Review Article

Behavioral Management of Sleep Problems in Infants Under

6 Months – What Works?
Georgina E. Crichton, PhD,*† Brian Symon, MD, MBBS†‡

ABSTRACT: Objective: Crying and unsettled behavior in infancy is common. Prolonged disturbed infant sleep
can have significant negative effects on the development of the child, and on the psychological well-being of
the mother. Compared to studies examining the effects of behavioral sleep programs such as extinction-
based techniques in infants over 6 months of age, fewer studies have looked at such strategies in infants
under 6 months of age. The aim of this article is to summarize the literature examining the effects of be-
havioral techniques on infant sleep outcomes in the first 6 months of life and provide evidence based rec-
ommendations for the management of infant sleep disturbance. Method: An electronic search of the
literature was performed to identify studies which examined the effects of a behavioral intervention aimed at
improving sleep in infants under 6 months of age. Results: Eleven studies were identified, of which 8
demonstrated improvements in infant sleep outcomes subsequent to the implementation of an educational
behavioral program. Conclusion: Education directed to parents about the use of simple, prescriptive, be-
havioral techniques is effective in improving infant sleep. Long term follow-up studies have failed to find any
negative effects on the child, either from a psychological or physical perspective.
(J Dev Behav Pediatr 37:164–171, 2016) Index terms: infant sleep, infant crying, behavioral intervention, sleep disturbance, night waking.

S leep problems, including delay in sleep onset, fre-

quent night awakenings, difficulty re-settling, and crying,
are reported by large numbers of parents throughout
infancy.1 A child’s behavioral, cognitive and physical
development may be negatively influenced by short
sleep duration in early infancy.2–5 Furthermore, persis-
tent infant sleep problems may contribute to postnatal
depression6–9 and parental stress.8,10 In the United
States, approximately 14% of mothers in their first year
post-partum experience postnatal depression.11 Simi-
larly, postnatal depression is experienced by 10% to 15%
of Australian mothers, but this may be as high as 45% in
mothers of infants with sleeping problems.8
The first 6 months of life can be a particularly chal-
lenging and exhausting time for new parents, as they
learn to manage an infant for the first time. Infant sleep
and crying problems are one of the primary reasons for
seeking professional health care in the first few months
of life.12 Continued concern about these issues by many
parents indicates that current models of care, which vary
considerably, are not totally successful. For the purpose
of this paper, “behavioral intervention” is defined as
From the *Alliance for Research in Exercise, Nutrition and Activity (ARENA),
Sansom Institute for Health Research, University of South Australia, Adelaide,
Australia; †Kensington Park Medical Practice, Kensington Park, South Australia,
Australia; ‡Faculty of Medicine, University of Adelaide, Adelaide, Australia.
Received July 2015; accepted December 2015.
Disclosure: The authors declare no conflict of interest.
*Address for reprints: Georgina E. Crichton, PhD, Kensington Park Medical
Practice, 84 Shipsters Road, Kensington Park, South Australia 5068, Australia;
e-mail: georgina.crichton@unisa.edu.au.
Copyright Ó 2016 Wolters Kluwer Health, Inc. All rights reserved.
a practice implemented by a parent or primary care-giver
with the primary aim of improving infant sleep. These
behaviors typically include ways of settling the baby at
sleep time, how and when to respond to infant crying or
signalling during a period of sleep, and other strategies to
promote undisturbed sleep.
Extinction-based strategies have been used for half
a century since early researchers identified that parental
attention was reinforcing problem behavior and noted
that when the parents ceased attending to the child, the
behavior diminished.13 A number of early studies sub-
sequently supported the effectiveness of this technique.
However, ignoring night waking often leads to an initial
increase in responding/crying, which can be alarming
for parents.14 To alleviate the potential stress for parents
to implement a full extinction program, graduated or
modified extinction techniques have been developed,15
whereby parents generally attend to the child’s crying
after a determined amount of time. The rationale behind
these approaches is essentially that “parent in-
dependent” cues of sleep are of the most benefit to
teaching independent sleep. An attachment parenting
style is an alternative, contrasting approach developed
from the principles of attachment theory,16,17 and is
based on responding quickly and sensitively to the
emotional and physical needs of the child in order to
facilitate secure attachment.18
A number of reviews have examined the effectiveness
of behavioral interventions on sleep disturbance in
infants.19–22 Ramchandani et al22 reviewed randomized
controlled trials of interventions for settling problems
and night waking in young children, including both

