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