For Getting Baby to Sleep, Sticking to a Plan Is What Counts

By DAN HURLEY
Published: December 12, 2006

After years of colicky debate over which method is best for getting babies to fall asleep by themselves, experts have a soothing new message: just about all the techniques work, so pick one you are comfortable with and stick with it.

Despite their apparent differences, most of the behavioral approaches reviewed in the October issue of the journal SLEEP were supported by evidence that they resulted in infants and toddlers learning to fall asleep independently at bedtime and when they woke during the night. Of the 52 studies examined in the review, 49 showed positive results, with 82 percent of the infants and young children in the studies benefiting significantly.

“The key to this whole thing is parents being consistent,” said the senior author of the review, Dr. Jodi A. Mindell, a psychology professor at Saint Joseph’s University in Philadelphia and chairwoman of the task force organized by the American Academy of Sleep Medicine to assess the techniques.

She added, “They need to pick a plan they can absolutely follow through on.”

Even Dr. Richard Ferber of Children’s Hospital Boston — so strongly linked in the popular imagination with the so-called cry-it-out method that it has come to be known as “Ferberizing” — agreed in an interview that no single approach worked for all children.

“Clinicians should try to make a diagnosis for a given family as to why that youngster is having problems, and then try to tailor the choice of treatment to fix that problem,” he said. “When an intervention is chosen that works not only for the child’s problems but for the family’s philosophy of child-rearing, it’s going to work that much better.”

Still, some methods in Dr. Mindell’s review were supported by stronger evidence than others. The strongest evidence was found for the toughest and the easiest approaches.

Perhaps not surprisingly, the easiest option is preventing sleep problems in the first place, through simple parent education, whether one-on-one training, group classes or booklets. Such programs typically encourage parents to have a peaceful, consistent evening routine in which children are placed in bed “drowsy but awake” to help them develop independent sleep skills. Three well-designed randomized trials have found that the babies of parents who had such training slept significantly better than those whose parents did not.

At the tough extreme is the cry-it-out method, formally known as “unmodified extinction,” in which parents are taught to put a child down for bed, close the door and ignore all crying unless the baby is in physical distress. Despite 23 studies showing its remarkable effectiveness, most parents find the technique too emotionally grueling, the task force found.

Dr. Ferber, despite his link to the technique, said he rarely used it.

“It’s not a pattern that most parents will do,” he said.

Instead, he said he relied on a variety of gentler approaches, including one called graduated extinction. Rather than entirely ignoring a child’s cries, the method teaches parents to briefly check on the child on a regular schedule, staying for just a couple of minutes. Each night, the time between the visits grows longer, until the child learns to fall asleep independently. The task force called the approach an “effective and recommended therapy.”

For all their effectiveness, all the methods reviewed by the task force defined success as having children fall asleep independently. And no matter how gentle the technique, once children become accustomed to falling asleep in the presence of a caregiver, they almost always respond tearfully to being left alone — for at least three to five nights.

And there’s the rub.

“It’s not a lot of fun for parents,” said Dr. Ralph Downey III, director of the Sleep Disorders Center at Loma Linda University in California.

“The child acts like it’s the end of the world,” he said. “Nobody wants to see their child suffer. The biological blueprint in us says we need to be there, to comfort and soothe them.”

Still, Dr. Mindell argues that it’s worth it. “What parents really need to focus on is the big picture,” she said. “In the end, you’ll have months and years of everyone sleeping through the night and functioning better through the day.”

The only popular method not reviewed by the task force was co-sleeping, in which children sleep in the same bed with parents, because Dr. Mindell’s team could find no scientific studies of the approach. Although many experts support the method, so long as parents are happy with it, the American Academy of Pediatrics advises against the practice because it raises the risk of sudden infant death syndrome, or SIDS.

The Academy also urges parents to put their infants to sleep on their backs on a firm surface to reduce the risk of SIDS, though sleeping belly down is not the only risk factor for the syndrome. A recent study in the Journal of the American Medical Association found that many babies who die of SIDS have a defect in the portion of their brain that controls breathing, heart rate and arousal.

Co-sleeping also raises the risk of a parent’s unintentionally smothering a baby. A report released last year by Betsey Gotbaum, Public Advocate of New York City, found that 15 children, all less than a year old, died in New York in 2004 while co-sleeping with a caregiver who accidentally rolled over on them or wedged them against the wall.

Despite the risks, Dr. Ferber came out in support of co-sleeping, for parents who prefer it, in the latest edition of his book, “Solve Your Child’s Sleep Problems” (Fireside, 2006). “To me, whether a family chooses to co-sleep should be their decision, and we work with them either way,” he said.

One of the most prominent advocates of co-sleeping, Dr. Robert Sears, who co-authored “The Baby Sleep Book” with his father, mother and brother, is a strong critic of “cry-it-out” methods. “We’re all for routines and consistency, so long as the baby isn’t left to cry it out alone,” Dr. Sears said in a telephone interview from his family’s pediatric clinic in Capistrano Beach, Calif.

“Certainly most methods do work, no matter how harsh it is on the baby,” he said. “But what happens to these babies left to cry it out for hours, if not weeks on end? What kind of trauma is inflicted on the babies, and what is their psychological and emotional makeup 3, 5, 10 years down the road?”

In fact, longterm studies have shown that children who never learn how to fall asleep independently are at increased risk of continuing sleep problems as they grow up, Dr. Mindell said.

Even on a short-term basis, the task force reported, “Infants who participated in sleep interventions were found to be more secure, predictable, less irritable and to cry and fuss less following treatment.”

While teaching a child to sleep independently can be emotionally wrenching for all those involved, Dr. Mindell said, “Parents need to understand that they’re not doing it for selfish reasons. Their children benefit greatly.”

http://www.nytimes.com/2006/12/12/health/12sleep.html