164 | www.jdbp.org Journal of Developmental & Behavioral Pediatrics

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psychological and drug treatments. However the trials
were conducted in children with established sleep
problems, and therefore very few included babies under
6 months of age.
This review concluded that behavioral interventions
showed both positive short and longer-term effects.
However, only studies conducted up until 1998 were
included, and a considerable number of infant sleep trials
have been conducted since this time.
Reviews by France and Hudson20 and Owens et al21
examined the efficacy of behavioral and cognitive-
behavioral methods in resolving infant sleep problems.
Owens et al21 included school-age children; while France
and Hudson20 also reviewed papers examining pharma-
cological treatments. Similarly, these 2 reviews were
published prior to 2000.
More recently, Douglas and Hill19 examined whether
behavioral interventions in infants under 6 months of age
improved maternal and infant outcomes. The authors
concluded that behavioral interventions for infant sleep
in the first 6 months are ineffective in decreasing infant
crying, preventing sleep and behavioral problems in later
childhood, or protecting against postnatal depression.
This review was based upon cross-sectional studies,23–25
longitudinal studies,5,26–32 review papers,1,33 and in-
tervention studies.25,34–38 None of the observational
studies employed, nor assessed, a specific intervention
or strategy targeted at improving infant (or maternal)
outcomes. In 2 controlled trials included in the review,
infant sleep outcomes were not reported by Fisher et al34
and only infant temperament was assessed by Goyal
et al35 A further 2 studies were reviews based on ob-
servational studies, neither specifically examining the
management of infant sleep disturbance.1,33 One was
a systematic review by Galland et al1 which aimed to
establish global norms with regard to normal sleep pat-
terns in infants and children, aged up to 12 years, whilst
the second review by Henderson et al33 investigated
capabilities for sustained sleep across the first year. Fi-
nally, the paper includes 4 trials39–42 from a Cochrane
review,43 but essentially the authors dismiss the in-
dividual findings from these studies, and report only the
overall estimate of effect reported in the Cochrane re-
view. It would therefore seem neither relevant nor ac-
curate to make overarching conclusions based on this
collection of heterogeneous studies, in many of which
infant sleep was not the primary focus. Evidence for any
positive or negative effect requires an assessment of in-
tervention delivery, typically in comparison with a con-
trol condition. The conclusions drawn from this paper
may therefore be viewed with some uncertainty.
High rates of maternal postnatal depression are being
managed in general practice.44 Postnatal depression can
subsequently have further detrimental effects on the
cognitive and emotional development of the child,45 as it
may impair the ability of a mother to form a secure at-
tachment with her infant. Postnatal depression is an in-
dependent risk factor for later child behavioral
Vol. 37, No. 2, February/March 2016
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problems.46 Establishing an effective model of care for
families experiencing infant sleep problems is therefore
of great significance to parents and their children, prac-
titioners, and other primary health care providers. Ad-
vice or treatment strategies need to be based on robust,
evidence-driven clinical research. In order to address
these limitations in the literature, and the existing
widespread problems experienced by many parents of
young babies in the community, we aimed to assess
whether behavioral interventions improve infant sleep
(and maternal/family outcomes) in the first 6 months
of life.
METHODS
An electronic search was undertaken on the following
databases for all years up to March 2015: Medline
(through PubMed), ISI Web of Science, Embase, and
PsycInfo. Papers had to describe and assess the effec-
tiveness of a behavioral intervention aimed at improving
infant sleep. Search terms included: infant; sleep; be-
havior; disturbance; night; trial; intervention. Searches
were limited to peer-reviewed English language pub-
lications. Studies had to include infants commencing in
the study within the first 6 months of life. Sleep outcome
measures could include, but were not limited to, sleep
duration (either day/night/total), number of night
awakenings, parental report of a sleep problem, or ob-
jective sleep measures (e.g., actigraphy). Studies
designed primarily to measure maternal outcomes (e.g.,
sleep) but which also assessed and reported infant sleep
were included. Studies did not have to be randomized
controlled trials, but had to include the implementation
of a treatment protocol.
Studies which described intervention programs pro-
vided during an in-patient or residential stay (e.g., Phil-
lips et al,36 5-day residential stay) were excluded, as the
aim of the review was to assess community-based inter-
ventions conducted in an out-patient setting. There were
no studies excluded due to examining samples of chil-
dren with a specific physical or mental health problem.
Abstracts were reviewed and the full text was
obtained for studies that met the inclusion criteria or if it
was not clear from the abstract whether these criteria
were met. Additional papers were identified through
inspection of reference lists of all included studies and
relevant published systematic reviews. Data was extrac-
ted on study design, participant characteristics, outcome
measures, intervention strategies, and results, in order to
summarize and describe them.
RESULTS
Eligible Studies According to Study Characteristics
Eleven studies were identified which specifically ex-
amined the effect of behavioral interventions on infant
sleep outcomes.37–42,47–51 Table 1 presents a summary of
the studies reviewed, including the location, study de-
sign, intervention employed, and main outcome
Copyright Ó 2016 Wolters Kluwer Health, Inc. All rights reserved. 165
 Table 1. Behavioral Intervention Studies in Infants Under 6 Months
166 Behavioral Sleep Management in Infants Under 6 Months

