Helping Babies Cope With Stress and Learn to Sleep

We’ve all seen the warnings that sleep training causes so much stress to a baby that cortisol floods the brain, killing neurons and altering development.

Even without these alarming stories, most parents considering sleep training naturally worry about how stressful it is to a baby. None of us like to hear our babies cry. It makes us feel stressed, and the baby probably feels the same way. But how stressful is it? And is it damaging to a baby’s brain?

Despite decades of research on sleep training, most studies have focused on outcomes related to sleep and daytime behavior, but few have examined babies’ stress responses to this change. Those that warn that letting babies cry is damaging to their brains cite studies of babies that were subjected to chronic neglect or abuse or raised in orphanages and lacking strong attachment figures. These are examples of chronic, toxic stress. They are deeply saddening to me, but I’m not convinced that they tell me, or any other loving parent, much about the effects of sleep training my little girl.

This has left me digging through reams of research, trying to put sleep training in perspective among other sources of infant stress. A good place to start is the American Academy of Pediatrics’ (AAP) recently released report entitled The Lifelong Effects of Early Childhood Adversity and Toxic Stress [1] and an accompanying policy statement. The AAP report gives us a framework for looking at stress that I think is very useful. It defines 3 types of stress responses in children:

  1. A positive stress response is one that is “brief and mild to moderate in magnitude” and in which a caring and responsive adult helps the child cope. Events that can cause positive stress responses include “dealing with frustration, getting an immunization, and the anxiety associated with the first day at a child care center.” The authors go on to say, “When buffered by an environment of stable and supportive relationships, positive stress responses are a growth-promoting element of normal development. As such, they provide important opportunities to observe, learn, and practice healthy, adaptive responses to adverse experiences.”
  2. A tolerable stress response occurs because of non-everyday events like a death in the family, divorce, or a natural disaster. Again, what makes this stress tolerable is a child’s relationship with a supportive adult, who can help the child adapt and cope with the changes in his life. In the best of circumstances, tolerable stress can even have positive effects [2].
  3. A toxic stress response is caused by “strong, frequent, or prolonged activation of the body’s stress response systems in the absence of the buffering protection of a supportive, adult relationship.” Examples include chronic stressors such as child abuse or neglect, parental substance abuse, and maternal depression. In early childhood, toxic stress can affect brain circuitry and disrupt the development of normal physiologic stress regulation. It can also compromise immune function and cause inflammation, both of which have been linked to a number of chronic diseases.

Given this framework, can we predict what type of stress response sleep training produces in a baby? Is sleep training more like starting daycare, coping with a divorce between the two most important people in your life, or being raised by someone abusing drugs?

In the vast majority of families, sleep training is nothing like the sad situations that cause toxic stress. Most parents find that sleep training takes only a few nights, or if done more gradually, no more than a couple of weeks. If it causes weeks of prolonged crying, then something isn’t working, and parents need to find a new strategy.

This is a good time to add that I define sleep training broadly. I would rather call it “sleep learning,” but I’ll stick with the terms we all know. To me, sleep training involves making changes in a baby’s sleep habits so that he learns to self-soothe, and it almost always involves decreasing parental involvement and some crying. I know that many readers balk at the mere mention of sleep training, but this discussion of change and stress may be helpful even to those considering gentle ways of shaping children’s sleep – such as transitioning to a separate bed or night weaning.

Learning to fall asleep in a new way isn’t easy. But just as we can’t start daycare for a baby, we can’t learn to sleep for a baby either. Stress is unavoidable, even for a baby born to the most caring family. My intention in this research and writing is most definitely not to give a stamp of approval to all sleep training methods. Rather, it is to move beyond blanket judgments, put the stress of sleep training in context, and to think critically about what we can do to support and respect babies as they learn to sleep so that it is a positive, not toxic, experience.

How do babies respond to stress?

When we experience stress, several physiological pathways kick into action. One response is the activation of the hypothalamic-pituitary-adrenocortical (HPA) axis, resulting in the release of cortisol. Cortisol shifts the focus of the body towards mobilizing energy and suppressing some functions such as immune responsiveness, which we can survive without on a short-term basis. Cortisol is essential for survival. It allows us to cope with and recover from stress.

Cortisol can be measured in saliva, so it can be sampled in a non-invasive manner without causing additional stress, even while a baby is sleeping. Without unusual levels of stress, cortisol has a natural circadian rhythm, being 300-400% higher in the early morning than at its lowest point around midnight [3]. This pattern does not develop until infants are several months old, and it is what helps them to sleep at night and be awake during the day. A surge in cortisol outside of this normal pattern can indicate that a baby is stressed. However, it is simplistic to assume that any rise in cortisol is dangerous, given its importance to daily function. Cortisol is not a problem unless it is elevated for extended periods of time as in the case of chronic stress [2]. Further complicating matters, children with a history of toxic stress caused by abuse or neglect often have lower cortisol and blunted cortisol rhythms compared to the norm [4].

Babies have a very reactive HPA axis at birth. A newborn baby will have a strong cortisol response to a heelstick, a bath, or a physical exam [5]. In one study, newborns were given a mock exam two days in a row. On the first day, the babies had increased cortisol and cried during the exam. However, when the exam was repeated on the second day, the babies did not show an increase in cortisol, though they still cried almost as much as they had on the first day [6]. Somewhere in their brains, they recognized that this experience had happened before. This study illustrates a positive stress response. The babies were initially stressed by the exam, but they were able to recover and learn from the experience so that they could cope with it effectively the next day. It also demonstrates the important point that crying is not always accompanied by increased cortisol.

First bath stress

Other studies have tested infants’ responses to acute physical pain, such as a vaccination. Physical pain causes a cortisol response in babies younger than 6 months, but beyond this age they show very little cortisol response, though they still cry just as much [7]. It has also been shown that anger, fear, and novelty stressors (such as the first time in a swimming pool) rarely cause a cortisol response in older babies [5].

Importantly, a mother or other attachment figure is usually present in the experiments described thus far. During sleep training, we are often trying to reduce parental presence and soothing around bedtime, and this is what makes it hard on babies. What do studies tell us about the stress response to sleep training or other parental separations?

