Infant Sleep Coaching

Behavioral treatment research

A task force appointed by the American Academy of Sleep Medicine reviewed 52 treatment studies of behavioral treatments for bedtime problems and night wakings in infants and young children. Its review was published in the journal Sleep in 2006. The task force graded the controlled group studies against Sackett criteria for evidence-based treatment. The sources reviewed for this page do not date the first use of these methods or the books that later popularized them.

Randomized trials of nurse-delivered programs followed in Melbourne, Australia. A 2002 trial in well-child clinics taught the controlled crying method over three consultations to mothers of infants aged 6 to 12 months who reported severe sleep problems. Later cluster-randomized trials tested a brief behavioral program delivered by maternal and child health nurses at infant ages 8 to 10 months, with follow-up reported at 10 and 12 months, at 2 years and at 6 years.

Disputed use in early infancy

A 2013 systematic review by Douglas and Hill examined behavioral sleep interventions for infants younger than 6 months. The authors argue that the belief that such interventions improve outcomes for mothers and babies is "historically constructed" and overlooks feeding problems. This is the reviewers' position and is contested by the trial authors cited elsewhere on this page.

A National Health Service community trust in England states that sleep routines such as controlled crying and gradual withdrawal have had trends in the United Kingdom in recent years. The same page says these routines do not have a place in responsively caring for a baby. Positions therefore differ between research groups and between health services.

Names for the practice

The research literature usually speaks of behavioral infant sleep interventions or behavioral treatments for bedtime problems and night wakings. The common terms sleep training and sleep coaching are used in consumer settings. An international association of professional sleep consultants describes its members as non-medical professional sleep consultants who work with clients from pregnancy through later life, including infants and families.

Named behavioral methods

The 2006 American Academy of Sleep Medicine review names unmodified extinction, graduated extinction, bedtime fading with positive routines, scheduled awakenings and preventive parent education. A 2016 randomized trial compared graduated extinction, bedtime fading and a sleep education control. The 2002 Melbourne trial taught the controlled crying method. The sources reviewed do not give one agreed definition of each label, and they do not define parental presence or chair approaches.

A community health trust uses the term responsive approach for caring for a baby without leaving the baby to cry, and contrasts it with controlled crying and gradual withdrawal. The sources reviewed do not describe a formal trial of responsive approaches as sleep coaching, so this page cannot report their effect on sleep.

How programs were delivered in studies

In the trials reviewed, behavioral techniques were taught to parents rather than carried out by clinicians. In a 5-year follow-up study of a cluster-randomized trial, they were delivered over 1 to 3 individual nurse consultations when infants were 8 to 10 months old, compared with usual care. In a 2016 trial, parents were assigned to graduated extinction, bedtime fading or sleep education, and sleep was measured with diaries and actigraphy.

Consultants and programs in practice

Paid sleep consultants work privately and are not part of a nurse-delivered public program. One international association states that it unites non-medical professional sleep consultants who follow its code of ethics and standards of practice. This page does not give step-by-step methods, timings or scripts. The trial evidence below comes from specific programs and should not be assumed to describe any particular consultant or commercial course.

Stated aims in the literature

The behavioral literature aims to reduce bedtime problems and night wakings in infants and young children. Trials also measure whether sleep programs change maternal depression symptoms, because mothers who report an infant sleep problem often report depressive symptoms. Trial authors have stated that these programs may reduce the short- to medium-term burden of infant sleep problems and maternal depression, a claim the next sections examine.

What the sources do not state

The sources reviewed do not report consumer-facing claims by individual consultants, and this page does not evaluate marketing promises. They also do not support claims that sleep coaching improves child development, feeding or health outcomes beyond the sleep and maternal mood measures described in the trials. Any claim of that kind falls outside the evidence opened for this page.

Reviews

The 2006 American Academy of Sleep Medicine review of 52 treatment studies reports that 94 percent of studies described behavioral interventions as efficacious. It reports that over 80 percent of treated children showed clinically significant improvement that was maintained for 3 to 6 months. It rated controlled evidence as strong for unmodified extinction and preventive parent education, and as supportive for graduated extinction, bedtime fading with positive routines, and scheduled awakenings. The review called for more research on longer-term effects.

