ArticleLiterature Review

Behavioral Sleep Interventions in the First Six Months of Life Do not Improve Outcomes for Mothers or Infants: A Systematic Review

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Abstract

The United Kingdom's National Institute for Health Research has recently invited proposals for the design of a multicomponent primary care package of behavioral interventions to reduce parental distress caused by excessive infant crying in the first 6 months of life. A systematic review was performed to determine whether behavioral interventions for sleep, when applied by parents to infants younger than 6 months, improve maternal and infant outcomes. Searches of PubMed, CINAHL, and Cochrane Database of Systematic Reviews were conducted to identify systematic reviews, meta-analyses, clinical trials, and cohort studies investigating the effects of behavioral sleep interventions in infants younger than 6 months (January 1993-March 2013). The evidence is critically analyzed, according to PRISMA guidelines. Cry-fuss, feeding, and sleep problems emerge out of multiple dynamically interacting and co-evolving variables in early life and are for this reason generically referred to as regulatory problems. Studies that link behavioral interventions for sleep in the first 6 months with positive effects on maternal and infant health demonstrate 3 methodological constraints. They fail to identify and control for feeding difficulties, fail to distinguish between the neurodevelopmentally different first and second halves of the first year of life, and apply reductive analyses to evaluations of complex interventions. Despite substantial investment in recent years in implementation and evaluation of behavioral interventions for infant sleep in the first 6 months, these strategies have not been shown to decrease infant crying, prevent sleep and behavioral problems in later childhood, or protect against postnatal depression. In addition, behavioral interventions for infant sleep, applied as a population strategy of prevention from the first weeks and months, risk unintended outcomes, including increased amounts of problem crying, premature cessation of breastfeeding, worsened maternal anxiety, and, if the infant is required to sleep either day or night in a room separate from the caregiver, an increased risk of SIDS. The belief that behavioral intervention for sleep in the first 6 months of life improves outcomes for mothers and babies is historically constructed, overlooks feeding problems, and biases interpretation of data.

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... Six studies, published in the last 5 years, describe infant sleep-related interventions with high relevance for the early postnatal period [26-28, 56, 58, 59]. In addition, four reviews summarize earlier studies and discuss the degree to which sleep-related interventions may increase sleep outcomes in the postnatal period of life [29,[53][54][55]. One intervention was started antenatally, two were implemented in maternity wards, and three were designed to support families at postnatal follow-up meetings. ...
... This review will not explore the gaps between different approaches, but some gaps seem important and may reflect the different conclusions reported in the reviews included [29,53,55]. A review from 2013 concluded that behavioral sleep interventions during the first six months of life do not have significant effects on infant sleep [53], while later reviews reported several positive effects [29,54,55]. ...
... This review will not explore the gaps between different approaches, but some gaps seem important and may reflect the different conclusions reported in the reviews included [29,53,55]. A review from 2013 concluded that behavioral sleep interventions during the first six months of life do not have significant effects on infant sleep [53], while later reviews reported several positive effects [29,54,55]. Some studies found that early interventions may increase infants' night-time sleep [26,54], reduce the frequency of nightwakings [71], increase the use of recommended early bedtimes for infants [56], prevent prolonged bedtime routines, eat as the last activity before sleep [27,56], and help infants to sleep more regularly in their own cot [27]. ...
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Background This scoping review focuses on infant sleep-related factors and themes that are relevant when health practitioners provide preventive health services to expectant and new parents. Methods A systematic literature search in CINAHL, PubMed, and PsycINFO, published in 2010 or later, identified 1661 records. The search was further narrowed to focus on sleep in healthy term-born infants until the second half of the first year of life. A blinded review by both authors covered 136 papers, of which 43 papers were reviewed in the full text. Finally, 38 articles were included in the data extraction. Results The analysis process showed that the selected studies formed three main information categories: 11 studies thematised safe infant sleep issues, 10 studies described design and findings from sleep-related intervention studies, and 17 studies focused on different parent-child interactive aspects that may influence the quality and duration of infant sleep in the first six months of life. The main finding is that knowledge about early infant sleep is very complex, and includes both child, parent, and environmental factors. Several studies have shown that the concepts and factors related to safe infant sleep also influence the development of healthy infant sleep patterns. Thus, these aspects are interwoven with each other and should be addressed together in communication with parents. Conclusions Health practitioners with different professional backgrounds need to search for an agreement on when and how different aspects of sleep-related knowledge should be communicated to new and expectant parents to enable the design of national follow-up programs. Parents want coherent and personalized services regarding infant sleep issues that may allow them to choose sleeping arrangements, routines, and behaviors that fit in with their sociocultural attitudes and traditions. Many different sources and formats may be used to empower parents regarding infant sleep issues. Studies have described the use of group or individual meetings, videos, and written materials. The key issue is the importance of consistent and seamless knowledge-based services.
... Studienresultate werden oftmals verzerrt interpretiert (Douglas & Hill, 2013 (Ferber, 1985) und wurde in 14 Studien evaluiert (Mindell et al., 2006). Obwohl diese Vorgehensweise länger dauert als die reine Extinktion können auch hier kurzfristig positive Effekte wie die Reduzierung von Einschlafproblemen und dem nächtlichen Aufwachen erwartet werden (Mindell et al., 2006). ...
... Neben der reinen und der graduierten Extinktion, bietet laut Papoušek, Scholtes, Rothenburg, Hofacker und Cierpka (2009) Bei allen Methoden bleibt aber unklar, inwiefern sich die Eltern an genaue Vorgehensweisen halten. Die Empfehlung, die Schlafprogramme nicht vor dem 6. Lebensmonat anzuwenden (Douglas & Hill, 2013;Ferber, 2006;Kast-Zahn & Morgenroth, 2013), werden häufig von Eltern ignoriert (Loutzenhiser et al., 2014). In einer Befragung von 411 kanadischen Eltern wendeten knapp die Hälfte (49.6 Prozent) aller Eltern das kontrollierte Schreienlassen an. ...
... It can be suggested that well-rested parents more positively rate their children. One systematic review found that research about behavioral sleep interventions in infancy often does not address other influence parameters or interaction effects when interpreting data (Douglas & Hill, 2013). Instead, the authors argued that behavioral interventions can unintentionally provoke more crying or lead to premature termination of breast-feeding. ...
... In the UK, the US and Australia, there is therefore evidence that babies are particularly vulnerable to the effects of parental sleep disruption, particularly where parents perceive their baby's night-waking or difficulty in settling to be a 'sleep problem' in early infancy (Douglas and Hill 2013;Sadeh and Anders 1993). Such babies may be medicalised (Douglas and Hill 2011), medicated (Owens et al. 2003), punished and, in extreme cases, abused (Reijneveld 2002) for displaying speciestypical infant behaviour, that is waking at night, frequent night-feeding, and crying when left alone (Ball 2013;Ball and Russell 2012). ...
... Such babies may be medicalised (Douglas and Hill 2011), medicated (Owens et al. 2003), punished and, in extreme cases, abused (Reijneveld 2002) for displaying speciestypical infant behaviour, that is waking at night, frequent night-feeding, and crying when left alone (Ball 2013;Ball and Russell 2012). Increasingly babies are subjected to clinic-based (Australia) or parentally imposed (US) sleep-training programmes from an early age (Blunden et al. 2011;Douglas and Hiscock 2010;Hiscock et al. 2007;Mindell et al. 2006), a practice that is not only controversial but developmentally inappropriate for young infants (Blunden et al. 2011) and potentially harmful for parent-infant well-being by increasing maternal anxiety, prematurely terminating breastfeeding, increasing the risk of sudden infant death syndrome (SIDS), increasing infant crying and potentially decoupling maternal-infant physiological synchrony (Douglas and Hill 2013;Middlemiss et al. 2012;Whittingham and Douglas 2014). ...
... 'Limit-setting' is presented as a preventative intervention supporting the development of settled infant night-time behaviour (St James- ). However, this position is challenged (Douglas and Hill 2013) and studies attempting to apply this approach have been unsuccessful in increasing the numbers of infants with long sleep periods at night (Hiscock et al. 2014;Stremler et al. 2013). ...
... Preventive measures and Behavioral Sleep Intervention (BSI) may affect mothers and infants. Without an overall consensus on the effect of BSI on infants, some consider it beneficial and necessary from the first months (Crichton & Symon, 2016;Henderson, France, & Blampied, 2011), while others doubt the effectiveness of these interventions for infants younger than six months (Douglas & Hill, 2013). There is evidence showing the positive effects of BSI on maternal mood (Crichton & Symon, 2016;Hall et al., 2015;Harriet Hiscock et al., 2014;Mindell et al., 2011), as well as no effects (Douglas & Hill, 2013;Galland et al., 2017;. ...
... Without an overall consensus on the effect of BSI on infants, some consider it beneficial and necessary from the first months (Crichton & Symon, 2016;Henderson, France, & Blampied, 2011), while others doubt the effectiveness of these interventions for infants younger than six months (Douglas & Hill, 2013). There is evidence showing the positive effects of BSI on maternal mood (Crichton & Symon, 2016;Hall et al., 2015;Harriet Hiscock et al., 2014;Mindell et al., 2011), as well as no effects (Douglas & Hill, 2013;Galland et al., 2017;. However, few RCTs have been performed to evaluate infant BSI's effectiveness, especially in infants younger vs. older than six months (Kempler, Sharpe, Miller, & Bartlett, 2016;. ...
... Selecting infants merely younger than six months was one of the study's strengths. For the reason that there is a lack of well-controlled studies in this age group (Douglas & Hill, 2013;Kempler et al., 2016;Martins et al., 2018) for claiming possible positive effects of BSI on infants under six months. To omit the impact of attention, the control group also received training about infant safety. ...
Article
Infant sleep problems are one of the first challenges for parents, negatively influencing infants and mothers. The present study examined the effects of preventive behavioural sleep intervention (BSI) on infant sleep patterns, maternal sleep quality, and depression. A clinical randomised multicentre controlled trial was conducted involving 82 mothers and their infants aged 2–4 months in Iran from August 2018 to April 2019. The intervention group received BSI, which included one individual 90‐min class session, booklet, voice messages, and follow‐up calls; while the control group received training on general infant safety. Details of infant sleep, maternal sleep quality, and postnatal depression were measured through the sleep diary, Pittsburgh Sleep Quality Index, and Edinburgh Postnatal Depression Scale, respectively, before and at 8 weeks after the training. In the intervention group, both the mean infant “night‐time sleep period” and infant “longest self‐regulated sleep period” were 81 min longer than the controls (p < .001). With an improvement of 160 min, the mean infant bedtime was decreased to 22:20 hours in the intervention group, substantially earlier than the controls (00:30 hours). The mean infant “night‐time awakenings with signals” did not significantly change (2.6‐ and 2.5‐times in the intervention and control groups, respectively). The intervention led to a significant improvement in maternal sleep quality and depression (p < .05). The present study acknowledges the positive effects of an early preventive infant BSI on infant sleep, maternal mood, and maternal sleep. Our present results also imply the importance of considering sleep patterns differences and cultural‐based intervention’s design.
... Sleep cycle develops gradually from the moment of birth, and 47%-81% of 4-month-old infants sleep without waking in the night (Henderson et al., 2011). Although frequent night waking does not seem to induce subsequent abnormal growth for under 6-month-old infants (Douglas & Hill, 2013), caregivers tend to consider it as the most serious sleep problem (Sadeh et al., 2011b). In fact, frequent night waking induces mental health problems in parents, such as parental stress, maternal depression and reduced sense of competence (Sadeh et al., 2011a;Teti & Crosby, 2012). ...
... However, the evidence is inadequate to infer that the same applies to younger infants, given the differences in sleep development between infants under 6 and over 6 months of age (Douglas & Hill, 2013). Therefore, the relationship between caregiver response and night waking in younger infants remains unclear. ...
... This suggests that the relationship between feeding and night waking may be common across cultures or countries. Indeed, a systematic review indicated that inappropriate feeding could induce frequent night waking (Douglas & Hill, 2013). Furthermore, breastfeeding is said to be difficult when performing proper feeding while the mother has low breast milk supply and experiencing physical discomfort (Ong et al., 2014). ...