There is one study of cortisol responses in babies undergoing sleep training [8]. 25 mothers and infants (4- to 10-month-olds) spent 5 days at a residential facility to participate in extinction sleep training (CIO without any reassurances). On the first night of sleep training, all babies had at least 2 bouts of 5-10 minutes of crying before falling asleep. On the third day, the babies all fell asleep with no more than a little fussing. Cortisol was measured in the infants before beginning the bedtime routine and at the time that they fell asleep, after crying-it-out. On both the first and third days of sleep training, there was no increase in cortisol between the pre-bedtime sample and the CIO sample.

Middlemiss et al. 2011

At first glance, you might think that this study provides evidence that sleep training is not stressful to babies. However, the study had some serious limitations. First, the standard deviations for these data (error bars in the graph) are HUGE. In addition, the babies’ cortisol levels were high all around, even before the bedtime routine, probably because they were in a strange place. Have you ever traveled with a baby and not found that their sleep routine was disrupted? That higher basal stress could hide the stress that the babies may have felt about crying it out. Still, given that these babies were in pretty much the most stressful sleep situation imaginable (poor kiddos), crying it out didn’t exactly cause their bodies to be flooded with additional cortisol.

How stressful might sleep training be to a baby in his own bed, with periodic reassurances from a parent? We can only speculate, but so far, I’m not convinced that it is as devastating as some would have us believe. What we really need is a study that has not yet been done: a longitudinal study of cortisol in babies that are sleep trained in their own homes, with age-matched controls. I think that such a study would ease our fears about sleep training. If I had to guess, I would predict that age-appropriate sleep training in a familiar and supportive environment would cause a small increase in cortisol for a few nights, but not chronically.

Other studies have looked at cortisol responses in babies briefly separated from their mothers. In 9-month-old babies, being left alone for 30 minutes with a stranger in a lab setting causes a 20-40% increase in cortisol, a minor bump considering that cortisol fluctuates by 10x that much on a daily basis. However, by 12-18 months of age, most studies find that maternal separation does not increase cortisol [9]. And again, being at home in a familiar bed rather than with a stranger in a strange environment may make sleep training less stressful.

There is one other type of stressful situation that might help us to understand sleep training: transition to day care. Like sleep training, starting day care involves a big change in routine and prolonged separation from an attachment figure. Starting day care for the first time causes an increase in cortisol, even if mom stays with baby for the first two weeks to help with the transition [10]. And even after many months, toddlers attending full-day daycare show a gradual increase in cortisol throughout the day, whereas children at home show no increase or a gradual decline in cortisol during the day [11]. However, across ages, the greatest daytime cortisol response is found in 2- to 3-year-old toddlers. Infants, including those around the period of peak separation anxiety at 9-12 months, do not have increased cortisol [12]. The authors speculated that the chronic elevation of cortisol in toddlers in daycare is related to the stress of group interactions rather than the separation from parents. The fact that cortisol decreases in young children during nap time at daycare, even if they do not actually sleep, supports this hypothesis [13].

Despite the stress of entering childcare at a young age, it has yet to have been shown to have any long-term effects on a person’s ability to regulate stress or form healthy relationships. Thankfully, I don’t see many claims that sending your child to daycare will cause brain damage. And despite the stress of daycare, many families in the modern world still make this choice, because for them, the benefits of daycare outweigh the risks. Daycare may allow parents to pursue careers that they love and for the family to be financially secure. It might benefit the child as well, giving him opportunities to learn about social relationships in group play and stimulating cognitive and social development.

We can think about sleep training as a similar risk-benefit analysis. Yes, it is stressful, but the benefits are also substantial. For most families, sleep training will result in a baby that has a new and important skill: the ability to sleep on his own. The whole family will get more sleep, and that comes with numerous benefits. In fact, recognizing that the current sleep situation is not working and making changes to improve it could reduce a child’s long-term exposure to stress and cortisol.

Consider the following examples:

-Babies that sleep more have lower basal cortisol [7].

-Toddlers with more fragmented sleep have higher cortisol in the morning, and this is correlated with daycare teachers’ ratings of greater internalizing behavior problems. These children were also more likely to become upset and tearful in response to minor stressors and challenges at daycare [14]. These last two data sets are only correlative, but a causal relationship is certainly plausible.

-Sleep deprivation puts mothers at higher risk for postpartum depression [15]. Babies who are cared for by depressed mothers have chronically higher cortisol in preschool [16] and adolescence [17].

-When 3- to 6-month-old babies play with a sensitive mother for 15 minutes, their cortisol decreases. However, playing with an insensitive mother can actually increase cortisol, or at best, cause no change [18]. If sleep deprivation is affecting a parent’s ability to be sensitive and responsive during the day, then that alone could increase a child’s exposure to cortisol. It is not selfish to sleep train your baby so that you can cope better with the stressors of life and be a more responsive parent.

There will always be those that judge sleep training to be unacceptable and offer the worst possible examples of childhood stress to incite fear in parents, but I believe that we have to put it in context. Stress is a part of life. It is important to recognize that making changes to a baby’s sleep routine is stressful and to minimize that stress as much as possible. However, a baby’s total stress load comes from a multitude of factors, and sleep training may actually alleviate other stressors. Telling parents that they must protect their babies from stress and do everything they can to stop a baby from crying, at all costs, may be counter-productive. Crying is a baby’s way of communicating, but it does not always communicate despair, and it is not always accompanied by a cortisol response. In fact, some studies suggest that crying may release tension and reduce the activity of the HPA axis and the cortisol response [19]. Lovingly allowing a baby to practice coping with stress in the process of learning a new skill can be a healthy thing.

An essential part of a positive stress response is the support of a caring adult. Yet, in order for babies to learn to sleep on their own, parents often need to decrease their presence and soothing. How do we, as parents, balance our important role of being supportive of our babies during this transition while still allowing them to develop their own self-soothing abilities? That’s the question I’ll tackle in my next post.

Have you made changes to your child’s sleep habits that were stressful? How did that stress compare to other stressors in your child’s life? Did you find ways to help your child cope with the stress?

Check out other posts from my infant sleep series:

REFERENCES

1. Shonkoff, J.P. and A.S. Garner. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 129(1): p. e232-46. 2012.

2. National Scientific Council on the Developing Child, Excessive stress disrupts the architecture of the developing brain: Working paper #3. 2005. p. Center on the Developing Child at Harvard University. http://www.developingchild.net.

