'Cry it out': Is it safe and effective?

The old-fashioned technique of letting a baby “cry it out” to fall asleep has its merits, despite criticism that it could result in lasting emotional and behavioral problems, according to a new study.

The study, published in Pediatrics, was performed on 43 healthy infants aged 6 to 16 months with parent-reported sleep problems. The children were fitted with actigraphy, and researchers used parent-reported sleep diaries, infant cortisol sampling, and self-reporting from mothers about their own stress and mood to perform their analysis.

Lead author Michael Gradisar, PhD, of Flinders University in Adelaide, South Australia, says the data suggest that graduated extinction is a safe and effective technique for parents to use and that bedtime fading is also effective as an alternative, gentler approach. Neither technique resulted in adverse effects, according to the report.

“In our clinical practice, we usually recommend beginning with bedtime fading, and then if there remain issues with overnight waking then graduated extinction can be introduced,” Gradisar says, noting that his practice has created specific instructions that parents can download.

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Nighttime waking is a normal part of infancy, and an important tool for infants to signal needs for nutrition and comfort. As infants age, however, nighttime awakenings should decrease as a result of homeostatic pressure and circadian rhythm development, according to the report. However, in 16% to 21% of infants, nighttime awakenings persist, leading parents to complain of infant sleep problems. Failure to sleep through the night in the 3-month to 6-month age groups may be the result of reduced sleep homeostatic pressure and/or behavioral conditioning “traps” caused by nocturnal responses from parents that are more reinforcing than sleep, according to the report.

Parents with infants with poor sleep patterns are more likely to use physical punishment or develop depression themselves, according to the report, making the use of evidence-based interventions to resolve infant sleeplessness “vital.”

“Several interventions exist for infants’ sleeplessness. Some with the strongest evidence are based on psychological learning theory (ie, operant conditioning), where the parents’ response to their infant’s nocturnal cries are totally ignored (extinction), or initially delayed (eg, 2 minutes) and then gradually extended up to 6 minutes on the first night (graduated extinction),” according to the report.

In the graduated extinction group in this study, parents were given a set schedule for gradually delaying responses to their infant’s cry. They were instructed to put their infant to sleep while awake, then leave the room within 1 minute. When re-entering the room, parents were instructed to comfort the child without picking them up or turning the lights on.

Despite evidence to support the efficacy of these methods, the researchers note that concern has been raised about their use, particularly complains of the immediate stress faced by parents using extinction techniques.

“Arguably more important is that the stress associated with extinction-based treatments might elevate cortisol levels that could have long-term consequences of infant helplessness, and later insecure parent-child attachments and child emotional and behavioral problems,” the research team notes.

NEXT: What about bedtime fading?

As a result of these concerns, the bedtime fading technique has gained traction. A more gentle approach, bedtime fading is based on the theory of sleep homeostasis, where parents take cues from when the infant falls asleep and begin the bedtime routine there. Parents put the infant to bed later and reduce the time spent awake in bed initially, then move bedtime earlier in increments.

In this study, researchers sought to determine whether the different methods were effective and what, if any, impact the various methods had on stress levels for both mothers and infants.

In the 3-month follow-up after the study began, infants in both groups showed significant declines in the time it took the infants to fall asleep—with a 12.7-minute decline in the graduated extinction group and a 10-minute decline in the bedtime fading group compared with no change in the control group.

The number of awakenings reported in the gradual extinction group also decreased significantly, dropping by 2, compared with no decreases in the bedtime fading or control groups. Wake after sleep onset was most improved in the graduated extinction group as well (decreasing by 44 minutes), compared with bedtime fading (decreasing by 24.6 minutes) and the control group (decreasing by 31.7 minutes).

Next: How to counsel parents about safe infant sleep

Total sleep time also increased moderately in the graduated extinction group and the control group (+20 minutes and +22 minutes, respectively), compared with a small increase (+5 minutes) in the bedtime fading group.

In terms of stress levels, there was a small decline in morning infant cortisol levels in the 12-month follow-up, and a moderate drop for the bedtime fading group compared with no change in the control group. Afternoon cortisol levels showed a large decline in the graduated extinction group; a moderate decline in the bedtime fading group; and a small decline in the control group, according to the report.

Maternal stress was unchanged in the control group early in the study, but showed a moderate reduction in the graduated extinction group and a large reduction in the bedtime fading group. Maternal mood didn’t change early in the study, but showed small improvements at the 12-month follow-up in the graduated extinction group and the control group, and a larger improvement in the bedtime fading group.

The research team also found no significant changes in parent-child attachment across the study groups.

“Compared with controls, graduated extinction produced large decreases in nocturnal wakefulness (time taken to fall asleep, number of awakenings, minutes awake after sleep onset),” according to the report. “Bedtime fading produced large decreases in sleep latency compared with the control group. The control group’s sleep did show improvements in nocturnal wakefulness and total sleep, suggesting developmental maturity and/or improvements from sleep education.”

There were no significant sleep changes identified by actigraphy, which researchers say suggests that infants may still experience wakefulness but not signal parents.

“We do not interpret these data as the infant ‘giving up,’ but instead self-soothing,” according to the report.

The report suggests that a combination of bedtime fading followed by graduated extinction may be beneficial in clinical practice to reduce the time it takes for the infant to fall asleep and reduce nighttime awakenings. Sleep education alone, however, may not be enough to help most families that perceive a sleep problem in their infant.