Article
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Objective To investigate the association between night waking frequency in 3‐ to 4‐month‐old infants and mothers' response to them. Design Cross‐sectional survey. Sample We examined 663 mothers of infants aged 3–5 months who attended regular health checks for 4 months at 7 public health centres in Japan between September 2006 and March 2007. Measurements Mother‐reported questionnaires were used, measuring the frequency of infants' night waking and four types of responses by mothers. Using multiple regression, the association between number of wakings and each response was evaluated adjusting for covariates, that is mother's (e.g. feelings of worry and bed‐sharing) and infant's (e.g. age and sex) demographic variables. Results The number of wakings was related to “immediately feeding and/or checking diapers” (β = 0.16, p = .002).This response to infants' night waking may be associated with night waking frequency. Conclusion Modifying caregiver responses to infants' night waking by reducing immediate feeding or diaper checks could improve infants' night waking frequency.
... Par conséquent, ces questionnements ont conduit à des points de divergence dans la littérature scientifique. En effet, dernièrement, des auteurs (e.g., Blunden et al., 2011;Douglas et Hill, 2013) ont contesté certaines interventions comportementales du sommeil reconnues comme efficaces en s'appuyant sur des arguments étayés sur les plans éthique, moral, social et développemental. ...
... Comme précisé précédemment, la consolidation du sommeil dure en général un an, mais certains auteurs conseillent des interventions comportementales dès l'âge de trois mois (Sadeh, 2005). Cependant, dans leur revue de littérature, certains auteurs (Martin, Hiscock, Hardy, Davey et Wake, 2007;Wake et al., 2006) ne partagent pas cette position et déconseillent l'application d'interventions comportementales du sommeil dans les six premiers mois, puisqu'elles ne permettraient ni de diminuer les pleurs du nourrisson ou de prévenir les problèmes de sommeil plus tard dans l'enfance, ni de favoriser l'allaitement (Douglas et Hill, 2013). En prenant ces éléments en considération, il ressort d'une part que combiner différents types d'interventions comportementales du sommeil peut s'avérer efficace et d'autre part, que le recours à une intervention comportementale du sommeil avant l'âge de six mois n'est pas recommandé. ...
... Peur des répercussions Certains parents craignent des conséquences négatives dues aux pleurs prolongés. La littérature diverge sur ce sujet: certains chercheurs (Blunden et al., 2011;Douglas et Hill, 2013) signalent l'existence d'effets secondaires négatifs tandis que d'autres les démentent (Hiscock, Bayer, Hampton, Ukoumunne et Wake, 2008;Price, Wake, Ukoumunne et Hiscock, 2012). ...
Article
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Il est bien établi dans la littérature que les troubles du sommeil chez l’enfant ont des répercussions sur son fonctionnement actuel, sur d’autres sphères développementales ainsi que sur le contexte familial (Byars et Simon, 2016 ; Sadeh, 2005; Stores, 2014). Il est donc crucial de disposer de traitements appropriés afin d’améliorer le sommeil des enfants. Cette revue de littérature vise à évaluer plusieurs types d’intervention comportementale du sommeil en fonction de leurs efficacités et leurs limites. Il ressort de la littérature des limites méthodologiques (type de mesure et manque de suivi) et l’absence de consensus sur l’âge d’application de ces interventions. En revanche, il existe différents types d’intervention comportementale du sommeil et elles n’ont pas toutes reçu le même soutien empirique. Par conséquent, cet article fournit un guide de lecture critique en soulignant les divergences entre les études concernant les bénéfices des interventions comportementales du sommeil (sur le comportement et l’humeur de l’enfant, et le fonctionnement familial). Nous portons une attention particulière aux méthodes de type extinction car des études ont rapporté des bénéfices à utiliser ce type d’interventions (Mindell, Kuhn, Lewin, Meltzer et Sadeh, 2006; Rickert et Johnson, 1988) alors que d’autres les remettent en question sur les plans éthique, moral, et social (Blunden, Thompson et Dawson, 2011; Etherton et al., 2016).
... Ignores evidence that crying durations are modifiable by infant care practices . High level evidence shows that FWB strategies do not decrease night waking (Bryanton et al., 2013;Douglas and Hill, 2013b;Kempler et al., 2016;NHMRC, 2017) 'A mysterious disorder of the microbiota-gut-brain axis' Rhoads et al., 2018;Zeevenhooven et al., 2018) Probiotics Probiotics may decrease crying in breastfed infants (placebo response 66%) but studies do not control for the breastfeeding problem of functional lactose overload and do not take into account complex bidirectional nature of gut-brain axis (multiple confounders). Gut dysbiosis is a confounder, not a cause (Fatheree et al., 2017;Sung et al., 2017). ...
... Infant sleep training emerged in the 1950s and 1960s when the first wave of the school of behaviorism (FWB) in psychology was applied to infantcare. Yet high level evidence demonstrates no decreased night waking or reliably improved maternal mood scores as a result of FWB interventions, and no improvement in developmental outcomes (Price et al., 2012;Bryanton et al., 2013;Douglas and Hill, 2013b;Mindell and Lee, 2015;Price et al., 2015;Kempler et al., 2016;NHMRC, 2017;Pennestri et al., 2018). ...
... Each of these may arise from, or be exacerbated by, a mismatch between popular sociocultural and clinical approaches, and infant biology. Health professionals report inadequate training in management of breastfeeding and unsettled infant behavior problems, and often recommend approaches which have been shown not to help, or may even worsen these problems, with associated deleterious effects on parent-infant biobehavioral synchrony (Price et al., 2012;Bryanton et al., 2013;Douglas and Hill, 2013b;Rimer and Hiscock, 2014;Mindell and Lee, 2015;Price et al., 2015;Blunden et al., 2016;Etherton et al., 2016;Kempler et al., 2016;Thompson et al., 2016;Gavine et al., 2017;NHMRC, 2017;Pennestri et al., 2018). There is widespread recognition of the importance of prevention of, or early detection and treatment of, perinatal anxiety and depression, the most common mental health condition post-birth. ...
Article
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Autism spectrum disorders (ASD) are an emergent public health problem, placing significant burden upon the individual, family and health system. ASD are polygenetic spectrum disorders of neural connectome development, in which one or more feedback loops amplify small genetic, structural, or functional variations in the very early development of motor and sensory-motor pathways. These perturbations trigger a ‘butterfly effect’ of unpredictable cascades of structural and functional imbalances in the global neuronal workspace, resulting in atypical behaviors, social communication, and cognition long-term. The first 100 days post-term are critically neuroplastic and comprise an injury-sensitive developmental window, characterized by a neural biomarker, the persistence of the cortical subplate, and a behavioral biomarker, the crying diathesis. By the time potential diagnostic signs are identified, from 6 months of age, ASD neuropathy is already entrenched. The International Society for Autism Research Special Interest Group has called for pre-emptive intervention, based upon rigorous theoretical frames, and real world translation and evaluation. This paper responds to that call. It synthesizes heterogenous evidence concerning ASD etiologies from both psychosocial and biological research literatures with complexity science and evolutionary biology, to propose a theoretical framework for pre-emptive intervention. This paper hypothesizes that environmental factors resulting from a mismatch between environment of evolutionary adaptedness and culture initiate or perpetuate early motor and sensory-motor lesions, triggering a butterfly effect of multi-directional cascades of atypical developmental in the complex adaptive system of the parent and ASD-susceptible infant. Chronic sympathetic nervous system/hypothalamic-pituitary-adrenal axis hyperarousal and disrupted parent-infant biobehavioral synchrony are the key biologic and behavioral mechanisms perpetuating these atypical developmental cascades. A clinical translation of this evidence is proposed, for application antenatally and in the first 6 months of life, as pre-emptive intervention for ASD.
... Understanding the important contribution of napping within the range of sleep factors potentially influenced by sleep interventions would give a more comprehensive picture of sleep development. Other reviews of sleep interventions have focused on measures of sleep other than duration [22], are narrative in form [23e27], consider narrow age ranges [26,27], are limited to children with identified sleep problems [22], or include data from retrospective or cross sectional study designs [26,27]. ...
... Understanding the important contribution of napping within the range of sleep factors potentially influenced by sleep interventions would give a more comprehensive picture of sleep development. Other reviews of sleep interventions have focused on measures of sleep other than duration [22], are narrative in form [23e27], consider narrow age ranges [26,27], are limited to children with identified sleep problems [22], or include data from retrospective or cross sectional study designs [26,27]. ...
Article
This review investigated whether randomised controlled trials attempting to improve sleep or prevent sleep problems in 0-5 year olds influenced nocturnal sleep duration, day-time naps, or 24-hour sleep. Medline (Ovid), EMBASE, and CINAHL were searched from inception until 9 July 2020 and supplemented with hand searching. Search results were screened, eligible data were extracted, and risk of bias was assessed by at least two reviewers. Of 8571 publications considered, 32 trials which used a variety of subjective and objective sleep measurements were included in generic inverse variance random effects meta-analysis of nocturnal (n=24), day-time (n=14), and 24-hour (n=13) sleep duration. Overall, sleep interventions increased nocturnal sleep duration by a mean of 9 min (95% CI 4.1 to 13.8, I ²28%) per night when compared with no sleep intervention. Increases were predominantly seen in sleep-only, rather than multi-component interventions. Total 24-hour sleep duration tended to increase by a similar amount (8.6 min (95% CI -2.7 to 19.8, I ² = 59%)), but this was mainly only seen in studies that assessed sleep using diaries. There was no evidence that interventions changed day-time sleep duration. Future studies should involve sleep-only rather than multi-component interventions, and use objective sleep measures. (reviewregistry857)
... Infant sleep problems are among the most common issues reported by parents, with 23-27% reporting infant sleep difficulties in the first 6 months of life (Armstrong, Quinn, & Dadds, 1994;Douglas & Hill, 2013). A recent community sample revealed that almost half of mothers (47%) had sought advice regarding their infant's sleep (Henderson, Motoi, & Blampied, 2013). ...
... There are problems with the current literature. Existing randomized controlled trials (RCTs) do not adequately control for feeding problems and use mixed ages samples which do not distinguish between the first 6 months of life and later infancy and even childhood (Bryanton & Beck, 2010;Douglas & Hill, 2013;Field, 2017). Further, long-term effects have not been established (Hiscock et al., 2014). ...
Article
Infant sleep problems are among the most common issues reported by parents in the postnatal period. Yet, infant sleep and infant sleep interventions remain controversial. This study evaluated health professional training in a novel approach to parent-infant sleep: the Possums Sleep Intervention. Health professionals (n = 144) completed a short survey before and after the training, which focused on the sleep component. The Possums Sleep Intervention training included the following topics: sleep science, cued care, sleep hygiene, relaxation for parents and babies, problem solving, and acceptance and commitment therapy (ACT). Health professionals reported: improvements in knowledge on infant sleep regulation, the mother-infant relationship and ACT; improvements in health professionals' own sleep quality; improvements in psychological flexibility; and a reduction in professional burnout and secondary traumatic stress. Moreover, the health professional training was received positively. Overall, this study is supportive of the Possums Sleep Intervention health professional training.
... Their wide-ranging expertise concerns areas of research that is argued to be linked to how the CIO method can impede sensitive and responsive caregiving, and the effects that has on stress to the developing brain (Gunnar & Quevedo, 2007a, b); a potential risk to attachment (Ainsworth et al., 1978); early cessation of breastfeeding (Tomori, 2015); and how it counters the typical development of emotion regulation (Rothbart et al., 1992), to name a few. Douglas and Hill (2013), who conducted a systematic review of sleep training literature, discovered that the use of sleep training strategies has not been shown to significantly protect mothers against maternal depression, decrease infant crying, or prevent sleep problems in later childhood. As they specifically argue, "[t]he belief that behavioral intervention for sleep improves outcomes for mothers and babies is historically constructed" (Douglas & Hill, 2013, p. 497). ...
