BEHAVIORAL AND MASSAGE TREATMENTS FOR INFANT SLEEP PROBLEMS

Medicine and Health Rhode Island,  Mar 2006  by Forbes, Elizabeth A

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The regulation and consolidation of sleep are major developmental tasks of infancy and usually occur by six to nine months of age. By that time, 70% of infants will have developed a consistent sleep pattern and "sleep through the night" as defined by a continuous period of sleep from midnight to 5:00 am. Although it is normal to have brief nighttime awakenings at this age, most infants are able to self-soothe, i.e. go back to sleep without assistance. However, research suggests that 30-40% of infants either fail to learn self-soothing techniques or develop new sleep problems in the second year of life.1 Many of these infants will subsequently develop long-lasting, complicated, or severe sleep problems.1-6

Infant sleep problems are parentally defined and most often present as bedtime struggles (i.e. limit setting disordet) and/or frequent nighttime awakenings (i.e. sleep onset association disorder). Sleep problems in this age group (less than two years old) can have a major impact on the infant's health and have been associated with poor feeding and growth, dysregulated daytime behavior, decreased attachment/socialization, and slowed developmental progress.12,5-8 As is true of many pediatric problems, the consequences of infant sleep difficulties are not limited to the individual but usually affect family functioning as well. Specifically, infant sleep problems have been strongly associated with high levels of family stress and maternal depression in several research studies.2,9-11

Standard treatments for pediatric sleep problems are often behavioral in nature and require close follow-up with repeated health care visits.1,12 The goal of "sleep training" is to remove parental interventions during sleep times so that the infant can learn to self-soothe. This usually involves putting the infant to bed "drowsy but awake" and letting him/her "cry themselves to sleep". Several sleep training methods are described in the medical literature, many of which are widely recommended by pediatric providers. These include well established treatment methods, such as modified and unmodified extinction programs.12-15 Other behavioral methods, such as positive bedtime routines and faded bedtime with response cost, are less established but appear promising.12-13 This review will briefly discuss some of the common behavioral treatments for infant sleep problems, including the use of infant massage as an adjunct to sleep training. Lastly, the importance of early intervention and prevention for infant sleep problems will be discussed, along with some practical considerations faced by those in clinical practice.

EXTINCTION PROGRAMS FOR INFANT SLEEP

Unmodified extinction programs involve putting the infant down for sleep at a designated bedtime, then ignoring the child until an appropriate rise time the next morning. Parents must limit their responses to infant crying, tantrums, and calls for help, and should interact with the infant only for illness, injury, or safety concerns. In many cases, infant behavior worsens in the first few nights of an extinction program, and prolonged crying and/or more frequent waking is often seen before infant sleep improves. This "extinction burst" can be dramatic, but usually resolves within three to five nights of treatment.1

The success of any extinction program depends on parental consistency. By responding to infant cries, parents can inadvertently reinforce inappropriate behaviors and make future attempts at treatment more difficult.1,12-15 Therefore, it is imperative that parents ignore all inappropriate infant behaviors regardless of frequency, intensity, or duration. Some parents find it difficult, if not impossible, to achieve this level of consistency due to various emotional or environmental factors. Parents who are unable to tolerate prolonged infant crying may find it easier to comply with a modified extinction program, such as extinction with parental presence or graduated extinction.

Modified extinction programs allow for an increased parental presence at bedtime and during infant wakings. These programs are similar to unmodified extinction, but may be more acceptable to parents who have concerns about the safety and/or emotional consequences of ignoring an infant who is out of sight.1, 12-15 In extinction with parental presence, a parent stays in the infant's room but completely ignores the infant and his/her behavior. In contrast, graduated extinction programs allow for brief periods of interaction at specified intervals during times of infant distress. Parents may respond to infant crying with brief (less than 60 second) periods of verbal reassurance and/or physical comforting. The infant is ignored between checks, which occur at pre-determined intetvals based on infant tempetament and parental comfort (typically five to 20 minutes). These intervals are gradually increased as parents grow more comfortable with infant crying and/or infant sleep improves.

Of all the behavioral treatments for infant sleep problems, unmodified extinction, extinction with parental presence, and graduated extinction programs have been the most carefully studied.12 Prior research supports the efficacy of these methods in the treatment of infant sleep problems, but no evidence suggests that one extinction program is more or less effective than the others. Therefore, the choice of an extinction program for infant sleep training must depend largely on the needs of each individual infant and his/her parents.