Forbes, Elizabeth A

The regulation and consolidation of sleep are major developmental tasks of infancy and usually occur by six to nine months of age. By that time, 70% of infants will have developed a consistent sleep pattern and “sleep through the night” as defined by a continuous period of sleep from midnight to 5:00 am. Although it is normal to have brief nighttime awakenings at this age, most infants are able to self-soothe, i.e. go back to sleep without assistance. However, research suggests that 30-40% of infants either fail to learn self-soothing techniques or develop new sleep problems in the second year of life.1 Many of these infants will subsequently develop long-lasting, complicated, or severe sleep problems.1-6

Infant sleep problems are parentally defined and most often present as bedtime struggles (i.e. limit setting disordet) and/or frequent nighttime awakenings (i.e. sleep onset association disorder). Sleep problems in this age group (less than two years old) can have a major impact on the infant’s health and have been associated with poor feeding and growth, dysregulated daytime behavior, decreased attachment/socialization, and slowed developmental progress.12,5-8 As is true of many pediatric problems, the consequences of infant sleep difficulties are not limited to the individual but usually affect family functioning as well. Specifically, infant sleep problems have been strongly associated with high levels of family stress and maternal depression in several research studies.2,9-11

Standard treatments for pediatric sleep problems are often behavioral in nature and require close follow-up with repeated health care visits.1,12 The goal of “sleep training” is to remove parental interventions during sleep times so that the infant can learn to self-soothe. This usually involves putting the infant to bed “drowsy but awake” and letting him/her “cry themselves to sleep”. Several sleep training methods are described in the medical literature, many of which are widely recommended by pediatric providers. These include well established treatment methods, such as modified and unmodified extinction programs.12-15 Other behavioral methods, such as positive bedtime routines and faded bedtime with response cost, are less established but appear promising.12-13 This review will briefly discuss some of the common behavioral treatments for infant sleep problems, including the use of infant massage as an adjunct to sleep training. Lastly, the importance of early intervention and prevention for infant sleep problems will be discussed, along with some practical considerations faced by those in clinical practice.


Unmodified extinction programs involve putting the infant down for sleep at a designated bedtime, then ignoring the child until an appropriate rise time the next morning. Parents must limit their responses to infant crying, tantrums, and calls for help, and should interact with the infant only for illness, injury, or safety concerns. In many cases, infant behavior worsens in the first few nights of an extinction program, and prolonged crying and/or more frequent waking is often seen before infant sleep improves. This “extinction burst” can be dramatic, but usually resolves within three to five nights of treatment.1

The success of any extinction program depends on parental consistency. By responding to infant cries, parents can inadvertently reinforce inappropriate behaviors and make future attempts at treatment more difficult.1,12-15 Therefore, it is imperative that parents ignore all inappropriate infant behaviors regardless of frequency, intensity, or duration. Some parents find it difficult, if not impossible, to achieve this level of consistency due to various emotional or environmental factors. Parents who are unable to tolerate prolonged infant crying may find it easier to comply with a modified extinction program, such as extinction with parental presence or graduated extinction.

Modified extinction programs allow for an increased parental presence at bedtime and during infant wakings. These programs are similar to unmodified extinction, but may be more acceptable to parents who have concerns about the safety and/or emotional consequences of ignoring an infant who is out of sight.1, 12-15 In extinction with parental presence, a parent stays in the infant’s room but completely ignores the infant and his/her behavior. In contrast, graduated extinction programs allow for brief periods of interaction at specified intervals during times of infant distress. Parents may respond to infant crying with brief (less than 60 second) periods of verbal reassurance and/or physical comforting. The infant is ignored between checks, which occur at pre-determined intetvals based on infant tempetament and parental comfort (typically five to 20 minutes). These intervals are gradually increased as parents grow more comfortable with infant crying and/or infant sleep improves.

Of all the behavioral treatments for infant sleep problems, unmodified extinction, extinction with parental presence, and graduated extinction programs have been the most carefully studied.12 Prior research supports the efficacy of these methods in the treatment of infant sleep problems, but no evidence suggests that one extinction program is more or less effective than the others. Therefore, the choice of an extinction program for infant sleep training must depend largely on the needs of each individual infant and his/her parents.