... We revealed that the groundwork for the CIO method to be constructed as authoritative knowledge was being laid as early as the beginning of the 19th century when the panic of spreading infectious diseases became a paramount concern. What followed was a sequence of cultural shifts (Apple, 1995;Rees, 2016;Wiebe, 1996); many unsupported, yet persuasive and seemingly logical, claims (see Dell, 1930;Douglas & Hill, 2013;Salzinger, 1994); and widespread advice disseminated by trusted experts (e.g., Alcott, Emerson, Holt, Watson, Ferber, and Weissbluth) that combined to allow the CIO method to be constructed as an acceptable, reasonable way to get infants to sleep. Once the CIO method became authoritative knowledge, parents felt validated if and when they decided to ignore their infants' nighttime cries so that they could achieve better household sleep. ...
Article
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The cry-it-out (CIO) method is a sleep training method that encourage parents to let their infants cry at night by themselves for increments of time in order to get them to eventually sleep through the night, on their own. The purpose of this analysis is to explore how the CIO method was constructed as authoritative knowledge to become a normative practice among modern parents. Drawing on various forms of media relevant to laying the groundwork for the promotion of the CIO method over the last 200 years, we examine how parents’ methods for getting babies to sleep have changed. We then argue that the CIO method ascended as authoritative knowledge mostly via the use of fear-based messages, enabling parents to feel validated when they decide to ignore their infants’ nighttime cries so that they can achieve better household sleep.
... Parents are often recommended from the beginning to implement one or a combination of the following interventions: delayed parental response to infant cues, initiated feed-play-sleep cycles, and adherence to sleep algorithms. [17,18] Delayed parental response. To teach infants to self-soothe at bedtime, parents delay responding to their infant's cues (e.g., crying or calling out) in either complete or graduated extinction. ...
... Opponents suggest that falling asleep while feeding is not a learned behavior, but rather a biologically driven phenomenon associated with the activation of the parasympathetic nervous system and elevated levels of oxytocin and plasma cholecystokinin after a feeding. [17,20] It is suggested that separating sleep from feeding can increase the arousal of the sympathetic nervous system and the hypothalamic-pituitary-adrenal system which can create inconsolable crying for the infant. [20] Sleep algorithms. ...
Article
The first year with a child is one of the most challenging times for mothers due to repeated awakenings typical for young infants. Research has shown that persistent fragmented sleep increases a mother’s risk for low overall well-being, which can challenge the mother-infant relationship. In an effort to improve sleep for both mother and infant, healthcare providers often recommend infant behavioral sleep interventions. The primary focus of this pilot study was to assess the feasibility of the Possums Sleep Intervention, a psychoeducational group workshop for women with infants between the ages of 0-6 months. A second goal of the study was to evaluate the potential of the Possums curriculum in improving maternal and infant sleep and self-reported mother-infant emotional availability. Participants were 24 mothers with their 0-6 month old infants assessed at the start of the study and again at the completion of the 4-week workshop. Results showed improvements in the perceived emotional availability in the mother-infant relationship; however, positive effects related to maternal or infant sleep were only on a trend level.
... Despite this, some mothers are encouraged to cease breastfeeding as a management strategy to improve infant sleep [16]. ...
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This study evaluated relationships between maternal perceptions of infant sleep, settling and crying patterns and breastfeeding. A prospective observational study of 91 mothers of healthy, term infants was conducted with follow ups over 9 months after discharge from a Western Australian maternity hospital. Feeding information, sleep, settle and cry behaviours, maternal bother at infant behaviours and confidence were measured using the Sleep and Settle Questionnaire. Breastfeeding confidence was measured using the Breastfeeding Self-Efficacy Scale—Short Form. Questionnaires were administered at 2 and 6 weeks, 3, 6 and 9 months. Linear mixed models were used to assess associations between maternal bother, feeding method and infant characteristics. The feeding method was not associated with maternal bother, and cessation of breastfeeding did not result in a change in bother scores (p = 0.34). Duration of infant crying in the day, evening and night, frequency of night waking and duration of settling to sleep in the day were associated with increased bother scores. Higher breastfeeding self-efficacy and maternal confidence were associated with lower bother scores (both p < 0.01). Maternal bother is associated with infant behaviours that require parental input, but not breastfeeding status. Resources that address parental expectations regarding infant sleep while providing strategies to support maternal wellbeing and breastfeeding are needed.
... Attitudes and beliefs about infant sleep inform parental expectations, resulting in perceived sleep problems when the infant's sleep pattern does not match expectations [50]. Traditional behavioural infant sleep interventions that include delayed responses to cues and feed-sleep routines do not improve infant or maternal outcomes and may result in unintended consequences [51]. Anticipatory antenatal and early postnatal education that includes typical infant sleep patterns may assist parents in forming realistic expectations. ...
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The COVID-19 pandemic has impacted new mothers’ wellbeing and breastfeeding experience. Women have experienced changes in birth and postnatal care and restricted access to their support network. It is unclear how these impacts may have changed over time with shifting rates of infection and policies restricting movement and access to services in Australia and New Zealand. This study investigated the longitudinal effect of the COVID-19 pandemic on breastfeeding and maternal wellbeing in Australia and New Zealand. Mothers ( n = 246) completed an online survey every 4 weeks for 6 months that examined feeding methods, maternal mental wellbeing, worries, challenges, and positive experiences during the pandemic. Mothers maintained high full breastfeeding rates at 4 months (81%) which decreased to 37% at 6 months. Perceived low milk supply contributed to the earlier cessation of full breastfeeding. Poor infant sleep was associated with stress, perinatal anxiety, mental wellbeing, and breastfeeding status. Although mothers initially reported that lockdowns helped with family bonding and less pressure, prolonged lockdowns appeared to have adverse effects on access to social networks and extended family support. Conclusion : The results highlight the changing dynamic of the pandemic and the need for adaptable perinatal services which allow mothers access to in-person services and their support network even in lockdowns. Similarly, access to continuous education and clinical care remains critical for women experiencing concerns about their milk supply, infant sleep, and their own wellbeing. What is Known: • The COVID-19 pandemic and lockdown restrictions have significantly affected perinatal mental health, disrupted maternal services, and subsequent breastfeeding. What is New: • In Australia and New Zealand, breastfeeding women experienced challenges to their mental wellbeing, sleep, and breastfeeding, which was likely exacerbated over time by the pandemic. Lockdowns, while initially beneficial for some families, became detrimental to maternal support and wellbeing.
... This umbrella term encapsulates strategies for helping baby settle, how parents should respond to infant crying or signaling during a sleep period, and various other techniques to promote self-soothing and undisturbed sleep. While research documenting the effectiveness of BSI is robust, data supporting BSI in infants under 6 months is mixed, with feeding patterns appearing to play a role in effectiveness (Douglas and Hill, 2013;Kempler et al., 2016;Honaker et al., 2018). As such, in infants under 6 months of age, parental education and prevention focusing on developing positive night-time habits and knowledge of infant sleep patterns remains one of these most powerful tools available (Crichton and Symon, 2016). ...
Chapter
The presentation of insomnia varies greatly across human development, from the referral process to evaluation and treatment. For example, adults with insomnia tend to present with difficulties initiating and/or maintaining sleep despite their best efforts to capture sleep. Young children, on the other hand, may actively resist sleep despite their parents' best efforts to coax them to sleep. The current article takes a developmental approach to describing the clinical presentations of insomnia across pediatric populations. Suggestions are provided to health professionals interested in conducting a thorough clinical evaluation of insomnia, then delivering evidence-based or emerging cognitive-behavioral and pharmacological interventions to infants, children and adolescents.
... This Although the literature is favourable towards the implementation of parent-directed behavioural interventions, there are critics, both among professionals and parents. [24][25][26] In some cases, this may be due to insufficient training and knowledge about infant sleep, and misapplications of attachment theory in the field of sleep. According to attachment theory, infants need sensitive, contingent and immediate responses to behavioural cues that express the need for protection, food, contact and care. ...
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Aim: Parents and professionals receive conflicting recommendations about management of infant sleep problems. The aim of this umbrella review was to provide an overview of summarised research on the prevention and treatment of sleep problems in infants (0-1 year), content of the interventions, and the conditions under which they are delivered. Methods: The umbrella review included five systematic reviews of 24 individual studies, mainly randomised controlled trials. Searches were conducted in PsycINFO, Cochrane, Campbell, Epistemonikos, PDQ-Evidence, IN SUM, and the Norwegian Institute of Public Health, for reviews published during 2010-2021. Results: The systematic reviews showed that behavioural interventions increased sleep in infants and parents. Interventions entailed reducing parental disturbances during sleep onset and enabling the infant to fall asleep and maintain sleep on their own. Knowledge about infant sleep and the establishment of positive bedtime routines seemed crucial for preventing and treating sleep difficulties. The interventions can be delivered in a few sessions, typically one-on-one during the postnatal period. Conclusion: Behavioural interventions can be recommended and adapted to the individual family. Positive outcomes for the infant and the family depends on a close and coordinated collaboration between child health clinics, community psychologists, general physicians, and other services.
... As an example, reported that, although behavioral sleep techniques did not cause long-lasting harms or benefit to child and parents, there were no differences between intervention and control families for any outcome (child's emotion and behavior, sleep problems, parent and child psychosocial functioning). Furthermore, behavioral interventions for infant sleep in the first 6 months of life did not decrease infant crying, nor prevent sleep and behavioral problems in later childhood, nor protect against postnatal depression; instead, they worsened maternal anxiety and increased risk of SIDS (Douglas and Hill, 2013). Another meta-analysis of psychosocial sleep interventions indicated an impact on maternal mood and small improvements in infant nocturnal sleep time with no evidence of reduction of the infant night awakenings (Kempler et al., 2016). ...
Article
This paper aims to review the limitations of the current classification of insomnia of early childhood and propose a new conceptual model allowing a better understanding of its pathophysiology. Our hypothesis is that chronic insomnia of childhood has different phenotypical expressions, associated to different pathophysiological mechanisms. Based on a long-lasting experience in evaluating a very large number of children with specific insomnia symptoms (nocturnal awakenings, difficulty in falling asleep, nocturnal restlessness, early morning awakenings) and on published data, we hypothesize that different phenotypes of insomnia might exist with different therapeutic implications. We describe three phenotypes of insomnia in early childhood: a) insomnia with motor restlessness; b) insomnia characterized without difficulties in falling asleep but with long-lasting early morning awakenings; c) insomnia with multiple night awakenings and falling asleep difficulty. This type of categorization might have important implications for treatment, based on the different hypothetical neurotransmitter dysfunctions. The early identification of a phenotype of insomnia might guide to specific behavioral and/or pharmacological interventions with the aim to prevent chronic insomnia.
... Drawing on Douglas and Hill (2013), it was hypothesised that a more stressful birth experience for the infant may have triggered a negative feedback loop in the infant's hypothalamic-pituitary-adrenal (HPA) axis responsible for their developing stress response system. Therefore, if a genetically susceptible infant (Belsky & Pleuss, 2009) is further sensitised by early stressors occurring during the birth, this could potentially lead to longer term interactional cry-fuss, feeding and sleeping problems and reduced soothability (Douglas & Hill, 2013b), otherwise known as regulatory problems (Schmid, Schreier, Meyer & Wolke, 2011). ...
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PhD thesis about maternal experience of childbirth, infant behaviour and early temperament
... They highlighted that infant sleep significantly improved when parents reduced their involvement at bedtime and during the night (ie, removing positive reinforcement related to crying upon waking during the night; [1,2,4]). To date, there is no support for the use of behavioural sleep interventions in infants under the age of 6 months, and intervening before this time may actually risk adverse outcomes [29]. It should be noted that research has identified a gap in paediatric sleep intervention research for non-white ethnic groups, and lower income families [30]. ...
