Baby sleep, sleep training, what do studies say?

Sleep is a topic that comes up very frequently in breastfeeding support meetings and lactation consultations, with questions about how to put the baby to sleep without the breast, about multiple awakenings, and anxiety about the lack of sleep, for both the mother and the baby.

In addition to physical and emotional fatigue, parents feel they are failing, “not managing,” that their baby should be sleeping better. There is then the desire to “find a solution” and “solve this problem.”

On the topic of baby sleep, I also invite you to read this article on baby swaddling, and the one on safe bedsharing and breast-sleeping.

The childcare industry has seized on this issue with the creation of objects designed to replace parents and fill the young mammal’s need for closeness or comfort

with cocoon beds, baby swings, hot water bottles, musical stuffed animals, nightlights making white noise, etc.

Similarly, the infant formula industry uses the lack of sleep as a marketing argument (1), leading parents to believe that formula allows better sleep for the baby, and therefore the parents. Some formula manufacturers even offer consultations with pediatric nurses on this topic (2).

We also observe the emergence of baby sleep coaches (3,4). They coach parents on how to get their baby to fall asleep alone and achieve “full nights.”

Thus, on one coach’s website, one can read that: “Around 3 months, all babies (whether bottle-fed or breastfed) become capable of linking together 5 to 7 hours of consecutive sleep before waking to eat! This is what is called ‘sleeping through the night’. This evolution is possible thanks to the establishment of the circadian clock. Full and uninterrupted nights of 11 or 12 hours arrive between 4 and 6 months, depending on the child’s nutritional needs, but especially depending on the maturation of the circadian clock, indicating to the body that during the night, everything is at rest (including digestion).” (5)

The prices are high: from 300 to 750 euros for 2 to 3 weeks of follow-up (4), prices that truly show how desperate and exhausted parents are, and that raise questions, especially when these professionals ask for reimbursement by mutual insurance companies and the national health system.

At the same time, an information website on children’s sleep (6) explains that “we, as parents, must teach our children to fall asleep independently” and “Falling asleep is not an innate skill, the child learns to fall asleep depending on their environment.” But it warns against sleep coaches and offers support by psychologists.

Ultimately, these methods are those of sleep training (7).

The discourse has slightly changed over the past ten years (we now speak of “autonomous falling asleep”), but overall, we find the same suggestions: putting the baby in the crib slightly awake and letting them fall asleep alone, staying in the room without picking up the baby and moving progressively farther away, gradual extinction (letting the baby cry for increasing minutes), with or without holding. Coaches teach parents how to accompany the baby’s emotions and help them grieve their current sleep strategy (parental presence, breast, etc.).

Some babies adapt quickly, but others react very poorly (intense crying, vomiting, etc.).

The book Sweet Sleep (8), a reference in sleep information, mentions differences in baby temperament, which may explain differences in adaptability to these methods.

As mentioned in a BBC article (9) about these training techniques, the main goal is not for the baby to stop waking up, but for the baby not to wake their parents and to fall back asleep alone. The objective is thus early autonomy for babies to fall back asleep independently.

But studies show that these methods do not work systematically and must be repeated several times during the first year. Moreover, studies comparing parents using these methods and parents not using them show mixed results: either no difference in the number of awakenings or little difference in the total sleep duration of parents (9).

There is also the question of bias in these studies, where parents report their child’s sleep durations and may overestimate them.

Even “pro sleep-training” researchers recommend not performing these interventions before 6 months, especially in breastfed infants (due to possible negative impact on lactation), but also in babies with an anxious or sensitive temperament or who have experienced trauma (8).

Before 6 months, these strategies do not provide benefits in reducing crying or decreasing the risk of postpartum depression. The risks associated with these methods include increased crying, increased maternal anxiety, and increased risk of sudden infant death if the baby is placed to sleep day or night in a separate room (10).

Are the babies to whom these sleep training methods are applied stressed?

Some experts believe that babies are capable of soothing themselves, that cries at bedtime are simply emotional discharge after a long day (6), whereas others believe they have given up calling: indeed, if cortisol levels are measured in the mother and the infant, the infant’s cortisol remains high even if the baby no longer signals their wakefulness (11).

Other researchers have examined the impact of these methods on the attachment relationship and recommend waiting at least until the age of one before trying sleep-training techniques. Human babies are born neurologically immature, and the brain area responsible for emotion regulation (the pre-cortex) is one of the last areas to mature around age 20. Thus, during early childhood, especially from 6 months to one year, the brain needs parental co-regulation to calm itself: the adult helps the child calm down when faced with a stressful event. Consistent parental responses are associated with cognitive, psychosocial, and language development and favor secure attachment.

Causing stressful situations (crying) while the child is developing their hypothalamic–pituitary–adrenal axis (which controls stress responses) could create risks of stress-management difficulties in adulthood (9).

So, when discussing baby sleep, it is useful to return to biology and “normality.”

Experts from The Lancet (1) recall that fragmented sleep in the first months is normal and that parents’ expectations of having a baby whose sleep rhythms resemble those of adults are unrealistic. They also mention that promoting continuous sleep in young infants may harm breastfeeding.

Professor Helen Ball (12), an anthropologist specializing in infant sleep and sudden infant death prevention, has given a very interesting webinar on the subject. She created the BASIS website (13), which provides information on infant sleep and the prevention of sudden infant death, including sheets in French for parents.

