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

Douglas, Pamela S. MBBS, FRACGP, IBCLC, PhD; Hill, Peter S. MBBS, DRACOG, PhD

Journal of Developmental & Behavioral Pediatrics: September 2013 - Volume 34 - Issue 7 - p 497–507
doi: 10.1097/DBP.0b013e31829cafa6
Review Article

Objective: 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.

Methods: 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–August 2013). The evidence is critically analyzed, according to PRISMA guidelines.

Results: 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 Sudden Infant Death Syndrome.

Conclusion: 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.

*Discipline of General Practice, Royal Brisbane and Women's Hospital, University of Queensland, Brisbane, Australia;

Australian Centre for International and Tropical Health, School of Population Health, University of Queensland, Brisbane, Australia.

Address for reprints: Pamela S. Douglas, MBBS, FRACGP, IBCLC, PhD, Discipline of General Practice, Level 8, Health Sciences Building 16/910, Royal Brisbane and Women's Hospital, University of Queensland, Brisbane 4029, Australia; e-mail:

Disclosure: The authors declare no conflict of interest.

P.S. Douglas conceptualized this article, drafted and revised the manuscript, and approved the final manuscript as submitted. P.S. Hill critiqued the conceptual basis of this article, advised on methodology, critically reviewed the manuscript, and approved the final manuscript as submitted.

Received February 08, 2013

Accepted May 07, 2013

Copyright © 2013 Wolters Kluwer Health, Inc. All rights reserved.