Article
Behavioural sleep interventions (e.g., extinction-based methods) are among the most efficacious evidence-based techniques in the treatment of infant sleep problems. However, behavioural sleep interventions can be challenging for families to successfully implement. This review aims to summarise current research surrounding the potential barriers that arise when clinicians attempt to implement extinction-based methods with parents of infants. We provide a model that summarises 3 types of contextual-barriers; socio-cultural barriers, parent barriers, and infant barriers. Based on the current evidence, we propose that adopting a stepped care approach, planning ahead, increasing support, motivational interviewing, and/or emotional regulation may serve as useful tools for parents when implementing extinction-based methods. By considering these techniques, more families may receive the benefits of improved infant sleep.
... Studies have shown that only 50% of infants sleep through the night by one year of age. 9 As doctors in primary health care, we are involved in patient care provision, complex decision making, and multidisciplinary team coordination. Medical mothers returning from maternity leave are required to resume work in the same capacity as their colleagues, while navigating the challenges of normal infant sleep patterns. ...
... In a meta-analysis of nine randomized clinical trials, small to moderate effects were found for psychosocial infant sleep interventions on improved maternal mood and improved maternal report of infant nocturnal sleep (Kempler et al., 2016). However, another systematic review of 43 such studies indicated that behavioral interventions aimed at improving infant sleep during the first 6 months of life do not improve long-term outcomes for mothers or infants and may increase risk of unintended outcomes, such as early discontinuation of breastfeeding and increased anxiety among new mothers (Douglas and Hill, 2013). Our results indicate that PREPP, which targets more than infant sleep, can positively influence infant sleep duration and/or maternal assessment of it even in the context of no treatment effect on mood-suggesting the possibility of downstream influence on maternal mood in the future, one that is mediated via changes in the infant (or maternal perception of the infant). ...
Article
BACKGROUND Prevention studies for perinatal depression rarely focus on the mother–infant dyad or consider the impact of maternal childhood maltreatment (CM). METHODS A secondary analysis of two combined randomized controlled trials of Practical Resources for Effective Postpartum Parenting (PREPP) examined the moderating role of CM on the efficacy of preventing perinatal depression and effects on infant behavior at six weeks. RESULTS 32% of 109 pregnant women endorsed CM (CM+). At six weeks postpartum, women who received PREPP compared to enhanced treatment as usual (ETAU) had significant reductions in depression and anxiety based on the observer-rated Hamilton Rating Scale for Depression (HRSD) and Hamilton Rating Scale for Anxiety (HRSA) (mean difference of M=-3.84 (SD= 0.14, p<0.01) and M=- 4.31 (SD= 0.32, p <0.001) respectively). When CM was added to the models, there no longer was a significant PREPP versus ETAU treatment effect on HRSD and HRSA outcomes in CM+ women though effects remained for CM- women. However, CM+ women who received PREPP vs ETAU reported a mean increase in infant daytime sleep of 189.8 minutes (SE= 50.48, p=0.001). LIMITATIONS: Self-report measures of infant behavior were used. CONCLUSIONS CM+ women versus CM- had limited response to an intervention to prevent perinatal depression yet still reported an increase in infant daytime sleep. This study adds to the growing literature that prevention studies may need to incorporate approaches tailored to fit women with childhood trauma histories while also considering infant functioning as both may be treatment targets relevant to maternal mood.
... It should be noted that randomized control trials of behavioral sleep interventions have shown mainly positive results and that many psychologists and health professionals advocate for their use (Gradisar et al. 2016;Hall et al. 2015;Mindell et al. 2011). At the same time, other researchers argue that the interventions are unnecessary and that the studies conducted were methodologically flawed (Blunden et al. 2011;Douglas and Hill 2013). In sum, this is still a highly controversial topic. ...
Chapter
Sleep is a necessary function of life and plays a key role in development. This chapter will discuss the association between prenatal stress and children’s sleeping behaviors. First, a description of the development of sleep-wake patterns in infancy will be provided. Second, an overview of the literature on the link between prenatal stress and sleep-wake behaviors will be presented from a developmental perspective. Then, key confounding variables that influence the association between prenatal stress and children’s sleep will be discussed. A few of the proposed mechanisms that could explain the relationship between prenatal stress and child sleep outcomes will also be reviewed. Lastly, clinical interventions targeting maternal stress and infant sleep will be discussed.
... Our simulations began at the age of 6 months, before which solids are generally not recommended for breastfed infants and night feeding is encouraged; (27) some literature suggests that behavioral night feeding interventions may not be developmentally appropriate earlier in life. (31) To simulate various success rates for an educational intervention targeting the reduction of night feeding by infants' caregivers, we tested various reductions in the probability of night feeding. We reduced the probability of feeding an infant during each night waking, ranging the probability from 70% to 10% beginning in month 6 (down from 79% when there was no intervention). ...
Article
Teaching caregivers to respond to normal infant night awakenings in ways other than feeding is a common obesity prevention effort. Models can simulate caregiver feeding behavior while controlling for variables that are difficult to manipulate or measure in real life. We developed a virtual infant model representing an infant with an embedded metabolism and his/her daily sleep, awakenings, and feeds from their caregiver each day as the infant aged from 6 to 12 months (recommended age to introduce solids). We then simulated different night feeding interventions and their impact on infant body mass index (BMI). Reducing the likelihood of feeding during normal night wakings from 79% to 50% to 10% lowered infant BMI from the 84th to the 75th to the 62nd percentile by 12 months, respectively, among caregivers who did not adaptively feed (e.g., adjust portion sizes of solid foods with infant growth). Among caregivers who adaptively feed, all scenarios resulted in relatively stable BMI percentiles, and progressively reducing feeding probability by 10% each month showed the least fluctuations. Reducing night feeding has the potential to impact infant BMI, (e.g., 10% lower probability can reduce BMI by 20 percentile points) especially among caregivers who do not adaptively feed. Teaching caregivers to respond to infant night waking with other soothing behaviors besides feeding has the potential to reduce infant BMI. When reducing the likelihood of feeding during night wakings from 79% to 50% to 10%, infants dropped from the 84th BMI percentile to the 75th to the 62nd by 12 months, respectively, among caregivers who do not adaptively feed. Night-feeding interventions have a greater impact when caregivers do not adaptively feed their infant based on their growth compared to caregivers who do adaptively feed. Night-feeding interventions should be one of the several tools in a multi-component intervention for childhood obesity prevention.
... The primary outcomes of these interventions include teaching infants to self-soothe to sleep, enabling them to have less fragmented nighttime sleep, and longer nighttime sleep periods [9]. Growing evidence supports the use of more responsive methods [12][13][14]. New interventions focusing on meeting infants' needs which enable mothers to continue breastfeeding are needed. ...
Article
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For infants and their families, sleep consolidation is important in maturing neural and circadian rhythms, and in family dynamics. The Possums Infant Sleep Program is a cued care approach to infant sleep, responding to infant cues in a flexible manner, dialing down the infant’s sympathetic nervous system. The current study evaluated the effect of the Possums program on infant sleep and breastfeeding in infants (6–12 months) from a well-child outpatient clinic in Turkey, with the program intervention group (n = 91) compared with usual care (n = 92). In total, 157 mother-infant dyads completed the study. Infant sleep and breastfeeding rates were assessed at baseline and after 3 months. Nocturnal wakefulness, daytime sleep duration, naps, and night wakening decreased in both groups. Nocturnal sleep duration and the longest stretch of time the child was asleep during the night increased significantly in both groups without any change in total sleep duration. Night wakening was significantly lower and nocturnal sleep duration was significantly higher in the intervention group. However, mixed effects model analyses indicated no significant differences between the groups on any of the sleep outcomes after adjusting for confounders. Despite this, breastfeeding rates were significantly higher in the intervention group compared with those in the usual care group at follow-up.Conclusion: The Possum infant sleep program provided equivalent positive results on sleep parameters compared to usual care while advocating a more cued response. The critical difference was evident in sustained breastfeeding. What is Known: • Responsive sleep programs produce sleep consolidation, by responding to the infant’s cues without ignoring, and then gradually reducing parental interaction. • Breastfeeding to sleep may be considered an undesirable sleep association in some infant sleep interventions. What is New: • The Possums Infant Sleep Program provided equivalent positive results to usual care while advocating a more cued response. • The critical difference was in sustaining breastfeeding, and the program was associated with better breastfeeding rates.
... A better understanding of infant sleep patterns can benefit parents by informing them of what sleep patterns may emerge in their newborn and when more mature sleep development may be expected, and may also help health professional and childcare advisors in counselling parents and guiding realistic parental expectations. This is especially important in the light of growing evidence that interventions to promote infant sleep can have unintended adverse consequences including increased maternal anxiety or premature weaning from breastfeeding [7]. ...
Article
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Background Infant sleep is of great interest to new parents. There is ongoing debate about whether infants fed with breastmilk substitutes sleep longer than those exclusively or partially breastfed, but what does this mean for the mother? What expectations are realistic for mothers desiring to exclusively breastfeed as recommended by health authorities? There are both biological and social influences on infant and maternal sleep. More accurate information on average maternal sleep hours for diverse feeding practices may help guide realistic expectations and better outcomes for mothers, infants and families. Methods Using a unique time use dataset purposefully designed to study the time use of new mothers, this study investigated whether the weekly duration of maternal sleep, sleep disturbance, unpaid housework, and free time activities differed by detailed feeding method. The study collected 24/7 time use data from 156 mothers of infants aged 3, 6 and/or 9 months between April 2005 and April 2006, recruited via mother’s groups, infant health clinics, and childcare services throughout Australia. Sociodemographic and feeding status data were collected by questionnaire. Statistical analysis used linear mixed modelling and residual maximum likelihood analysis to compare effects of different infant feeding practices on maternal time use. Results There were no significant differences in time spent asleep between lactating and non lactating mothers, though lactating mothers had more time awake at night. Lactating mothers spent more time (8.5 h weekly) in childcaring activity ( p = 0.007), and in employment (2.7 vs. 1.2 h, p < 0.01), but there were no significant differences in free time. Those not breastfeeding spent more time in unpaid domestic work. Exclusive breastfeeding was associated with reduced maternal sleep hours (average 7.08 h daily). Again, free time did not differ significantly between feeding groups. Exclusively breastfeeding mothers experienced reduced sleep hours, but maintained comparable leisure time to other mothers by allocating their time differently. Domestic work hours differed, interacting in complex ways with infant age and feeding practice. Conclusions Optimal breastfeeding may require realistic maternal sleep expectations and equitable sharing of paid and unpaid work burdens with other household members in the months after the birth of an infant.
... [22,38,39]. Although several trials have tested the effectiveness of educational interventions (based on sleep hygiene, self-settling, and the use of routines) alone or in combination with other psychological approaches [13,[23][24][25] they have at best produced mixed results, and most have been found to be ineffective [14,[40][41][42]. 'Limit-setting' educational approaches designed to support the development of 'settled infant night-time behaviour' have been examined as preventative interventions [7,24,26] but have been unsuccessful in achieving their primary outcome of increasing the duration of infant night-time sleep, although researchers do not agree on the strength of evidence for these approaches and better research is needed. ...
