Tuesday
Sep182012
The Infant Sleep and Cry It Out Study That Proved...Nothing
Tuesday, September 18, 2012 
A couple of weeks ago a new study was published in and promoted by the American Academy of Pediatrics journal Pediatrics. The study called Five Year Follow-up of Harms and Benefits of Behavioural Infant Sleep Intervention: Randomized Trial is being promoted as proof that the graduated cry it out method (i.e. where you let the baby cry and go back in and comfort them and then let them cry some more and repeat until they fall asleep) causes no harm and is perfectly safe to use.
In fact, their conclusion, based on a follow-up with the families of six-year olds who had been recruited into the study as infants reads as follows:
Behavioral sleep techniques have no marked long-lasting effects (positive or negative). Parents and health professionals can confidently use these techniques to reduce the short- to medium-term burden of infant sleep problems and maternal depression.
Initially I was interested in reading the study to see how they defined and measured positive and negative effects. In the end, I decided that didn't matter at all because the methodology for randomization and intervention was so ridiculous that it rendered the study completely useless.
Do What You Want vs. Do What You Want
The parents and infants who participated in the trial were recruited from well-child centres in Australia when the child was 7 months old. If the parent reported sleep problems, they were eligible for the study (if there were no sleep problems, they were not eligible, which could bring up a whole other set of questions around how our society influences what we consider to be a sleep problem).
The well-child centres where parents were recruited were assigned as intervention or control groups. Here is what happened:
- Intervention Centres: In the centres where interventions were administered, the nurse who meets with parents at their well-baby check ups was trained to "deliver a brief, standardized behavioural sleep intervention at the routine 8 month well-child check." The standardized intervention included describing two possible interventions -- controlled comforting or camping out (the former involves the parents leaving the room and coming back at specified intervals and the the latter involves sitting in the room with the child, gradually moving your chair further and further from their bed). Parents were then free to implement one of those interventions, try both of them, or ignore them altogether and do something completely different.
- Control Centres: In the centres that were designated as control groups, parents attended the 8 month well-child check as planned and met with a nurse (as they would have if there had been no study). If the parents asked for sleep advice, the nurse could give them sleep advice, just as she would have if there had been no study. Parents were then free to implement something the nurse told them or to ignore the advice altogether and do something completely different.
So, the only difference between the intervention group and the control group is that the nurses that in the intervention group were given formal training on sleep interventions. From what I can the parents were never asked which sleep interventions they used (if any).
So all of the results of the study with regards to positive or negative impacts on the child, child-parent relationship, or the mother are based on whether they received a "brief, standardized" lecture when their child was eight months old. What other sleep advice the parents received from friends, family, books, other health professionals or random people on the Internet wasn't considered. Which techniques parents actually selected and used wasn't considered (from what I can tell) or at least wasn't used in the reporting on results, which only looked at whether parents received that standardized lecture or not.
So really, the conclusion of the study should be:
Giving a behavioral sleep technique lecture at 8 months has no marked long-lasting effects (positive or negative). Parents and health professionals can confidently use these techniques to reduce the short- to medium-term burden of infant sleep problems and maternal depression.
With all the different places that parents get sleep advice, basing any conclusions on one short lecture is ridiculous, especially when there was no follow-up to determine which approach parents actually used.
But of course most journalists reporting on this study either didn't bother to read it or didn't consider what it really meant when they simply extrapolated from the summary and declared that "cry it out is perfectly safe".
My Other Beef -- The "M" Word
There are other things I could analyze with regards to how positive and negative impacts were measured, but given what I explained in the previous section that isn't really worth getting into. I do, however, want to express my disappointment that this study, like so many others, focused on THE MOTHER exclusively. The study, like so many others, looks at maternal outcomes, maternal depression, maternal mental health and parenting style and so on. All this does is further reinforce the idea that the mother is responsible for infant sleep.
What about shared parental responsibility?
Often when I hear about moms who are completely stressed out over their infant's sleep, it is because they are getting up multiple times per night with the baby while their husband sleeps or both parents are getting up at the same time to care for the baby together. It doesn't seem to matter whether the mom works or not, it just seems to be assumed that regardless of what she has on her plate during the day, she is responsible for getting the baby to sleep and taking care of any night wakings. The father, on the other hand, needs his sleep obviously.
When babies are going through particularly difficult sleep periods and waking frequently, I would recommend that parents in two parent households split the nighttime duties. Have one parent be "on call" for night wakings from 8pm to 2am and the other one from 2am to 8am. This helps ensure that both parents get at least some quality sleep and that no one is so tired that they cannot function the next day. (Edited to add: I don't recommend this as a permanent solution for an exclusively breastfed baby with normal nightwaking/feeding patterns. I was recommending it as a way for parents of babies over 6 months of age to survive through a period where their baby is waking up every hour or so and the mom is so desperate for sleep that she feels she has no option other than to use cry it out.)
Let's take some of this off the back of the mother and find a way for parents to share responsibility for their children, both in the home and in research studies.
Need a Sleep Intervention?
Whether it is a specific sleep intervention that makes a difference (or doesn't) isn't really clear in this case. But in the event that any sleep intervention is beneficial to parents and children, here is my recommended list of gentle baby and toddler sleep tips for those who feel their child's sleep needs to be addressed.
