Randomised controlled trial of behavioural infant sleep intervention to improve infant sleep and maternal mood

BMJ 2002; 324 doi: http://dx.doi.org/10.1136/bmj.324.7345.1062 (Published 4 May 2002)
Cite this as: BMJ 2002;324:1062

Recent rapid responses

Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on bmj.com. Although a selection of rapid responses will be included as edited readers' letters in the weekly print issue of the BMJ, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window.

Displaying 1-8 out of 8 published

9 October 2005

I read about CC in pregnacy, felt totally against it. Decided to parent my son in the most natural way possible. co sleeping, breastfeeding on demand etc. However, at 4 months he was waking every hour - he did this for 6 weeks, in the previous weeks it had been every hour and a half.I was totally exhausted. Even feeding him to sleep wasn't working anymore. I tried "no cry' methods, then finally gave in to cc, with much heartfelt regret. That was 3 days ago. He slept 9 hours last night - straight. Am I damaging him? I sincerely hope not. Was this a last resort? absolutely. I know how it shocks people who haven't been in a position of needing it so badly. I still worry.

Competing interests: None declared

Competing interests: None declared

Elizabeth J Austin, midwife IBCLC

at home mother

Click to like:

Pampering is giving into demands for the latest playstation game, not providing a baby with it's basic need for a parent! Just because it's nighttime doesn't mean my job as a Mum ends. To be honest i'm quite surprised that using cc doesn't contribute to parental depression because leaving my children to cry would be agony for me and certainly depressing. Fighting what comes naturally to a Mum can't be good for anyone, certainly not the baby. When left to cry they believe they have been abandoned and shut up to conserve energy, not a nice way for a baby to end the day. There's no need for such measures. Once i got my head around the idea a baby needs to wake and feed at night it wasn't a problem anymore, perfectly normal. We coslept, I got lots of sleep and when my son reached 18 months he decided himself it was time to sleep in his brother's room all through the night. No stress and no upset, just the way it should be. There is no need to train babies, they know what's good for them (breastmilk and cuddles) so trust them and go with it. It certainly doesn't lead to a "spoilt" child. If anything they end up confident and independant as they are secure in the knowledge that you are there if they need you.

Competing interests: None declared

Competing interests: None declared

Tracy Hayden, Mum


Click to like:

Hiscock and Wake's study (1) is fascinating for what it fails to reveal as much as for what it shows. I would have expected the behavioural intervention to be as least as effective, if not more effective, in the subgroup without post-natal depression, because I would expect this group to be more capable of implementing it. However only the subgroup where mothers had an Edinburgh score >10 showed a statistically significant improvement in resolution of infants' sleep problems at two months (absolute risk reduction, 95%CI: 39%, 18%-61%). This is a most curious finding, and raises the question of what exactly was going on here?

The intervention required a social interaction to occur in the intervention group, while the control group merely received an information sheet. It is possible, therefore, to attribute the improved outcome in the intervention group to the fact that they participated in a social interaction focussed on the perceived problem rather than to the intervention per se. It is not possible to decide from the information we were given which interpretation is correct. The outcome itself, "maternal report of an infant sleep problem (yes or no)", was subjective. Following the intervention depression improved faster than in the control group. One interpretation of this is that the interaction was therapeutic for them. The reported improvement in infant sleep could have been in their perception of it - or the infants could have started sleeping better because their mothers were no longer depressed. Once again, however, it is not possible to decide which interpretation is correct.

The key to understanding the problem lies in the methodology, which was positivist and reductionist (2). The human experience under investigation was reduced to a symptom score to determine the presence or absence of postnatal depression, and maternal reports of an infant sleep problem. This was necessary in order to subject the outcomes to statistical analysis. Randomised controlled trials require interventions to be precisely defined and reproducible, and for the outcomes to be clearly and unequivocally measurable. The positivist assumptions underlying them require, so far as possible, the elimination of bias at every stage. This study cannot fulfil these requirements because both the intervention and the outcome are socially constructed and therefore impossible to control tightly or measure reliably.