3. de Weerth, C., R.H. Zijl, and J.K. Buitelaar. Development of cortisol circadian rhythm in infancy. Early Hum Dev. 73(1-2): p. 39-52. 2003.

4. Gunnar, M.R. and B. Donzella. Social regulation of the cortisol levels in early human development. Psychoneuroendocrinology. 27(1-2): p. 199-220. 2002.

5. Jansen, J., R. Beijers, M. Riksen-Walraven, and C. de Weerth. Cortisol reactivity in young infants. Psychoneuroendocrinology. 35(3): p. 329-38. 2010.

6. Gunnar, M.R., J. Connors, and J. Isensee. Lack of stability in neonatal adrenocortical reactivity because of rapid habituation of the adrenocortical response. Dev Psychobiol. 22(3): p. 221-33. 1989.

7. Gunnar, M.R., L. Brodersen, K. Krueger, and J. Rigatuso. Dampening of adrenocortical responses during infancy: normative changes and individual differences. Child Dev. 67(3): p. 877-89. 1996.

8. Middlemiss, W., D.A. Granger, W.A. Goldberg, and L. Nathans. Asynchrony of mother-infant hypothalamic-pituitary-adrenal axis activity following extinction of infant crying responses induced during the transition to sleep. Early Hum Dev. 88(4): p. 227-32. 2012.

9. Gunnar, M.R., N.M. Talge, and A. Herrera. Stressor paradigms in developmental studies: what does and does not work to produce mean increases in salivary cortisol. Psychoneuroendocrinology. 34(7): p. 953-67. 2009.

10. Ahnert, L., M.R. Gunnar, M.E. Lamb, and M. Barthel. Transition to child care: associations with infant-mother attachment, infant negative emotion, and cortisol elevations. Child Dev. 75(3): p. 639-50. 2004.

11. Vermeer, H.J. and M.H. van IJzendoorn. Children’s elevated cortisol levels at daycare: A review and meta-analysis. Early Childhood Research Quarterly. 21: p. 390-401. 2006.

12. Watamura, S.E., B. Donzella, J. Alwin, and M.R. Gunnar. Morning-to-afternoon increases in cortisol concentrations for infants and toddlers at child care: age differences and behavioral correlates. Child Dev. 74(4): p. 1006-20. 2003.

13. Watamura, S.E., A.M. Sebanc, and M.R. Gunnar. Rising cortisol at childcare: relations with nap, rest, and temperament. Dev Psychobiol. 40(1): p. 33-42. 2002.

14. Scher, A., W.A. Hall, A. Zaidman-Zait, and J. Weinberg. Sleep quality, cortisol levels, and behavioral regulation in toddlers. Dev Psychobiol. 52(1): p. 44-53. 2010.

15. Karraker, K.H. and M. Young. Night Waking in 6-Month-Old Infants and Maternal Depressive Symptoms. J Appl Dev Psychol. 28(5-6): p. 493-498. 2007.

16. Essex, M.J., M.H. Klein, E. Cho, and N.H. Kalin. Maternal stress beginning in infancy may sensitize children to later stress exposure: effects on cortisol and behavior. Biol Psychiatry. 52(8): p. 776-84. 2002.

17. Murray, L., S.L. Halligan, I. Goodyer, and J. Herbert. Disturbances in early parenting of depressed mothers and cortisol secretion in offspring: a preliminary study. J Affect Disord. 122(3): p. 218-23. 2010.

18. Spangler, G., M. Schieche, U. Ilg, U. Maier, and C. Ackermann. Maternal sensitivity as an external organizer for biobehavioral regulation in infancy. Dev Psychobiol. 27(7): p. 425-37. 1994.

19. Lewis, M., D.S. Ramsay, and K. Kawakami. Differences between Japanese infants and Caucasian American infants in behavioral and cortisol response to inoculation. Child Dev. 64(6): p. 1722-31. 1993.

40 thoughts on “Helping Babies Cope With Stress and Learn to Sleep

  1. Regardless of the physiological response by the body during prolonged periods of crying, the one simple fact remains: if a child or an adult were in a room, shouting that they needed comforting and needed some help, nobody in their caring, nurturing capacity would try to regulate their pleas for help. Therefore I cannot comprehend why anybody would ignore or “ration” their attention towards a baby who is using their only means of communication to attract the attention they need. It is simply nature in action to go to a baby who is crying, to soothe them and to nurture them.
    Indeed, how many of these studies compared breastfed babies with formula fed babies? I assume that, as you have not mentioned breastfeeding in your article, that you have not considered the massive physiological benefits as well as the well-documented psychological advantages of breastfeeding and bed-sharing? Sleep training sounds likes something I might do to train my puppy to settle, not my children!
    Everybody has high cortisol levels in the morning. It is one reason why heart attacks are common between 4-7am. Having worked in a coronary care unit, I concur!
    My experience has shown me that, whereas I did not bed share with my daughter, but used the baby-whisperer shhh-pat, slow retreat approach to settling her at night, breastfed her and put her back to bed and spent endless hours each night trying to get her back to sleep in a cold cot, when actually what she needed was hugs and warmth, and my body to regulate her, went to nursery two days per week, and is very sociable and intelligent; my son bed-shares, demand breastfed, I have been using an attachment parenting style, and my son is actually more relaxed, independent, self-regulating and calmer than his big sister. Last night he came into my bed for a hug at 11pm and a quick breastfeed. I asked him to go back to bed, which he did, all by himself, and slept through til 6.30am. My daughter, who is 4 years older than her brother, if she comes to us in the night, will cry and beg and plead for us to put her back to bed, stay with her, and be generally more stressed and insecure about sleeping alone.
    Big question: why should babies sleep on their own? They’ve been tucked away inside mum for 9 months, then expected to “learn” to go to sleep by themselves in a cold cot, away from their biggest, best and warmest source of comfort? How does sleep training promote a warm, secure environment? How does a baby sleeping alone help to reduce SIDS? How can you explain the lower risk of SIDS in many Asian and African groups who co-sleep or bed share? Babies are not animals, to be tucked away in another room and taught to “stay!” – they are naturally sociable beings who are designed to be close to their parents, particularly the mother, and function better in this way. Babies who are sleep-trained only sleep because they learn that nobody will give them what they need, and forget the attachment they are naturally programmed to receive, and have a natural right to be exposed to over a frequent and prolonged period of time.
    Could you perhaps expand your “sleep training” to look at how bed-sharing actually improves the sleep of the baby and the parents, as well as any other siblings who are at risk of being woken by their crying younger brother or sister – let alone neighbours? Not to mention overall productivity in the work environment – I guarantee that the bed-sharing, breastfeeding, working parents will generally sleep much better than the poor mum and dad who spend hours “training” themselves to ration the positive attention they give to their children. Cortisol levels are only a part of it!

