Which baby sleep interventions are most effective?

Morgan Liotta

9/01/2023 5:35:28 PM

With many parents now using behavioural sleep interventions, a new study examines which of the most common work best and cause the least harm.

Baby in crib.
Around 64% of parents in the study reported implementing behavioural sleep interventions with their babies.

There are many suggested interventions to help babies adopt good sleeping patterns, from sleep school and controlled crying to the more controversial melatonin use and strict sleep routines.
With so much information available, how can families decide which intervention works best and has the least impact on the infant–parent relationship and postnatal mental health of parents?
An international study published in the Journal of Pediatrics last year included details from more than 2000 parents of babies aged 3–18 months to examine the benefits and safety of behavioural sleep interventions (BSIs).
The study used the real-world frequency, timing, duration, difficulty, and helpfulness of the following three BSI approaches used to promote sleep self-regulation for infants:

  • Parental presence
  • Controlled crying (known as modified extinction)
  • Cry it out (unmodified extinction)
The majority of study participants – 64% of parents – reported implementing BSIs, with the infants’ average age standing at 5.3 months when the intervention began.
Lead study author Dr Michal Kahn is a Flinders University postdoctoral research fellow and senior lecturer at Tel Aviv University’s School of Psychological Sciences.
She told newsGP that as paediatric insomnia is common and can cause distress for families, the safety and efficacy of BSIs has long been a contentious issue.
‘Behavioural sleep interventions for infants – and extinction-based approaches in particular – have triggered tempestuous debates during the past decades,’ she said.
‘The main critique focuses on the potential of these interventions to harm the infant–parent relationship.
‘Despite the lack of scientific evidence to support these concerns, they continue to be voiced in social media outlets, websites, and colloquial sleep advice, eg of “sleep coaches” and “influencers”.’
The study looked at the effectiveness and safety of the three BSI approaches by comparing infant sleep, parent sleep, daytime sleepiness, depression, and parent–infant bonding between parents who had implemented these interventions and those who had not.
Unmodified and modified extinction were rated as ‘significantly more difficult’ to implement compared with parental presence, but also as more helpful, shorter, and quicker to show improvements. 
No differences were found between BSI groups in parent sleep, sleepiness, depression, or parent–infant bonding.
Acknowledging GPs’ central role in maternal health, postnatal mental health, and in providing support to families experiencing baby sleep issues, Dr Kahn hopes the study can offer GPs some guidance.
‘GPs meeting parents of young infants may be asked about the safety and effectiveness of infant sleep interventions, and may thus wish to be informed of the most recent scientific evidence,’ she said.
‘Our recent investigation adds to the mounting evidence for the effectiveness of extinction-based interventions in improving infant sleep.’
According to the authors, implementation of BSIs outside clinical settings is common and occurs earlier than generally recommended.
They noted that unmodified and modified extinction are associated with longer and more consolidated infant sleep.
And despite concerns regarding the potential harm of BSIs, implementation of these approaches was not linked with negative outcomes, providing additional evidence for their safety and effectiveness.
‘Importantly, our study found that intervention implementation was not adversely associated with parent wellbeing or the parent–infant relationship,’ Dr Kahn said.
To help parents make informed decisions, GPs and other paediatric health providers can make parents aware of the range of evidence-based interventions available, according to Dr Kahn, as well as their benefits and costs – such as the higher difficulty yet greater helpfulness of the modified extinction approach – and the lack of evidence for any harmful consequences.
‘GPs could considerably help parents by revising any communications of misinformation, and reducing the possible concerns, shame, or guilt associated with these interventions,’ she said.  
‘Of course, we should clearly acknowledge that behavioural interventions for infant sleep may not be appropriate for everyone. Many parents feel that they do not fit well with their emotional resources, belief systems, or life circumstances at that time.
‘As clinicians, we should respect parents’ choice to implement any or none of them, as research continues to collect evidence, refine existing interventions, and develop novel approaches.’
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Dr Lauren Wilson   10/01/2023 1:26:26 PM

I think the most important point in this article is the assertion that parents need to be given the information to support them to make their own decisions. Given this it should be made clear that the improvement in sleep with extinction methods in this study was 9 minutes per night. Parents need all the information, not just the summary that there was longer sleep.