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Behavioral Sleep Interventions in the First Six Months of Life Do not Improve Outcomes for Mothers or Infants: A Systematic Review

Douglas, P.S., Hill, P.S. (2013). Behavioral Sleep Interventions in the First Six Months of Life Do not Improve Outcomes for Mothers or Infants: A Systematic Review. Journal of Developmental and Behavioral Pediatrics, 34:7, 497-507.


A systematic review was performed to determine whether behavioral interventions for sleep, when applied by parents to infants younger than 6 months, improve maternal and infant outcomes.

Design: Literature Review


  • N=3 Databases, 43 individual studies
  • Search Method: The databases of PubMed, CINAHL and Cochrane Database of Systematic Reviews were searched using the time period between January 1993 to August 2013 and including the following search terms: infant, sleep, night waking, unsettled, and behavioural or behavioral.
  • Inclusions Criteria: Studies that considered the effects of behavioral intervention on infant sleep, were published in a peer-reviewed English language publication, the participants were parents, and their typically developing infants with an upper age limit of six months.
  • Exclusion Criteria: Data pooling and statistical analysis for comparisons across studies were not considered


  1. None cited in the article. (however, the authors may have been a little biased. They put in a plug for their own ‘holistic clinical approach to unsettled infant behavior’ called  “The Possums Approach” at the conclusion of their review...interesting).


  1. Three main methodological problems were identified that complicate the interpretation of evidence concerning behavioral interventions for infant sleep younger than six months:
    1. Unidentified and unmanaged feeding problems confound almost all studies reviewed. Many studies failed to control for the effects of method of infant feeding.
    2. Evaluations of interventions with behavioral components commonly fail to differentiate between the different neurodevelopmental stages and apply reductive analyses to evaluations of complex interventions.
    3. Lastly, in evaluations of complex interventions that include a behavioral intervention component, correlations are commonly interpreted as causal. For example, positive outcomes on maternal mood symptom scores are often attributed to a single component of the intervention, that is, the education about behavioral intervention, when the positive effect is likely to be explained by multiple covariates.
  2. Behavioral interventions for infant sleep, applied as a population strategy of prevention from the first weeks and months, risk unintended outcomes, including increased amounts of problem crying, premature cessation of breastfeeding, worsened maternal anxiety, and, if the infant is required to sleep either day or night in a room separate from the caregiver, an increased risk of Sudden Infant Death Syndrome.
  3. We observed that the widespread promotion of behavioral interventions as preventive strategies creates unnecessary anxiety for many families. This is corroborated by evidence that societies in which behavioral approaches to infant care are promoted in the first weeks and months postbirth demonstrate paradoxically high levels of parental anxiety concerning infant sleep.
  4. Lastly, the belief that behavioral intervention for sleep in the first 6 months of life improves outcomes for mothers and babies is historically constructed, overlooks feeding problems, and biases interpretation of data.