Sleep training

Should I train my baby to sleep?

Sleep training means not responding (let-them-cry-it-out) or delaying the response, to the baby’s crying with the aim of having the baby sleep longer. Delaying breastfeeding through the night may make a baby sleep longer, but it can cause problems for babies and mothers. The American Academy of Pediatrics has raised concerns that babies whose caregivers followed the advice of one of the let-them-cry-it-out books were at an increased risk of dehydration, slow growth, and slow development. If a baby is sleeping more than five hours at a time during the first year, caregivers need to consider the risks and monitor the baby’s growth.

A) How to manage the baby’s sleeping patterns

Caregivers need to consider their culture and expectations, their approaches to night waking, their baby’s temperament, and average baby sleeping patterns. Western cultures in particular expect that babies should sleep through the night and sleep independently (Mindell 2010). These expectations can be unrealistic and result in stress for caregivers (Mileva-Seitz 2017).

If a breastfed baby is sleeping more than five hours at a time and is under one year of age, it is important to ensure the baby is getting enough milk

B) Describing sleep training

One approach to the baby waking at night is sleep training, which involves varying degrees of not responding to a baby’s signs and cries with the aim of having babies sleep longer, even through the night. The let-them-cry-it-out approach is the most extreme version. Others involve delays in comforting or feeding the baby.

Studies show that sleep interventions before six months (Douglas 2013; Santos 2019):  

  • Did not decrease overall crying.
  • Did not prevent sleep and behavioral problems in later childhood.
  • Did not protect against postnatal depression.

Some studies show sleep training is effective but do not differentiate between breastfed and infant formula-fed babies nor measure its impact on breastfeeding (Mindell 2006). 

C) The risks of sleep training

1) Underfeeding the baby

The American Academy of Pediatrics found that some breastfed babies whose caregivers followed the advice of one of the let-them-cry-it-out books suffered from the following (Aney 1998):

Delaying breastfeeding and creating long night sleeps can cause many problems for babies and mothers. We have seen this repeatedly in our clinic.

2) Increasing the baby’s stress

Rather the evidence indicates that babies do not respond well to neglect and will cry and become stressed when put down. Because they are born relatively immature, they need frequent contact with their caregivers. Excess stress can have long-term negative effects. Not surprisingly, responding to the baby’s needs can have beneficial long-term effects (Feldman 2007).

One study showed that on Day 3 of sleep training, the babies no longer cried when put to sleep but their stress hormone (cortisol) level remained high. Sleep training also resulted in the mother’s and baby’s hormone levels no longer rising and falling together (Middlemiss et al. 2012). Another study did not find this effect (Gradisar 2016).

D) The sleep industry

Many caregivers are concerned about their baby’s sleep patterns and not surprisingly, there are many books, websites, and devices which, for a price, advertise quick solutions. One study showed that mothers who followed the advice of baby care books that promote strict routines were less likely to breastfeed, sleep in the same room as their babies, cuddle their babies, or respond quickly to the baby’s cries (Harries 2019).

Some people have started businesses as sleep coaches, providing services in person, by phone, or over the internet. A review of sleep coaches showed a remarkable range of education and training. One survey found that few sleep coaches are licensed health-care providers (Ingram 2016). There are also concerns that there is (Mindell 2016):

  • No standard of care or definition of the scope of practice.
  • No certification process.
  • Limited evidence supporting various practices.

E) Sleep routines

Responding to the baby’s needs helps them to reduce stress and establish their sleep cycles. Calming routines at bedtime may also support this (Philbrook 2014). Routines may include (Kelly 2013; Mindell 2017):

  • Quiet activities before bedtime
  • Washing or bathing
  • Reading and talking
  • Listening to calming music
  • Touching through cuddling or rocking
  • Breastfeeding

Around six months healthy snacks can be added to the routine. Once teeth are present, they should be brushed before bed.

Children who can talk can express their concerns and understand direction and limits regarding bedtimes.

References

Aney M. "Babywise' advice linked to dehydration, failure to thrive. AAP News Apr 1998 Apr; 14(4): 21
 
Douglas PS, Hill PS. Behavioral sleep interventions in the first six months of life do not improve outcomes for mothers or infants: a systematic review. J Dev Behav Pediatr. 2013 Sep;34(7):497-507
 
Feldman R. Parent–Infant Synchrony: Biological Foundations and Developmental Outcomes. Current Directions in Psychological Science. 2007:16(6);340–345

Gradisar M, Jackson K, Spurrier NJ, et al. Behavioral Interventions for Infant Sleep Problems: A Randomized Controlled Trial. Pediatrics. 2016 Jun;137(6):e20151486
 
Harries V, Brown A. The association between baby care books that promote strict care routines and infant feeding, night-time care, and maternal-infant interactions. Matern Child Nutr. 2019 Jun 19:e12858
 
Ingram DG, Mindell JA, Puzino K, et al. A Survey of Practicing Sleep Coaches. Behav Sleep Med. 2016 Jun 30:1-12
 
Kelly Y, Kelly J, Sacker A. Changes in bedtime schedules and behavioral difficulties in 7 year old children. Pediatrics. 2013 Nov;132(5):e1184-93
 
Middlemiss W, Granger DA, Goldberg WA, et al. Asynchrony of mother-infant hypothalamic-pituitary-adrenal axis activity following extinction of infant crying responses induced during the transition to sleep. Early Hum Dev. 2012 Apr;88(4):227-32
 
Mileva-Seitz VR, Bakermans-Kranenburg MJ, Battaini C, et al. Parent-child bed-sharing: The good, the bad, and the burden of evidence. Sleep Med Rev. 2017 Apr;32:4-27
 
Mindell JA, Kuhn B, Lewin DS, et al.; American Academy of Sleep Medicine. Behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep. 2006 Oct;29(10):1263-76

Mindell JA, Owens JA, Babcock D, et al. Child Sleep Coaches: Current State and Future Directions. Clin Pediatr (Phila). 2016 Nov 20
 
Mindell JA, Sadeh A, Kohyama J, et al. Parental behaviors and sleep outcomes in infants and toddlers: a cross-cultural comparison. Sleep Med. 2010 Apr;11(4):393-9
 
Mindell JA, Williamson AA. Benefits of a bedtime routine in young children: Sleep, development, and beyond. Sleep Med Rev. 2017 Nov 6
 
Philbrook LE, Hozella AC, Kim BR, et al. Maternal emotional availability at bedtime and infant cortisol at 1 and 3 months. Early Hum Dev. 2014;90(10):595–605

Santos IS, Del-Ponte B, Tovo-Rodrigues L, et al. Effect of Parental Counseling on Infants' Healthy Sleep Habits in Brazil: A Randomized Clinical Trial. JAMA Netw Open. 2019 Dec 2;2(12):e1918062