Age of
Country, Infant at
Authors Study Design Setting Baseline n Intervention Key Information Given Relevant Findings
Adair et al51 Prospective USA 4 mo 164 One sleep discussion/education Sleep onset associations, sleep At 9 mo: intervention infants had 36%
cohort (not session with paediatrician diaries, instructed to put infant to less NW per wk compared with
blinded) bed awake controls, controls had twice amount of
frequent NW as intervention infants.
Wolfson RCT (not USA, Hospital Prenatal, 60 4 group education sessions: Sleep physiology, routines, At 6–9 wk: intervention infants had longer
et al42 blinded) newborns prenatal and postbirth; written independent sleep, focal feed*, sleep episodes, fewer waking episodes,
material differentiate night and day fewer feedings than controls; no
difference at 16–20 wk.
Pinilla and RCT (not USA, Own Prenatal, 26 Pre-birth home visit: verbal and Focal feed*, differentiate night and At 3 wk: intervention infants significantly
Birch50 blinded) home newborns written education, weekly day, self-settling, try to avoid longer night sleep. At 8 wk: 100%
home visits post-birth holding, rocking, nursing infant to intervention infants sleeping through
sleep, at 3 wk: stretch night time the night vs 23% of controls.
feeding intervals
Kerr et al49 RCT (not Scotland, 3 mo 169 One home visit: verbal education, Settling methods, routine At 9 mo: Significantly fewer NW and
blinded) Own home booklet settling difficulties in intervention
group than controls: 46% of controls
woke $2 times/night, compared to
23% of intervention babies.
St James- RCT (not UK, hospital, Newborns 610 One home visit: Behavioral Prescriptive program: feed on At 9 wk: 77% babies in behavior group,
Roberts blinded) own home program group: booklet demand, focal feed*, self- compared to 66% controls slept for $5
et al39 outlining prescriptive program, settling, minimal interaction at hr at night. Focal feed not
Journal of Developmental & Behavioral Pediatrics

Education group: written night, differentiate night and day; implemented. Fewer behavioral
advice, not prescriptive, phone from 3 wk increase feeding program parents sought help for
helpline intervals at night crying/sleeping problems between 3
and 9 mo of age.
Symon RCT (not Australia, 2–3 wk 268 One 45-min education sessson Infant sleep patterns, cues of sleep, At 6 and 12 wk: total sleep, day and
et al41 blinded) Hospital with nurse, booklet influence of fatigue, independent night sleep, per 24 hr significantly
sleep skills and self- higher in intervention group than
settling, minimal parent response controls,.
Stremler RCT (not Canada, Newborn 30 One 45-min education session Infant sleep strategies: maternal sleep At 6 wk: intervention infants fewer NW,
et al38 blinded) Postnatal with nurse, booklet, weekly hygiene, relaxation techniques, longest nocturnal sleep period greater
hospital phone contact infant sleep structure and cues, in intervention infants than controls.
unit self-soothing, culturally sensitive.
Smart and Pre-post Australia, 2 wk 27 mo 131 1 hr consultation with Infant sleep patterns, self-settling, use At 3 wk post-intervention: significantly
Hiscock37 intervention Pediatric paediatrician of behavior diaries, advice fewer parents reported presence of
(not blinded) outpatient regarding maximising social primary problem; parental depression
clinic support, written management plan scores significantly decreased; infant
temperament less difficult post-
intervention; sleep quality improved
for mothers.
(Table continues)

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 measures, according to the year in which the study was

depression, shorter attendance at NW.

