Randomised controlled trial of behavioural infant sleep intervention to improve infant sleep and maternal mood
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7345.1062 (Published 04 May 2002) Cite this as: BMJ 2002;324:1062All rapid responses
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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: No competing interests
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: No competing interests
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: No competing interests
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: No competing interests
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: No competing interests
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: No competing interests
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: No competing interests
why I needed it
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: No competing interests