A systematic review of treatments for settling problems and night waking in young children
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7229.209 (Published 22 January 2000) Cite this as: BMJ 2000;320:209
All rapid responses
The paper by Ramchandran et al misses two important points.
Firstly,
children often rouse during the night and if there is subsequent
disharmony then perhaps this indicates that the problem belongs to the
parents and not the child. After all if the child were to receive the
attention it appears to need in order to pacify him or her all will be
well - although the parents will be somewhat disturbed.
Secondly, I would
commend a treatment about which he makes no mention and which is almost
guaranteed to succeed within 30 seconds. Breastfeeding!! There are no side
effects and an excellent safety record. It has certainly been a huge
success in our household.
Competing interests: No competing interests
I read the interesting article on settling problems and would like to
add two points.
1)Many children who experience difficulties settling to sleep have "
regulatory disturbances". One of the features of this group of problems is
trouble making transitions, for instance from being awake to falling
asleep. This is not taken into consideration by the article. There may be
a 5 to 10% of children who have those regulatory difficulties. These
children even in the "best" families who have bedtime routines, soothe the
child, and devote time to settle him or her to bed, are sensitive,
reassure,etc. may find that the the child has much trouble setting to
sleep. He or she may " toss and turn", talk, think about many things and
simply struggle to fall asleep. The usual " sleep hygiene" techniques do
not work with these children. These children should be properly identified
as special behavioral techniques are necessary to help them, and sometimes
at least for the short term, medications.
2) The advice for parents to ignore their child crying may be
inadequate for many families. Many parents struggle with problems in being
sensitive to their child's anxieties, fears and difficulties. advicing
them to ignore the child's cry only because this " works " may be
counterproductive in terms of the whole parent-child relationship. That
is, even if ignoring " works" parents may not want to convey to their
child that his/her distress is ignored and the child has to figure on
his/her own that there is no help, and he willjust have to go to sleep or
" cry himself to sleep". I would worry that parents would worry that
physicians or other health professionals might convey the message that the
child's distress should be ignored.
Competing interests: No competing interests
As a community pharmacist I was interested in the paper submitted by
Paul Ramchandani, Luci Wiggs, Vicky Webb and Gregory Stores,1
I am often approached by parents requesting a sedative for their young
children. Many are aware that liquid preparations of some antihistamines
e.g. Promethazine (Phenergan) can be bought over the counter without the
need to 'bother the doctor'. While their use may be justified in some
cases for short term use for children over two years old I am very
reluctant to supply these products without carefully questioning the
requester first.
From experience I have found that a simple dose of a proprietary
children's gripe water before settling the child down often does the trick
and I believe that the child's sleep disturbance may sometimes be caused
by hyperacidity in the stomach. Has any research been carried out in this
area?
It is always satisfying to use a simple remedy where possible.
Malcolm Cooper BPharm MRPharmS
1. Ramchandani P,Wiggs L,Webb V,Stores G. A Systematic review of
treatments for settling problems and night waking in young children. BMJ
2000;320: 209-213.
Competing interests: No competing interests
The systematic review of treatments for sleeping problems in young
children (1) and a recent review of treatment of colic (2) provided
evidence for the efficacy of behavioural treatments. This, despite the
generally lower quality ratings that behavioural trials received compared
to drug or dietary trials.
It is worrisome that quality criteria derived from drug trials are
used as "off the shelf" gold standards (3) to judge the quality of
behavioural treatments in recent reviews in the BMJ. Double blinding is
used in trials to guard against performance bias, i.e. systematic
differences in the care provided apart from the intervention being
evaluated (4). Double blinding is not possible in behavioural or many
other medical treatment studies. Imagine the therapist or surgeon who does
not know why or what s/he is doing with this patient? Thus a range of safe
guards have been proposed and tested to guard against performance bias
such as the investigation of generalised placebo effects, e.g. comparison
of a treatment to a different treatment and a no-treatment group. The
difference between a different (placebo) treatment and no treatment
indicates generalised placebo effects (e.g. how just attention leads to
improvements) (5). Randomisation is applied to exclude selection bias.
However, in small samples (e.g. < 30) effect sizes may become inflated
due to outliers and thus checking for a range of pre-treatment differences
may be as important than randomisation itself (6). The reviewed drug or
dietary trials (1,2) were mostly small sample studies.
It should be remembered that the aim of quality ratings is to judge
how optimal the internal validity of a trial is (i.e. the confidence that
the cause of any observed differences is due to the treatment conditions)
rather than to apply a set of criteria that are "off the shelf" and were
developed without behavioural treatments in mind.