At 4 and 6 mo: infant outcomes similar.
At 6 mo: intervention mothers lower
morning fatigue, sleep disturbance,
No difference in depression, anxiety,
conducted. Eight of the 11 studies were randomized

maternal sleep, infant sleep, night

awakenings for mother or child,
between intervention or control
number of NW or time to settle

At 6 and 12 wk: no differences in

controlled trials; the remaining 3 were pre-post in-
tervention studies.
Relevant Findings

Characteristics of Active Preventive Intervention in

maternal depression.
Infants Under 6 Months of Age
Age of Infant, Timing and Duration of
Intervention Delivery
Two studies commenced prenatally,42,50 5 studies
groups.

commenced in the first 4 weeks of life,37–41 and 3 studies

commenced at infant age 3 to 4 months.49,51 Two
studies recruited families with an infant aged less than 6
months of age, who were seeking assistance for a sleep
and cues, self-soothing, parenting
environment, settling techniques,

techniques, infant sleep structure

“Ngala Day Stay”: sleep cycles and

independent settling techniques,

medical causes of crying, parent problem.37,47
Maternal sleep hygiene, relaxation

Intervention delivery commenced prenatally in the

Key Information Given

ranges, understanding cries,

support, culturally sensitive,

centers 4 wk 781 At 4 wk: booklet, DVD at 6–8 wk: Infant sleep and cry patterns,

self-care, bedtime routines

studies by Wolfson et al42 and Pinilla and Birch.50 Wolf-
routines, sleep habits and

son et al42 used group sessions to deliver the in-

respect family choices
respond to all crying

tervention, whilst Pinilla and Birch50 conducted home

visits. Similar recommendations about implementing
a focal feed, differentiating night and day, and self-
settling were given in both studies. A focal feed refers
to a scheduled feed between 10 PM and midnight, given
and midnight, given even if infant is asleep. NW, night waking; RCT, randomized controlled trial.

even if the child is still asleep at this time. Both studies

showed that at approximately 8 weeks of age, in-
tervention infants were sleeping for longer at night than
with nurse in hospital, booklet,
phone contact at 1, 2 and 4 wk

individual phone consult, at 12

their respective controls.

246 One 45–60 education session

Studies which commenced in the newborn period all

178 One 6-hr education session

wk: 1.5 hr parent group

utilized just one session for delivery of the intervention,

Intervention

either in the home or hospital setting.37–41 Both Symon

et al41 and St James-Roberts et al39 both showed signifi-
cant improvements in infant night time sleep duration
following one session given in the first few weeks of life.
Both of these studies gave more prescriptive advice in
terms of minimising parental responding overnight.
Smart and Hiscock37 similarly used a single consultation
to teach parents about normal sleep patterns and self-
n

settling, in infants from 2 weeks of age to 7 months.

The above 3 mentioned studies all showed significant
Infant at
Baseline

and rapid improvements in infant sleep, observed from

Newborns
Age of

between 3 and 12 weeks of age.37,39,41

4–6 mo

Mixed results have been reported by Stremler

et al38,40 In their first, smaller pilot study, they showed
that advice provided in the early postnatal period around
Australia, 42
Country,

parenting

postnatal

maternal sleep hygiene, relaxation techniques, infant

Setting

hospital
Canada, 2

centres
Australia,

center

sleep structure, cues and self-soothing lead to reductions

Early

child
units

in night awakenings and increased nocturnal sleep

PM

durations in the intervention infants as opposed to the

*focal feed: scheduled feed between 10

“usual care” infants, who did not receive direct advice.

consent only)
(not blinded)
Study Design

allocation at
intervention

RCT (blinded)

RCT (blind to

However, their larger trial of over 200 children, in which

the same intervention was employed, failed to find any
time of
Pre-post

group

differences in infant or maternal sleep, or maternal de-

Continued

pression at 6 or 12 weeks post-intervention between

intervention and control infants.
A large Australian study of over 700 children aged 4 to
Authors

et al47

et al40

et al48
Stremler

12 weeks at the time of the intervention did not find any

Hiscock
Table 1.

