I remember thinking, after my pregnant wife's water broke, minutes after I went to bed, anguishing really, over one thought as we drove to the hospital: "I'm never going to be well rested again."
If there's one thing all new parents wish for, it's a good night's sleep.
Unfortunately, infants sometimes make that impossible. They wake up repeatedly, needing to be fed, changed and comforted. Eventually, they reach an age when they should sleep through the night. Some don't, though. What to do with them continues to be a topic of a heated debate in parenting circles.
One camp believes that babies should be left to cry it out. These people place babies in their cribs at a certain time, after a certain routine, and don't interfere until the next morning; no matter how much the babies scream or cry, their parents ignore them. After all, if babies learn that tantrums lead to the appearance of a loved one, they will continue that behavior in the future. The official name for this intervention is Extinction.
The downside, of course, is that it's unbelievably stressful for parents. Many can't do it. And not holding fast to the plan can make everything worse. Responding to an infant's crying after an extended period of time makes the behaviour harder to extinguish. To a baby, it's like a slot machine that hits just as you're ready to walk away; it makes you want to play more.
A modification of this strategy is known as Graduated Extinction. Parents allow their infant to cry it out for a longer period each night, until infants eventually put themselves to sleep. On the first night, for instance, parents might commit to not entering the baby's room for five minutes. The next night, 10 minutes. Then 15, and so on. Or, they could increase the increments on progressive checks each night. When they do go in the room, it's only to check and make sure the baby is OK - no picking up or comforting. This isn't meant to be a reward for crying, but to allow parents to be assured that nothing is wrong.
Another choice is Bedtime Fading. The point of this plan is to teach your children how to fall asleep on their own at bedtime, in the hope that if they develop this skill, when they wake up in the middle of the night, they'll choose to employ it rather than call for you. With fading, you temporarily set bedtime later than usual and preface it with a good bedtime routine. Your babies learn that bedtime is fun, and have little trouble falling asleep because they're more tired than usual. Then you move their bedtime earlier and earlier, so that infants learn how to put themselves to sleep when they are less and less tired.
A fourth method is Scheduled Awakenings. In this method, a parent tries to disrupt spontaneous awakening by getting up in the middle of the night to wake children 15 to 30 minutes before they usually wake up on their own. They then help the baby fall back asleep. The scheduled awakenings are later phased out.
Of course, even with fading and scheduled awakenings, it's possible that your baby will wake up in the middle of the night, screaming. Then you face a choice: Go to them or wait it out?
Some people always choose to comfort the child. They think that making a baby cry it out is inhumane and could even lead to psychological problems. Others feel that giving in to babies prevents them from learning needed skills and leads to later problems.
A final thing doctors can do is Parental Education, which is closer to prevention. It involves talking to parents about many of these options, especially training infants to fall asleep on their own, before problems develop.
As a paediatrician, the first thing I do with parents who are experiencing problems is calm them down. Sometimes it feels as if it will never go away, but I try to remind them that few teenagers have this issue. They go to bed fine, and if they wake up in the middle of the night, they go back to sleep without anyone's help. This almost always, eventually, gets better.
On the other hand, I don't want to minimise the short-term problems for parents. Nor do I want to do nothing. Sleep deprivation leads to significant and serious consequences in adults. A 2008 study published in Pediatrics found that mothers of infants with sleep problems, in which no intervention was tried, were more likely to report symptoms of clinical depression when their child was two years old. Sleep problems also lead to significant parental stress, and, potentially, physical punishment.
The good news is that almost all interventions work. In 2006, a systematic review was published in the journal Sleep that examined all the relevant research on the efficacy of these interventions; 94 per cent of the 52 reviewed studies found that the interventions led to improved sleep. More than 80 per cent of children who were treated improved significantly.
The strongest evidence supported the extinction method and parent education (ie, prevention). Still, there was evidence that also supported graduated extinction, fading and scheduled awakenings methods.
People become surprisingly heated about which method to use. This isn't just because they think one works better than the other, but also because they think some are harmful. They worry about the long-term effects of some methods. Those concerns may be overblown, though. A small study published recently followed children who were randomly sorted to use graduated extinction, fading or parent education. Besides looking at the effectiveness of the intervention on sleep, researchers measured the cortisol hormone in infants' saliva (as a measure of stress) as well as mothers' moods and stress.
Again, all of the interventions worked to improve sleep. More important, none caused any concerning levels of stress. This confirmed the findings of two previous studies that found that infant sleep problems, and the interventions used to remedy them, do not predict long-term outcomes, even at six years of age.
Parents become stressed about infants who don't sleep well. That's understandable. What they don't need to stress about is that fixing it will cause more harm or have long-term negative consequences.
A good night's sleep makes almost everything better.
Aaron E. Carroll is a professor of pediatrics at Indiana University School of Medicine who blogs on health research and policy at The Incidental Economist.