Image credit: tamakisono on flickr
Reader Comments (88)
Wow. Thanks for the commentary to give some context to this. I always thought studies were a little strange, because people are so apt to buy into them. Did you read Freakonomics? People raved about it, but when I read it, I was shocked at the blatant racism there. Gender bias is just as annoying. Co-parenting, I'm in.
I agree with you the study is so poorly designed and executed as to be completely useless. Too bad that's not being as widely reported in the media.
I am curious about your suggestion for parents to take shifts though--in our family, my sons were breastfed, and both woke in the night to nurse frequently at the age of 7 mos. (and long after). My DH is great, a very involved father, and in fact would have gladly gotten up in the night with them, except for one thing :)
My oldest did in fact have a bottle of EBM about once a week (until I gave up pumping when he was about 5 mos old), but the younger never had a bottle. So that wasn't an option for night-feedings. And personally, I think under 12 mos is way too young to night-wean or space out feedings (unless the baby is doing so naturally of course). So there was, in my mind, no other option but for me to be the one to get up with them in the night (we have co-slept p/t in a variety of ways, but honestly, I was never a "sleep through the feeding" type). I feel being in Canada, with decent maternity leave, made this a viable option--though arguably, what I did all day was more taxing than my DH's work! ;) But the night-waking continued long after I returned to my job too. So, I'm not really sure how parents can take turns like this when exclusively bf--my kids never had a schedule, but would almost certainly have been up at least once wanting to nurse in a four-hour shift. Even if I could have slept through them crying in daddy's arms during his shift, I wouldn't have. My babies' needs came first, esp. when they were infants.
love this info... such an "interesting" way to study sleep. not.
I tried CIO method. It worked ONLY to get my son to nap. but NOT to get him to go to bed at night. I suspect b/c naptimes have an "end" within 1-2 hours, but bedtimes...well that can be half a day if babies are supposed to sleep 11-12 hours! So... my son would cry for an hour or two. fall asleep. wake up a few hours later and start all over.
With my 2nd son, I am not doing the CIO thing. I just comfort him like as at any other time that he would be crying. Why does sleeping make it that I should not comfort him? Geez.
Now... when you recommend parents take shifts - what about a nursing mom? I end up having to get up all thru the night to nurse b/c pumping is such a pain and I get engorged anyway if I just sleep thru the night. so... I end up being awake all night... it's getting better though. :)
In our case, both of our babies took bottles of breast milk. This was partly out of necessity and partly a choice. So if we had a really bad sleep phase, which wasn't frequent (by my very liberal standards), I could request a 5 hour period of sleep and go to the guest room to get that.
If it comes down to introducing a bottle or doing cry it out, I'd opt for introducing the bottle for sure. Or, with an older baby, even just having the dad rock the baby back to sleep without the bottle insteadof leaving the baby to cry alone. Of course it helps if the baby is used to being comforted by the dad at times, which is why co-parenting from the start was so important to us.
oh my gosh I cannot cosleep - I get NO rest and I can't sleep thru feedings either. Sigh. Fortunately BOTH my babies LOVED being comforted by dad. Neither seem to be "mama's boys" LOL... so that works out for me. but not for the pumping/engorged thru the night part. oh well.
I replied in part to your comment when replying to Andrea above. With regards to engorgement, I'd suggest taking shifts at night when sleep is really bad, not when it is normal. So if you are used to getting up every 3 hours and the baby starts waking every hour, you could opt to have your partner bring you the baby after 3 hours so that you don't get engorged.
Great take on the article... thanks for being the voice, again.
However, it seems several of us are having the same questions about your comment regarding parents taking shifts. This sounds ideal, but I'd question this recommendation for breastfeeding moms. I'd be concerned with routinely giving the baby a bottle instead of the breast as it may cause a decrease of milk supply (especially if the mom isn't getting up to pump to keep up the milk supply due to the missed feeding). Of course, it all depends on the mother's expectations and goals for breastfeeding... but for someone who wanted to breastfeed for an extended period of time, this is not/was not an option for me. So, except for the hubby getting up to help with diaper changes, I really didn't see why he should also wake up... (?)
On the other hand, co-sleeping eased my waking woes tremendously. I slept GREAT with my 2nd because I chose to co-sleep from birth... and I was well rested even though he nursed like a champ overnight... and this, well past his 2nd birthday!
I wouldn't recommend shifts as a long term solution for an exclusively breastfeeding mom, but I did find it useful to get through a sleep "crisis", which is when I think people often end up turning to CIO.
I would pump before going go sleep and after waking up to help maintain supply.
Usually the sleep issue passed after a while and we could get back to normal.
First off, thanks so much for your take on the study. I only read through part of the news article since I find the idea of CIO totally repulsive. It was nice to have something I could confront reading that gave me all the info vs an incomplete and crappy news article.