Article
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Disrupted parental sleep, presenting as post-partum fatigue and perceived as problematic infant sleep, is related to increased symptoms of depression and anxiety among new mothers and fathers. Previous research indicates that UK parents would value an approach that facilitates meeting their infants’ needs while supporting their own sleep-related well-being throughout their infant’s first year. Six initial stakeholder meetings were held with 15 practitioners and 6 parents with an interest in supporting parent-infant sleep needs, to explore existing service provision and identify gaps. The Possums Sleep Program developed and delivered in Brisbane, Australia in a GP clinic setting, was chosen as an appropriate approach. Working collaboratively with a stakeholder group, we translated the Possums Sleep Program into an intervention that could be universally delivered in the UK via NHS antenatal and postnatal practitioners. Parent and practitioner views of the initial materials were obtained via feedback questionnaires and the tool was revised. The intervention was then field-tested by 164 practitioners who delivered it to at least 535 new parents and babies over 5 UK locations, to capture anonymous parent and practitioner views of the intervention concept, the materials, and their experiences with both. The intervention helps parents recalibrate their expectations of infant sleep development, encourages responsive parenting and experimentation to meet their infant’s needs, offers parents strategies for supporting the development of their babies’ biological sleep regulators and promote their own well-being, and teaches parents to manage negative thinking and anxiety that can impede sleep using the principles of Acceptance and Commitment Therapy. The ‘Sleep, Baby & You’ discussion tool, a 14 page illustrated booklet for parents, was field-tested and evaluated by practitioners and parents who offered enthusiastic feedback. Practitioners reported the ‘Sleep, Baby & You’ materials were easy for them to explain and for parents to understand, and were a good fit with the responsive parenting approaches they employed in other areas of their work. Parents who received the intervention postnatally understood the material and found the suggestions easy to follow. All parents who provided feedback had implemented one or more of the suggested changes, with the majority of changes (70%) being sustained for at least two weeks. Practitioners recommended development of digital and antenatal versions and offered feedback on circumstances that might challenge effective uptake of the intervention. ‘Sleep, Baby & You’ is a promising tool for promoting parental attitude and behaviour-change, that aims to adjust parental expectations and reduce negative thinking around infant sleep, promote responsive infant care in the face of infant-related sleep disruption and fatigue, and support parental well-being during the first year of parenthood. Initial field-testing provided insights useful for further development and subsequent testing via a randomised trial. Support exists for incorporating ‘Sleep, Baby & You’ into an anticipatory, universal intervention to support parents who may experience post-partum fatigue and infant sleep disruption.
... This is particularly targeted at infants after 6 months as prior to 6 months evidence suggests that decreasing assistance does not decrease crying. [51][52][53] As discussed above, in most standard definitions of Camping Out in the academic literature, even if parents can respond minimally, periodic ignoring is usually included. 10,[54][55][56] In RwDA, the parent is not instructed to ignore but to gradually reduce interaction so this is a compromise and integration between the theoretical models of extinction and attachment and more to the point, makes an attempt to systematically define the differences and or similarities of these two similar approaches. ...
Article
In families with infants between the ages of 6 and 18 months, sleep disruption can be significant, often putting parents at risk of a range of negative psychological and psychosocial consequences. Commonly prescribed sleep interventions typically involve ‘extinction’ methods, which require parents to completely or periodically ignore their infant's overnight cries. These methods can be effective in many, but not all cases. For over 40 years 30–40% of parents have consistently reported difficulty ignoring their child. For this group, ignoring their child is behaviourally and/or ideologically difficult with attrition often leading to a perceived sense of failure. For these parents the treatment may be worse than the problem. On the other hand, there is emerging evidence to support the use of more responsive methods for those who find extinction approaches behaviourally or ideologically challenging. In this paper we propose an integrated, less polarised approach to infant behavioural sleep interventions that better caters to those who have difficulty with extinction methods – our so‐called ‘Plan B’. This approach potentially resolves the often opposing ideological and theoretical perspectives of extinction versus responsiveness into a practical, complementary and pragmatic treatment framework. Recommendations on how best to implement Plan B are also presented. In our view, Plan B could provide practitioners with a logically integrated well‐targeted suite of clinical interventions that could potentially improve compliance, reduce attrition and ultimately benefit the sleep and well‐being of all infants and their parents, especially those who struggle with traditional extinction methodologies.
... For sleep, many parents may try many different techniques such as pacifiers, stopping breastfeeding, or placing the infant in the other room-none of which have a consistent impact on improving infant sleep (Brown & Harries, 2015;McKenna et al., 2007;Tomori, 2018). Likewise, interventions to reduce infant crying that involve reduced response to the infant do not have consistent results (Blunden, Thompson, & Dawson, 2011;Douglas & Hill, 2013). ...
Article
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Baby care books that promote strict infant care routines are popular but little research has considered their impact upon maternal infant care behaviours. We explored whether mothers who have read these books guide their infant care behaviours based on their concepts, and how this is associated with infant feeding, night time care, and response to infant's needs. Three hundred and fifty‐four UK mothers with a baby aged 0–12 months completed an online questionnaire exploring use of baby care books, motivations for use, whether guidance was followed, and infant care behaviours. Mothers who read the books were drawn to them for information about how to settle their infant, infant sleep and infant feeding behaviour. Those who read the books were less likely to breastfeed, feed responsively, have their infant sleep in the same room, cuddle their infant to sleep, or respond promptly to infant cries. Although the causality between reading these books and care cannot be determined through this study design, and is likely bidirectional with some reading the books to confirm existing preferences, around 25–40% of mothers noted the information determined their care decisions. Regardless of specific causal pathways, there is an association between these books and behaviours that go against infant feeding and responsive care recommendations. Understanding what drives mothers to follow these books, and increasing support for new mothers in these areas is important. The findings will be important for those supporting mothers in the perinatal period in starting conversations around responsive infant care.
Article
Purpose To examine the factors associated with the early initiation of breastfeeding and exclusive breastfeeding among mothers in Vietnam during the first 6 months postpartum. Design and methods A cross-sectional study including 200 mother-infant dyads was conducted at community health stations. Information on demographic characteristics, modes of delivery, infant sleep problems, and breastfeeding practices was collected using structured questionnaires. The main independent variable of social support was assessed using the Multidimensional Scale of Perceived Social Support. Multivariable logistic regression analysis was used. Results Among the study cohort, 37.5% of mothers had initiated breastfeeding within 1 h after birth, and 27.5% continued exclusive breastfeeding for the first 6 months postpartum. Mothers living in urban areas or who had undergone cesarean delivery were less likely to have initiated breastfeeding within 1 h after birth (p < 0.05). The odds of exclusive breastfeeding were lower among infants with longer waking hours at night (≥4 h) and sleep problems (p < 0.05). Support from the mother's significant other and friends was significantly associated with exclusive breastfeeding (p < 0.05). Conclusions Early initiation of breastfeeding and exclusive breastfeeding were not common in a community sample of Vietnamese mothers. Identifying and assessing mothers who lack breastfeeding support is necessary to promote and sustain breastfeeding practices. Practice implication Further comprehensive breastfeeding interventions and support are needed for postpartum women in Vietnam.
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This systematic review and meta-analysis was conducted to investigate the effectiveness of behavioral sleep interventions (BSIs) on the number of child night awakenings, and maternal sleep quality and depression. The search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA) using PubMed, CINAHL, Cochrane, and EMBASE databases and retrieved studies published until April 2021. We calculated the odds ratios (ORs) and 95% confidence intervals (CIs) for child sleep problems, and the mean differences (MD) and 95% CI for the number of child night awakenings, and maternal sleep quality and depression. Ten studies of 1628 initial searched were included in the final analysis. Two of the 10 studies were divided into two subgroups by participants and intervention type; thus, 12 subgroups were included in the meta-analysis. BSIs significantly reduced child sleep problems (OR 0.51; 95% CI 0.37–0.69) and improved maternal sleep quality (MD − 1.30; 95% CI − 1.82 to − 0.77) in the intervention group. There were no significant differences in the number of child night awakenings and maternal depression between the two groups. More RCTs to examine the effect of BSIs considering children’s age, duration of intervention, and outcome measuring time points are needed.
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Night-waking is typical across infancy and early childhood, inevitably disrupting family sleep. For some children, sleep problems develop and endure throughout childhood. This systematic review focused on fathers, and synthesised the evidence pertaining to the effects of children’s sleep (from birth to 12 years) on fathers’ health and wellbeing. A total of 29 studies were included. Key outcomes reported for fathers were: sleep and fatigue; mental and general health; and family functioning. An association between child sleep and father's sleep was observed when child's sleep was measured via actigraphy or paternal report, but not when measured via maternal report, suggesting that mothers may not always be aware of disruptions that awaken fathers. Findings showed poorer child sleep was associated with poorer general health and wellbeing among fathers, however, associations of poor child sleep with depression were fewer, and less frequent than those reported for mothers in the same households. Poor child sleep was negatively associated with the quality of family relationships, both within the couple and between parent and child. Future studies seeking to understand the interplay of child sleep and family wellbeing should apply objective measurement of sleep and integrate formal measures of family dynamics into the study design.
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Global rates of obesity and Type 2 diabetes mellitus (T2DM) are increasing globally concomitant with a rising prevalence of sleep deprivation and sleep disorders. Understanding the links between sleep, obesity and T2DM might offer an opportunity to develop better prevention and treatment strategies for these epidemics. Experimental studies have shown that sleep restriction is associated with changes in energy homeostasis, insulin resistance and β-cell function. Epidemiological cohort studies established short sleep duration as a risk factor for developing obesity and T2DM. In addition, small studies suggested that short sleep duration was associated less weight loss following lifestyle interventions or bariatric surgery. In this article, we review the epidemiological evidence linking sleep duration to obesity and T2DM and plausible mechanisms. In addition, we review the impact of changes in sleep duration on obesity and T2DM.
Chapter
Sleep during infancy and toddlerhood is a high-priority issue for parents, especially at night, because when the baby doesn’t sleep, neither do the parents. Many mothers and fathers resume their work within a few months after the birth, and working after a poor night’s sleep is both difficult and exhausting. Babies often nap during the day, but many parents cannot afford that luxury, especially if they do not remain at home during the day. This chapter systematically reviews the evidence about the “normal” evolution of night- and daytime sleep in babies and toddlers as the child ages and about factors other than age that may influence sleeping behaviors: infant feeding, the sleeping arrangements of the baby and parents, the baby’s sleeping position, noise and light in the baby’s bedroom, and the use of pacifiers. After a brief section summarizing the evidence concerning possible effects of the baby’s sleep on long-term health and brain development, most of the chapter summarizes the evidence from randomized trials of interventions designed to help the baby sleep through the night.
Article
Study objectives: This study evaluated the effect on infant sleep of a novel intervention (Play2Sleep) that combined infant sleep information with self-modeled video feedback on parent-infant interactions. Methods: An explanatory sequential mixed methods design consisting of a randomized controlled trial with 63 mother-father-infant triads randomized to Play2Sleep or comparison home visit interventions was used. We used RM-ANCOVA to detect changes in infant night wakings, nocturnal wakefulness, and sleep durations and Wilcoxon signed rank test to evaluate changes in perception of infant sleep problems. Family interviews (n = 20) were used to explain the quantitative findings and analyzed qualitatively using thematic analysis. Results: Play2Sleep was effective in reducing maternal-reported infant wakefulness, F(1, 55) = 5.33, p = .03, partial η2 = .09, and the number of paternal-reported naps, F(1, 58) = 4.90, p = .03, partial η2 = .08. Parents in the Play2Sleep group reported significant improvements in problematic infant sleep that were not observed in the comparison group, however Play2Sleep was not effective in reducing the number of parent-reported night wakings. Information overwhelm, learning infant cues, and working together with a subtheme of father involvement were key qualitative themes developed to explain the quantitative results. Unplanned exploratory analyses revealed a significant improvement in maternal depression symptoms in the Play2Sleep group. Conclusions: This study suggests Play2Sleep could improve infant sleep by promoting parental awareness of infant cues and father involvement and improving maternal depression. Additional research is needed to determine the optimal number and timing of sessions. Clinical trial registration: Registry: ClinicalTrials.gov; Identifier: NCT02742155.
Article
Health visitors play a central role in assessing and supporting families to manage sleep concerns; but with little evidence-based guidance on managing infant sleep difficulties this can be challenging, says Bethany Boddy
Article
Infants evolved in the context of close contact (including co-sleeping). Evolutionary context is rarely considered in psychological infant sleep research, and Western sleep researchers make assumptions about what optimal “normal” infant sleep is and how to achieve early, deep, infant sleep consolidation and avoid infant sleep problems. However, an evolutionary and anthropological view of infant sleep as species-typical recognizes that human evolution likely prepared the infant brain for optimal development within its evolutionary context – co-sleeping. Thus, “normal” infant sleep, sleep consolidation, and sleep problems should all be understood within the framework of co-sleeping infants, not the historically new-phenomenon of solitary-sleeping infants. Much work needs to be done in order to understand “normal” infant sleep as species-typical and how adaptive infants are to environments that stray from their evolutionary norm.
