Behavioural intervention: infant sleep problems and maternal mood
One-third to one-half of Australian parents report a problem with their infant’s sleep in the second 6 months of life.
A brief sleep intervention based on teaching parents techniques of ‘controlled crying’ or ‘camping out’.
With controlled crying, parents respond to infant’s cry at increasing time intervals, allowing the infant to fall asleep alone.
Parents sit with infant until infant falls asleep and gradually reduce their presence over a period of 1–3 weeks.
Infants aged 6–12 months with severe sleep problems according to parents. Problems include waking more than 5 nights a week, waking more than 3 times a night, taking more than 30 minutes to fall asleep or requiring parental presence to fall asleep.
Infants with sleep problems are more likely to sleep in the parental bed, be nursed to sleep, take longer to fall asleep, and wake for often and for longer periods.
The presence of an infant sleep problem is a strong predictor of maternal depression.
Infant sleep problems and postnatal depression are both associated with increased marital stress, family breakdown, child abuse, child behaviour problems and maternal anxiety. Postnatal depression can adversely affect a child’s cognitive development.
Behavioural sleep techniques have no marked long-lasting effects (positive or negative) on children.
Behavioural sleep interventions can be delivered in a primary care setting by GPs or practice nurses. Training is required (refer to Training).
Parents attend two or three private sessions with a healthcare professional trained in infant sleep intervention.
Session 1. Education and choice of intervention
Discuss normal sleep cycles, the learned behaviours of sleep (eg falling asleep independently, settling after night waking) and how factors that reinforce sleep problems can be eliminated with appropriate behavioural interventions.
Give parents a choice of intervention (controlled crying or camping out) and techniques to manage other factors that affect infant sleep such as bedtime routine, weaning off overnight feeding and dummy use during the night.
Provide the parents with a sleep management plan, information about the development and management of sleep problems and a sleep diary to monitor progress.
Session 2: Follow-up after 2 weeks
Warn parents about ‘extinction bursts’. This is a burst of behaviour that happens 2–4 weeks after the behaviour was extinguished. This occurs in about 20% of infants and takes the form of infants waking again overnight in the absence of an explanation (eg febrile illness).
Advise parents to manage this by re-instating their chosen behavioural technique; infants typically settle back to their good sleep habits after a few nights.
If the sleep problem has not improved, consider possible reasons, such as:
- behavioural technique not being correctly implemented
- parent disagreement about how to manage sleep problem
- maternal or paternal depression.
Tips and challenges
The behavioural intervention is acceptable to parents and reduces the need for other professional sleep services.
Techniques are effective at reducing the short- to medium-term burden of infant sleep problems and maternal depression. While the intervention has shown no long-term (5-year) effect on children, there is a prolonged reduction in maternal depression (2 years).
In choosing between camping out and controlled crying, you should consider the impact of each on the parents.
This intervention is not recommended for use in infants under 6 months of age
Infant Sleep eLearning Program: designed for health professionals and parents to help babies aged six months and older learn to sleep during the day and overnight.
Register via Murdoch Childrens Research Institute (hyperlink 'Murdoch Childrens Research Institute' https://mcri.learnupon.com/store/35721-infant-sleep-elearning-program?tab=1
NHMRC Level 1 evidence
- Hiscock H, Wake M. Randomised controlled trial of behavioural infant sleep intervention to improve infant sleep and maternal mood. BMJ, 2002;324(7345): 1062–5.
- Hiscock H, Bayer J, Gold L, Hampton A, Ukoumunne O, Wake M. Improving infant sleep and maternal mental health: a cluster randomised trial. Arch Dis Child, 2007;92: 952–8.
- Price A, Wake M, Ukoumunne O, Hiscock H. Five-year follow-up of harms and benefits of behavioral infant sleep intervention: randomized trial. Pediatrics, 2012;130: 643–51.
The RACGP gratefully acknowledge the contribution of Associate Professor Harriet Hiscock in the development of this intervention.
First published: May 2014