1. Ramchandani P, Wiggs L, Webb V, Stores G. A systematic review of
treatments for settling problems and night waking in young children.
British Medical Journal 2000;320:209-213.
2. Lucassen PLBJ, Assendelft WJJ, Gubbels JW, van Eijk JTM, van
Gelfrop WJ, Knuistingh Neven A. Effectiveness of treatments for infantile
colic: systematic review. British Medical Journal 1998;316:1563-1569.
3. Jaddad AR, Moore RA, Carroll D, Jenkinson C, Reynolds JM, Gavaghan
DJ, et al. Assessing the quality of randomized clinical trials: is
blinding necessary? Controlled Clinical Trials 1996;17:1-12.
4. Cook TD, Campbell DT. Quasi-experimentation: Design and analysis
for field settings. Chicago: Rand McNally, 1979.
5. Howard KI, Moras K, Brill PL, Martinovich Z, Lutz W. Evaluation of
Psychotherapy. American Psychologist 1996;51:1059-1064.
6. Lipsey MW, Wilson DB. The efficacy of psychological, educational,
and behavioral treatment. American Psychologist 1993;48:1181-1209.
Competing interests: No competing interests
The basic assumption that very young children should settle down to
sleep away from their parents, and not be seen or heard from again until
morning, is flawed. In many non-Western societies, this type of sleep
patern would be seen as an aberation.
Antropolgogist Carol Wortham of Emory University in Atlanta uncovered
a variety of sleep patterns in ten traditional, hunter-gather societies,
none of which coincides with our sociey's current ideal of sleeping alone
without waking for the entire night. (Worthman, C.M., and M.K. Melby. In
press. Toward a comparative developmental ecology of human sleep. In
Adolescent Sleep Patterns: Biological, Social, and Psychological
Influences, M. A. Carskadon, ed. New York: Cambridge University Press.)
Perhaps some amount of night waking in children and their desire for
comforting by parents is both natural and healthful. Our difficulty in
combating this behavior may be because we are struggling against nature
and basic human biology. We must be careful not to confuse that which is
desirable for health and well-being with that which is merely a current
preference and expectation of our society.
Competing interests: No competing interests
The timely systematic review on the treatment of sleeping problems in
young children (1) reported that behavioural treatments are effective.
There are a number of behavioural methods that allow for interventions
that are suitable to different families. The review will inform practice
but omitted three issues that are important for practitioners to note.
First, at what age can we expect infants and toddlers to sleep
through the night and should commence treatment? It is of concern that two
of the nine identified studies included infants as young as 1 month of age
in their treatments (1). Infants are not born with the ability to sleep
through the night but the sleep architecture develops to be roughly
identical to the adult during the first 6 months of life and sleep
patterns are entrained by environmental cues (2). Waking at night in the
early months of life is adaptive to secure frequent feeding and to allow
for rapid weight gain and brain growth. Sleeping through the night in the
early weeks of life and a lack of waking for feeds is likely to put
vulnerable infants (e.g. preterm infants, SGA infants, poor feeders) at
risk for poor appetite development and sub optimal growth (3,4). While
provision of information on appropriate bed and nighttime routines in
early infancy is encouraged, behavioural treatments for night waking
should not commence before 6 months of age, a time when night waking is
not anymore necessary for appropriate growth.
Secondly, infants who are breastfed do sleep less during 24 hours (5)
and are more likely to wake at night than bottlefed infants (3). It is
important to inform parents about this and to reassure them that
breastfeeding does not impede the learning to sleep through the night (3).
The establishment of early routines, avoidance of feeding the infant into
"submission" and the use of focal feeds (6) help to reduce the stress of
nighttime breast feeding and prevent premature change to bottle feeding.
Thirdly, sleeping problems, both in the community or clinical
practice often co-occur with other behavioural problems such as excessive
crying or feeding difficulties (7, 8). Parents with infants with multiple
difficulties are more likely to seek help from health professionals. We do
not know from the review whether the young children had other behavioural
difficulties. Effectiveness studies (treatment evaluation in the field)
are thus needed to establish that behavioural interventions are still
effective with infants with multiple problems. Considering that
behavioural interventions are also successful with crying (9) and feeding
problems (10) it is most likely that they are effective in multiple
problem groups.
