Preventing and Managing Infant Sleep Problems

Author: Ian St. James-Roberts, PhD, FBPsS

baby sleeping

Ever since Dr Benjamin Spock’s 1946 book on baby and child care, parents have been faced with conflicting advice about the benefits and costs of ‘strict’ versus ‘permissive’ parenting. On one side, parents are told that the use of routine-based care by parents from the early days of infancy is the secret to producing satisfied parents and a happy baby. On the other hand, writers who recommend ‘infant-demand’ parenting (always responding to the infant), have claimed that parents can avoid crying and sleeping problems by following natural instincts to respond quickly, to feed in response to the babies’ cries, and to hold and sleep with them.

Focusing on infant sleeping problems, two pieces of the evidence summarized earlier (in the section ‘What Do we know About Infant Sleep Problems?’) are critical for providing parents with understanding, guidance and things to try:

It follows that parents do not need to adopt one particular form of care because it is ‘correct’ or because the alternatives will harm their baby. It is not the case that parenting approaches such as cuddling a baby to sleep are medically ‘wrong’ or ‘right’. Rather, parents need to choose the form of parenting which fits their values, needs and circumstances best.

Once it is realized that these parenting decisions do not involve sick or abnormal infants, this allows the parents’ social and cultural ways of doing things to be more positively considered. For example, it is easy to understand why a baby who wakes his/her parents at night is a greater problem when both parents have to get up early and work office hours, compared to a situation where parents can adjust their sleep-waking schedules to suit their baby’s behavior. To a degree, an infant waking up in the night is a problem because of the constraints jobs and other responsibilities impose on many parents. Also, to a degree, what the parents believe is normal, or their families and friends believe is normal, can influence how much of a problem the parents think their infant waking up at night can be.

"If parents lack support from others or experience depression, 
this can also affect a parent’s ability to cope with night waking."

In summary, choices about parenting techniques need to be based on parents’ values and circumstances, as well as on the evidence about the likely effects of using different parenting methods, described below, when dealing with infant night waking. These principles translate into the following advice, guidelines and things to try to prevent infant sleeping problems.

Parenting methods which involve lots of carrying and close physical contact between parents and babies, along with a lot of parental responsiveness to infant signals (sometimes called ‘infant-demand’ care) are valued by some parents because they allow close relationships between parents and their infants. Parents may also want to use this kind of parenting in the first few weeks of infancy because it can minimize crying at this age.

Currently, both the American Academy of Pediatrics and the Canadian Paediatric Society recommend that parents should not bed share with infants. It is a good idea to read their statements in which the available evidence for this recommendation is presented. There are a number of reasons for this recommendation. Some professionals advise against bed-sharing on the grounds that parents may lie on their babies and cause SIDS (Sudden Infant Death Syndrome, where an infant dies for unexplained reasons). It is now well known that settling babies to sleep on their backs (rather than tummies) can make SIDS less likely. Sometimes, factors often associated with bed-sharing, rather than bed-sharing itself, may be the true risk factors for SIDS. However, bed-sharing after parents consume alcohol or illicit drugs, or sleeping with an infant on a soft surface such as a sofa, should certainly be avoided.

Although it is not a safety issue, it is known that bed-sharing after the first few weeks of age may lead the infant to continue to wake up and signal during the night. Although the evidence is less clear, bed-sharing may also make it more difficult to persuade an infant or young child to leave the parents’ bed and sleep alone at older ages. We do not yet know why this happens in some cases but not others.

If parents wish to prevent their infant from waking and signaling in the night after 3-4 months of age, there is evidence that using ‘structured’ parenting from about 6 weeks of age is likely to help. This form of parenting is described below. Unfortunately, (as noted in the section: ‘What Do We Know About Infant Sleep Problems?’) the evidence in support of this approach is not yet conclusive, so that parents will need to use their judgment, as well as the evidence, when deciding what to do.

The evidence itself comes from four separate carefully controlled studies, each of which found that ‘structured’ parenting methods increased the numbers of infants who remained settled at night by 3-4 months of age. Because these studies were carried out separately by different research groups, it is most unlikely that their findings were due to poor research methods. An important advantage is that this approach was effective with breastfed infants and that, unlike ‘controlled crying’ methods used to treat infant sleeping problems after they have arisen, it does not involve leaving babies to cry for long periods.

Unfortunately, two recent studies have not been able to confirm these findings in general health service settings. That may be due to the practical difficulties involved in research of that kind, but we do not yet know the reasons. Recently, too, a review of the evidence has drawn attention to the possibility that early use of structured parenting methods may have unintended consequences, including increased infant crying, premature stopping of breast-feeding, and parental anxiety. The review raised concerns about those possible outcomes rather than proving they would happen, while there is certainly evidence that infant sleep problems can distress infants and parents. But, even the possibility that steps to prevent them might give rise to poor outcomes needs to be taken seriously.

One thing both the review and studies agree on is that there is no evidence to support the use of structured parental care in the early weeks after birth. For instance, the largest of the research studies found that structured parenting had no effect on infant night-time behavior before infants were 6 weeks of age. Since other studies have found infant-demand parenting to lessen infant crying during these early weeks, as well as helping to establish breast-feeding, that is clearly preferable at this early age.

The remaining question is whether the potential benefits of moving towards a more structured form of parenting after six weeks of age (that is, settled infant night-time behavior at an early age) outweigh the possible disadvantages - and, if so, the best age to introduce this change. Until the research provides a clearer answer, parents will need to make choices which take their baby’s age, individual development and vulnerability, and their own circumstances and priorities, into account. If they are unsure, seeking guidance from a health service professional may be helpful. Where parents choose to introduce structured parenting methods after six weeks of age, the three steps found to be effective in reducing night waking and signaling at three months of age are given below.

The three steps found to be effective in more than one study:

This section of the website was revised in December 2013 to include recent research evidence.