Douglas and Hill searched PubMed, CINAHL and the Cochrane Database of Systematic Reviews up to March 2013. This is a systematic review in a developmental pediatrics journal and is not itself a Cochrane review. For infants younger than 6 months they concluded that interventions had not been shown to decrease crying, prevent later sleep and behavioral problems, or protect against postnatal depression.

Randomized trials in infants 6 months and older

In the 2002 trial of 156 mothers, more sleep problems had resolved at two months in the controlled crying group than in the control group (53 of 76 versus 36 of 76). By four months changes in sleep problems were similar between groups. A 2006 cluster-randomized trial of 328 mothers reported fewer sleep problems at 10 months (56 percent versus 68 percent) and 12 months (39 percent versus 55 percent), and lower depression scores.

In the 2016 trial, 43 infants aged 6 to 16 months were randomized to graduated extinction, bedtime fading or sleep education. Both behavioral groups showed large decreases in sleep latency, and the graduated extinction group also had fewer awakenings. Salivary cortisol showed small-to-moderate declines in the behavioral groups compared with controls. At 12 months the authors found no significant differences in emotional and behavioral problems or in attachment classification. The sample was small.

Long-term follow-up

At 2 years, mothers in the intervention group were less likely to report depression symptoms (15.4 percent versus 26.4 percent at the community cut point), while parenting style and child mental health did not differ markedly. At age 6, 225 families (69 percent of the sample) took part in the five-year follow-up and no evidence of differences was found for child emotional or conduct behavior, sleep problems, stress, the child-parent relationship or maternal mental health. The authors concluded the techniques have no marked long-lasting effects, positive or negative.

Concerns raised by reviewers and parents

The 2012 follow-up trial states that concerns persist that behavioral sleep interventions may harm children's emotional development and later mental health, which is why long-term outcomes were measured. Douglas and Hill argue that studies in the first 6 months fail to control for feeding difficulties and to distinguish the first and second halves of the first year. They also describe risks of unintended outcomes from population-wide use, including more problem crying, earlier stopping of breastfeeding and worsened maternal anxiety.

Limits of the trials

The trials were mostly delivered by nurses in Australian public child-health services, and parents could not be blinded to their own group. Follow-up was incomplete in the five-year study, and the cortisol and attachment trial was small. None of the sources reviewed tested paid private consultants, online programs or toddlers beyond the ages studied, so those settings are not covered by this evidence. The sources reviewed also report no trial of responsive approaches against behavioral methods.

Safe sleep guidance for every sleep

The American Academy of Pediatrics recommends placing babies on their backs for all naps and at night, on a firm, flat sleep surface, with soft objects and loose bedding kept out of the sleep area. It recommends room sharing for at least the first 6 months and advises against bed sharing. It also states that no method can be relied on to prevent sudden infant death syndrome (SIDS) with certainty. The Centers for Disease Control and Prevention gives the same back, firm flat surface and soft bedding statements, and room sharing ideally until at least 6 months.

The National Health Service advises placing the baby on the back, using a firm, flat mattress, keeping the cot clear of pillows, duvets, bumpers, loose blankets and soft toys, and keeping the baby in a separate cot in the same room for at least the first 6 months. The Lullaby Trust lists the same steps, adds smoke-free and avoiding overheating, and advises following them for every sleep, day and night, until 12 months.

Age and care boundaries

The controlled trials of behavioral programs enrolled infants from about 6 months, and the Douglas and Hill review of earlier use did not find benefit. Douglas and Hill also state that a baby required to sleep in a room separate from the caregiver has an increased SIDS risk, which sits against the 6-month room-sharing guidance above. Their review notes that feeding problems are often not controlled for. This page does not advise on when to start any method. The American Academy of Pediatrics states its web information should not substitute for a pediatrician's care, and a sleep problem with other symptoms is a question for a doctor.

Consultant credentials

The sources reviewed describe credentials set by private associations, not a state licensing system. One international association of sleep consultants requires completion of an approved program or at least two years and 500 hours of consulting experience, two references, a phone interview, a business website, four hours of annual continuing education and agreement to its code of ethics. It describes its members as non-medical. No statutory regulation or national training standard for infant sleep consultants was found in the sources reviewed.