Finally, the behavioural methods detailed in the review have been
developed with one aim in mind, to help the child to learn to fall asleep
unaided both in the evening and at night (11). Children who have never
learned to fall asleep by themselves have no strategies when they awake at
night other than to call for or go to their parents. Behavioural
management helps the child to self regulate: "Yes I can fall asleep by
myself".
1. Ramchandani P, Wiggs L, Webb V, Stores G. A systematic review of
treatments for settling problems and night waking in young children.
British Medical Journal 2000;320:209-213.
2. Wolke D. Feeding and sleeping across the lifespan. In: Rutter M, Hay D,
editors. Development through life: a handbook for clinicians. Oxford:
Blackwell Scientific Publications, 1994:517-557.
3. Wolke D, Söhne B, Riegel K, Ohrt B, Österlund K. An epidemiological
study of sleeping problems and feeding experience of preterm and fullterm
children in South Finland: Comparison to a South German population sample.
Journal of Pediatrics 1998;133:224-231.
4. Skuse D, Reilly S, Wolke D. Psychological adversity and growth during
infancy. European Journal of Clinical Nutrition 1994;48:113-130.
5. Lucas A, St James-Roberts I. Crying, fussing and colic behaviour in
breast- and bottle-fed infants. Early Human Development 1998;53:9-18.
6. Pinilla T, Birch LL. Help me make it through the night: behavioral
entrainment of breast-fed infants' sleep patterns. Pediatrics 1993;91:436-
444.
7. Wolke D, Meyer R, Ohrt B, Riegel K. Co-Morbidity of crying and feeding
problems with sleeping problems in infancy: Concurrent and predictive
associations. Early Development and Parenting 1995;4:191-207.
8. Wolke D, Gray P, Meyer R. Excessive infant crying: a controlled study
of mothers helping mothers. Pediatrics 1994;94:322-332.
9. Lucassen PLBJ, Assendelft WJJ, Gubbels JW, van Eijk JTM, van Gelfrop
WJ, Knuistingh Neven A. Effectiveness of treatments for infantile colic:
systematic review. British Medical Journal 1998a;316:1563-1569.
10. Wolke D, Skuse D. The management of infant feeding problems. In:
Cooper PJ, Stein A, editors. Feeding problems and eating disorders in
children and adolescents. Chur: Harwood Academic Publishers, 1992:27-59.
11. Wolke D. Die Entwicklung und Behandlung von Schlafproblemen und
exzessivem Schreien im Vorschulalter. In: Petermann F, editor. Kinder-
Verhaltens-therapie: Grundlagen und Anwendungen. Baltmannsweiler:
Schneider-Verl. Hohengehren, 1997:154-203.
Competing interests: No competing interests
The recent review in the journal (1) gives the impression that
behavioural interventions are the best option in the management of
settling to sleep and night walking in young children. However, several
considerations are appropriate before total acceptance of this statement.
1) Behavioural treatments may help families to cope actively with
their child’s disorders and make the necessary life accommodations to
optimise family functioning. Because of those reasons, parent’s opinions
may be biased toward behavioural interventions. Nevertheless, behavioural
management has a high cost and in consequence it should be prescribed only
in the most disturbed patients.
2) It is important to consider the possibility to obtain the greatest
benefits for these young children using both drug and behavioural
treatments. For example, these benefits has been reported for the combined
management in the attention-deficit / hyperactivity disorder in childhood
(2) in which multimodal treatment has yielded significant low medication
doses and modest superiority in overall results.
3) Drug treatment for any child disturbances, needs to be a carefully
skilled decision. The controlled trials reviewed in the article, report
bad long-term results with general sedative drugs (antihistamines) or
benzodiazepines, which are not the best options for the management of the
present puzzle. The problems of difficulties in functional settling to
sleep and night walking are chronic but tend to disappear with the time.
In consequence the short-term benefit of some psychotropic drugs like
tricyclic antidepressants and others can be exploited for the benefit of
the patients.
May I suggest that until further randomised controlled trials discard
the value of drug treatments in this problem, patients may be considered
to receive combined behavioural and drug treatments whenever possible ?
1.- Ramchandani P, Wiggs L, Webb V, Stores G. A systematic review
of treatments for settling problems and night waking in young children.