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Objective: To describe the changes in temporal characteristics of sleep-wake cycle, which can serve as non-motor manifestations of an early stage of Parkinson's disease (PD), using the model of preclinical PD in rats of two age groups. Material and methods: A prolonged (up to 21 days) model of preclinical PD in middle-aged (7-8 month) and aged (19-20 month) rats was created. The model was based on cumulative inhibition of proteasomal system of the brain caused by intranasal administration of lactacystin, a specific proteasome inhibitor. Polysomnographic data were recorded daily using telemetric Dataquest A.R.T. System (DSI, USA) in unrestrained animals. Results and conclusion: Aging was accompanied with increased sleepiness during the active (dark) phase of the day (as was implied by a two-fold increase in the total time of drowsiness) and with 1.5-fold growth of light sleep during the inactive phase of the day. A common feature of sleep disturbances in the model of preclinical PD in both middle-aged and aged rats was hypersomnia during the active phase of the day. It was suggested to be similar to the excessive daytime sleepiness in humans. Hypersomnolence was more pronounced in aged rats because it added to sleepiness developing with aging. In both age groups, the model of preclinical PD was also associated with a decrease in EEG delta power during slow-wave sleep. It is considered dangerous because it might represent the decrease in protein synthesis rate and the weakening of restorative processes in neurons, occurring with the prolonged inhibition of proteasomal system of the brain. Sleep disturbances, identified the model of preclinical PD in rats of different age, may be recommended for clinical validation as low-cost early signs indicating the initial stage of PD.
Article
Behavioral insomnia is the most common sleep disorder in young children. It significantly reduces the quality of parent's life and is one of the common complaints to a pediatrician or neurologist. The basis treatment of childhood insomnia is behavioral therapy, which includes sleep hygiene, age-appropriate daily routine and sleep associations, stable bedtime routines, positive reinforcement, bedtime fading, scheduled awakenings. Although a systematic ignoring («crying it out») is effective and widely used in behavioral therapy, it has low compliance and its safety is insufficiently studied. Therefore, a systematic ignoring is not a priority method of behavioral therapy and should not be used in children under 6 months of age. Behavioral therapy of childhood insomnia is complemented by psychological and informational support from parents, and in some cases, drug therapy. Prevention includes education of expectant parents on baby sleep hygiene.
Article
Importance: This Practice Guideline provides stakeholders with a condensed summary of a large number of effectiveness studies. It is a valuable tool for facilitating decision making related to occupational therapy interventions for children ages birth–5 yr. Objective: Early childhood (birth–5 yr) is a critical period in which the foundation of key life occupations is developed (e.g., eating, dressing, play, learning, social participation, rest and sleep, and chores). The development of cognitive, motor, social–emotional, and self-care skills is important to support these occupations. This Practice Guideline synthesizes recent systematic reviews (SRs) on these areas of development to promote decision making for and high-quality interventions with this population. Method: Four SRs related to cognition, mental health, motor function, and ADLs analyzed studies published from 2010 to 2017 retrieved from six electronic databases (MEDLINE, PsycINFO, CINAHL, ERIC, OTseeker, and Cochrane). Results: A total of 196 articles were included in the SRs, which served as a guide to final clinical recommendations. Case studies describe translation and application to practice. Conclusions and Recommendations: A variety of interventions within the domain of occupational therapy were found to support the development of cognitive, social–emotional, motor, and self-care skills. Although some of these interventions are typically implemented by occupational therapy practitioners, others can be implemented by parents after training or by teams working in preschool settings. These findings should be used to inform evidence-based practice provided by occupational therapy practitioners working in various early childhood settings. What This Article Adds: This Practice Guideline gives occupational therapy practitioners clear information about which interventions will be effective for specific outcomes. Better intervention choices mean better outcomes for young children and their families.
Article
This study used data from 2,222 mothers and infants participating in a population‐based birth cohort to verify whether maternal depression in the perinatal period was associated with poor infant sleep. Mothers who scored ≥13 points on the Edinburgh Postnatal Depression Scale at 16–24 weeks of gestation and/or 3 months after delivery were considered perinatally depressed. The main outcome variable was poor infant sleep at 12 months of age, defined as >3 night wakings, nocturnal wakefulness >1 hr or total sleep duration <9 hr. Infant sleep data were obtained with the Brief Infant Sleep Questionnaire (BISQ) and 24‐hr actigraphy monitoring. Prevalence of perinatal depression in the sample was 22.3% (95% confidence interval [CI], 20.5–24.0). After Poisson regression, infants of depressed mothers showed an adjusted relative risk (RR) of 1.44 (95% CI, 1.00–2.08; p = .04) for >3 night wakings with questionnaire‐derived data. When actigraphy data were analysed, no association was found between perinatal depression and poor infant sleep (adjusted RR, 1.20; 95% CI, 0.82–1.74; p = .35). In conclusion, although mothers in the depressed group were more likely to report more night wakings, objective data from actigraphy did not replicate this finding. Dysfunctional cognition, maternal behavioural factors and sleep impairment associated with perinatal depression may affect the mother's impression of her infant's sleep.
Article
Study objectives: This study tested the acceptability and efficacy of a perinatally delivered behavioral-educational sleep intervention. Methods: Participants were 40 primiparous women assigned in late pregnancy to either an intervention (n = 20) or control (n = 20) group. The sleep intervention group (SIG) received prenatal anticipatory education and guidance regarding their own and their infant's sleep during the first 3 months postpartum. This was reinforced during phone calls within the first 6 weeks postpartum. The control group (CG) received brief sleep hygiene information at a prenatal session, followed by 2 phone calls during the same period. Mother-infant pairs wore actigraphs for 48 hours at 6 and 12 weeks postpartum, and mothers kept sleep diaries. Questionnaires completed in late pregnancy and 6 and 12 weeks postpartum related to sleep, newborn care, and mood. The main outcome measures included maternal sleep quantity, efficiency, and self-reported quality and infant sleep duration and consolidation. Results: Mothers reported high acceptability of the study processes. Sleep duration and quality increased for mothers and infants across time in both groups, with a significantly greater increase in nocturnal sleep duration for mothers in the SIG. Conclusions: Prenatal sleep guidance and postnatal follow-up seems to enhance nocturnal sleep of mothers, change their perceptions of their own sleep, and increase confidence in managing their infant's sleep. Follow-up at later intervals and replication with larger, more diverse samples may reveal further differences.
Article
Importance: It is critical for providers to use evidence-based interventions to address mental health and behavioral barriers to occupational performance during early childhood. Objective: To identify evidence-based interventions within the scope of occupational therapy practice to improve mental health and positive behavior for children ages 0-5 yr and their families. Data sources: PsycINFO, Cochrane, ERIC, MEDLINE, and OTseeker databases were searched for publications from 2010 through March 2017. Study selection and data collection: This review was completed in accordance with the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Risk of bias was assessed for each article using either A Measurement Tool to Assess Systematic Reviews (AMSTAR) or the Cochrane method. Articles meeting inclusion criteria were critically appraised. Findings: Forty-six articles met inclusion criteria and were organized into three themes: touch-based interventions (n = 9), parent-child interaction therapy (PCIT; n = 4), and instruction-based interventions (n = 33). Statistically significant findings and overall risk of bias supported the use of touch-based interventions, PCIT, and parent training. Conclusions and relevance: The evidence indicates that touch-based interventions can improve infant self-regulation (strong), social behavior, and attachment (moderate) and reduce maternal stress, anxiety, and depression (low). Moderate-strength evidence supports PCIT to improve child behavior. The evidence indicates that parent training can improve parent behavior, maternal-infant attachment (strong), and parent mental health (moderate). Teacher training can improve mental health and behavior (moderate). Group-based parent training and sleep training have insufficient support (low). What this article adds: Occupational therapy professionals working with children younger than age 5 yr can use the results of this systematic review to guide clinical decision making related to mental health and behavioral outcomes.
Article
The human need for sleep is universal and unquestioned; however, humans vary in their sleep needs according to age, individual differences, as well as cultural and social norms and practices. Therefore, what is “normal” in infant sleep and the development of sleep architecture in humans is highly dependent on biological and sociocultural variables as well as socially constructed assumptions about what infant sleep “should” look like. This paper uses a multidisciplinary approach to review papers from fields including pediatrics, anthropology, psychology, medicine, and sociology to understand “normal” infant sleep. Because human culture and behavioral practice changes much more quickly than evolved human biology, and because human evolutionary history occurred in the context of breastfeeding and cosleeping, new work in the field of infant sleep architecture development would benefit from a multidisciplinary approach. To come to a consensus about what is “normal” infant sleep, researchers must agree on underlying basic assumptions of infant sleep from which to ask question and interpret findings.
Article
Objective: The primary objective was to identify the characteristics of parents and infants and parenting practices associated with delayed responsiveness to infant crying during the first year of infant life. A secondary objective was to evaluate, in a subsample of maternal-infant pairs, the associations between delayed responsiveness to infant crying and observational measures of maternal-infant interaction and infant-maternal attachment. Method: This is a secondary analysis of the data from a community sample of pregnant women recruited to the Alberta Pregnancy Outcomes and Nutrition study. Mothers completed questionnaires during the first year of infant life (n = 1826), and a convenience subsample of maternal-infant pairs (n = 137) participated in laboratory assessments of maternal-infant interaction at 6 months of age and infant-maternal attachment at 20 months. Results: Parental use of "cry out" as a strategy to deal with a crying infant was associated with parental characteristics (being white and having a relatively higher income), infant characteristics (higher problematic behavior at 3 months and reduced problematic behavior at 12 months), sleep ecology (infants sleeping alone), and parental soothing strategies (less frequently taking the infant into the parent's bed, cuddling, or carrying the crying infant). Cry out was not associated with observational measures of maternal sensitivity or infant-maternal attachment. Conclusion: When used selectively and in response to the specific needs and characteristics of the infant, delayed responsiveness may reduce problematic behavior and does not harm the infant's socioemotional development.
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Currently, one out of every 59 infants born in the United States will be diagnosed with an autism spectrum disorder (ASD) at some point in their future (Baio, 2018). Families may face unique challenges related to atypical infant behaviors and feeding patterns before diagnosis of ASD occurs. There is wide variation of symptoms among children with ASD, yet, children with ASD are five times more likely to have both behavioral and skill-based feeding issues. However, little is known about when feeding issues begin, how atypical behaviors impact infant caretaking needs, and whether practitioners have sufficient training to identify infants for further developmental assessment. As a result, despite identifiable early indicators of ASD during infancy, most children are not diagnosed with ASD until they begin preschool. When practitioner views of infant feeding focus exclusively on nutrition, atypical feeding behaviors may be overlooked as a way to identify atypical development. Infants who have behaviors associated with later diagnosis of ASD may face unique challenges breastfeeding. Practitioners need to have knowledge of development, early indicators of ASD, and infant feeding behaviors to provide support to parents and promote healthy development. The purpose of this study was to better understand practitioners’ knowledge of infant feeding behaviors and early indicators of ASD within the context of mother’s experiences raising infants later diagnosed with ASD. Quantitative measures of lactation consultants’ and pediatricians’ knowledge of early indicators of ASD and lactation were integrated with phenomenological analysis of maternal experiences seeking help managing breastfeeding and atypical behaviors in infants later diagnosed with ASD. Individual and professional level influences on maternal access to support and barriers to support were explored.
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Aim: The aim of this review was to evaluate the evidence for interventions for behavioural sleep problem in infants. Methods: Systematic review based on a search in MEDLINE, Web of Science and PsychINFO in December 2017 for articles published in English during 2007-2017 about preventive and treatment interventions for sleep problems in infants. The review included controlled trials and meta-analyses with at least 20 infants in study groups assessed according to the Grading of Recommendations Assessment, Development and Evaluation criteria. Results: Out of 476 original articles assessed for eligibility, 12 studies were included in the synthesis. Interventions with behavioural, educational and massage strategies were evaluated. No intervention was evaluated in more than one trial. Five interventions with behavioural methods for establishing consistent routines or controlled crying showed modest short-term effects while the evidence for elements of education was inconsistent. Studies of massage were of poor quality. Knowledge gaps were identified regarding interventions in cross-cultural context, involving fathers, in children below six months of age, in high risk populations and consequences of interventions that include extinction. Conclusion: Some support for short term effects of behavioural treatment strategies were found, but more studies are needed to establish evidence.