As far as co-parenting goes. Sleep has, for the most part, been my department. Neither of my boys would take a bottle, ever. We co-slept and my boys were both fairly awful sleepers. With my first, when we were new parents and not used to the incessant sleep interruptions, it was really hard on us. My husband helped some, in fact he was better at soothing our first born during the first few weeks than I was, which was somewhat depressing. But after that initial newborn period it was up to me. There were many nights that we fought over it (with my husband pressuring me to let him cry it out). In the end, we didn't let him cry it out, we stuck with it and suddenly, just after our second was born, when our first was 2 years old, he started sleeping through the night like a champ. Our second was actually even worse of a sleeper than our first was. But we co-slept more comfortably for some reason (just fit together better, like 2 puzzle pieces) and I was already well adapted to the lack of sleep, it never caused any upset in our family. He's 3 now and still wakes plenty during the night. I just moved out of his bed a few weeks ago, only because I'm pregnant and it was just really uncomfortable. I think co-parenting is awesome and very important. I also think that the idea of co-parenting is going to vary vastly from family to family depending on how the household and daily activities are split up. Being a stay at home mom, I obviously handle the kids a lot more than my husband does. However, he's in there right now putting the boys to bed, after reading to them and give them lots of attention and snuggles. If we were both working parents, we would definitely split things differently. I'm curious to see how life is when #3 joins us!
We do co-parent. DH did/does pretty much everything but breastfeed, I don't see that as him being less involved. I was also the one to give birth because well, I'm female. :) But when it came down to it, the boys wanted me in the night while they were nursing. Rocking didn't cut it when they were hungry. CIO was never an option, and I don't think introducing a bottle is always that simple--some babies, like mine, have no interest (and personally I got very little milk using a pump, plus I found it was more work than just nursing), and others will wean prematurely because they reject breast for bottle. It's great you found a solution that worked for you, but I don't think it's one that will work for all babies or all parents. There can be a short time (months or years, in the grand scheme, not long) that the bulk of that particular responsibility is going to fall on the nursing mother, and it doesn't have anything to do with letting daddy get his sleep, and it doesn't suggest he never comforts the baby or can't bond with the baby other ways. Just that he can't breastfeed them.
I wouldn't suggest any family change their approach if it is working for them. I just don't like hearing a mom say that she is so exhausted that CIO is her only option if the family hasn't considered the possibility of splitting nighttime duties. Going from being nursed to sleep all night long to being comforted by dad is a gentler transition than going from being nursed to sleep all night to being left alone to cry to sleep.
Thanks so much for analysing this! When I saw the conclusion reported in the media I was pretty concerned... Now that I know how terribly designed this study is, I'm even more concerned at the recommendations being reported in the mass media based on this study. I'm surprised this was even published in a peer-reviewed journal! Where was the critical appraisal?
Anyway, as for the sharing the night time parenting - I think it's great if you can make it work and definitely something more people should consider - it shouldn't just be mom's burden. However, for my family, I never even considered it an option for two reasons. First, concern about milk supply (I have chronically low supply and was fine with nursing on demand through the night to keep my supply up). Second, my husband is a beast without 8 hours of sleep... and carries a gun a work... Not a great combination in my mind. :) Cosleeping definitely helped me get enough sleep to be functional at work.
When we were ready to night wean and stop co-sleeping, Dr. Jay Gordon's Sleep, Changing Patterns In The Family Bed (http://drjaygordon.com/attachment/sleeppattern.html) worked wonderfully!
Part way through my pregnancy with my second child, we permanently transferred nighttime parenting duties for our first child to my husband. It was mostly me at the start, then shared for a while, then became primarily him during my pregnancy. We didn't want him to feel like he got displaced by the baby, so we felt it was important to make the transition before the baby arrived.
Ah, see, waking every few hours from birth until 2 (and after, even when no longer nursing, just in case anyone thinks night-weaning equals STTN LOL) WAS our normal. Yes, there were times when part of me wished that I believed CIO was OK. But it was never an option.
Every family should definitely figure out what works for them. I like the idea of people who carry guns getting enough sleep. :)
I definitely agree with you there. I have to say (since it is so very rare for me to disagree with you, normally I just nod my head along), what I was getting from your initial post and response was that it was anti-feminist and not true co-parenting if dad doesn't take an equal share of night-feedings. I admit it's a pet peeve of mine when women are pressured to immediately introduce bottles so dad can be involved (as if there is no other facet of a baby's life in which he could be involved those first 6 mos!)
My DH also took on night-time parenting of our first when the second was born. Funny thing, we tried to do this before the baby was born for the same reasons you gave above. He wouldn't go for it. But the minute his brother was home, it was a non-issue. He completely accepted dad for bedtime and night wake-ups.
Just thought I'd add that my husband did plenty of nightshift with both our boys and we breastfeed and don't give bottles. We just go for shorter 3 hour shifts.
I believe that settling in the evening and getting a good night’s sleep is one of those important life skills. How many adults do you know who do not do this easily? For this reason I would like to equip each of my children with the self-knowledge to sleep easily and well, most nights anyway. Every family will develop their own bedtime routines to wind down and soothe in preparation for a good night’s sleep. Learning how to cry yourself to sleep, especially if left alone to do it, cannot be a good way to establish good sleeping patterns.
In families where both parents work and a bad night’s sleep cannot be so easily weathered, then a decision to take care of the parents’ needs ahead of the child’s may be considered for that family overall.