    • “Why should babies learn to sleep on their own?” In my case, it’s because I need my baby to sleep on his own. I can’t sleep with him in my bed, and I can’t function at work when I’ve been up three times overnight soothing him back down.

      I also don’t think the one-to-one comparison between crying babies and crying adults is valid. Adults (generally) have learned to modulate their external displays of emotion such that they only call for help or cry when in serious distress. As you say, crying is one of a very few ways for babies to communicate, and, therefore, doesn’t necessarily indicate serious distress.

      Insofar as the SIDS data, whether cosleeping helps or hurts is a matter of some debate, and my perusal of the available data haven’t led me to be able to decide which “side” is correct. Some studies show an increase in SIDS with bedsharing; others show the opposite.

      One thing I am sure of, though, is that racial differences in SIDS have to be separated from cultural differences – Asian babies have a MUCH lower SIDS risk than other races, regardless of whether they’re cosleeping Japanese babies or crib sleeping Asian-American babies. The current consensus is that this is primarily a matter of genetic background risk. (Similarly, African genetic background seems to increase risk substantially, all other things being equal.)

    • Hi Nikki,
      Thanks for your comment and for sharing your experience with your children. I agree that cortisol is only one part of the story. I’m not sure I have the energy to address every objection to sleep training:) Cortisol is, so far, our best measure of physiological stress, and because it has been used to study many types of stressors, I think it is useful to look at these studies. That cortisol increases when babies cry (which I learned is not always the case) is one of the major arguments used to warn that sleep training is damaging to babies, so I wanted to look at what the science actually says about this.

      I discussed the research on bedsharing and infant sleep patterns in a previous post. My focus was just on sleep patterns, and the research on this is varied. Several small studies have found that mothers and infants sleep just as much when they bedshare as when infants sleep alone – they wake more often but transition back to sleep faster. Cross-cultural surveys with very large samples indicate that bedsharing decreases the total amount of infant nighttime sleep. It really comes down to what works best for each family and each baby. Some babies do need that physical closeness to sleep well, and bedsharing is a good fit for them. I believe that most babies can adapt well to sleeping on their own, and some sleep better with their own space. I do know several working moms who love bedsharing because it allows them to be close to baby at night and to breastfeed often. I have no doubt that there are benefits to bedsharing and that it is the right choice for many families (if done safely), but it is not my place to say that one way of sleeping is better than the other. It is a personal choice – one that is influenced by culture, baby’s temperament, marriage dynamics, living space, parenting philosophy, etc. I haven’t seen evidence that babies suffer from sleeping alone, and just as you made the mindful choice to bedshare with your son, many families make the mindful choice to sleep separately.

      If my husband cried out to me that he needed comfort throughout the night, I would certainly offer my support, but I would also talk with him about what we could do to help him sleep better. I wouldn’t just do whatever it took to stop him from crying and hope that he grew out of it eventually. I think we can only take this analogy so far, because of course, my baby is not an adult, and she needs to be supported in a different way than an adult. But if we are mindfully working to help babies sleep better, we are not trying to regulate their pleas for help but rather addressing why they need help and trying to support them in learning to cope, eventually on their own. Although I have no doubt that there are exceptions, most babies can do this, if given the chance.

    • “the one simple fact remains: if a child or an adult were in a room, shouting that they needed comforting and needed some help, nobody in their caring, nurturing capacity would try to regulate their pleas for help”

      Sometimes they are not pleas for help, sometimes they are expressions of being tired or over stimulated. My son is almost 8 months old, and in all the time I have been blessed to share my days and nights with him, I have learned what his cries mean (through trial and error, through care, nurturing and observation). There are times when I put him to bed, and he cries, and it is not always an indication that he needs my help. In fact, sometimes it is an indication that he needs me to go away.

      I have tried sleeping with my son, but he sleeps longer and better when he is by himself in his crib. When he wakes at night, I hear him right away and go to him. After I have fed him (he only wakes to feed), I place him back in his crib, often still awake, and he goes back to sleep on his own without crying. It was not like this at the beginning, and I certainly didn’t try sleep training before I thought (again through my close bond with him and my understanding of him as a person) that he was physically and psychologically ready, and then I gauged my behavior, including my response to his behavior, according to where he was developmentally and the multitude of other factors that went into his day and how he was doing. In short, I would use the author’s words and say I am a sensitive mother (attune to the needs of my child).

      You’ve hit the nail on the head that “training” brings up images of something you might do with a domesticated animal, but I do not think this takes away from the truth that as parents our purpose is to love, guide and nurture our children.

      I am not speaking against bed-sharing, but I do not think it is the only way, and I also do not think it is the best way, which I find your comment more than suggests.

    • GREAT job, Nikki!!! that is exactly, to a ‘T’, how I feel about the whole thing. I like how you used your own children as an example….very interesting too. thanks for sharing – and caring. cheers!

  2. Well, you know I obviously disagree with you (even on your take of some of the research that we haven’t discussed before), but I just wanted to highlight a few things.

    1) You imply that there’s nothing suggesting daycare is problematic – see Jay Belsky’s work on that matter. There is a fair amount of information suggesting daycare is damaging to children.
    2) Thomas Anders (who you hopefully know) has acknowledged that the term “self-soothing” was simply developed as a means to differentiate the behaviour from crying and that there is NO evidence that children are actually self-soothing in the sense we believe it. In fact, work on emotion regulation in childhood and adulthood shows that it’s responsiveness to distress that’s related to better emotion regulation.
    3) While you’re right to suggest that extreme sleep deprivation can cause negative effects in maternal sensitivity, many people start sleep training for very different reasons and also start it far earlier than the six-month stage recommended by anyone who knows anything about infant development (if they suggest it at all). Pulling out the sleep deprivation/PND card is a bit of a red herring because it doesn’t apply to the vast majority of cases.
    4) Even without cortisol, there are many reasons people argue not to use sleep training. If you feel that everything we do passes messages onto our children, do you really want that message to be that you won’t be there when they’re stressed and upset?
    5) You completely ignore the effect of child temperament. I would suggest that you look at Belsky & Pluess 2007 for a look at effects of parenting on temperamentally-difficult or fearful children. While sleep training may not have the extreme negative outcomes for all children, there’s little doubt it can have very negative effects for temperamentally-difficult children, who are probably more likely to be given this type of behaviour because they’re “difficult”.