Chapter
Following their infant’s birth, parents in many societies in the global North experience acute sleep disruption for which few are adequately prepared, and which may result in profound and enduring negative outcomes such as parental depression and anxiety. For some babies, their parent’s inability to cope with sleep disruption results in harmful short-term outcomes (such as infants being medicalised, medicated, and abused); long-term consequences are more difficult to identify and therefore are understudied. Yet other parents, and indeed whole nations of parents, seem resilient to infant-related sleep disruption and take it all in their stride—so what differs? This chapter considers parental perceptions and experiences of night-time infant care and the strategies that are promoted and used for coping with infant-related sleep disruption. The potential consequences of these for parents, their babies, and society in general will be explored with suggestions for future research to fill current evidence gaps.
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This paper reviews the evidence regarding the efficacy of behavioral treatments for bedtime problems and night wakings in young children. It is based on a review of 52 treatment studies by a task force appointed by the American Academy of Sleep Medicine to develop practice parameters on behavioral treatments for the clinical management of bedtime problems and night wakings in young children. The findings indicate that behavioral therapies produce reliable and durable changes. Across all studies, 94% report that behavioral interventions were efficacious, with over 80% of children treated demonstrating clinically significant improvement that was maintained for 3 to 6 months. In particular, empirical evidence from controlled group studies utilizing Sackett criteria for evidence-based treatment provides strong support for unmodifi ed extinction and preventive parent education. In addition, support is provided for graduated extinction, bedtime fading/positive routines, and scheduled awakenings. Additional research is needed to examine delivery methods of treatment, longer-term efficacy, and the role of pharmacological agents. Furthermore, pediatric sleep researchers are strongly encouraged to develop standardized diagnostic criteria and more objective measures, and to come to a consensus on critical outcome variables.
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Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field [1],[2], and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research [3], and some health care journals are moving in this direction [4]. As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews. Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in four leading medical journals in 1985 and 1986 and found that none met all eight explicit scientific criteria, such as a quality assessment of included studies [5]. In 1987, Sacks and colleagues [6] evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in six domains. Reporting was generally poor; between one and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement [7]. In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized controlled trials [8]. In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1). Box 1: Conceptual Issues in the Evolution from QUOROM to PRISMA Completing a Systematic Review Is an Iterative Process The conduct of a systematic review depends heavily on the scope and quality of included studies: thus systematic reviewers may need to modify their original review protocol during its conduct. Any systematic review reporting guideline should recommend that such changes can be reported and explained without suggesting that they are inappropriate. The PRISMA Statement (Items 5, 11, 16, and 23) acknowledges this iterative process. Aside from Cochrane reviews, all of which should have a protocol, only about 10% of systematic reviewers report working from a protocol [22]. Without a protocol that is publicly accessible, it is difficult to judge between appropriate and inappropriate modifications.
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Problem crying in the first few months of life is both common and complex, arising out of multiple interacting and co-evolving factors. Parents whose babies cry and fuss alot receive conflicting advice as they seek help from multiple health providers and Emergency Departments, and may be admitted into tertiary residential services. Conflicting advice is costly,and arises out of discipline-specific interpretations of evidence. An integrated, interdisciplinary primary care intervention ("The Possums Approach") for cry-fuss problems in the first months of life was developed from available peer-reviewed evidence. This study reports on preliminary evaluation of delivery of the intervention. A total of 20 mothers who had crying babies under 16 weeks of age (average age 6.15 weeks) completed questionnaires, including the Crying Patterns Questionnaire and the Edinburgh Postnatal Depression Scale, before, and three to four weeks after, their first consultation with trained primary care practitioners. Preliminary evaluation is promising. The Crying Patterns Questionnaire shows a significant decrease in crying and fussing durations, by 1 hour in the evenings (p=0.001) and 30 minutes at nights (p=0.009). The median total amount of crying and fussing in a 24 hour period is reduced from 6.12 to 3 hours. The Edinburgh Postnatal Depression Scale shows a significant improvement in depressive symptoms, with the median score decreasing from 11 to 6 (p=0.005). These findings are corroborated by an analysis of results for the subset of 16 participants whose babies were under 12 weeks of age (average age 4.71 weeks). These preliminary results demonstrate significantly decreased infant crying in the evening and during the night and improved maternal mood, validating an innovative interdisciplinary clinical intervention for cry-fuss problems in the first few months of life. This intervention, delivered by trained health professionals, has the potential to mitigate the costly problem of health professionals giving discipline-specific and conflicting advice post-birth.
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A variety of arbitrary and often unphysiological rules for breastfeeding are frequently suggested to breastfeeding mothers. Many of these rules duplicate strategies commonly used to increase milk supply, and thus, when undertaken by the many women who already have a generous milk supply, can lead to overproduction. Oversupply, or hyperlactation, is a frequent yet often unrecognized problem that can present with a variety of distressing symptoms for the breastfeeding mother and her infant. Infants may present with symptoms suggesting colic, milk protein allergies, or gastroesophageal reflux, or may present with unusually rapid or slow growth. Mothers may present with tender leaking breasts, sore infected nipples, plugged ducts or mastitis, or even the perception of insufficient milk supply. With an understanding of the pathophysiology of these symptoms, proper diagnosis and breastfeeding management can allow milk production to return to homeostatic levels and provide dramatic symptom relief.
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#### Summary points Community cohort studies report that a fifth of parents say that their otherwise healthy baby has cry-fuss problems at two months of age.1 2 Excessive crying is usually a transient neurodevelopmental phenomenon, although it may herald problems that are more long term and serious. Various studies have found that it is often difficult for parents to access the help they need when they experience problem crying; that they resort to use of multiple health services, including of emergency departments; and that they receive conflicting advice.3 w1 We review evidence from heterogeneous studies across multiple health disciplines to provide a practical guide to the management of term infants who cry excessively in the first few months of life. Our review is aimed at paediatricians, general practitioners, community child health nurses, and midwives. Although definitions of infant crying vary considerably, for practical purposes we use the terms cry-fuss behaviour, excessive crying, colic, and unsettled infant behaviour interchangeably to refer to any crying behaviour that parents report …
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This paper explores two areas in which the translation of research into practice may be improved in the management of cry-fuss behaviours in the first few months of life. Firstly, babies who cry excessively are often prescribed proton pump inhibitors, despite evidence that gastro-oesophageal reflux disease is very rarely a cause. The inaccuracy of commonly used explanatory mechanisms, the side-effects of acid-suppressive medications, and the failure to identify treatable problems, including feeding difficulty when the diagnosis of 'reflux' is applied, are discussed. Secondly, crying breastfed babies are still prescribed lactase or lactose-free formula, despite evidence that the problem of functional lactose overload is one of breastfeeding management. The mechanisms and management of functional lactose overload are discussed. These two problems of research translation need to be addressed because failure to identify and manage other causes of cry-fuss problems, including feeding difficulty, may have adverse outcomes for a small but significant minority of families.
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Objective To evaluate the effectiveness of a behavioural-educational sleep intervention delivered in the early postpartum in improving maternal and infant sleep. Design Randomised controlled trial. Setting Postpartum units of two university affiliated hospitals. Participants 246 primiparous women and their infants randomised while in hospital with an internet based randomisation service to intervention (n=123) or usual care (n=123) groups. Interventions The behavioural-educational sleep intervention included a 45-60 minute meeting with a nurse to discuss sleep information and strategies to promote maternal and infant sleep, a 20 page booklet with the content discussed, and phone contacts at one, two, and four weeks postpartum to reinforce information, provide support, and problem solve. The usual care group received calls at weeks one, two, and four to maintain contact without provision of advice. Main outcome measures Primary outcome was maternal nocturnal (9 pm to 9 am) sleep (minutes) and secondary outcome was longest stretch of infant nocturnal sleep (minutes) measured at six and 12 weeks postpartum by actigraphy. Other outcomes measured at six and 12 weeks were number of maternal and infant night time awakenings by actigraphy, fatigue visual analogue scale, general sleep disturbance scale, and Edinburgh postnatal depression scale. Rates of exclusive breast feeding were measured at 12 weeks postpartum only. Results All women who completed any outcome measures at six or 12 weeks were included in analysis. Sleep outcomes were completed at one or both of six and 12 weeks postpartum for 215 of 246 (87%) women (110/123 intervention and 105/123 usual care). Longitudinal mixed effects model analyses indicated no significant differences between the groups on any of the outcomes. The estimated mean difference in maternal nocturnal sleep between the intervention and usual care groups was 5.97 minutes (95% confidence interval −7.55 to 19.5 minutes, P=0.39). No differences in any outcomes were noted based on the specific nurse delivering the intervention or the number of phone contacts received. Conclusion A behavioural-educational intervention delivered in the early postpartum, in hospital, and in the first weeks at home, was ineffective in improving maternal and infant sleep or other health outcomes in the first months postpartum. Trial registration ISRCT No 13501166.
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The objectives of this study were to analyse the perspectives of key informants with clinical expertise in the care of unsettled babies in the first few months of life and their families, concerning changes required to improve outcomes. The research used a purposive selection strategy and thematic analysis of key informant interviews of 24 health professionals from 11 disciplines. Informants were selected for extensive experience in the management of unsettled babies and their families. Participants corroborated existing evidence that post-birth care in Australia is fragmented. All held the view that, first, early primary care intervention for unsettled infants and their families, and second, improved cross-professional communication, are vital if the burden of this problem to the infant, family and health system are to be minimised. There was consensus, third, that significant gaps exist in health professionals' knowledge base and management behaviours. The development of education resources, best practice guidelines, shared assessment frameworks for primary care practitioners and strategies for improved cross-professional communication are necessary to improve the health outcomes and decrease the burden of this common yet complex post-birth problem.
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Australia's Early Parenting Services support families and intervene early in mental health problems in parents. The Victorian Early Parenting Strategy, a platform for government policy recommended a stronger evidence base for early parenting services. Tweddle Child and Family Health Service (TCFHS) is a not-for-profit public sector early parenting centre, which provides residential, day stay, home visiting and outreach programs. This study aimed i) to examine the health, social circumstances and presenting needs of clients attending the Tweddle Day Stay Program (DSP) with infants under 12 months old and ii) to assess the parent mental health and infant behaviour outcomes and the factors associated with program success. A cohort of clients was recruited prior to admission and followed-up 8 weeks after discharge. Data were collected using standardised measures in a study specific questionnaire at baseline, participant's Tweddle records and a follow-up telephone interview. Health, social circumstances and presenting needs of clients were described. Changes in parents' symptoms of depression and infants' sleep and settling between admission and follow-up were calculated. Multiple regression analyses were conducted to examine factors associated with changes in primary outcomes. Of the total 162 clients who were eligible and invited to participate, 115 (72%) were recruited. Parents admitted to the DSP had worse general self-reported physical and mental health than community samples. Infants of DSP participants were no more likely to be premature or have low birth weight, but significantly more unsettled than other community samples. Participants' mental health and their infants' behaviours were significantly improved after DSP admission. In multivariate analysis, higher depression score at baseline and greater educational attainment were significantly associated with improvements in parents' mental health. Worse unsettled infant behaviours and longer time between discharge and follow up were significantly associated with improvements in infant sleep and settling. Tweddle DSPs appear to respond effectively to the needs of families presenting with substantial physical and emotional health morbidity and a range of vulnerabilities by treating parental mental health and infant behaviour problems together. DSPs offer important potential benefits for prevention of more serious family problems and consequent health care cost savings.