We are therefore in the uncomfortable position of having a study that demonstrates an effect following the use of a particular intervention in a particular group of people, but without any certainty as to exactly what the effect was, or what it was in the intervention that caused it. The lack of effect on infant sleep where mothers had an Edinburgh score >10 suggests that the improvement in the depressed subgroup was related to the effect on the mothers' depression. However, as Perl points out (Rapid Responses, 15th May), some aspects of the intervention could cause distress or harm, so we should be careful before using it in practice. Further studies are needed to evaluate the effects of addressing maternal depression as the main intervention, and should include qualitative work in order to understand the experience of these families. Where therapeutic interventions and outcomes are complex and socially constructed it is unsafe to rely on randomised controlled trials alone to determine their effects and effectiveness.

Toby Lipman

1. Hiscock H, Wake M. Randomised controlled trial of behavioural infantsleep intervention to improve infant sleep and maternal mood. BMJ 2002;324:1062-5. 2. Guba EG, Lincoln YS. Competing paradigms in qualitative research. In: Denzin NK, Lincoln YS, editors. Handbook of qualitative research. 1st ed. Thousand Oaks: Sage; 1994. p. 105-117.

Competing interests: None declared

Toby Lipman, General Practitioner

Westerhope Medical Group, Newcastle upon Tyne, NE5 2LH

Click to like:

Crying is one of the main ways which babies have available to signal their needs and experience to their parents. An important aspect of the mother-child relationship is for the parental figure to help the infant manage anxieties (the mother's task is to metabolize these for baby and re -present them in a digested and more manageable form). So the mother ideally demonstrates that she understands why the child is crying, and sensitively and appropriately responds to the need (which may or may not involve picking up a baby who cries). This gives the infant the experience of a benevolent world where s/he can feel safe as opposed to feelings of fear and despair where there is a lack of containment.

Responding to crying in early infancy has been shown to have a satisfying effect that enables babies to cry less (Bell and Ainsworth, 1972, in Dilys Dawes. Through the Night. Free Association Books, London, 1989).

Training mothers to use a "controlled crying" intervention encourages mothers to respond to the behaviour rather think about the underlying issues. Seeing crying as a behaviour that can be extinguished in no way addresses the function of the expression. Giving depressed mother's permission to ignore their baby's crying signals is a very misleading intervention for women who often need help responding to their babies.

Competing interests: None declared

Catherine Mathews, Epidemiologist

Cheryl Baker

South African Medical Rearch Council, PO Box 19070, Tygerberg, 7505, South Africa

Click to like:

Re:Hiscock, H. and Wake, M.: Randomised controlled trial of behavioural infantsleep intervention to improve infant sleep and maternal mood BMJ 2002;324: 1062-5

Disclaimer: No competing interests.

Dear Editor,

Hiscock andWake’s (1) approach to mother-infant pairs in general and to their sleep concerns in particular raises more questions than it answers. As a parent, I am shocked at the degree of insensitivity towards infants' feelings- key participants in the study who could neither consent to nor decline the intervention that must have been painful to them. Did noone ever wonder what a baby would like? Should babies be treated like commodities? The interventions proposed could be considered cruel and unusual punishment for helpless and innocent individuals. As an obstetrician, I am surprised no concept of bonding between mother and child ever entered the discussion (6). As a breastfeeding expert, not finding any mention of breast feeding despite the fact that “6-12 months old” infants were the subjects of the intervention, makes me wonder what the authors' concept of “normal infant development” really entails. Nor was there any concern what the interventions would do to the continuation of breastfeeding- or to the relationship between parents and child.

As a German, I am unhappy to find fairly undiluted ideas of militaristic nazi infant care (2,3) uncritically repeated by these Australian care providers. The nazis undderstood very well the crucial effect of letting young babies cry on their future development and made this a central theme in their child care. As a scientist, I find it hard to believe that all of the results of mother-infant sleep research of the 1990’s (4,5) completely escaped theauthors’ notice.

Would there be any infant sleep problems if we accepted that under one year olds expect to sleep in someone’s arms, at least most of the time, and have free access to their mother’s breast, at least most of the time?