Positive bedtime routines are designed to “cue” the infant for sleep by providing him/her with a predictable sequence of calm, enjoyable activities at bedtime. The infant’s bedtime is delayed to encourage rapid sleep onset, and appropriate cues for sleep are paired with positive parent-child interactions. Once the infant’s behavior is well established and he/she is falling asleep quickly, the bedtime is gradually advanced to the desired time.

Faded bedtime with response cost involves removing the infant from the crib for specified periods of time when sleep onset is delayed. This strategy is similar to positive bedtime routines. Both methods take advantage of the infant’s decreased arousal at his/her natural sleep onset time to enforce appropriate bedtime behaviors, in contrast to extinction programs, which aim instead to decrease inappropriate bedtime behaviors (i.e. prolonged crying).

There is some evidence to suggest that positive bedtime routines and faded bedtime with response cost may be rapid and effective treatments for infant sleep problems.1215 Although these strategies have not been widely studied, they offer a promising alternative to families who are unable to tolerate any of the extinction methods of infant sleep training.


The importance of parental consistency in the behavioral treatment of infant sleep problems has been discussed. However, many parents have difficulty adhering to these methods due to the perceived emotional and/or environmental consequences of letting their baby cry unattended. Even when successful, sleep training is work intensive for parents and health care providers alike. These difficulties have promoted an ongoing interest in alternative methods to treat infant sleep problems and improve parental adherence with behavioral treatments. Infant massage may be a safe, simple, and effective way to meet both of these goals.

Infant massage is commonly used in many areas of the world, especially Africa, India, and Asia. Its use has been steadily increasing in the West, and many hospitals now offer massage programs that apply specific techniques to infants and children. Research over the past 10-15 years has shown massage to be a beneficial adjunct to the medical treatment of many pediatric problems, including: prematurity, burns/trauma, mental health and behavioral issues, disordered and/or incompetent immune systems, respiratory illnesses, and chronic pain syndromes.16-17 In infants, massage has been associated with improved alertness, temperament, consolability, and growth. Positive effects on learning, development, and sleep have also been reported.17-18

It has been postulated that the direct benefits of infant massage are due to a variety of behavioral and physiological factors. Physiologically, massage may decrease stress hormones such as cortisol, epinephrine, and norepinephrine, and increase relaxation hormones such as serotonin. Massage has been associated with increased vagal tone, which may increase alertness, improve growth, and promote a greater sense of well being.17 Massage in adolescents and adults has also been associated with EEG findings that reflect a heightened sense of alertness, such as decreased alpha and beta wave amplitudes.17,19

Infant massage may also benefit the person who gives the massage. Parents, other infant caregivers, and adult volunteers have all reported decreased anxiety and a heightened sense of well being after administering infant massage. In addition, previous research suggests that infant massage may significantly improve parent-child bonding and the quality of parent-child interactions.17,20

Although the calming properties of massage are widely recognized, its effects on pediatric sleep have not been well studied. Existing research in this area is somewhat limited in scope and methodological design. However, recent studies have shown that massage in the newborn period may have a long-term effect on melatonin synthesis and the development of normal circadian rhythms.21 Only a few studies have looked at massage as an intervention for pediatric sleep problems, all of which report shortened sleep onset latency, fewer nighttime awakenings, and improved daytime alertness/behavior following regular bedtime massage. Prior infant massage studies have typically measured infant sleep only by subjective measures, including parent report measures such as child behavior rating scales and sleep diaries.2123 Although some studies included brief periods of video monitoring to document sleep-wake patterns around the time of intervention, the effects of massage on infant sleep problems have yec to be measured with validated, objective measures of sleep (i.e. actigraphy, polysomnography).


Research suggests that parent education and prevention are among the most cost-effective and efficient approaches to behavioral sleep problems in infancy.12, 24-25 Parents who receive preventive education are able to support their infant’s early sleep skills while avoiding the inadvertent reinforcement of negative night time behaviors. In addition, early education is an effective way to impact large populations of infants who may be at risk. The high prevalence and chronicity of infant sleep problems support the need for widespread, early preventive education in pediatric practice.