When you're in the midst of the early-years parenting, and sleep deprived, and living in a culture that struggles to tolerate baby's night-time needs "Not sleeping through the night yet? That's terrible!" then it is hard to surrender and relax into what our babies need from us through the night. It seems to go on for ever - but really it passes so fast.
Establishing good habits is a life-time gift that you can give to your children. Bedtime can be such a special, nurturing time and I wish for my children that this will always be so, right into their childhood.
I can't bedshare because of my back, I struggle to get a position I'm comfortable in, although sometimes he had them (we're both very light sleepers). When baby woke at night he would pick them up, cuddle them and try to settle them, if that didn't work he'd bring them to me, then afterwards take them back off me and either put them back to their bed or let them curl up on his chest. That way neither of us was ever completely disturbed.
I think parents need to do what works best for their child. If bed sharing works, great. If co-sleeping works, great. If sleep training works, great. ALL of these studies are inconclusive. I would like to see someone refute or disagree with the horrendous claims that CIO cause, "brain damage." It is actually laughable and rather terrible. Our society has turned to demonizing parenting strategies that work (gasp) for many people and (another gasp) the babies turn into healthy children.
With all that being said, my son as an infant was a good sleeper, easy breast feeder, and was a generally "easy" baby. At 5 1/2 months he would no longer sleep in his crib, it was like the mattress was lava. I sat up with him every night for two weeks, he slept in spurts on my chest. I quickly became zombie mom and we tried bed sharing, this did not work. He kept waking up and nobody was sleeping, so we went back to sitting up. Since I worked part-time during that period, it wasn't helping that I was sleep deprived and driving my son in my car on no sleep.
Finally, I read Ferber's book and gave it a shot. Within 4 days, my son slept through the night, in his crib, and sleeps 12 hours every single night. He is 26 months and sleeps happily in his toddler bed and still takes 2 hours naps everyday.
Truthfully, Ferber's method does not involve letting your baby scream in a dark room for hours with no contact. You simply go in and comfort your child by rubbing their backs, (this by the way, would immediately put my son into a calm state and lull him to sleep, he still loves this). This method worked wonders for us and if necessary, I would do it again.
I know many, many women who have toddlers who still struggle with sleep issues. Children shouldn't have sleep issues. I do believe we prevented many future sleep problems with the Ferber method and my son does not have brain damage and he will not "suffer long term effects," because for four nights we rubbed his back in his crib and didn't pick him up.
The bottom line, please educate yourself. These wacky studies are nothing more than junk research.
I'm curious what you would define as "sleep issues"?
Your critique of this study leaves me shuddering. I am in Australia and this ridiculous study has been all over the news. Sigh.
I would love to read the whole article but the site wants me to pay for it. Do you know where I could read it for free?
I would love to read the full study too but am also not subscriber. The abstract should be enough to give the necessary details of how the study was conducted though, and it just baffles me that a group of academics could all agree it is a worthwhile study. 1 to 3 sessions with a nurse who has been coached about what to say vs the same number of sessions with a nurse who has not formally been coached? The difference in those two approaches would be negligible in my experience. Of course it depends on the individual nurse but I suspect many of them would suggest parents try CIO regardless of whether they had been instructed to do so. And to have no information on what the parents then went away and did- how can this be? Even if the parents did go away and try CIO and then reported 5 years later that there were "no issues", is self-reporting a reliable indicator? As you said it is not even worth going any further into what is meant by the outcomes when the initial difference between the control group and the intervention group is so flimsy.
Furthermore I agree with your objection to focusing on maternal health outcomes. I breast fed exclusively and my partner still helped during the night even though he worked outside the home during the day. It was a tough time for both of us. He would get up and bring the baby to me for a feed - even though I still had to wake up a little, not having to get out of bed each time made a big difference. With my second child we co-slept from Day 1 and I found that made a big difference to all of our sleep patterns.
Sandi:
If you know anyone who is a registered student at a university, they should be able to get a copy from the academic databases that they have access to.
I read Freakanomics. What part was blatant racism?
As a doula, I constantly hear the "well, he has to work tomorrow, so he needs his sleep" argument. I understand that it's ideal to be alert on the job, but I point out that Mom is doing a full day's work as well - she just isn't getting paid for it. If she is exhausted to the point of depression, clearly, the partner needs to suck it up and deal with a bit of tiredness. I love your idea of doing "shifts" (for the older baby, as you pointed out). My daughter had reflux and woke up every 45min - she was younger than 6 months. We still did shifts, but they were just shorter shifts. I would go to bed at 8pm and my hubby would take her until 11pm. Then I would feed her, and he would take her back and deal with the screaming/crying while I put in ear plugs. Around 1am, he would bring her back to me and I would deal with the night waking until morning. If it was a day he was home from work, he would take over again at 6 or 7am, and I would go back to bed for a few hours. It was survival mode, but it got us through the worst of it :)
My 3yo still wakes up once per night (although she does go through stretches of 1-2 weeks sleeping through). I don't define this as a "sleep issue" at all; just part of normal childhood development. She usually just wants a little bit of water or to go pee. I think we need to redefine what we understand to be "sleep issues." It's not the baby/toddler that has the issue - it's the parents!
