Hands-Off Approaches OK for Sleepless Infants

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An infant who cries through the night—or even a fraction of the night—can have a big impact on a household. Parents who repeatedly wake up to soothe and cradle their baby may find themselves sleep-deprived, stressed-out, and even depressed.

This is especially true for mothers, who tend to be the primary nighttime caregivers. Having an infant with sleep problems roughly doubles a mother’s risk of experiencing depression symptoms, by some estimates.

“If the infant or child doesn’t sleep, the parent doesn’t sleep, and this can have an impact on the parent’s mental well-being, as well as productivity in the workplace,” says Patricia Ritch, M.D., a pediatric neurologist and sleep specialist at Scott & White Healthcare, in Temple, Texas.

Growing awareness of the fallout from infant sleep problems has spurred specialists to develop a repertoire of bedtime routines designed to help babies—and by extension, their parents—sleep better.

Nowadays, pediatricians generally don’t recommend leaving babies alone to cry themselves to sleep (a technique known as “extinction”). Preferred strategies include “controlled comforting,” in which parents gradually reduce the amount of time they stay in the room with a crying baby, and “camping out,” which involves sitting or sleeping in the room without picking the baby up.

These methods have produced promising results. A landmark 2007 study from Australia, for instance, found that controlled comforting and camping out reduced the odds of infant sleep problems by 50% and maternal depression by 60%, compared to a control group.

The study followed children only until age 2, however. And some pediatricians have expressed concern that hands-off strategies like controlled comforting may harm children over the long term, by disrupting brain development, mother-child bonding, or the child’s mental health, says Tarig Ali-Dinar, M.D., a pediatric pulmonologist who researches breathing-related sleep disorders at the University of Miami Miller School of Medicine.

A follow-up to the 2007 study, published today in the journal Pediatrics, may help quiet some of those concerns. The same research team tracked the mental health, behavior, and stress levels of 326 children from the original study up to age 6, and found no differences between the groups who did and did not follow the bedtime routines.

Nor did the researchers turn up any differences in the quality of the children’s relationships with their parents or the mother’s depression levels, suggesting that the routines have little lasting effect, good or bad, beyond infancy and early toddlerhood.

“The findings were very pleasing, in that at least we can put to rest what had been discussed in the past about an adverse impact on infant development, mother-child relationship, and maternal depression,” says Ali-Dinar, who was not involved in the study.

For infants, in fact, having a depressed mother could conceivably pose greater long-term risks than having a mother who uses hands-off sleep techniques.

A second study appearing in the same issue of Pediatrics highlights just one of the long-term concerns associated with depression in mothers. In that study, infants whose mothers were depressed had higher odds of being in the 10th percentile or less for height at ages 4 and 5, even after various health and socioeconomic factors were taken into account.

Possible explanations for the children’s short stature include “poor parenting behaviors,” malnutrition stemming from haphazard meals, and chronic stress, the authors suggest.

The two studies are unrelated, and it doesn’t necessarily follow that mothers who address their baby’s sleep problems—and therefore their own sleep deprivation—end up raising healthier kids because they themselves are happier and better rested. “That link is too early to make,” Ritch says.

So what should you do if your baby is having trouble sleeping? Dennis Rosen, M.D., a pediatric sleep disorder specialist at Boston Children’s Hospital, says there is no wrong or right way to help children fall asleep.

“Children, and especially infants and toddlers, will get all the sleep they need, whether by falling asleep in a high chair while eating corn flakes or napping in the car,” Rosen says. “The question is how it affects the parents.”

The extinction method, also known as the “cry-it-out” method, can be stressful for babies and parents alike, Rosen says, but there are a number of other strategies parents can choose from—including the two used in the Australian study.

Controlled comforting is designed to slowly acclimate an infant to being left alone at night. Typically, a parent puts the baby to bed and stays in the room while the child is still at least partially awake. Then he or she goes away for a predetermined amount of time—a few minutes, say—and returns after successively longer intervals until the baby is asleep.

Similarly, camping out gradually withdraws a parent’s physical presence. To start, the parent stays in a chair or cot in the baby’s room until the baby falls asleep. Then, as sleeping comes more easily to the child, the parent moves farther away from the bed and eventually out of the room.

Regardless of the specific method parents choose, consistency is key. A scheduled, daily routine is a “must,” says Ali-Dinar. In addition, a baby should be put to bed while they’re still drowsy but not asleep, which “will help the infant learn how to fall asleep,” he says.

Ali-Dinar also counsels against giving a bottle to infants when they’re falling asleep, or even rocking them to sleep. “When they wake up, the first thing they will look for is the bottle, or they will remember there was somebody there who was holding them, and they will cry for that until somebody comes,” he says.

Finally, it’s important for parents to talk with their pediatrician about which infant sleep behaviors are normal and which are not, Ali-Dinar says. “Sometimes,” he says, “the problem is parent expectation and not really an infant sleeping problem.”

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