Incidentally, this would also deal with most postpartum depression and increase mothers’ sense of capable mothering.

What can we learn from Hiscock and Wake’s study? That it is high time we stopped conceptualizing infants as dumb and insensible chattels and instead began respecting them as competent persons fully equipped after millions of years of human development with the capabilities of managing what would be optimal environment for them: a fully breastfeeding and cosleeping mother for most of their first year of life- if we are only prepared to stop and listen to them.

There is no reason why this simple and inexpensive “intervention” cannot be introduced at any time thereafter when it proves important to the infant. There is no need to stage a war at the beginning of life- unless this were our goal (2).

F. M. Perl, M.D., D.R.C.O.G.
Consultant Obstetrician and Gynaecologist
Co-Editor of “Frauen-Heilkunde und Geburts-Hilfe“ (Schwabe Verlag Basel) and of „Stillen – evidenzbasiertes Textbuch für Ärzte“ (Deutscher Ärzteverlag Köln).

1. Hiscock,H., Wake, M.: RCT of behavioural infant sleep intervention to improve infant sleep and maternal mood. BMJ 2002; 324: 1062-5.

2. Chamberlain, S.: Adolf Hitler, die deutsche Mutter und ihr erstes Kind. Über zwei NS-Erziehungsbücher. Psychosozial-Verlag Giessen, 1997. ISBN 3-930096-58-7.

3. Dill, G.: Nationalsozialistische Säuglingspflege. Einefrühe Erziehung zum Massenmenschen. Enke Verlag Stuttgart 1999. ISBN 3 43230711 X.

4. McKenna, J.J. , Bernshaw, N.J.. Breastfeeding and infant-parent co -sleeping asadaptive strategies. In: Breastfeeding: Biocultural perspectives. Stuart-Macadam P. Dettwyler, K. eds. Aldine de Gruyter New York 1995 ISBN0-202-01192-5.

5. Mosko,S. McKenna, J., Dickel, M., Hunt, L.:Parent-infant co- sleeping: the appropriatecontext for the study of infant sleep. Journal of Behavioral Medicine 1993; 16:589-610.

6. Klaus, M.H., Kennel, J.H.: Parent-infant bonding. Mosby Co. St. Louis 1982.

Competing interests: None declared

Friederike M. Perl, Consultant Obstetrician GYnaecologist

WOmen's HOspital

Click to like:

I've found your article of interest, because as a professional, I observe children with sleep pattern disturbances, which are attributed to the parent's depression/stress factors. I agree with your article that the family breakdown is sensed by the child, therefore rendering the child with the inability to relax & sleep. Upsetting environmental factors cause the child discord which is projected downward from the parent. In my opinion, until the family is relieved of its stressors, depressions, or other underlying factors, the family's sleep pattern disturbance will prevail. Assist the parents with their needs & I believe the child will innately sense security & sleep will be restored.

Competing interests: None declared

Diane Driscoll

Click to like:

As an independent researcher, I found the article/paper fine and interesting. The primary feature of intelligence is perception and responses to external or internal situation and crying is a form of response, especially that of infants and children.

Due attention is needed in cases of crying of children, due to colic, severe thirst or hunger, heat or cold, insect bite, bedwetting etc., In other cases, generally children cry and stop, if left on their own. If such crying is stopped by cuddling or breast feeding, it amounts to pampering and they tend to become dependent on various forms of pampering throughout life, which is the problem of mankind all over.

For those interested, details of my finding are at: http://education.vsnl.com/naturalmind/gist.html

Competing interests: None declared

Prasanna P, Independent Researcher

Bangalore India 560061

Click to like:

This subject has interested me for many years, and of course, this particular research is not new, nor are its findings.

However, there are some questions that need to be asked.

How many of the women whose infants had sleep problems and who reported symptoms of depression, had this before giving birth?

Has any other research determined whether behavioural intervention to reduce infant sleep problems has had any significant outcome, in the long- term, for anxiety states as the child ages?

Competing interests: None declared

Alan Challoner, Retired

LL18 5UR

Click to like: