Hands up who doesn’t have an opinion about the best way to help babies get to sleep? It’s been a hotly contested topic in recent years, at dinner parties and playgrounds across the land.
Behavioural sleep techniques have been shown to be effective at reducing sleep problems in infants and the associated maternal depression in the short- to medium-term (4–16 months’ post treatment) (Mindell, 2006).
Two main techniques are quite widely recommended:
- “Controlled comforting”: where the parent responds to the cry of the baby at increasing time intervals, to allow the child to “self-settle”
- “Camping out”: where the parent sits with the baby as they independently learn how to fall asleep; slowly removing themselves from the child’s room
However, the long-term safety and efficacy of these interventions has been challenged in recent publications (Blunden, 2011) which have suggested that there may be better ways to help children to sleep.
Thankfully, a team from Australia and the UK have recently published the results of a population-based cluster-randomised trial that assesses the long-term benefits and harms of behavioural infant sleep interventions.
The researchers recruited children from health centres in Australia. Mothers were asked to complete a screening questionnaire and some reported that their baby’s sleep had been a problem in the last 2 weeks. Children who had been born premature (<32 weeks gestation) were excluded from the study, as were families who had insufficient English to participate.
326 children were randomised to one of two treatments:
- Behavioural sleep techniques, shown to parents over 1-3 individual nurse consultations, and given to babies aged 8-10 months
- Usual care
Allocation was concealed and researchers (but not parents) were blinded to group allocation.
- Child mental health and behaviour (this was the main outcome measured using the Strengths and Difficulties Questionnaire)
- Psychosocial functioning
- Stress regulation
- The child-parent relationship
- Maternal mental health
- Parenting styles
- At 6 years of age, there was no evidence of any difference between intervention and control families for any outcome:
- SDQ total score adjusted mean difference (AMD) +0.5, 95% CI −1.0 to +1.9
- SDQ emotion score AMD −0.04, 95% CI −0.6 to +0.5
- SDQ conduct behaviour score AMD +0.1, 95% CI −0.3 to +0.6
The authors concluded:
Behavioral sleep techniques did not cause long-lasting harms or beneﬁts to child, child-parent, or maternal outcomes. Parents and health professionals can feel comfortable about using these techniques to reduce the population burden of infant sleep problems and maternal depression.
So this important new RCT provides the evidence that parents need to confidently use “controlled comforting” and “camping out” techniques to help their children sleep. The long-term safety of these approaches have been proven by this research, but a number of unanswered questions remain.
- Very few children were still suffering from sleep problems at the end of this trial. Were these new cases or were they the same children who had problems at the beginning?
- Most of the children in the usual care group were also sleeping well by the end. How did they learn to sleep and what advice did their parents receive from elsewhere?
- This research excluded children with learning disabilities or developmental problems, so it may well be that the results cannot be applied to these groups, or possibly to specific ethnic groups that weren’t studied here in detail. Further research is needed before all parents can confidently use these behavioural sleep techniques.
We elves are obviously delighted with the results of this RCT. We “camp out” in the woodland most weekends (come rain or shine) and the thought of discovering that there were long-term risks associated with this behaviour had filled us with a terrible dread. We look forward to reading more research that investigates this area.
Price AM, Wake M, Ukoumunne OC, et al. Five-year follow-up of harms and benefits of behavioral infant sleep intervention: randomized trial (PDF). Pediatrics 2013;130:643–51.
Price AM, Wake M, Ukoumunne OC, et al. Outcomes at six years of age for children with infant sleep problems: Longitudinal community-based study (PDF)
. Sleep Medicine 2012;
Mindell JA, Kuhn B, Lewin DS, Meltzer LJ, et al. Behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep. 2006; 29: 1263-1276. [PubMed abstract]
Blunden SL, Thompson KR, Dawson D. Behavioural sleep treatments and night time crying in infants: Challenging the status quo. Sleep Med Rev. 2011; 15: 327-334. [PubMed abstract]
Got a baby with sleep problems? Check out @Mental_Elf blog on important (and reassuring!) evidence http://t.co/5dJ03CaJ #parenting #sleep
I have been in contact with Dr Anna Price, the researcher who wrote the RCT featured in this blog. She has kindly answered some of the questions I asked and given me permission to use her responses on the site.
Very few children were still suffering from sleep problems at the end of this trial. Were these new cases or were they the same children who had problems at the beginning?
All children in the trial had sleep problems at 7 months; this was an eligibility criterion. The persistence of sleep problems in this group of children is described in a second paper, which showed that only 2% of children had persistent sleep problems at all time points from 4 months to 6 years; very few children had sleep problems that persisted from 2 years to 6 years; and 23% had no sleep problems at any time point from 4 months to 6 years.
(This second paper is included in the blog links above – Price, Sleep Medicine, 2012)
Most of the children in the usual care group were also sleeping well by the end. How did they learn to sleep and what advice did their parents receive from elsewhere?
All families (whether intervention or control) were free to access any other care in the community. This ranged from talking to family members or neighbors to staying at parenting centers. In terms of sleep problems resolving, we know that much of this would be due to maturation, as sleep problems become less common as children grow older.
This research excluded children with learning disabilities or developmental problems, so it may well be that the results cannot be applied to these groups, or possibly to specific ethnic groups that weren’t studied here in detail. Further research is needed before all parents can confidently use these behavioural sleep techniques.
There has been some sleep research done with these populations (e.g. Meltzer & Mindell (2006) http://upload-community.kipa.co.il/611201246111.pdf), and colleagues at the Centre for Community Child Health are doing quite a bit of research into ADHD & sleep techniques (e.g. the Sleeping Sound with ADHD project: http://www.rch.org.au/ccch/az/AZ_of_Projects/#_) and around melatonin prescribing, in case this interests you.
Thanks+ to Anna for this really helpful addition to the blog. It’s great to see researchers who are keen to get involved with disseminating their publications to those who need it. These further explanations and links add real value.
If you’ve got any further questions or comments on this research, please feel free to ask them here.
Where can I find this article?
It’s here Hana: