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Monday, August 22, 2011

Sleep Training Part IV—The Data Behind the Philosophy

According to an article called “Sleep Disorders and Sleep Problems in Childhood,” written by C. Carolyn Thiedke, M.D., and published in American Family Physician, sleep behaviors are some of the most discussed concerns between parents and pediatricians. She makes a distinction between sleep disorders and sleep problems, however. Thiedke defines a sleep disorder as one “confirmed by reproducible findings in a sleep laboratory” and a sleep problem as “a sleep pattern that is unsatisfactory to the parents, child or physician.”

It’s not phrased as a health issue; it’s phrased as one of convenience. I get it. Sleep is probably the thing I obsess about the most with my kids—especially with my first—and sleep deprivation can wreck your sanity, your relationships, and your ability to function as a human being.

But then physicians shouldn’t discuss it as a black and white health matter. So often, the inability to go back to sleep without parental intervention is painted as a sure sign that your child will become obese, bratty, or behaviorally challenged as he or she gets older. But maybe they should just come out and say what the problem really is: sleep deprivation can really be detrimental to some people and some families.

If people (and pediatricians) were more honest about sleep deprivation, maybe more parents would feel supported and not resort to drastic measures like letting their babies cry it out. Honestly, it would be refreshing to hear a pediatrician say, “I completely understand that sleep deprivation is compromising your ability to be a good parent. If you feel like you aren’t able to give your baby your full attention and compassion during the day because you are up all night, then maybe you need to consider sleep training.” Stop phrasing it as a health issue for the baby and frame it as it really is: an issue of convenience and—for some—necessity.

In fact, parental intervention in soothing a baby back to sleep after night wakings can actually be good for both the baby and the parent. In an article titled “Rethinking ‘Healthy’ Infant Sleep,” James McKenna, Ph.D. (he runs the University of Notre Dame Mother-Baby Behavioral Sleep Laboratory), describes how expecting babies to sleep alone is a new cultural phenomenon. New babies expect the same stimuli that were present when they were in the womb—which are mom’s sounds, smells, temperature, and movements.

Mothers who cosleep with their babies soothe them (usually by nursing) upon waking. In his studies, McKenna has also found that cosleeping infants and mothers have intertwined breathing, sleeping, and arousal patterns. No conclusions have been drawn from this, but the findings are significant. Babies’ arousal mechanism may be what protects them from potentially fatal breathing or cardiac delays.

What if infants need that soothing and closeness for physiological reasons? McKenna suggests that maybe the babies who don’t fuss when they sleep alone don’t need as much contact for some physiological reason, but those who have trouble sleeping alone or going back to sleep on their own are acting out of a biological need. This goes back to the argument I made in Sleep Training Part I, where I questioned why so many pediatricians treat all patients as though they are the same. Every baby has different needs when it comes to sleep and sleep training, and maybe there is a biological reason for it.

I was browsing the abstracts in the AAP’s journal “Pediatrics,” and it’s alarming how many say that sharing a family bed or full-time cosleeping results in sleep “problems.” And many of the studies find that parents who somehow help their babies fall asleep have babies who wake more at night. However, in the abstracts at least, the word “problem” is not usually defined when it comes to sleep. One study even went as far as describing a sleep problem as: “the infant sleeping in the parent's bed, being nursed to sleep, taking longer to fall asleep, waking more often and for longer periods overnight, and taking shorter naps.” But who is saying that the infant sleeping in the parent’s bed or being nursed to sleep is a problem, other than an exhausted parent who just wants to get more sleep?

And although many of the studies do find that soothing babies to sleep or cosleeping increases night wakings, those studies also insinuate that night wakings are negative. But I’m still struggling to find a study that has actually documented the negative effects of night wakings in infants. There is more information out there for negative effects of night wakings (or short sleep duration) in children older than five, but not much has been concluded about the relationship between health and night wakings in babies or toddlers, as far as I can tell. (By no means have I done exhaustive research, so if anyone has any studies to point me to, I would love to read them).

In fact, in “A Longitudinal Study of Bed Sharing and Sleep Problems Among Swiss Children in the First 10 Years of Life,” a study conducted between 1974 and 2001, the researchers found that not only did bed sharing and night waking increase as children got older, (between the ages of about 1-5 on average), “bed sharing and night wakings during early infancy were not predictive for bed sharing or night wakings during childhood.”

A 2006 study compared nighttime crying in infants with more attached parents vs. those with less responsive parents in an effort to help parents decide how to best care for their children (and to help determine if parenting techniques that involve rigid feeding and sleeping schedules actually help kids). The article begins by saying “In Western societies, infants who cry persistently or wake at night are common concerns for parents1–3 and costly problems for health services.” (Again, it’s talking about night waking in terms of something other than a health problem).

The study did find that more attached parenting styles resulted in less crying overall, but more crying after night wakings. It also stated this, which I thought was interesting:
“Infants who continue to wake and cry at night are often described as having “sleeping problems,” although they differ from other infants by waking and crying at night, rather than in biological sleeping. However, it is precisely because the night waking is accompanied by crying that it disturbs many parents. Because their infants are next to them in bed, it is possible that [parents who cosleep] are more aware of infant fussing and crying at night.”

A 2005 study analyzing sleep/fuss patterns in children up to 24 months old explained its results as follows: “This article shows not only that the great majority of infant cry-fuss and sleep problems in the first 2 years of life are transient but also that these problems do not seem to be strongly related to later adverse outcomes.”

This is all very reassuring.

When I go back for Little M’s nine-month well visit, I really want to challenge my pediatrician to tell me why they push for sleep training so hard. I want evidence-based answers if they try to bring up that it’s better for an infant’s health. Because I don’t think it is. We’ll see what happens.

Read the other posts in the Sleep series:  
Sleep Training Part I - What's the Problem?
Sleep Training Part II - Then and Now 
Sleep Training Part III - A Momentary Lapse of Reason 
Sleep Training Part IV - The Data behind the Philosophy


Patti @ Jazzy Mama said... Best Blogger Tips

Excellent post, Tmuffin.
Really, really well put-together.

I have been telling my doctor for the past 7 years that I come in for medical advice, not parenting advice. She still tells me her parenting opinions, but she no longer argues with me. Now, with my 4th child, I just don't bother going in for all the 'baby wellness appointments.'

Joy to you,

Jill @ Healthy Kiddo Snacks said... Best Blogger Tips

What a great, well-researched post. I came from a family of co-sleepers and fully support it. I think too often people think that babies should sleep quietly through the night, and if they don't then it's a parenting issue. But I think that babies wake up during the night just like everyone else, we just don't even realize it as adults after a long day. Great post!

melissa said... Best Blogger Tips

It has been said already, but this is wonderfully done. Thank you! This series is exactly what I needed, and I'm grateful for the reassurance it has provided. There really does seem to be a lack of evidence for the supposed importance of "helping" young children stay asleep, self-soothe, etc. I'm still reading more on the subject as I decide what our path forward is, but this has been a great help! said... Best Blogger Tips

Thanks everyone! Sorry I haven't been back to reply to your comments.

@Patti: that's so interesting about parenting vs. medical advice. I think one of the problems is that so many parents DO go to pediatricians for parenting advice, so they feel they have to give it. I just don't like being treated like everyone else.

@Jill: That's exactly it! Adults wake during the night. Sometimes I wake up every hour or two as well. But the difference is I can get up and get my own snack or go to the bathroom on my own; I don't need someone to help me. Babies do.

@Melissa: I'm glad this helps give you some reassurance. That's exactly what I was looking for when I did all the research, too. And I feel better now :)

runningmussells said... Best Blogger Tips

At 7 months, my daughter is still walked to sleep and we respond immediately to her "calls" in the night. Sometimes its once, sometimes is 4 or 5 times. Yes, I'm tired. But she is happy, healthy, and won't need me to go to college with her to walk her to sleep, so all is well. I read about parents letting babies CIO at 5 weeks old and I cringe. My heart hurts for those little ones who are probably hungry, wet, and/or need a snuggle.

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