Letters from Maine

Behavioral sleep interventions can work – if done


Sleep has begun to emerge from the shadows to gain its rightful place in the health pantheon. With this emergence has come a motley group of physicians and self-proclaimed experts (myself included) eager to share their anecdotal evidence and opinions on how new parents can shorten the inevitable and often painfully slow process of settling in.

Baby crying in a crib a-fitz/Stockphoto

A study in the May 2018 Journal of Pediatrics is an attempt to provide some data-driven guidance for sleep-deprived parents and their physician-advisors (“Real-World Implementation of Infant Behavioral Sleep Interventions: Results of a Parental Survey”). Using the responses from 652 parents who participated in a Facebook peer support group, the investigators created four categories of behavior sleep intervention for the parents of infants a mean age of 6 months: Modified extinction in which parents left the room and returned to briefly reassure the infant at intervals ranging from 5 to 25 minutes; unmodified extinction in which the parents let the infant cry it out; parental presence with support in which the parents remained in the room and interacted with the child; and parental presence without support. Extinction, both modified and unmodified (50% and 35%), was far and away the most frequently used method.

There was little difference in the effectiveness of the four strategies. By 2 weeks, 79% of the parents reported success, and the interventions were successfully discontinued in a mean and mode of 7 days. Not surprisingly, with success came reduced parental stress, as well as more consistent bedtime routines and smoother transitions to sleep.

When choosing a behavioral sleep intervention to suggest, I have tried to consider what I have learned about each family’s personality in the few months I have gotten to know them. But I have always been a big fan of extinction. And I suspect that my bias is simply a reflection of my no-nonsense, let’s-get-it-done-now personality. The results of this new study suggests that my poorly disguised pessimism about parental presence strategies may have discouraged some parents from trying an intervention that might have been successful for them.

The good news is that all four strategies can be successful. The problem is helping parents find the time and energy required to make any intervention successful. In the short term, extinction or parental presence is likely to mean less sleep for the parents. If work schedules and other family stressors already have drained a family’s energy reserves, it may not be the right time to try an intervention. When it becomes clear that there is never going to be right time, it is time for a frank discussion with the family about rearranging their priorities.

Behavioral sleep interventions require consistency and a family must be prepared to commit at least a week of uninterrupted evenings to get the job done. Business trips, visitors, and social engagements must take a back seat.

Extinction strategies are going to involve some crying, and while as pediatricians, we have developed the ability to buffer ourselves from crying (ignore really isn’t the right word), we must accept that listening to one’s child is too painful for some parents. When only one parent can’t tolerate the crying, the solution may be having that parent leave the home on the intervention evenings. When both parents share the vulnerability, the better answer is a parental presence strategy.

Although this study was small with a self-selected group of parents, the good news is that behavioral sleep intervention can work. We need to share the news with young families and encourage them to just do it.

Dr. William G. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years.

Dr. William G. Wilkoff

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