The problem I have - theoretically, and in my experience - with suggesting EBM bottles at night is that it will decrease your supply unless you are getting up to pump (instead of to nurse baby). If you are not actively nursing through the night, then your body will adapt to needing less milk, thus will produce less milk. If you are also working during the day, your milk will decrease even more (as you won't be letting down as often, and a pump is not as efficient as a a baby at removing milk). If you are planning to be up at night to pump (in order to keep your supply up), then why not nurse the baby instead (this was the conundrum I faced myself) as it is more effective in releasing milk - and at putting baby back to sleep? Additionally, when you're in synch with your night-waking baby, even if you were to be in a different room, with earplugs, when your baby wakes, you wake. Your milk is ready, you become uncomfortable, you know it's time to feed, you wake. I could never sleep through my baby's waking periods; I'm not sure its a good suggestion for mothers to train themselves to do that in order to get better sleep, as it involves turning off, or at least dulling, that connection. And sleeping WITH your baby is key in the first year, for reasons that extend beyond breastfeeding convenience. So where does sharing nighttime duties sit with breastfeeding, bedsharing mothers? I don't think it's realistic for a sleepsharing mother lying next to her breastfeeding infant who wakes, to instead of feeding, go to another room to pump, and then sleep while her partner feeds a bottle of EBM.
Certainly, if mom's health is at stake, something needs to be addressed, and yes, I agree, a bottle is preferable to cry-it-out, but that first year is a pretty short period of time, and shift sleep doesn't seem ideal or realistic for several reasons for a bedsharing breastfeeding mother of an infant. I think expectations of normal infant sleep and responsibilities need to change. Life will just be different in that first year.
Why do they even bother to spend the time and money on such stupid, useless studies?
I breastfeed and my husband and I both take turns with our son at night. He is 13 months. I always get him the first time because he will inevitably be hungry. Then if he wakes again fairly soon I can assume he's probably wet or just needs a hug and I send my husband in. Even if I get up with him, if I've fed and changed him and he won't settle for me, I'll pass him off to Daddy, who can always get him back to sleep, and much more easily than I can. (He expects me to nurse and snuggle him until he is sound asleep, but Daddy can just set him in the crib! With no crying.)
If we're *really* struggling, then he sleeps in bed with Daddy and I go sleep elsewhere. That happens if he's sick or something.
We have been able to "teach" him to sleep by getting both parents involved, without crying. Any brief crying he did do was with a parent there to comfort him. It only took one night of my husband staying in his room for a few minutes at bedtime to reassure him his room was just fine and safe for him to be okay with sleeping there. (We transitioned him from co-sleeping at 11 months after I got pregnant again.) There are ways to help babies sleep that do not involve crying, and YES, both parents should be involved if at all possible!
(My older two go to bed every night around the same time, typically fall asleep right away, sleep all night, wake up happy. They don't fight bedtime or naps typically -- we NEVER had that drawn-out toddler battle over bed. We taught them to sleep in basically the same way.)
With the babies, I got up at night, since I was the one with the food supply on my chest. To help make up for that burden, my husband got up in the morning with the bigger kids, got them off to school, and had coffee ready for me when I finally surfaced. It didn't always work with our second baby (fourth total chid, between us), because he often had to leave before the kids, often not getting back until after their bedtime. During those semesters, he would give me a whole weekend day to sleep, laze and rest, bringing the baby to me for food, but taking almost all the parenting duties on those days.
I really think the way to "reduce maternal depression and the burden of short- and medium-term infant sleep problems" is to make sure the mother has support, no matter what method of parenting is used at night :)
I'll stay out of the CIO debate here because as a pp said, too many people demonize parents one way or the other and forget that parents only want the best for their children, whatever sleep-training method they use.
So that aside, I just want to point out that the methodology used in this study is extremely common (e.g., here it was used in a randomized trial studying the relationship between breastfeeding and cognitive development: http://archpsyc.jamanetwork.com/article.aspx?articleid=482695). It would be impossible to enforce a true randomization of the groups to one sleep method or another (and some would say, in the case of the breastfeeding study among others, cruel). The best researchers can do in some cases is to instruct one group on the technique in question and suggest that they try it, while the other group does not get such instruction. From there, the preferred method of analyzing the results is an intention-to-treat analysis, where the researchers include all participants in all groups, whether they adhered to the intervention or not. "The rationale for this approach is that we want to estimate the effects of allocating an intervention in practice, not the effects in the subgroup of participants who adhere to it " (from http://www.cochrane-net.org/openlearning/html/mod14-4.htm). The idea is that at baseline, the groups will on average use the same techniques for getting their babies to sleep. With additional instruction, some members of the treatment group will behave differently than they originally would have, while the control group's behavior will not be affected. This methodology is ubiquitous in epidemiologic and health outcomes studies, and is considered to be a preferred approach when full randomization to a treatment cannot be enforced.
The part with the names was really racist and some of the names they mentioned turned out to be totally fabricated - no child had ever been born with those names.
That is fair, but then, as I said, their conclusion should have been:
Giving a behavioral sleep technique lecture at 8 months has no marked long-lasting effects (positive or negative). Parents and health professionals can confidently use these techniques to reduce the short- to medium-term burden of infant sleep problems and maternal depression.