In one of these documents, we can read information that contradicts that mentioned by sleep coaches:

“Sleep is a developmental process and our sleep needs change throughout our lives. Night awakenings are part of the norm during childhood, and healthy babies wake several times per night at the end of sleep cycles.” A diagram shows the great variability in sleep durations among babies.

Another interesting piece of information: “13% of babies do not have regular 5-hour or longer sleep at the end of the first year. Some perfectly healthy babies continue to wake several times at night beyond one year.”

Dr. Pamela Douglas, an Australian expert and author of many articles (10, 14–18) and a book addressing this theme (19), has developed a training program for healthcare professionals (which I have completed), based on information about normal baby sleep and on the regulation of the circadian clock in cases of very frequent nighttime awakenings.

You will find an interview with Dr. Douglas in this blog article, in which she explains the parameters enabling this regulation.

This approach (called “Possums,” ) has been taken up in England in collaboration with Professor Ball, in the program “Baby, sleep and you”: it is a training program for healthcare professionals on this topic.

Dr. Pamela Douglas’ approach is cited by the latest protocol of the Academy of Breastfeeding Medicine (11) as a needs-based (“cued care”) approach that can improve family sleep.

This approach reiterates information about normal baby sleep: it is normal for babies to wake frequently during the first year; these awakenings, especially in breastfed infants, have a protective effect against sudden infant death; and there is great variability in sleep duration among children—for example at 2 months, between 9 and 22 hours of sleep per 24 hours (10). Based on biological sleep regulators, one can help families find balance. By informing parents, we can help them find strategies to sleep longer.

In conclusion, biology tells us that sleep cannot be learned; it is a physiological function. “Autonomous sleep-learning” techniques are questioned by some infant sleep experts. Thus, the recent ABM protocol advises against these sleep-training techniques before the age of one.

But of course, in France, explaining to a mother of a 2.5-month-old baby that it is normal for her baby to wake at night when she has to go back to full-time work is not very helpful… especially if at the same time she is advised not to sleep with her breastfed baby.

While it is important to develop information initiatives involving the first 1000 days of a child’s life, it is also essential to support young parents in the perinatal period, to give them clear information that reflects the reality concerning sleep and sleep-training methods. Extending maternity leave, as is the case in other countries, would allow parents to live more peacefully through the challenge represented by the normal awakenings of babies.

Are you a healthcare professional and looking for training on breastfeeding or baby sleep? Visit the Lactasource website.

Please contact me for advice or questions: “My Baby Moon” by Elise Armoiry, IBCLC lactation consultant & founder of My Baby Moon.

• More than 2000 families supported since 2014

• Doctor of Pharmacy by training, specialized in breastfeeding and sleep, trained with Dr. Pam Douglas.

Email: info@mybabymoonibclc.com

Tel: 00337.49.50.67.82

Website: https://www.mybabymoonibclc.com/

Book an online appointment

Bibliographic references

1. Marketing of commercial milk formula: a system to capture parents, communities, science, and policy. Nigel Rollins,et al. 2023 Lancet Breastfeeding Series Group

2. Laboratoire Gallia. Bébé ne fait pas ses nuits. Disponible ici, consulté le 10/01/2023

3. Article Slate. Fr. Coachs sommeil pour bébé: miracle pour les uns, arnaque pour les autres. Consulté le 10/01/23 et disponible ici

4. Article Les Échos. Faire dormir les enfants : le nouveau business des coachs en sommeil. Consulté le 17/02/23 et disponible ici

5. Site fée dodo . Consulté le 14/02/2023. Disponible ici

6. Site Sommeilenfant.org. Attention aux arnaques des coachs de sommeil. Disponible ici. Consulté le 28/03/2023

7. Site Sleepfoundation.org. Sleep training. site Disponible ici. Consulté le 28/03/2023 La

8. Leche League International et al. Sweet Sleep: Nighttime and Naptime Strategies for the Breastfeeding Family Ed 2014

9. Ruggeri A. Article de la BBC. Mars 2022.What really happens when babies are left to cry it out. Consulté le 17/02/23 et disponible ici

10. Douglas P, Hill PS. Behavioral sleep interventions in the first six months of life do not improve outcomes for mothers or infants: a systematic review. J Dev Behav Pediatr. 2013;34:497–507.

11. Deena Zimmerman et al. ABM Clinical Protocol #37: Physiological Infant Care—Managing Nighttime Breastfeeding in Young Infants.Breastfeeding Medicine 2023 18:3, 159-168

12. Elise Armoiry, Article IPA. Sommeil « normal » des bébés: retour sur le Webinar de l’anthropologue Helen Ball. Rédigé en 2020, disponible ici 

13. Baby Sleep Information Source. Le sommeil normal de l’enfant. Consulté le 19/01/23 et disponible ici 

14. Pamela Douglas. Interview à la radio sur le sommeil de bébé . Ecouté le 15/01/2023. Disponible ici 

15. Pamela Douglas. Podcast. Can you let your baby sleep whenever they want ? Disponible ici. Consulté le 15/01/2023

16. Pamela Douglas. Hey baby are you upset because you are overstimulated ? 2021. The Medical republic. Disponible ici. Consulté le 15/01/23

17. Pamela Douglas. Hey baby, why can’t I put you down for daytime naps ? 2021. The Medical republic. Disponible ici. Consulté le 15/01/23

18.  K. Whittingham et al. Optimizing parent-infant sleep from birth to 6 month : a new paradigm . Infant mental health Journal 1–9 (2014) C 2014

19. Elise Armoiry. Article de blog . Présentation de l’ouvrage de P Douglas: The little discontented baby book.