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:

1. “Controlled comforting”: where the parent responds to the cry of the baby at increasing time intervals, to allow the child to “self-settle”
2. “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.

Methods

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:

1. Behavioural sleep techniques, shown to parents over 1-3 individual nurse consultations, and given to babies aged 8-10 months
2. Usual care

Allocation was concealed and researchers (but not parents) were blinded to group allocation.

Outcomes were:

• Child mental health and behaviour (this was the main outcome measured using the Strengths and Difficulties Questionnaire)
• Sleep
• Psychosocial functioning
• Stress regulation
• The child-parent relationship
• Maternal mental health
• Parenting styles

Results

• 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

Conclusions

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.

Links

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)

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]