BMJ 2000 ;320 : 209 - 213
2.- The MTA Cooperative Group. Moderators and mediators of
treatment response for children with Attention-Deficit / Hyperactivity
Disorder. Arch Gen Psychiatry 1999 ; 56 : 1088 - 1096
Competing interests: No competing interests
I am disappointed to see that once again children with sleep
disorders are being lumped into a homogenous group of "behavioral"
problems, then "studied" without using polysomnography. I think it's
presumptuous and dangerous of us to think every child who has trouble
sleeping is a behavioral problem. Few physicians are aware that breathing
difficulty can cause night waking and bedtime resistance, and it is due to
studies like this.
Doctors don't look for sleep disorders properly, don't know much
about them, and are told over and over again that behavioral treatments
are the way to go. This is wrong unless we can guarantee these are
behavioral problems. When you consider that a study looking at obese
children using polysomnography diagnosed unsuspected OSA in 75% of the
children studied - meaning the physicians examining the children only
picked up 1 in 4 cases - it seems a big leap of faith to not be doing
polys more often. Why couldn't some of these night waking kids or bedtime
resisters be those with UARS where this is also a problem? Most doctors
can barely take a proper history for sleep disorders, let alone diagnose a
subtle case of UARS causing repeated night waking or bedtime resistance.
Studies like this certainly don't help because they take the emphasis off
of finding a "real physiologic" problem and stress behavioal modification.
Before we continue to send physicians our to behaviorally modify
breathing difficulties or other subtle causes of sleep disorders that can
mimic behavioral problems, we need to do polysomnography on these
children.
I think it's just good experimental technique that I'm advising.
Don't bother comparing the different types of treatment available until
you know what you are treating.
Competing interests: No competing interests
The prevention of infant sleep disturbance
Ramchandani et al [1] in their systematic review of treatments for
established infant sleep problems show that behavioural interventions
improve sleep patterns. The authors reference the frequency of sleep
disorders as 20% in children aged one to three years, the tendency for
these problems to be persistent and their associations with behavioural
difficulties and family disharmony. Other authors quote the frequency of
sleep disturbance to be as high as 35%.[2]. Armstrong [3] reported 60% of
parents still rising from their beds when their child was 12 months old,
and half of them were rising three times per night or more.
We tested the impact of a short-behavioural intervention in normal
neonates in a randomised trial (submitted for publication). In all, 269
families with normal newborn singletons were recruited within the first
three weeks of life and were randomly allocated to intervention or control
groups. Intervention families received a single 45-minute tutorial from a
research nurse. Points of emphasis in the tutorial were that in children
who were healthy and gaining weight satisfactorily, that sleep achievement
should be regarded as a 'learned skill' influenced by environmental
factors or 'cues of sleep'. Parents were encouraged to avoid fatigue in
their infants by not overhandling and to establish cues of sleep
independent of the parent. Outcomes were measured through a sleep diary
at six weeks of age.
All aspects of sleep performance were significantly improved in the
intervention group. Total sleep increased by almost nine hours per week
at six weeks (p<0.0001). The proportion of infants achieving 15-hrs
sleep per day was 61% in the intervention group and 28% among controls (p
<0.0001). 78% of sleep cycles in the intervention group achieved >
8.0 hrs of night sleep, compared to 61% of controls (p <0.0001).
While the technique emphasised minimising parental handling at sleep time
there was no difference in the amount of crying in either group. (p =
0.2). Follow up at three months of age showed that improvements were
maintained. Our findings therefore support, and add to, those reported in
the systematic review.
Despite doing a well designed systematic review, our unpublished work was
not identified, and it would be unreasonable to expect it to have been.
This experience therefore supports the calls for a register of planned and
on-going randomised trials [4], and also demonstrates the importance of
regularly updating systematic reviews through the Cochrane Collaboration,
as new evidence becomes available.
1. Paul Ramchandani, et al., A systematic review of treatments for
settling problems and night waking in young children. BMJ, 2000(320): p.
209-213.
2. Johnson, M.C., Infant and toddler sleep. A telephone survey of
parents in one community. Developmental and Behavioural Pediatrics,
1991(12:2): p. 108-114.
3. Armstrong, K.L., R.A. Quinn, and M.R. Dadds, The sleep patterns of
normal children. The Medical Journal of Australia, 1994(161): p. 202-206.
4. Horton R and S. R., Time to register randomised trials. 1999(319):
p. 865-866.
Dr Brian Symon.
Senior Lecturer
Department of General Practice, University of Adelaide,
South Australia
Dr James Martin
Director of Respiratory Medicine
Adelaide Women's and Children's Hospital
Adelaide, South Australia
Professor John Marley
Professor of General Practice
University of Adelaide, South Australia
Competing interests: No competing interests