1. Beal, Judy A. DNSc, RN, FNAP, FAAN

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A quick perusal of parenting Web sites reveals 20+ current sources addressing sleep problems. With catchy and enticing names such as "the baby sleep geek," "precious little sleep," and "the sleep lady," these sites offer advice and support to parents that is consistently not evidence-based. What we do know from the research is that during the first 12 months of life, nocturnal wakefulness is normal and serves the useful purpose of alerting parents to the need for comfort and feeding. Nocturnal wakefulness declines steadily with stabilization usually occurring at 3 to 6 months. However, in 16% to 21% of infants this wakefulness continues beyond 6 months and is identified as a "sleep problem" by parents and providers (Wake et al., 2006). This experience is associated with serious problems for families that range from daytime impairments (Banks & Dinges, 2007) to an increase in physical punishment (Korsch, Christian, Gozzi, & Carlson, 1965), and parental depression (Wake et al.).


There are a variety of interventions for infant sleeplessness and those with the strongest evidence are based on operant conditioning. Many parents today were sleep trained by the Ferber method that was first introduced in 1985 and has regained popularity as a similar approach (Ferber, 2006). Despite significant research that has demonstrated positive outcomes of sleep training, concerns still linger. These concerns center around perceptions that sleep training is inhumane, contrary to instinctual parenting behavior, and causes increased infant and parental stress.


"Cry it out" is typically defined as a process whereby parents put their infant to sleep and then ignore their crying. This can be a complete ignoring of crying which is called the "extinction method" or a more graduated process, called the "graduated extinction method." In a recent article, Gradisar et al. (2016) conducted a randomized controlled trial with 43 infants with identified sleep problems and their parents. The triads were randomly assigned to one of three interventions: graduated extinction, bedtime fading, or a control group. The researchers instructed parents assigned to the graduated extinction method (N = 14) to put their baby to bed while still awake and to then leave the room within 1 minute. When crying began, they were instructed to enter the room, comfort the child, but to avoid turning on lights or picking up the infant. Subsequent reentry and comfort was gradually decreased over time. Bedtime fading involved extending bedtime by 15 minutes each night but staying with the infant until he or she fell asleep (N = 14). The control group (N = 14) received educational materials and 24/7 telephone support. After 3 months, significant decreases were found for sleep latency, number of awakenings, and waking after sleep onset for infants in the two experimental groups, especially in the graduated extinction group. There were no significant decreases in infant and maternal stress levels for the intervention groups. There were no adverse effects on behavior or attachment at 12-month follow-up (Gradisar et al.). This was the first study that tested the bedtime fading technique and to have reported no adverse effects to "crying it out." Parents may be reassured by these findings and may choose to use the more gentle and gradual approach of bedtime fading as an alternative to "cry it out" techniques.


Nurses can offer advice to new parents based on the most recent evidence about various ways to handle their baby's night wakefulness.




Banks S., Dinges D. F. (2007). Behavioral and physiological consequences of sleep restriction. Journal of Clinical Sleep Medicine, 3(5), 519-528. [Context Link]


Ferber R. (2006). Solve your child's sleep problems (2nd ed.). New York, NY: Fireside. [Context Link]


Gradisar M., Jackson K., Spurrier N. J., Gibson J., Whitham J., Williams A. S., ..., Kennaway D. J. (2016). Behavioral interventions for infant sleep problems: A randomized controlled trial. Pediatrics, 137(6). doi:10.1542/peds.2015-1486 [Context Link]


Korsch B. M., Christian J. B., Gozzi E. K., Carlson P. V. (1965). Infant care and punishment: A pilot study. American Journal of Public Health and the Nation's Health, 55(12), 1880-1888. [Context Link]


Wake M., Morton-Allen E., Poulakis Z., Hiscock H., Gallagher S., Oberklaid F. (2006). Prevalence, stability, and outcomes of cry-fuss and sleep problems in the first 2 years of life: Prospective community-based study. Pediatrics, 117(3), 836-842. [Context Link]