    I will also add as a side note that the idea that new environments alter an infants’ sleep doesn’t always hold. Though it’s all anecdotal so I can’t speak to research, but bedsharing infants I’ve heard of (my own and others on EP) don’t show that change. The comfort of having mom nearby seems to provide all the comfort they need. To me, it’s akin to the findings of very securely attached infants – they show no fear in new environments because they have their anchor in mom being close by.

    • Hi Tracy,
      Thanks for reading and for your comments. To respond…
      1. I did not say that there’s nothing suggesting that daycare is problematic. Like many things, there are risks and benefits to daycare. I described one of the risks – chronically elevated daytime cortisol. However, the evidence suggests that this most likely reflects stress associated with group dynamics rather than anxiety about being separated from mom. I have not studied the daycare issue fully, but my understanding is that many of the risks can be mitigated with high quality care and small class sizes. Furthermore (and happily for working parents), studies find that parenting is a much stronger and consistent predictor of children’s development than childcare. Each family has to evaluate this choice based on their unique situations and their children’s unique temperament. Personally, putting BabyC in daycare would not have been a good fit for us. I think she has benefited from being home with me, but I also know many children what have adapted to attending daycare and are well-attached.

      2. I don’t doubt that responsiveness to distress in early infancy is related to better emotion regulation. Without knowing what research you are referring to, I have to guess that it is measures of overall maternal responsiveness in which low responsiveness is rather extreme compared to the type of gentle and supportive sleep training I would recommend. As for self-soothing, there is no evidence that babies aren’t self-soothing when they fall asleep without our help or transition back to sleep after a normal night waking. Based on my experience, self-soothing is the most likely explanation. When I hear my daughter wake in the night, she babbles quietly or makes happy grunts and sighs. When we say goodnight, she kisses me and smiles. There is nothing to suggest that she is afraid or stressed or unable to handle the task of falling asleep without me.

      3. In everyone that I have talked with about their sleep training experience, they all do it because baby is not sleeping well and mom and dad – and sometimes baby – are sleep deprived. I have yet to meet someone who did it just for the heck of it. Nobody takes this lightly. I know that there are parents out there that want their babies scheduled and sleep train to fit their expectations about sleep, but I haven’t interacted with them directly so can’t speak more about their motivations. Multiple studies have found that sleep training alleviates symptoms of maternal depression. Unfortunately, depression impacts a great deal of mothers, more than I think any of us realize. If sleep training helps prevent depression or alleviate it, then I think it is worth considering without the burden of guilt.

      4. I am there for my daughter when she is stressed and upset, and she knows that. She learned to fall asleep on her own – and yes, that was likely stressful, but I let her know that I was close, and she did it! She continued to ask to be fed during the night for months after she learned to fall asleep on her own, and I was happy to have those sleepy snuggles with her. These last few months, she has gone through a few bouts of teething and illness, and I have been there for her throughout the night as well.

      5. This is an excellent point and always worth mentioning. Parents should above all know their own baby, respect his needs and abilities, and make the best decisions from there. I have heard from many parents who had a child that really needed a lot of physical closeness and another that did not. Parents are a better judge of this than you or I. Since I’ve spent all of this time researching sleep training, I’ll probably be blessed with a child that wants to sleep on me at all times next time around☺ Don’t worry – I’ll roll with it.

      I’m sure you’re right that babies adapted to bedsharing have an easier time traveling. I usually find that I need to stay with my daughter while she falls asleep when we are traveling. Again, I’m there when she needs me, but when we’re at home and she’s in her own bed, she falls asleep easily without my presence.

      Thanks again for your comments and the good discussion.

    • And there is a fair amount of information suggestion day care is NOT harmful. The fact that you disregard that makes me think you are picking and choosing the research that agrees with your pre-formed opinion, and I’m sorry, but that makes me less likely to take anything else you say seriously. Even though I suspect we have handled sleep very similarly.

      To really use research in your decisions (parenting and otherwise), you have to evaluate the research on its scientific merits- i.e., was the methodology sound, did they use the appropriate controls, etc.- and THEN form an opinion. There is absolutely nothing wrong with parenting based on your own instincts and feelings about what is right. I am trained as a scientist, and I would still say that I do most of my parenting by instinct and “common sense.” It does other parents a great disservice and perpetuates needless arguments about the “best” way to raise kids when you cherry-pick the research. There is no one “right” way. If there were, our species would probably have died out ages ago. We can look to science for information and ideas to feed into our decision making process, but we should also remember that (1) we are a resilient species and (2) the scientific studies are usually far from conclusive.

  3. I sleep trained my son. It was not a cruel process. He never cried for longer than five minutes before I went in and gave him a top up feed. I did it when he was about eight months. I was returning to work and he would not sleep during the day if he was not on the boob. We were both miserable. It was not a great situation. He is now almost eleven months, happy as Larry and still breast fed. He still wakes once or twice during the night and I tend to his needs. He is a champion sleeper during the day now though and that’s what we really needed!

  4. I like this article because it attempts to add some real science to the debate. My personal experience with my two children has shown me that we need to pay attention to the child, and determine on an individual basis whether sleep training is a good fit. As a baby, my son wanted to be on top of me in order to fall asleep. If I nursed him to sleep, and then set him down drowsy, he would wake himself up screaming. If he actually fell asleep in the crib, he always started screaming the moment he woke up. After deciding that crying it out was a terrible fit (15 minutes of hard crying, and no signs of calming, several times), I tried the the pick-up-put down method. This helped some, but going to bed was always a struggle, with lots of crying. Finally, we just co-slept. He started sleeping through the night (sometimes)! This was huge!

    When my son was two, I had another child. I abruptly moved out of his room. Guess, what? My son is OK! Sometimes he needs help at night, other times he sleeps through the night. We gave him what he needed (sleeping with mom for a few years), and he is a stronger, more secure toddler because of it.

