies were suggesting sleep training as preventative not as an intervention which would make the age issue possibly moot? And perhaps it would be safer to say first three months, but it seems the few studies looking at 4-6 also found problems (which is also why early “trainers” like Dr. Ferber were clear in never using the methods prior to six months). But thank you for sharing your perspective on it… definitely makes me want to find time to read *all* the articles now 🙂
Now here is a study that could be used to assess CIO-effects that would be interesting:
http://pediatrics.aappublications.org/content/early/2013/10/02/peds.2013-1178d.abstract?papetoc
This is an abstract on the utility of hair to assess cortisol levels as a marker for chronic stress. Take a cohort of infants who were ‘ferberized’ and/or ‘weissbluthed’ (meeting specific criteria for how the sleep training was conducted and during which months of life, say months 4-6, another group of 6-9 and then another group of months 9-12), and then a cohort of infants, age- and sex-matched, and possibly race/ethnicity-matched, who underwent absolutely no sleep training. Make sure you have accurate information on their feeding practices, socioeconomic status, geographic location, and medical/birth history (i.e. gestational age of birth and birth weight, NICU stay, PPD in mom, etc..), and then assess cortisol levels in their hair while controlling for all of these other factors during the sleep training, right after, and then 6 months and 1 and 2 years out. Also assess sleep patterns in both groups over time in objective and standardized ways. This way you can build time series multivariate models that evaluate both the outcomes of cortisol levels in hair over time and also sleep status. Now even though it’s still observational and not a randomized control trial (which would honestly just never happen for this), this approach is what it would take to start to really give better and more definitive answers.
Wish I could do it! Of course, that’s outside of my scope (I do infectious diseases). However, the NIH National Children’s Study would be a great place to look at this.
Love it – like you, wish I could do it 🙂 Sadly, not in the near future (but am working on a longitudinal study to try and determine pre-pregnancy and labour predictors of PPD and birth trauma)…
I should pass this on to some sleep researchers I know though!! One thing I think of though is that I don’t see chronic stress as a long-term outcome for all. I think it would interact with temperament (which would need to be assessed) but also I subscribed to the domain-theory of parenting which supposes that outcomes based on practices will vary based on the practice. So would sleep training affect all elements of a child’s life? No, not in terms of measured outcomes (but of course any experience shapes the child’s view of the world, however slightly). So I would want long-term assessments of night behaviours, empathy, negative affect regulation, etc. – all linked to responsiveness to distress and distinct from warmth.
(Don’t you wish you could just throw together studies sometimes and just have the answers immediately???)
Ha, completely! It’s amazing to me how little research is often available on very important topics especially pertaining to kids. That’s because it’s difficult in general to study children. You can’t easily do randomized control trials on them due to the numerous hurdles involved with IRBs, most parents don’t want to enroll their kids in studies unless they are inherently different for some reason and need the help (introducing bias), and there just isn’t a lot of funding out there for it. So many questions go unanswered. Also, many disciplines are fairly light on stats and just don’t set their analyses and methodology up in a way that allows them to adequately address the main issues in a robust way. I find this to often to a major issue with many clinical psych studies unfortunately (and my best friend has her PhD in clinical psych, but also an epi/stats masters, and she will attest to this as well). With an issue like sleep training and CIO, it would be very interesting and helpful for better decision-making and I honestly think wouldn’t be that difficult!
I’ve done a minor in stats during my degree and can attest to this as well – stats in many disciplines is horrid. It’s really a problem. Then there’s the issue of people not wanting to take the time to develop new measures meaning we’re limited to what’s out there which is often rather flawed as well.
“Information should never be hidden because someone doesn’t like it.” Amen!
The recent post on the research showing a greater risk of harm
In a recent post on the research its showing a great risk of harm than good for early sleep training aroun six month of age. . this is the most early sleep training .
Look, I totally get where you are coming from. I had a lot of problems with you article, but most of them came from a research standpoint. When I see assertions like that, I want to know sample sizes, methodology, p-values, correlation coefficients. Something can be correlated without showing significance. Anyway, statistics rant over. (Although in the future, you might at least point us to where we can find that information.)
