What works with persistent sleep problems?

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The Centre for Community Child Health, Royal Children’s Hospital, recently completed a review of recent research into sleep problems in young children.

What was researched

Research covered a range of approaches to managing settling and waking problems in children over six months old, including:

• behavioural strategies for teaching children to fall asleep on their own rather than with the assistance of an adult
• medical treatment involving the use of either trimazeprazine or niaprazine at night to treat sleep problems
• a combined approach involving the use of medication along with a behavioural strategy
• information and advice about sleep, with or without support visits. 

What the research found: in a nutshell

Behavioural strategies were found to be the most successful in dealing with sleeping problems. Research has shown that the behavioural strategies most likely to be effective include:

• positive routines
• controlled comforting (controlled crying)
• systematic ignoring
• scheduled waking. 

The strategy known as ‘camping out’ was also researched.

Understanding behavioural strategies

There are many behavioural strategies. Each involves teaching the child to fall asleep without a parent in the room.

The basics
An underlying assumption of behavioural strategies is that the way children are settled to sleep will become their preferred way to return to sleep after waking naturally.

For example, an infant who falls to sleep in a parent’s or carer’s arms is likely to want to return there to be settled after waking during the night. The aim of behavioural strategies is to help a child ‘unlearn’ problematic settling behaviour and replace it with more constructive behaviour (that is, falling to sleep without the help of an adult).

Age range
Behavioural strategies are generally used for children over six months old. Younger infants might still require night feeds, might still be establishing a mature sleep-wake rhythm, and might not respond to behavioural management techniques.

Professional involvement
Behavioural strategies often involve health professionals working with a family to develop an individualised sleep management plan with appropriate strategies. 

Professionals support parents to carry out the strategies. They also provide advice about related issues such as bedtime routines, daytime sleeps and practices that might contribute to sleep problems.

Parental involvement and values
Some behavioural strategies might be at odds with a parent’s or carer’s natural way of relating to a child. One example is controlled comforting. This strategy requires that the adult leave the child to cry when the adult’s inclination might be to always pick up and console a crying child. Generally, parents and carers must be comfortable with the strategy in order for it to be effective.

Evidence on approaches to children’s sleep problems: a summary

Although they commonly occur together, night waking and settling problems have typically been studied separately. Therefore, they are disussed separately below.

Night waking
Research has focused on:

• children aged six months to four years
• children who do not have a learning disability, physical problem or mental health problem
• parent-identified problems
• problems defined as ‘waking frequently, waking for long periods, or both’.

Here are the key findings of the research into night waking:

1. Behavioural interventions have been shown to be effective in reducing the frequency of night waking and the duration of episodes, with effects maintained at short-term follow-up. These interventions have strong empirical support from multiple randomised controlled trials. 
2. Systematic ignoring, scheduled waking and controlled comforting (with support for parents) have strong empirical support. The effect each has had on night waking is significantly greater than a control group. Further testing is required to conclusively determine whether one type of behavioural intervention is more effective than another.
3. Medical treatments using trimeprazine were found to be effective in reducing both the frequency and duration of night waking. The clinical importance of these results is uncertain, however. This is because there was no evidence of an effect over time.
4. The use of trimeprazine with systematic ignoring was also found to be effective, although it too did not have a proven sustained effect over time. These findings are based on multiple randomised controlled trials.
5. Initial research on approaches that use medication and behavioural strategies is encouraging. But further testing is required to confirm their effectiveness and contrast them with behavioural interventions alone.

Settling problems
Research has focused on:

• children aged six months to four years 
• children who do not have a learning disability, physical problem or mental health problem
• parent-identified problems
• problems defined as ‘taking a long time or refusing to settle at night, or tantrums at bedtime’.

Here are the key findings of the research into settling problems:

1. Behavioural strategies were found to be effective in reducing settling problems. But their long-term effects are yet to be established. There have been fewer randomised control trials for settling problems than for night waking. 
2. There is strong research evidence for the positive routine program and controlled comforting (with professional support for parents or carers). The research also suggests that the positive routine method achieves quicker results than controlled crying, is more easily understood by parents and carers, and is their favoured approach.  
3. Medical intervention – that is, the use of trimeprazine – was found to be effective in reducing settling problems. But this evidence comes from only one study, and the effect was not present in a six-month follow-up.

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