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Problems experienced within the first year of an infant's life can be precursors of later mental health conditions. The purpose of this study was to examine the frequency and continuity of difficult behaviors in infants at 3 and 6 months of age and the associations of these difficulties with biomedical and psychosocial factors. This study was a part of an ongoing prospective birth-cohort study. Study participants were 189 uniparous mothers and their full-term newborns. The index of infant difficult behavior was constructed. This index was then associated with the following factors: delivery mode, newborn function after birth, maternal emotional well-being, risk behavior, subjective evaluation of the quality of the relationship of the couple, and attitudes toward infant-rearing. Common difficult behaviors, including crying, sleeping and eating problems, were characteristic for 30.2% of 3 month old and for 22.2% of 6 month old full-term infants. The expression of infant difficult behaviors at the age of 3 months increased the likelihood of the expression of these difficulties at 6 months by more than 5 times. Factors including younger maternal age, poor prenatal and postnatal emotional well-being, prenatal alcohol consumption, low satisfaction with the couple's relationship before pregnancy, and deficiency of infant-centered maternal attitudes towards infant-rearing increased the likelihood of difficult behaviors in infants at the age of 3 months. Low maternal satisfaction with the relationship of the couple before pregnancy, negative emotional reactions of both parents toward pregnancy (as reported by the mother) and the deficiency of an infant-centered maternal attitude towards infant-rearing increased the likelihood of infant difficult behaviors continuing between the ages of 3 to 6 months. Perinatal biomedical conditions were not related to the difficult behaviors in infants. Our study suggests that early onset of difficult behavior highly increases the risk for the continuation of difficult behavior during infancy. In general, the impact of prenatal psychosocial environment on infant behavior decreases from the ages of 3 to 6 months; however, some prenatal and preconceptional psychosocial factors have direct associations with the continuity of difficult behaviors through the first half-year of an infant's life.
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There is a common belief that children are not getting enough sleep and that children's total sleep time has been declining. Over the century, many authors have proposed sleep recommendations. The aim of this study was to describe historical trends in recommended and actual sleep durations for children and adolescents, and to explore the rationale of sleep recommendations. A systematic literature review was conducted to identify recommendations for children's sleep requirements and data reporting children's actual total sleep time. For each recommendation identified, children's actual sleep time was determined by identifying studies reporting the sleep duration of children of the same age, gender, and country in the same years. Historical trends in age-adjusted recommended sleep times and trends in children's actual sleep time were calculated. A thematic analysis was conducted to determine the rationale and evidence-base for recommendations. Thirty-two sets of recommendations were located dating from 1897 to 2009. On average, age-specific recommended sleep decreased at the rate of -0.71 minute per year. This rate of decline was almost identical to the decline in the actual sleep duration of children (-0.73 minute per year). Recommended sleep was consistently ∼37 minutes greater than actual sleep, although both declined over time. A lack of empirical evidence for sleep recommendations was universally acknowledged. Inadequate sleep was seen as a consequence of "modern life," associated with technologies of the time. No matter how much sleep children are getting, it has always been assumed that they need more.
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To examine the relationship between breastfeeding and maternally-rated infant temperament at age 3 months, 316 infants in the prospective Cambridge Baby Growth Study, UK had infant temperament assessed at age 3 months by mothers using the Revised Infant Behavior Questionnaire, which produces scores for three main dimensions of temperament derived from 14 subscales. Infant temperament scores were related to mode of infant milk feeding at age 3 months (breast only; formula milk only; or mixed) with adjustment for infant's age at assessment and an index of deprivation. Infant temperament dimension scores differed across the three infant feeding groups, but appeared to be comparable between exclusive breast-fed and mixed-fed infants. Compared to formula milk-fed infants, exclusive breast-fed and mixed-fed infants were rated as having lower impulsivity and positive responses to stimulation (adjusted mean [95% CI] "Surgency/Extraversion" in formula-fed vs. mixed-fed vs. breast-fed groups: 4.3 [4.2-4.5] vs. 4.0 [3.8-4.1] vs. 4.0 [3.9-4.1]; p-heterogeneity = 0.0006), lower ability to regulate their own emotions ("Orienting/Regulation": 5.1 [5.0-5.2], vs. 4.9 [4.8-5.1] vs. 4.9 [4.8-5.0]; p = 0.01), and higher emotional instability ("Negative affectivity": 2.8 [2.6-2.9] vs. 3.0 [2.8-3.1] vs. 3.0 [2.9-3.1]; p = 0.03). Breast and mixed-fed infants were rated by their mothers as having more challenging temperaments in all three dimensions; particular subscales included greater distress, less smiling, laughing, and vocalisation, and lower soothability. Increased awareness of the behavioural dynamics of breastfeeding, a better expectation of normal infant temperament and support to cope with difficult infant temperament could potentially help to promote successful breastfeeding.
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Background: Many popular childcare books recommend feeding babies to a schedule, but no large-scale study has ever examined the effects of schedule-feeding. Here, we examine the relationship between feeding infants to a schedule and two sets of outcomes: mothers’ wellbeing, and children’s longer-term cognitive and academic development. Methods: We used a sample of 10 419 children from the Avon Longitudinal Study of Parents and Children, a cohort study of children born in the 1990s in Bristol, UK. Outcomes were compared by whether babies were fed to a schedule at 4 weeks. Maternal wellbeing indicators include measures of sleep sufficiency, maternal confidence and depression, collected when babies were between 8 weeks and 33 months. Children’s outcomes were measured by standardized tests at ages 5, 7, 11 and 14, and by IQ tests at age 8. Results: Mothers who fed to a schedule scored more favourably on all wellbeing measures except depression. However, schedule-fed babies went on to do less well academically than their demand-fed counterparts. After controlling for a wide range of confounders, schedule-fed babies performed around 17% of a standard deviation below demand-fed babies in standardized tests at all ages, and 4 points lower in IQ tests at age 8 years. Conclusions: Feeding infants to a schedule is associated with higher levels of maternal wellbeing, but with poorer cognitive and academic outcomes for children.
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To examine the potential for publication bias, data availability bias, and reviewer selection bias in recently published meta-analyses that use individual participant data and to investigate whether authors of such meta-analyses seemed aware of these issues. In a database of 383 meta-analyses of individual participant data that were published between 1991 and March 2009, we surveyed the 31 most recent meta-analyses of randomised trials that examined whether an intervention was effective. Identification of relevant articles and data extraction was undertaken by one author and checked by another. Only nine (29%) of the 31 meta-analyses included individual participant data from "grey literature" (such as unpublished studies) in their primary meta-analysis, and the potential for publication bias was discussed or investigated in just 10 (32%). Sixteen (52%) of the 31 meta-analyses did not obtain all the individual participant data requested, yet five of these (31%) did not mention this as a potential limitation, and only six (38%) examined how trials without individual participant data might affect the conclusions. In nine (29%) of the meta-analyses reviewer selection bias was a potential issue, as the identification of relevant trials was either not stated or based on a more selective, non-systematic approach. Investigation of four meta-analyses containing data from ≥10 trials revealed one with an asymmetric funnel plot consistent with publication bias, and the inclusion of studies without individual participant data revealed additional heterogeneity between trials. Publication, availability, and selection biases are a potential concern for meta-analyses of individual participant data, but many reviewers neglect to examine or discuss them. These issues warn against uncritically viewing any meta-analysis that uses individual participant data as the most reliable. Reviewers should seek individual participant data from all studies identified by a systematic review; include, where possible, aggregate data from any studies lacking individual participant data to consider their potential impact; and investigate funnel plot asymmetry in line with recent guidelines.
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To estimate the prevalence of insomnia and examine its correlates (for example, demographics and physical and mental health) and treatments. A sample of 2000 Canadians aged 18 years and older responded to a telephone survey about sleep, health, and the use of sleep-promoting products. Respondents with insomnia were identified using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, and the International Classification of Diseases, Tenth Edition, criteria. Among the sample, 40.2% presented at least 1 symptom of insomnia (that is, trouble falling or staying asleep, or early morning awakening) for a minimum of 3 nights per week in the previous month, 19.8% were dissatisfied with their sleep, and 13.4% met all criteria for insomnia (that is, presence of 1 insomnia symptom 3 nights or more per week for at least 1 month, accompanied by distress or daytime impairment). Insomnia was associated with female sex, older age, and poorer self-rated physical and mental health. Thirteen per cent of respondents had consulted a health care provider for sleep difficulties once in their lifetime. Moreover, 10% had used prescribed medications for sleep in the previous year, 9.0% used natural products, 5.7% used over-the-counter products, and 4.6% used alcohol. There were differences between French- and English-speaking adults, with the former group presenting lower rates of insomnia (9.5%, compared with 14.3%) and consultation (8.7%, compared with 14.4%), but higher rates of prescribed medications (12.9%, compared with 9.3%) and the use of natural products (15.6%, compared with 7.4%). Insomnia is a prevalent condition, although few people seek professional consultation for this condition. Despite regional differences in the prevalence and treatments used to manage insomnia, prescribed medications remain the most widely used therapeutic option.
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This overview attempts to synthesise current understandings of the neuroendocrine basis of parenting. The parent-infant bond is central to the human condition, contributes to risks for mood and anxiety disorders, and provides the potential for resiliency and protection against the development of psychopathology. Animal models of parenting provide compelling evidence that biological mechanisms may be studied in humans. This has led to brain imaging and endocrine system studies of human parents using baby stimuli and concerted psychological and behavioural measures. Certain brain circuits and related hormonal systems, including subcortical regions for motivation (striatum, amygdala, hypothalamus and hippocampus) and cortical regions for social cognition (anterior cingulate, insula, medial frontal and orbitofrontal cortices), appear to be involved. These brain circuits work with a range of endocrine systems to manage stress and motivate appropriate parental caring behaviour with a flexibility appropriate to the environment. Work in this field promises to link evolving models of parental brain performance with resilience, risk and treatment toward mother-infant mental health.
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Cry-fuss problems are among the most common clinical presentations in the first few months of life and are associated with adverse outcomes for some mothers and babies. Cry-fuss behaviour emerges out of a complex interplay of cultural, psychosocial, environmental and biologic factors, with organic disturbance implicated in only 5% of cases. A simplistic approach can have unintended consequences. This article reviews recent evidence in order to update clinical management. New research is considered in the domains of organic disturbance, feed management, maternal health, sleep management, and sensorimotor integration. This transdisciplinary approach takes into account the variable neurodevelopmental needs of healthy infants, the effects of feeding management on the highly plastic neonatal brain, and the bi-directional brain-gut-enteric microbiota axis. An individually tailored, mother-centred and family-centred approach is recommended. The family of the crying baby requires early intervention to assess for and manage potentially treatable problems. Cross-disciplinary collaboration is often necessary if outcomes are to be optimized.
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David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses
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Excessive crying, sleeping or feeding problems are found in approximately 20% of infants and may predict behavioural problems in childhood. A quantitative meta-analysis of 22 longitudinal studies from 1987 to 2006 that statistically tested the association between infant regulatory problems and childhood internalising, externalising and attention-deficit/hyperactivity disorder (ADHD) problems was carried out; 1935 children with regulatory problems were tested. Cohen's d was used to express the association between regulatory problems and behavioural problems. Heterogeneity of the effect sizes was assessed using the I(2) statistic and meta-analysis of variance and meta-regressions were conducted to assess the influence of moderators. Rosenthal's classic fail-safe N and correlation of sample sizes to effect sizes were used to assess publication bias. The weighted mean effect size for the main regulatory problems-behavioural problems association was 0.41 (95% CI 0.28 to 0.54), indicating that children with previous regulatory problems have more behavioural problems than controls. Externalising and ADHD problems were the strongest outcome of any regulatory problem, indicated by the highest fail-safe N and lowest correlation of sample size to effect size. Meta-analyses of variance revealed no significant moderating influences of regulatory problem comorbidity (I(2)=44.0, p>0.05), type (I(2)=41.8, p>0.05) or duration (I(2)=44.0, p>0.05). However, cumulative problems and clinical referral increased the risk of behavioural problems. The meta-analyses suggest that children with previous regulatory problems have more behavioural problems than controls, particularly in multi-problem families. Further studies are required to assess the behavioural outcomes of previously sleep, feeding or multiply disturbed children.
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