Instead of:
Behavioral sleep techniques have no marked long-lasting effects (positive or negative). Parents and health professionals can confidently use these techniques to reduce the short- to medium-term burden of infant sleep problems and maternal depression.
It isn't the effect of the actual behavioural sleep techniques that they tested, it is the effect of the standardized sleep advice intervention. If they had at least done a detailed sleep tactic survey among both groups to understand whether one group was more likely to use certain tactics than the other then maybe the results would have some validity. But in reality, the advice to use cry it out is mainstream enough that it was probably as common in the control group, if not even more common (since they may not have had the benefit of the gentler "camping out" approach, which is not written about/talked about as often as letting the baby cry).
Kelly:
The only time we used this approach was when my son went through a short period where he was waking up every 45 minutes to hour during the night. I ensure that I nursed or pumped as frequently as I would have on a normal sleep night, but I didn't have to be the one getting up every 45 minutes and then getting him back to sleep. So, for example if we were doing a shift where my partner was on duty from 8pm to 2am and I was on duty from 2am to 8am, it might look something like this:
7:30pm: Nurse baby to sleep
8:00pm: I go to sleep in the guest room while my partner takes care of any wakings/feedings
11:00pm: I get up to nurse (if baby is awake) or pump and then go right back to sleep
2:00am (or first night waking thereafter): My partner brings the baby to me in the guest room and he goes back to sleep
2:00am to 8:00am: I sleep with the baby in the guestroom, dealing with nightwaking as required, while my partner sleeps in the other room undisturbed
That way, I got at least two 3 hour chunks of undisturbed sleep plus up to another 6 hours of disturbed sleep.
In that case then there may as well not be a study. The sample size is too small for starters. And the likelihood of the 'non-trained' group giving similar instructions is high (I think, and at least there is nothing to indicate they would not give similar instructions). The problem with assumptions based on statistics is that they don't work in studies such as these - you have to look at the underlying cultural indicators first. In a culture where sleep training was unheard of and unlikely to be suggested by your average maternal health nurse, then yes, introducing a system where one group gets this advice and another doesn't MAY lead to the conclusion that a certain percentage of the intervention group may have taken up this practice where they otherwise may not have. But it's still a huge assumption and does not take other cultural influences into account. There needs to be some feedback mechanism to indicate whether the parents did in fact use the methods suggested, and how many in each group did so, before any kind of valuable information can be extracted. Otherwise it's just grasping at straws. Perhaps this methodology can be used successfully in other health-based research, but I would suggest that in this particular area it is at best useless and at worst completely misleading and damaging. There are many other, better ways (including researching cognitive function in babies/children, analyzing neurological activity and measuring levels of cortisol) to research this topic. In terms of long-term outcomes, this is harder to predict because of the myriad factors involved in child development - but I would also suggest that self-reporting by parents (as I believe was the case in this study) who have used CIO is not the most reliable form of feedback.
I 100% agree!!!! My daughter slept horribly as a baby and my dh would wake to help me when I needed him. There were times I worried that he had to go to work the next day but then I reminded myself that I was up all night long with a fussy baby and would be taking care of the baby all day long as well. Unfortunately my dd wanted nothing to do with dh at night so most of the responsibility for getting her back to sleep fell on me. With my 2nd baby I started MUCH earlier having him help out at night. Despite what many breastfeeding mothers seem to believe, it IS ok, once your baby is a bit older, to send dad in to comfort and get baby back to sleep. You do NOT have to do it all yourself. My son never took a bottle yet my husband could help him get back to sleep. If he truly was hungry, he would let us know.
Thank you, thank you for taking a look at this study. When my husband mentioned something about it to me (including the phrase, "I saw this on Yahoo news today and thought you might be interested in it"), I had a feeling that the research itself would be far more nuanced (or, as it looks in this case, flawed) than what the media had reported.
On a semi-related tangent, I get so infuriated at "science writers" (I'm not even sure I would call some of these reporters science writers) whose articles seem to have little to no grasp on the research about which they are writing. And the headlines? THE HEADLINES! I know not every writer creates her/his headline, but sometimes the headlines themselves can do more to perpetuate ignorance about scientific research (and, in this case, parenting practices and infant/child/parental health) than the poorly-written articles do.
Thanks for this. I've seen some other critiques of this study, and they were useful, but this is very simple to express verbally in a conversation with others, so I find it a valuable tool! Debating posting it on my FB page (boy, I hate FB wars, though).
To speak to the point that's a primary focus in your comments: I work FT outside the home, and my partner is a SAHD. We're also cosleepers who are still BFing our 28-month-old (really winding down now). MUCH has changed over the course of our son's life, but we did do the shift thing (just slightly shorter shifts) at first, with my partner covering the first shift with a single bottle. This typically scored me an uninterrupted five hours of sleep. Um, yes, I would sometimes soak the bed. But I managed to sleep through it, because I had to. And later, when my son was better able to roll over and nurse without needing my help, I would just doze through night feedings. Now that we're night weaning, my partner covers any significant wake-up, while I manage all the small stirrings (so if I can give him a sip of water and get him back to sleep, my partner snores through it. If he starts to go into tantrum mode because he's not allowed to nurse at night anymore, my partner will deal with it while I go back to sleep).