    After this experience, my daughter has shocked me. I put her to bed drowsy, and SHE FALLS ASLEEP. If she “cries”, it is fussing and over quickly. She wakes up cooing and playing. She can spent long periods playing by herself without asking to be with mom and dad. These are two incredibly different children. They need very different treatment. I firmly believe that sleeping alone was too stressful for my son. My daughter is perfectly fine at 4 months of age sleeping alone.
    Let’s pay attention to our kids, not just take hook line and sinker what the books and “experts” tell us.

    • Yes, Nancy, thanks so much for sharing your story! These differences between children are always ignored in the sleep training research, which is too bad, and I think you make such an important point. The research on toddlers in daycare has done a better job at looking at children’s response to daycare depending on secure vs. insecure attachment and temperament, and it does indeed find that children that are insecurely attached or have a more fearful temperament are more stressed by daycare. I absolutely agree that our first priority should be on paying attention to our kids, figuring out their needs, and supporting them as best we can. We do have to consider the health of the rest of the family as well, but usually, the best solution is the one in which baby gets the best night of sleep – everyone benefits from that. I’m glad to hear that you have two sleeping babes now:)

  5. It’s so nice to read a well-done but brief research review on a topic that gets people all hot and bothered. lol. Sure, there’s no way you can cover everything in a blog post–or even a peer-reviewed journal article for that matter–but wide reviews of research (rather than simply focusing on the work of one or even a few researchers or studies) tend to show that dogmatism on many parenting issues is rarely justified.

    • “wide reviews of research (rather than simply focusing on the work of one or even a few researchers or studies) tend to show that dogmatism on many parenting issues is rarely justified” – Can I quote you on that? It is a wonderful point and exactly what I have found. After reading all of this research, I don’t feel comfortable saying that any one way of helping babies sleep is better than another. No scientist can model every factor affecting infant sleep and produce a formula that will work for everyone. What I have found is pretty good evidence that we should give each other a break and support sleep. period. Thanks for the lovely comment.

  6. Nicely done…of course there will still be questions about “sleep training” and its effects on baby. No study will ever answer the actual emotional impact on an individual baby. Scientific evidence is mostly inexact but it is really all we have to explain some of the things that we actually already know in our hearts and heads.
    There will always be parents who will argue about sleep training and feeding choices. There are no definitive answers. There is only the knowledge of what might be better for an individual child under their specific circumstances. No study will ever be able to adjust for all the variables that influence each baby.
    So the discussion goes on and on…I really appreciate your post for discussing some of the scientific information that is out there. It helps to understand the research that is currently available so that as a parent we can make educated, thoughtful, loving decisions when it comes to parenting our children.

    • Lorette, thanks for your comment. I agree that there is not one right answer for every child. The research on this topic has not addressed many important questions, but I also have not seen any evidence that letting babies cry as they learn to fall asleep will harm them – and certainly not the type of harm that is suggested when likening sleep training to toxic stress. In some families, sleep training can help solve big, debilitating problems with sleep. As you say, each parent has to follow their heart and weigh the costs and the benefits of making changes. My opinion is that sleep training sucks, actually. It is hard on parents and babies alike, though I doubt that it is harmful. The fact that it is so controversial shows us that we aren’t really comfortable with it, even when it works beautifully and we like the results. It is an imperfect solution. I’m now convinced that we need to think more about prevention of sleep problems. I think that as a new parent, I did whatever it took to soothe my baby – which was bouncing – without thinking that I was setting her up to NEED sleep training later. I think it is much better to gently support our babies in learning to sleep from the first few weeks rather than do what I did and so many of us do.

      • I have to say I completely agree. I am currently sleep training my first child, and I hate doing it. However, we’re sticking with it because change has come so quickly, and my son, although he still cries a bit and it makes me want to tear my hair out, is sleeping more (he wasn’t sleeping anywhere near the recommended amount for his age), is calmer during the day and even falls asleep under circumstances that he never would have before – even when we’re not putting him to sleep. He is more focused and alert.

        We started sleep training because I had reluctantly started bedsharing full-time during a period where his sleep habits had regressed and we were both sick with a bad cold. It makes me angry to read posts by people implying that all a sleep training parent wants is a good night’s sleep. The truth is I loved bedsharing, and I loved nursing my baby to sleep. However, there is abundant research out there to indicate that bedsharing, as is generally practised in western culture, is not safe. For this reason, I decided to start sleep training when it became obvious my son would no longer sleep in his crib.

        That being said, I completely agree that I set bad habits that made this process harder on my son, and that I deeply regret. I am disappointed in the lack of information presented on infant sleep in my prenatal class… All that was said was that “it’s a good idea to put your baby to sleep awake”, which when I heard in the first few weeks of being a mom made me go, “Are you on crack??” It is only now that I’ve had to train my son to go to sleep in his crib, awake, that I understand that doing this earlier on would have made it do that we might not have had to do any training at all.

        I’ll be wiser the next time around. Meanwhile, thank you for your objective approach, and for your open-minded ness… It makes for a much easier read as compared to all the zealots put there.

  7. Pingback: Sleep “training” or “teaching”…is it good for baby or you? « ParentingInTheLoop's Blog

  8. Pingback: 6 Little Secrets of a Sleeping Baby | Science of Mom

  9. I am amazed, how do you know so much?
    I have bookmark your website.
    You should do a post with what I feed the children, that is healthy and what not, what types of products should we avoid.

  10. Again, tremendously useful advice. Many parents react to the idea of “sleep training” or “self soothing” like it is child abuse. How you allow your child to sleep certainly comes down to parenting philosophy. Not allowing your child to develop normal healthy sleep patterns has significant consequences for children and families as children get older.

    Some children will develop normal sleep patterns no matter what you do. Others will require some assistance. Some of that assistance may come in the form of extinction or a “cry it out” approach, which research has shown to be the most effective method for extinguishing night time awakenings. Other techniques, such as “bedtime fading” or temporarily moving the bedtime later, may minimize the child’s distress.

    The patients I see in sleep clinic are likely outliers. But after several years of frequent nocturnal awakenings many parents are willing to try methods which previously they did not want to consider. Moreover, sleep training is frequently effective within a week.

    Sometimes, parents describe to me that they tried to sleep train but failed after a day or two. There is a phenomenon called the extinction burst where the behavior you are trying to extinguish worsens before improving. If the parents had pushed on a day or two later they likely would have finished.

