Some parents believe that “sleep training” is the key to getting a good night’s sleep. Others argue that it is upsetting to babies. What do scientists think about its risks and advantages?

Wendy Hall, a paediatric sleep researcher based in Canada, studied 235 families with babies aged six to eight months in 2015. The goal was to see if sleep training was effective.

Sleep training, in its broadest sense, refers to any strategy used by parents to encourage their babies to sleep at night, which can be as simple as establishing a nighttime routine or learning how to read an infant’s tiredness cues. Such suggestions were an important part of Hall’s intervention.

So was a strategy that has become commonly associated with “sleep training” but is far more divisive: encouraging babies to put themselves to sleep without their parents’ help, including when they wake up in the middle of the night, by limiting or changing a parent’s response to their child. This could indicate that a parent is present but does not pick up or nurse the baby to physically soothe them. It can involve a baby being left alone for set periods of time, punctuated by parent check-ins. Alternatively, in the cold-turkey approach, it may imply leaving the baby and closing the door. Any of these approaches often mean letting the baby cry – hence the common, if increasingly unpopular, moniker “cry-it-out”.

In general, “training” babies to sleep alone and unaided is uncommon. Modern Mayan mothers, for example, expressed surprise when they learned that babies in the United States were placed in a separate room to sleep. However, many families in North America, Australia, and parts of Europe swear by some variation of the technique. When broken nights begin to affect the entire family’s well-being – for example, poor baby sleep is associated with maternal depression and poor maternal health – parents may be especially willing to give it a try. In the US, more than six in 10 parenting advice books endorse some form of “cry-it-out”. Half of parents polled in Canada and Australia, and one-third of parents polled in Switzerland and Germany, said they’d tried it (although the surveys are not necessarily representative of parents as a whole in these countries, due to the way they were conducted). An entire industry is dedicated to assisting parents in sleep training.

In their study, Hall and her team predicted that the babies whose parents were given instructions for sleep training along with advice would sleep better after six weeks than those who were not, with “significantly longer longest sleep periods and significantly fewer night wakes”.

This would be consistent with previous findings. Dozens of studies have found sleep interventions to be effective; paediatricians in countries such as the United States and Australia routinely recommend sleep training (although infant mental health professionals often do not). However, research is never perfect, and many of the previous studies had drawn criticism, which Hall hoped to address.

For one thing, few studies on sleep training have met the gold standard of scientific research: trials in which participants are randomly assigned to receive the intervention, have a control group that did not receive the intervention (especially important in sleep research, because most babies naturally sleep in longer stretches over time), and have a sufficient number of participants to detect effects.

Relatively few studies on sleep training have met the gold standard of scientific research

A number of studies, for example, have been non-randomised, with parents making their own treatment decisions. This makes establishing cause and effect difficult. For example, parents who believe their babies will only cry briefly (or not at all) before falling asleep may be more open to trying out controlled crying in the first place, which may skew results to make it appear more effective than it is. Alternatively, it is possible that parents whose babies struggle to fall asleep on their own are more drawn to the method, making it appear less effective than it is. And, of course, one of the challenges of researching something like sleep training is that, even in a randomised trial, A “perfect” study is impossible to set up because parents assigned to a controlled crying method may decide against it. Many trials have high drop-out rates, which means that parents who struggled with sleep training may not see their experiences reflected in the results.

Meanwhile, most studies rely on “parent report,” such as questionnaire responses or sleep diaries kept by parents, rather than an objective measure to determine whether a baby is awake or asleep. However, if a child has learned not to cry when he wakes, his parents may also not wake, leading them to report that their child slept through the night regardless of what happened.

There’s also the issue of confirmation bias: if parents expect an intervention to improve their child’s sleep, they’re more likely to see that child’s sleep improving after the intervention.

Hall’s study, which included 235 babies and their parents, was intended to address some of these criticisms. In a randomised controlled trial, half of the parents were taught “graduated extinction,” “controlled comforting,” or “controlled crying”: soothing a crying baby for short increments, then leaving them for the same amount of time, with intervals gradually increasing regardless of the child’s response. The researchers advised parents who were “really uncomfortable” leaving their crying child alone in the room to stay in the room – However, instead of picking up the child, a method known as “camping out” is used.

The intervention group also received infant sleep tips and information, such as debunking the myth that fewer naps lead to more nighttime sleep. (It’s worth noting that this combination of a controlled crying method and other advice is common in sleep training studies, but it makes it more difficult to determine which, if any, results are due to the controlled crying alone.) The control group parents were given information about infant safety to ensure that both groups received some kind of instruction.

Hall’s study included actigraphy, which uses wearable devices to monitor movements to assess sleep-wake patterns in addition to asking parents to keep sleep diaries.

When the researchers compared sleep diaries, they discovered that sleep-trained parents believed their babies woke less at night and slept for longer periods. When they examined the sleep-wake patterns revealed by actigraphy, they discovered that the sleep-trained infants awoke just as frequently as the control group. “At six weeks, there was no difference in mean change in actigraphic wakes or long wake episodes between the intervention and control groups,” they wrote.

In other words, parents who sleep-trained their children believed their children were sleeping less. However, according to the objective sleep measurement, the infants were waking up just as frequently – they were just not waking up their parents.

SAM

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