Hauck

significant differences in infant sleep outcomes between

those who received an educational program compared

Vol. 37, No. 2, February/March 2016 Copyright Ó 2016 Wolters Kluwer Health, Inc. All rights reserved. 167

Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
to usual care.48 Whilst similar information was given (i.e.,
infant sleep patterns, independent settling techniques,
medical causes of crying, bedtime routines), the advice
was not as prescriptive as the aforementioned
studies.39,41
The 2 studies which commenced with infants aged 3
to 4 months both utilized just one education session,
assessed sleep outcomes at 9 months of age, and repor-
ted consistent findings: significantly less night waking in
intervention infants (up to 36%51) compared to
controls.49,51
The final study by Hauck et al47 differed from the
other reviewed studies in a number of ways. Infants
were older (4–6 months), parents were seeking help for
an identified sleep problem, and the treatment consisted
of a “Day Stay.” The Day Stay involves the caregiver and
child attending the parenting center for a 6-hour visit
with the provision of one-on-one assistance.47 The key
information provided was similar: sleep cycles and
ranges, understanding cries, the use of routines, the
sleep environment, and settling techniques. However it
differed in that parents were advised to respond to all
infant crying. At 1-month follow-up, there were no dif-
ferences in night awakenings, time to settle at night,
maternal depression or anxiety between the intervention
group and usual care control group. The only differences
observed were higher perceptions of confidence and
competence, and less use of active physical comforting
and settling techniques in the intervention group than in
the control group.47
Type of Recommendations Given
The active preventive intervention in each study was
the provision of education to parents, typically provided
by a nurse or paediatrician (in individual or group set-
tings) and then reinforced with written material. The
studies fell into 1 of 3 groups in terms of the type of
recommendations given to parents.
1. Focus on self-settling: information is provided on
normal sleep patterns in infants, self-settling techni-
ques, sleep cues and use of bedtime routines. The
strategies revolve around parents minimising
contact and responding during the night to teach
self-settling and independent sleep achieve-
ment.37,39,41,42,48–51 These studies often also recom-
mended a focal feed.39,42,50
2. Focus on consistent responding: the major empa-
hasis is placed on responding to all crying.47
3. Maternal focus: where the strategies are centered
on behaviors for the mother, such as maternal sleep
hygiene, relaxation techniques, and optimizing par-
ent support.38,40
Secondary Outcomes to Infant Sleep
In terms of maternal outcomes, behavioral inter-
ventions targeting improving infant sleep also had a pos-
itive effect on maternal health in a number of studies.
Significant reductions in depressive symptoms were
168 Behavioral Sleep Management in Infants Under 6 Months
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reported in 2 studies,37,52 as well as improvements in
maternal sleep.37 These 2 studies used education to in-
form parents about self-settling techniques and routines,
with the aim of reducing parental contact. Two studies
showed no differences in maternal depressive symptoms
between intervention and control groups (usual com-
munity care), where the intervention consisted of gen-
eral sleep education.38,47
Summary of What Works
Firstly, it is apparent that success is reliant upon the
information given. Seven studies that used a behavioral
intervention demonstrated significant improvements in
infant sleep.37,39,41,42,49–51 All provided infant sleep ed-
ucation to parents in order to encourage self-settling,
teach independent sleep cues, and to minimize paren-
tal contact during the night. No differences in night
awakenings or time to settle at night were observed
following a “Day Stay” intervention which encouraged
frequent responding to crying.47 Interventions with
a greater focus on maternal behaviors showed in-
consistent effects.38,40
The time spent with parents does not appear to be
necessarily indicative of the success of the program. The
longest treatment (one 6-hour session), advocating fre-
quent responding, did not result in improved infant
sleep,47 whilst multiple studies utilizing just a single 45 to
60 minutes consult demonstrated significant improve-
ments in infant sleep.37,39,41,49,51 These successful stud-
ies involved infants from newborn to several months of
age, reinforcing that there is not necessarily a “critical
age window” in which such strategies may be most ef-
fective. Preventive recommendations given as early as
the prenatal period and continuing into the newborn
period have also been successful, delivered in both
group settings or individually.42,50
DISCUSSION
The findings of these studies provide evidence that
active preventive intervention improves sleep in the
early months of life. For babies in the first few months of
life without an established sleep problem, the provision
of education about infant sleep patterns, routines, and
parental behavior to facilitate self-settling has demon-
strated effectiveness. It would appear that the more
prescriptive or direct the advice given with regard to
placing the baby down awake and minimizing respond-
ing, the greater the success of the strategy. In slightly
older infants with an established sleep problem, similar
succinct and prescriptive techniques have proven ben-
efit. This is consistent with many studies in the literature
demonstrating the effectiveness of active extinction
techniques in children over 6 months of age.14,15,53–56
Studies giving less prescriptive advice, or detailed in-
formation on multiple topics rather than focussing on