Finally, I read all this and think, “Great, yes, I agree it’s totally better to go by baby’s cues. But…I have to go back to work.” And then I feel like a horrible mother for having needs of my own and not being able to cater to my baby the way I “should”. Not only that, but apparently my child will be scarred for life. So I either get a child who starves to death now because we have no money, or a child who hates me later because I had to work. Awesome.
Look, I’m not saying you’re wrong. But can’t we put a little more energy into practical solutions that WILL work for mothers, rather than just making those of us who can’t be up all day and all night feel horrible?
Kelly, I included the citation for the full article. It’s WHY I include citations so people who want can go read all the stuff they want from the original article.
And if you look around you’ll see Gentle Resources here along with articles on solutions. Just because they aren’t in every article I write doesn’t mean they aren’t here.
I’m also a researcher and like you I do my research before making important health or child-rearing related decisions, and I listen to doctors’ and midwives’ experienced advice with a critical attitude.
However, over the years I have come to realise that most of these correlation studies that are used to “guide” parents in the media or websites like yours are complete junk. Just look at breastfeeding: hundreds if not thousands of contradictory studies performed over decades to conclude what we have known all along: breastfeeding has no measurable advantages over formula-feeding. We have a feeling that breastfeeding is better because it’s “natural”, but it is impossible to prove this, because it probably isn’t better. So was it worth doing such a cruel campaign against women that can’t or choose not to breastfeed? I breastfed all my four children (including twins) but this wasn’t enough, I heard judgement even about how often or for how long I was breastfeeding, this is absurd. Since when does the whole world have an opinion about how I choose to fed my children?
And the same goes for sleep training. I bet there will be many new studies disproving the one you have just cited. Because these are correlation studies on people, and you can play around with your variables and statistics to get the result you want. It is impossible to measure a significant effect of something so small occurring at early infancy years or decades later on a complex older child or adult. You can’t possibly control for all the variables affecting your study, and there are no numbers high enough that can counteract this noise in your study.
One thing is to measure the long term effects of a traumatic event that affected a child for a long period, another is to measure the effect of something as simple as letting your child cry for some minutes over a few days at most. In that case we should consider that all children are traumatised with child birth and you should advocate for systematic cesarians to spare them from that trauma. Oh wait, but no, this isn’t “natural”, so all the studies try to prove the opposite.
Sometimes we just have to use our common sense.
So please, stop making parents feel guilty. No parent wants to sleep train their child. Parents do it because they feel they don’t have any other choice, it’s a desperate act. And rest assured that if parents knew that sleep training would harm their child in the slightest way they wouldn’t do it.
I never heard any promotion for sleep training. I have always read “it’s ok from 4 months but better do it from 6 months”, and “sleep training is ok but avoid it if possible”. Quite the contrary, people usually say it’s a horrible thing and judge you. Like you’re doing, only claiming that your judgement is based on research.
I will wait to see if you will write an article about the study showing that sleep training at 4 months is ok, you know, the study that will be published at some point.
By the way did you read this? http://www.nature.com/news/over-half-of-psychology-studies-fail-reproducibility-test-1.18248
Excellent response! Thank you for posting!
Excellent and Thank you for educating families ! I am a RN and IBCLC ( International board-certified lactation consultant) I’ve been trying to find great research done by a sociologist / anthropologist that I learned about many years ago who educated out how babies / children who are ignored when crying ( communicating) and cues ignored (as with sleep training ) are much CLINGIER when older as toddlers and young children , much more dependent and cry much more when infants / young. Do you have these papers. I Think his first name was Jay? It was plentiful – years of his research. Lmk
Are you thinking of Jay Belsky?
I forgot to add he includes information on how important it is for them to learn “when I cry someone comes “ Multiple times this occurs and sets up brain. Child eventually learns to trust and know. Otherwise they are confused about trusting. (It is confusing when they cry sometimes someone comes and other times they cry and nobody comes. ) This can develop into an insecure child. When they are responded to more quickly they learn to trust and as they get older theyve learned by then they just need to wait longer sometimes and can now do so because they’re confident their needs will be met. In comparison, a child who is not confident may panic when their needs are not met because they’re not sure that they will be met. They can be more demanding and erratic.