  11. Pingback: A Bedtime Routine For Your Baby « All Baby Things You Need To Know

  12. Interesting post! Of course, I can just say “interesting” because I am mostly past this phase now. I think the sleep issue is one that our current culture has turned into far more of a black and white issue than it really is. My husband and I took a middle ground, and I suspect most other people do, too. I could never bring myself to do the true “cry it out” approach- and I should be clear, this was because it bothered ME too much, not because I was worried about the impact on my child- but there have been times when we have tired to make changes at bedtime or during the night and the child whose routine is changing has cried. When we first nightweaned my first child, for instance, she cried for me. My husband was there comforting her, but she was still crying and I’m sure that she was stressed. But as you say, there were other things to consider. Parental sleep deprivation is a really tough thing, and it impacts the kids as well. That child is now 5. She sleeps through the night in her own bed, and has done since she was 2. She falls asleep on her own, and has done since she was 3, with the occasional backsliding on that.

    My second kid is finding her way towards sleeping through the night now. Her path has been different from her sister’s, and it is taking her longer to get there- but to be fair, the path hasn’t been as hard on us, either. Some of that is us making different decisions (we started partial night cosleeping much earlier with her) and some of that is her personality (she has learned how to self-soothe faster than her older sister did).

    From where I sit now, looking back over 5+ years of sleep concerns with the benefit of hindsight, it seems so obvious. Each kid was trying to show me what she needed, but I had too much expert advice in my head to really see it, particularly the first time around. Each kid needed different things. My needs/wants as a parent factor in, too, and are different from other people’s needs and wants. For instance, since I work outside the home, I eventually decided that the togetherness/snuggle time partial night cosleeping gave us was more important than the higher quality sleep I could have gotten if I pushed through and insisted my girls spend the entire night in their own bed. I also learned that I cannot stand crying in the middle of the night and completely lack the resolve to do anything other than make it stop by whatever means necessary. So we weren’t good candidates for CIO. But that doesn’t mean that my way is “right” and someone who used CIO methods is “wrong.” A different family with different needs and personalities would be a completely different story! Heck, if I’d been a stay at home mom, I might have thought that alone time was more important than the extra cuddle time and nixed the cosleeping. It all depends on so many factors.

    Which is why, when someone asks me for sleep advice now, the only expert stuff I point them to is the book Bedtiming, because it had information that helped me figure out WHEN to try whatever it was I was going to try, and that seems fairly universal. The WHAT to try is so specific to individual situations that all I am ever willing to do is tell our story and say why we chose how we did.

    • I love reading stories from moms who are at a place where they can look back and finally see the big picture, so thank you. Finding the right solutions for each family really means listening to the kid and caring for the parents as well. And you may be onto something with your comment re cosleeping. As a SAHM, I do really need some alone time at night, and I need to wake up feeling somewhat rested and ready for a day with my kid. I know this from the experience of traveling and cosleeping with BabyC. As much as I love the snuggles, I don’t sleep deeply with a toddler next to me:)

      I thought Bedtiming was extremely helpful. Thanks again for recommending it.

  13. Pingback: At Long Last: Sleep Training Tools For the Exhausted Parent | Craig Canapari, MD

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  18. Pingback: News Flash: Sleep Training Doesn’t Hurt Your Child | Craig Canapari, MD

  19. Pingback: The Last Word on Sleep Training? | Science of Mom

  20. Sleep training or not you should avoid both extremes and not be overly neglectful or overly caring. A wise man/woman avoids both extremes!

  21. Hi Alice,

    thank you for writing this and sharing it. I also come from a science background (although not medical) and have amused and frustrated my partner with my research, fact gathering approach to decision making during pregnancy and so far in our sons 4 months :)

    I had a similar experience to you with our son needing a lot of soothing to fall asleep and then back to sleep, especially with day sleeps. I was also struggling with carpel tunnel and so the bouncing, rocking, holding was causing me real pain.

    One thing that kept coming up for me me was how different is it for a baby to cry itself to sleep in your arms vs on its own? I would love to see this measured! My little one often cried for up to an hour in my arms and it didn’t *appear* that my being there was helping much. However, I have found that me holding my son when he cries makes ME less stressed than not holding him – and interestingly, someone else holding him does not relieve my stress….

    Many thanks again,
    Janneke

  22. We really love your blog. Your story sounds a lot like ours – our baby needed more and more bouncing to go to sleep, and we finally hit a wall when it was taking 45-60 minutes to bounce him to sleep and then he was only sleeping for 30-45 minutes…around the clock. We were ALL so tired, that we were not being optimally emotionally available parents and the baby was screaming and cranky from the time he got up from a nap until he was bounced off to sleep. He couldn’t self-soothe, he couldn’t transition between sleep phases, and he was exhausted. We were having him sleep on us whenever we could because that was the only time we were guaranteed that he would get at least 1 hour of sleep, but we couldn’t even co-sleep – he couldn’t fall asleep next to us because there was no movement involved. Our baby started sucking his thumb the moment he got out of the womb (really!), but as his fussiness increased and we were having to use motion to get him to sleep, so we also increased the so-called soothing techniques recommended by the experts, and so little man was swaddled and had become reliant on it.

    We were really grateful to find your blog and a similar-sounding story, and the goal of teaching a child some self-soothing techniques really resonated. We took away the swaddles, helped him to find his hands, and with heavy hearts we opted to let him cry with the primary goal of breaking him of the movement habit that we, as well-intentioned but naive parents, had created. We didn’t expect him to sleep through the night (he was about 3 months at the time), but it was so painfully obvious that our soothing was robbing him of needed sleep, that this was really the only option. It really took only 1-2 nights of “check and console” and he learned to use his hands to self-soothe, and started sleeping in 2 then 3-hour blocks. Now, when he wakes up and cries out at night we know that he needs something – be it a feed, change, cuddle – and we respond because we know that there is a reason that he isn’t transitioning himself between sleep phases. We are a month out, and he still rarely sleeps for more than 4 hours at a time overnight, but is a much happier and better-rested baby.