Most infants with sleep problems will respond to behavioral treatment. However, little research has been done to describe the efficacy of different sleep training methods relative to each other. Many of the existing studies involve at least two interventions, such as an extinction program paired with a consistent bedtime routine. It is therefore impossible to choose a behavioral treatment for infant sleep problems based on empirical evidence alone. Instead, the choice of a behavioral program for infant sleep problems is based largely on the characteristics of each case.

In order for infant sleep training to be successful, the pediatric provider must consider the best way to deliver information and provide support to parents. As with choosing a treatment method, the means of information delivery and parental support can vary widely and should be tailored to the needs of each family. Infant sleep training may therefore require a certain level of commitment from the provider as well as the infant’s parents. Again, early prevention may be more time and cost effective than the treatment of established sleep problems, and many pediatrie organizations recommend a routine sleep assessment during every well child visit.


Infant sleep problems are common and can impair individual and family functioning. Evidence supports the efficacy of unmodified and graduated extinction programs in the treatment of infant sleep problems. Other behavioral treatments, such as positive bedtime routine and faded bedtime with response cost, are less studied but promising alternatives to standard extinction programs. Infant massage may also be a helpful adjunct in the treatment of infant sleep problems. However, as is true in many pediatric behavioral disorders, early education and prevention may be the most efficient approach to the treatment of infant sleep problems.


1. Mindell J, Owens J. A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems 2003; Chapters 1-7.

2. Glaze D, Rosen C, Owens J. Current Therapeutic Res 2002; 63, Supplement B: B4-B17.

3. Thunstrom M. Acta Paediatr 1999;88:1356-63.

4. Blum NJ, Carey WB. Pediatr Rev 1996;17:87-92.

5. Kataria S, Swanson MS, Trevathan GE. J Pediatr 1987;110:642-64.

6. Lam P, Hiscock H, Wake M. Pediatrics 2003;111:e203-7.

7. Lundqvist-Persson C. Acta Paediatr 2001;90:345-50.

8. Minde K, Popiel K, et al. J Child Psychol Psychiatry 1993;34:521-33.

9. Hiscock H, Wake M. Pediatrics 2001;107:1317-22.

10. Field T. Pediatrics 1998;102(5 Suppl E):1305-1310. Review.

11. Field T. Prev Med 1998;27:200-3. Review.

12. Mindell JA, Kuhn B, et al. An American Academy of Sleep Medicine Review, 2005.

13. Owens JA, Palermo T, Rosen CL. Current Therapuetic Res 2002; (63):(Suppl B) B38-B52. Review.

14. Kuhn BR, Elliott AJ. J Psychosomatic Res 2003;54:587-97.

15. Owens JL, France KG, Wiggs L. Behavioural and cognitive-behavioural interventions for sleep disorders in infants and children: A review 1999;3(4):281-302.

16. Field T. Med Clin North Am 2002;86:163-71. Review.

17. Field TM. Am Psychol 1998;53:1270-81.

18. Dieter JN, Field T, et al. J Pediatr Psychol 2003;8:403-11.

19. Field T, Ironson G, et al. Int J Neurosci 1996;86:197-205.

20. Field T, Grizzle N, et al. Adolescence 1996;31:903-11.

21. Ferber SG, Laudon M, et al. J Dev Behav Pediatr 2002;23:410-5.

22. Field T, Hernandez-Reif M. Early Child Development and Care 2001;168:95-104.

23. Field T, Kilmer T, et al. Early Child Development and Care 1996;120:39-44.

24. St James-Roberts I, Gillham P. J Paediatrics Child Health 2001;37: 289-97.

25. Kerr S, et al. J Advanced Nursing 1996; 24:938-42.


Elizabeth A. Forbes, MD, is Director of Pediatrics, Bradley Hospital.


Elizabeth A. Forbes, MD

Bradley Hospital

1011 Veterans Memorial Parkway

East Providence, RI 02915

Phone: (401) 432-1213


Copyright Rhode Island Medical Society Mar 2006

Provided by ProQuest Information and Learning Company. All rights Reserved