So yeah, it's going to differ from family to family. The "partnering" part for us comes from our conversations about what we each need and how our strategy will continually change to reflect those needs. As long as that conversation is happening and all people's needs are being considered (including the child's), what you decide is "right."
I totally agree with your findings. Very good stuff & you went through the information very thoroughly...systematically, scientifically...a lot of people do not understand research, the scientific method, findings, journals, source, credibility, reliability, evidence based practice, etc. I was so glad to see that you have good training & detected the holes in the findings & reporting, methodology, etc.
Keep up the GREAT work! God Bless! ~Rose
While the study was poorly done, we do have to be mindful that many mothers are often functioning in less than ideal circumstances where they may be single parents, the other parent may do shift work, the mother may be a full time student or work multiple jobs, the mother may be experiencing intimate partner violence, the list goes on. It is important for us to consider the health of the whole family, not just that of the baby or just the mother. No baby can thrive in an unhappy household, being parented by a completely depleted mother. For many the decision to use some form of behavioral sleep techniques in the very short term may ultimately be creating an environment that facilitates greater nurturing for the child in the long term. Most mothers are trying their best and an insistence on decrying any parenting technique without fully understanding that particular family's circumstances is unhelpful. Research is constantly evolving and the choices that were demonized 20 years ago are encouraged today and I'm sure 20 years from now everything that we thought was right today will be proven harmful. The tone of some of these comments is worrisome.
Misty, I would not define your child's occasional waking as a sleep issue, nor did I indicate such in my post. I would define a sleep issue as a child who not only adamantly fights going to bed at night, or a 2+ year old who wakes on a chronic basis like an infant would, without the instance of a medical or other common toddler occurrence ( i.e. teething, illness, etc.). My son occasionally wakes due to a dream or the need to have his diaper changed, that is not what I would consider a sleep issue.
I know numerous mothers who pull their hair out, on a nightly basis, because their children fight sleeping or sleep as if they were infants (waking every other hour). I am sorry, but a 2+ year old, should sleep (under normal circumstances) peacefully and comfortably.
I think mothers are terrified to let their babies cry for any reason due to outrageous claims by studies that state, "a crying infant will sustain brain damage." Babies cry for many reasons, some stop when held, some continue to cry. Each mother needs to learn their own child's cues, and react accordingly. Sitting up all night, holding a 6 month old, is in fact causing sleep deprivation for both mother and baby and we all know sleep deprivation is detrimental to one's health.
Everyone is jumping all over a study with no foundation that states CIO has been shown to have no ill lasting effects; however, I haven't seen a single person jump all over studies that state, "CIO causes brain damage," or "CIO is detrimental to the future mental health of the child." It is very disturbing to me that no one finds those studies, which also have no scientific basis, to be "ok."
The truth is, nobody knows anything about the effects of sleep training but in my own observations, and having used the Ferber Method, I can assure people my child does not have "brain damage," and the only lasting effects are, he sleeps and he is comfortable and feels safe while sleeping.
I'm willing to let you live your own life and raise your own kids, of course. If sleep training really did work so well for your kid -- with you right there to comfort him -- then good for you. Some kids don't magically get sleep-trained in four nights. Some kids actually DO have REAL sleep issues ... that make it impossible for them to sleep through the night. I have two of those kids. With the first one, I tried SO many things to get him to sleep through ... guess what, he's two and he still doesn't. With the second, I decided that my priority was to get as much sleep for the whole family as I could. I nurse or rock him till he's drowsy and plop him in bed, as recommended -- miraculously, that kid falls asleep! However, that doesn't stop him from waking up 45 minutes later. My kids just sleep lightly. I just make the sacrifice and help them back to sleep when they wake. Someday, they'll be old enough to switch on their bedside lamp and read a book, or get up and go to the bathroom or get a drink, all without waking me. They're just not there yet.
I'm not trying to judge what you did. It sounds like you were pretty gentle (though for all I know, that was just a brief sleep phase that would have passed on its own anyway -- I've watched those come and go a few times!). But PLEASE do not tell me that "children should not have sleep issues" and blame my children's waking on me. You were blessed with a "good sleeper" and "easy baby." I wasn't. *Crying it out does not work on members of my family.* Bad sleep can be genetic. And I don't want to let my children scream for extended periods *every night* just to prove something. No one knows for sure it's harmful -- but I think this post does show that no one has proven it ISN'T harmful.
Meghan, I agree that I think a toddler waking every hour would mean a sleep issue for our family! What I see most commonly as a doula is first-time parents with no real understanding of newborn/infant sleep. Many people (because of how obsessed our society is with STTN - sleeping through the night) don't understand that small babies have naturally short sleep patterns, so frequent night wakings are common. So in a sense, it does become a "parent issue" because if we understood that it's normal for infants to wake, we might not feel so inclined to use CIO methods. Instead, we would seek out other ways to cope with the sleep deprivation.
That said, I know that many families use modified CIO methods with older babies/toddlers with a lot of success, and as you've pointed out, no lasting damage to their brains :) As a person who is against CIO in principle, I DO recognize that it works for some families.