just a few strategies, may not be effective.38,48 Our
search failed to find a study that demonstrated any
Journal of Developmental & Behavioral Pediatrics
improvement in infant sleep as a result of repeated
responding.
The provision of education to parents, either in verbal
and/or written form, and given either individually or in
a group setting formed the basis for all active preventive
interventions. The key information given to parents was
to ensure the baby is placed in the cot awake to self-
settle, to keep parental interaction within a block of
sleep to a minimum, to include a “focal feed” to help
increase feeding intervals at night, and to differentiate
between day and night.
There is no clear evidence that extinction-based
techniques in infants under 6 months of age cause any
harm psychologically or physically. Raised blood cortisol
levels in response to stress (prolonged crying), is one
reason cited by those opposed to extinction strategies.57
Cortisol is a steroid hormone which is released from the
adrenal gland in response to stress or low blood glucose.
This is no clear evidence regarding the short- or long-
term effects (positive, negative or neutral) of raised
cortisol levels during infancy. This unsubstantiated “fear”
may be preventing some parents from trying behavioral
techniques. None of the included studies measured or
reported on cortisol levels, or specifically at infant stress
at the time of the intervention. Two studies examined
infant temperament. Pinilla and Birch50 found that con-
trol parents rated their infants as less predictable, com-
pared with parents in the treatment group. Similarly,
Smart and Hiscock37 found that parents reported infant
temperament to be less difficult 3 weeks following their
behavioral sleep intervention.
In terms of longer term sleep outcomes, it has been
suggested that night waking may commence later in in-
fancy. For example, Scher58 examined the sleep patterns
of 34 healthy infants and found that sleep was unstable at
12 months and disruption at this age was unrelated to
whether or not the infant woke frequently prior to this
time. While the majority of reviewed studies assessed
sleep outcomes within 12 weeks of the intervention
delivery, 2 included studies both reported outcomes at 9
months.49,51 Both studies used one education session to
deliver messages around settling and sleep associations at
infant age 3 to 4 months, and both reported significantly
less night waking in the intervention babies than in the
control babies at infant age 9 months.49,51 A number of
follow-up studies have been conducted in the Infant
Sleep Study,7 which originally recruited infants at 7 to 8
months of age with a parent reported sleep problem, and
used modified extinction strategies as the primary in-
tervention (“controlled crying” and “camping out”
techniques). “Controlled crying” refers to parents
responding to their infant’s crying at increasing time
intervals, and “camping out” involves the parent sitting
next to/with their infant until they fall asleep, a tech-
nique commonly referred to as “extinction with parental
presence.” Prevalence of infant sleep problems were
lower in the intervention group than in the control
group at 10 and 12 months.7 At 2 years of age, fewer
Vol. 37, No. 2, February/March 2016
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children in the intervention group had a sleep problem
(27%) than in the control group (33%),59 and in-
tervention mothers had fewer depressive symptoms.
Longer term follow-ups of the Infant Sleep Study have
also shown that infants who received behavioral inter-
ventions during the first year of life do not have impaired
child-parent relationships, experience more child-parent
conflict, have emotional or conduct problems, have im-
paired psychosocial functioning or stress in later child-
hood (up to 6 years of age).31,60
Despite evidence for significant benefit from pre-
scriptive behavioral approaches, there are a number of
reasons why parents may not be comfortable or willing
to implement such strategies. These could include the
intervention impacting upon a family’s cultural practices
(e.g., a desire to co-sleep), potential conflict between 2
parents if one can implement and the other cannot, or
conflict within the larger family, if grandparents or other
relatives are not supportive of using such techniques.
Infant sickness or other factors may also adversely im-
pact upon adherence despite parents’ interest in trying
such strategies. Other parents or caregivers may not be
aware of these strategies and of their potential benefit.
These points must be considered in a clinical setting.
Future Research
None of the studies in the present review measured or
reported on parental comfort with regard to the imple-
mentation of the intervention. Beneficial information
would be obtained from future studies that included
a measure of how comfortable or willing parents were in
implementing specific behavioral strategies. Other im-
portant issues that should be considered in future re-
search include examining the short and long-term effects
of raised cortisol, exploring barriers to parents’ willing-
ness, and including longer term follow-ups of infants into
childhood and early adolescence.
CONCLUSIONS
The negative consequences of sleep deprivation on
infant and mother have been clearly established.2,8,10
The findings from studies which have employed active
interventions in infants under 6 months are consistent.
Education on preventative behavioral techniques is ef-
fective in improving infant sleep. Providing education
about these techniques to parents in the community is
recommended. Current evidence suggests that the most
effective programs are prescriptive, concise and clear.
These conclusions may help to guide both future clinical
research and practice.
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