    Naps, however, are still a challenge, he rarely naps for more than 30 minutes at a time, and going down for a nap is rarely smooth, and this is where I have a question for anyone who might have advice. Our baby is not on a schedule, and we have been trying to use his cues combined with clock-watching (usually ~1.5 hour cut-off) to know when to put him down for a nap. The real problem we are running into is the witching hour. When he wakes from one of his naps between 3 and 4, we know that we are all in for it – he isn’t tired by 4pm to go to sleep, and there seems to be this no man’s land between 4pm and 6pm when he can not sleep. The problem with this is that, if we just keep him up until his bedtime (between 6 and 7 pm) he’s up for 3 hours and is beside-himself exhausted, and then cries until crashing whether or not we are holding him. We’ve tried putting him down when he looks sleepy between 4 and 6, but inevitably he can not fall asleep, despite self-soothing and ends up crying. We worry about picking him up because we don’t want to send him mixed messages, but after 1 week of being as consistent as possible, we have started picking him up to abort the nap after a 10 minute “test” of whether it is sleepy time or after prolonged crying even if he is tired/overtired, because it seems unfair to him when he clearly can’t fall asleep despite being tired at this time. We’ve tried other things to get him to sleep, but he hates the car seat and is far to curious to fall asleep in the pram or carrier, though it is easier to manage his fussiness during this period with walks. So, we wonder if you have any tips on the naps, particularly during the witching hour. Also, we notice that you stay with BabyC when you travel or during difficult periods and wonder if you could tell us more about these experiences and about whether or not that messes up her ability self-soothe or her expectations on how she falls asleep.

    Thank you again for your thoughtful blog.

  23. Your post just saves my life. I sleep trained my 6 month for a week now, and though it DOES work as his time of crying lessens gradually, I still cry my heart out eveytime I hear him cry because of the fear that I put my baby at risk of “brain damage”. Thus I’m thirsty for serious scientific research on it. And now you just satisfy every corner of my soul with your post. Thanks so much. I’m deeply appreciating it.

  24. Stress can dramatically increase the ability of chemicals to pass through the blood-brain barrier.
    (During the Gulf War, to protect themselves from chemical and biological weapons, Israeli soldiers took a drug called pyridostigmine. Nearly one-quarter of them complained of headaches, nausea, and dizziness – symptoms which occur only if the drug reaches the brain.)

    When your baby is stressed/crying, this may not be the best time to vaccinate.
    http://www.fi.edu/learn/brain/stress.html

  25. Thank you so much for your posts. I have always been anti-CIO in theory, but at this point, my husband and I have arrived to the conclusion that we need to CIO as a last resort. Since I have always read anti-CIO material, I am thankful that your blog puts things in a more balanced perspective. You are neither demonizing it or glorifying it. One quote in particular really put things in to perspective for me:

    “Given this framework, can we predict what type of stress response sleep training produces in a baby? Is sleep training more like starting daycare, coping with a divorce between the two most important people in your life, or being raised by someone abusing drugs?”

    3-4 nights of crying while “Ferberizing” will not un-do the months of trust I’ve built with my daughter, and the years of trust to come. It’s the equivalent of a baby having 3-4 nervous days of starting at day care (which my baby will not experience, because I stay home with her). Anyway, I have a few questions about your experience. I look forward to your answers because you seem to be really balanced in your take on things.

    1) Was your baby swaddled during her 3 night “sleep training”?
    2) Was a pacifier involved?
    3) Besides being better rested, were there any other personality changes? Did she seem detached or vacant afterwards, as if she had a broken will?
    4) How long did she cry on the first night (the longest night)?
    5) After the 3 nights of crying, were naps taken care of too, or did you have to do a CIO round for naps as well?

    Thank you!!

  26. Maybe I’ve missed it somewhere but is there a book that you would recommend for sleep training? I know there are many but I wondered if there was one that helped you.

  27. I came across your first post of this series in an unrelated search, but had to read the whole series. I, too, am a scientist-turned-SAHM, so I really appreciate your research efforts here.

    In an earlier comment, you said you didn’t know anyone who sleep-trained for scheduling reasons. I did, for both of my children.

    Before I had my daughter, a friend recommended sleep-training, and a specific book they used. Aside from their praise, I saw how happy their daughter was and how easily she always went to bed. I read the book they recommended, which, from reviews gets anti-cio types very upset. But I knew that I need not follow it to the T, and that each family/baby is different. For example, my friends were a SAHD/working mom (in a high powered career) and had an elective c-section and formula feed their daughter (these choices were to accommodate mom’s career). I had an unmedicated natural birth and ebf both my children for 6 months, followed by bf until they weaned themselves at 12+ months. The book was 12 hours by 12 weeks by s. Giordano. I used it as a guide, and adjusted where it was necessary for us. For example, I did not start using it before 12 weeks for either of my children, let alone get either of them to sleep through the night by then. And the author herself says that you can use her methods at any later time, as well as cautions against starting before the baby is ready. I also liked that her “cio” was only 3 minutes at a time…probably

    What I did get from the book was an idea that naps are really important, too. I am hooked on making sure my kids get the daytime and nighttime sleep they need. On the one hand, the scheduled aspect of the naps, meals, and nighttime fits with my personality and makes it easier for me to feel in control of my day (within the chaotic setting of life with little kids). On the other hand, placing so much emphasis on naps and bedtime is a sacrifice because we try to be at home and not out “having fun”. On a busy day, my 4 year old still naps, and my husband can always tell, when he gets back from work, if she got a nap or not. So, my early conviction that naps are important is still a cornerstone to our parenting.

    With my first, I was still working, and I knew I would need my sleep. My daughter responded really well to scheduling and sleep-training. She was a happy, well-rested, fat baby. With my second, I had decided to stay home. I co-slept with him as an infant, because it felt right, and then started partial night co-sleeping as he got older. It was great in those early weeks, but i didn’t sleep well with him and i needed better sleep to be a good mom. I started sleep-training/scheduling with him a bit later and dragged it out for longer, because I had no deadline to get back to work and also, I think, because i must have noticed it didn’t suit him as well. But it eventually worked out for him after some tweaking. I think I would tweak things even more if there is a next time. You just keep learning and getting perspective. Not to mention, your lifestyle and priorities change, and each child is different.

    I will note that, for both kids, teaching them to self-soothe at bedtime was remarkably easy. We had to go in to comfort them once or twice the first two nights, they cried less than 3 minutes the 3rd night, and basically no crying after that. Also, if they cry in the middle of a nap or night now, I know 1) they need my comfort, and 2) they are still tired and need more sleep. When they are well-rested, they wake up happy (from naps and in the morning).

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