Psych studies are 91.7% terrible (there is a study that I have somewhere here to support that percentage :). Very many of them suffer from bad design and draw conclusions that cannot be supported by the study. Horrible. Then you have media who don't actually read the studies quoting some small part of it without caveats and before you know it, it's a fact. Disgusting, but it makes for a great parenting advice industry.
However, I do believe that the conclusion is probably right. In parenting, as in life generally, nothing much matters anyway in the long run. Truth is, most everyone ends up "average" if you try to measure, and the any mental programming is mostly dominated by societal programming rather than the parent ... in the long run. I still try though, and I must persevere in the hope that I do make a difference in this life.
My husband and I have always shared the sleep responsibility. In fact, since she was 7 weeks, he's done her bedtime. I EBF until she was just over a year and self weaned.
And you know what? The kid DID NOT SLEEP for more than a 1 hour period for 7 consecutive months. 2 hours to get her to sleep, up every hour. WELL past when she was in the infancy stage, needing to be fed around the clock. She wouldn't nap unless in motion, which left me unable to catch up on ANYTHING in the day, including sleep.
I read every damn book. We tried 100 techniques. We did everything, I was NOT going to let my baby cry!
And then, I snapped. Whether the hubs got up with her or not, I was waking up. No one was rested, not her, not me, not him. I was on mat leave (for a year YAY CANADA) and he had to work, but HE was doing a majority of the nights because I lost it. I finally caved, she was just going to have to cry because we had been parenting her to sleep for 7+ months and had nothing but frustration and exhaustion to show for it.
So, to be fair, even sometimes when you've got a really dedicated co-parenting situation, there isn't an easy solution. We did some cry it out. She cried 10 mins the first night, then STTN. It wasn't flawless, we've had many set backs but now she sleeps in until 9am most days and naps.
I get really annoyed with the anti-cry at all advocates. Sometimes, they have to cry, they just do. Or at least, in my family that's the case. She's a very happy, well adjusted and extremely smart person. I don't care about the studies, what is worse than a 7 month old who has to cry is a 7 month old who hasn't really every slept.
Even when I was working full time out of the house and my husband worked at home and set his own schedule, I still couldn't get him to wake up. Our first daughter woke every 45-60 minutes every night for 5 months. That is definitely a sleep issue! I read the "No Cry Sleep Solution" and when I started keeping a sleep log like they suggested, it just made me crazier. It was only 4am and I'd already been up 13 times when I opened the window and threw my notepad/sleep log outside.
My husband is a heavy sleeper and I'm a light sleeper. So any cry or sound would wake me. It took me longer to wake up my husband and push him out of bed than it did for me to get up and rock and nurse the baby back to sleep. If he DID drag himself out of bed, I still couldn't sleep because she would scream at him. And even if the doors were closed, I thought I heard the screaming, even when it wasn't there, like when you're vacuuming and think the phone is ringing. So I stopped bothering to even wake him. We nearly got divorced because of that, and it is the #1 reason we only have 2 kids. I wanted one more, but I knew I'd hate him SO much if I had to do that every again (work full time, come home and nurse babies and care for them, then get woken up at the minimum once per hour all night, then have to get up and do it all again the next day). He wasn't a jerk, he just slept really heavily and I didn't, and I paid for it.
We coslept with our 2nd daughter (I said if I'm the one tending to her, I get to choose how I do it), and it was better, but not great. I had to go back to work when she was only 3 weeks old, and I'd worked until the day before she was born (3 weeks late, I might add). It was hell. I am glad they are 5 and 8 now and I can try to forgot about it all. I NEVER let my kids cry it out, though, even after all that. I don't care if studies show it is fine or that it's horrible. I just couldn't do it.
The only way for me to get rest while my partner was taking care of the baby at night was for me to be in a different room in a different part of the house. I had to be somewhere that I wouldn't even hear him or the baby. Ear plugs helped too if needed.
Hello,
thank you for this very clear information!
I have a question of someone who had read this and afterwards said "but you don't have any reference of a correct study to confirm that there IS brain damage if you let them cry it out", and I don't remember where I had seen this information before, so I'm now looking for the studies/references about such studies (she gave information of studies on neglected children or on 'persistent cryers', but I would want to find back some studies about the risks of the CIO-method).
Can you help me?
Thank you very very much!!
Bianca
Bianca:
There are studies that link prolonged crying in infancy to a variety of different negative outcomes. There is a summary of them here:
http://www.askdrsears.com/topics/fussy-baby/science-says-excessive-crying-could-be-harmful
These are not specifically about cry it out, but about prolonged crying in general. Each parent will need to decide and interpret for themselves whether cry it out is "prolonged crying" and could have those negative consequences. I believe that it does have the potential to be harmful both to the baby's brain and development, as well as to the parent-child relationship. I also feel that it is disrespectful of the child's needs. Those are http://www.phdinparenting.com/2008/07/05/no-cry-it-out/" rel="nofollow">some of the reasons why we do not use cry it out in our home.
Other parents will have to read the research (or not) and come to their own conclusions. More on that here: http://www.phdinparenting.com/2008/08/11/cry-it-out-cio-is-it-harmful-or-helpful/" rel="nofollow">Cry It Out: Is It Harmful or Helpful?
Thank you so much, I'll read them tomorrow (it's 11 pm now here, time for me to get some sleep :-)).