Santos et al1 have conducted a large (586 participants) randomized clinical trial to determine whether an educational intervention delivered by trained lay people in the family home at infant age 3 months could improve infant nighttime sleep duration and self-settling at infant age 6, 12, and 24 months. Secondary outcomes included infant growth and neurodevelopment at 12 and 24 months.1 The authors report on 14 sleep outcomes overall across the 3 follow-up points. Overall, the sleep outcomes did not differ significantly between the intervention group and the control (usual care) group. At 6 months, according to sleep diaries kept by the mother, mean nighttime sleep duration was 0.31 hours longer in infants who received the intervention than in those who did not, and median nocturnal awakenings reported by maternal interview were 1 vs 2 per night, respectively. By 12 and 24 months, these differences had disappeared. No differences in infant growth or neurodevelopment were apparent at any point. Strengths of the trial include use of multisource measures of the infant’s sleep (actigraphy, sleep diary, and Brief Infant Sleep Questionnaire) and excellent sample retention (93% at all follow-up times). The authors conclude that their “educational intervention did not achieve longer nighttime sleep duration among infants in the intervention group.”1 Why might this be so?
Several studies have tried to improve later infant sleep by providing parental psychoeducation around sleep and sleep strategies in the first months of a baby’s life. When restricting these studies to randomized clinical trials, small to moderate effects are found for the interventions increasing total nighttime sleep.2 No effects are found for reducing nocturnal awakenings, possibly because most healthy infants will learn to self-settle without any intervention.3 On the other hand, psychoeducational and behavioral sleep interventions targeted to older infants and toddlers whose parents view their sleep as problematic appear to be effective in reducing the time taken to fall asleep as well as the number and duration of nocturnal awakenings.4
Another reason for the lack of effect for the intervention evaluated by Santos et al1 might be the lack of adherence to the recommended sleep practices. While mothers in the intervention group consistently reported greater use of the recommended sleep practices than mothers in the control group, use of practices was still low. For example, at 6 months, only 24% of mothers in the intervention group waited 1 to 2 minutes before attending to their infant’s nocturnal waking (thereby allowing the infant a chance to self-settle) and only 12% put their infant into the crib drowsy but still awake. These are 2 key practices known to promote self-settling at the start of the night and after normal nocturnal wakings.5 We need more research to understand why mothers may or may not adopt these sleep practices.
Another reason for the intervention’s lack of success may relate to trust between the mother and the individual delivering the sleep intervention. Parents are more likely to take advice from a person they trust than one they do not. The lay educators in the trial by Santos et al1 were unknown to the mothers, and there may have been insufficient time to build a trusting relationship between them. Future interventions aiming to improve infant sleep might need to incorporate techniques known to increase trust and uptake of behavioral strategies, such as motivational interviewing.6
Only mothers were involved in the intervention. What is the role of fathers and extended family members in an infant’s sleep? Could it be that the low uptake of suggested sleep practices was due to sabotaging by fathers or other family members? When a baby wakes and cries overnight, some mothers report pressure to settle them as soon as possible to allow other family members to sleep, thereby denying the infant a chance to learn to self-settle. Alternatively, could it be that fathers, who may be more likely to adopt limit-setting approaches to settling,7 were not included in the intervention and, therefore, were less able to support their partner in adopting the recommended strategies? While very little infant sleep research has focused on fathers, one study7 of 56 couples found that higher involvement of fathers in their infant’s care (bathing, playing, settling to sleep) at 1 month predicted more consolidated sleep at infant age 6 months as assessed by actigraphy.
The aim of this trial was noble—to improve infant nighttime sleep duration and evaluate possible benefits to infant growth and neurodevelopment. It did not succeed, and this is an important contribution to knowledge in the field. It is likely that the benefits of universal interventions in this area are small and difficult to detect. A better use of future resources might be to target interventions to families who report problems with their infant’s sleep, ensuring that the mechanisms for uptake of beneficial sleep practices are understood and supported, that fathers and relevant extended family members are involved, and that interventions are delivered within a trusted partnership between the family and the practitioner.
Published: December 20, 2019. doi:10.1001/jamanetworkopen.2019.18061
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Hiscock H. JAMA Network Open.
Corresponding Author: Harriet Hiscock, MBBS, MD, The Royal Children's Hospital, 50 Flemington Rd, Parkville, Victoria 3052, Australia (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
Identify all potential conflicts of interest that might be relevant to your comment.
Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.
Err on the side of full disclosure.
If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.
Not all submitted comments are published. Please see our commenting policy for details.
Hiscock H. An Educational Intervention for Improving Infant Sleep Duration—Why Won’t You Sleep, Baby? JAMA Netw Open. 2019;2(12):e1918061. doi:10.1001/jamanetworkopen.2019.18061
Customize your JAMA Network experience by selecting one or more topics from the list below.
Create a personal account or sign in to: