ChildHelpingReview Vol. Manage Infant Crying and Sleeping Abuse
Parents to 16: 4769 (2007) Published online in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/car.968
47
Helping Parents to Manage Infant Crying and Sleeping: A Review
of the Evidence and its Implications for ServicesInfant crying and
night waking are common concerns for parents, costly problems for
health services and may trigger infant abuse or lead to serious
child disturbances. Parents are given contradictory advice on how
to manage infant crying and sleeping, indicating the need for
evidence-based guidance. This review of recent research draws
distinctions between infant crying and sleeping problems, between
the problem identied by parents and the infant behaviour underlying
the problem, between different types of crying behaviour and their
causes, and between the types of cases which present at different
ages. It proposes that the two main approaches to parenting
advocated by baby-care experts, infant-demand and structured
parenting, have different benets, and costs. Comparative studies
have found that infant-demand parenting is associated with low
amounts of fussing and crying in the rst three months of age, but
with night waking which continues beyond three months. Randomised
controlled trials have provided evidence that structured parenting
leads to more overall fussing and crying during the rst three
months, but reduced night waking and crying after that. The ndings
are translated into recommendations for preventing and treating
infant crying and sleeping problems, for policy debate, and for
further research. Copyright 2007 John Wiley & Sons, Ltd. KEY
WORDS: infant crying; infant sleeping; parental care; community
healthcare services
Ian St JamesRoberts*Thomas Coram Research Unit, Institute of
Education, University of London, UK
Parents are given contradictory advice on how to manage infant
crying and sleeping
infant-demand and structured parenting, have different benets,
and costs
Correspondence to: Professor Ian St James-Roberts, Thomas Coram
Research Unit, Institute of Education, University of London, 27/28
Woburn Square, London WC1H 0AA, UK. E-mail:
[email protected] Contract/grant sponsor: Wellcome Trust
Project; Contract/grant number: 065486. Copyright 2007 John Wiley
& Sons, Ltd. Accepted 19 October 2006 Child Abuse Review Vol.
16: 4769 (2007) DOI: 10.1002/car
48
St James-Roberts
The need for an evidence-based approach to the management of
infant crying and sleeping
he professional time spent helping parents to manage crying and
sleeping in one to three month-old infants is estimated to cost the
British National Health Service around 66 million per year (Morris
et al., 2001). As this gure suggests, problems with their babys
crying and sleeping are a source of concern for many parents in the
UK, as well as in mainland Europe and North America (Alvarez and St
James-Roberts, 1996; Forsyth et al., 1985; GoodlinJones et al.,
2000). The parents consult popular baby books, which offer
conicting advice (Ford, 2002; Liedloff, 1986), and resort to
dubious remedies (Danielsson and Hwang, 1985). More rarely,
exasperated parents shake, smother or hit their babies, sometimes
resulting in brain damage or even death (Barr, 2003; Reijneveld et
al., 2004). Adverse parent-child relationships and serious longterm
childhood problems develop in some cases (Papousek and von
Hofacker, 1998). These ndings indicate the need for an
evidencebased approach to the management of infant crying and
sleeping. The aim here is to review recent research, develop an
evidencebased conceptual framework that will advance understanding,
and help parents and professionals to make choices. The main focus
will be on the rst three months of infancy, since infant crying and
parental concern about it peak during this period, while infant
night waking after three months of age predicts persistent sleeping
problems (St James-Roberts and Halil, 1991; Wolke et al., 1995).
The review has four main parts. Section 1 delineates the phenomena
requiring an explanation. Next, key dimensions of parenting are
distinguished. Third, the causes of variations in infant crying and
sleeping, including these aspects of parenting, are examined.
Lastly, the implications for managing infant crying and sleeping,
for healthcare services, and for further research, are
discussed.
T
1. The Nature of Infant Crying and Sleeping Problems 1a. The
Distinction Between the Infant Behaviour and the Problem This
distinction needs to be clear from the outset, since a baby who
cries a lot, or will not sleep at night, is rst and foremost a
problem for parents. According to the best available evidence, only
about one in 100 infants overall, or one in ten cases taken by
parents to health professionals because of problem crying, have an
organic disturbance such as gastrointestinal disorder or cows milk
protein intolerance (Gormally, 2001). Procedures for distinguishing
these organic cases will be reviewed below, but healthcare
professionals should expect them to be rare, particularly at the
primary referral stage. Most infants who cry a lot gain weight
satisfactorily, are not unwell and do not have long-term problems
(Gormally, 2001; Lehtonen, 2001).Child Abuse Review Vol. 16: 4769
(2007) DOI: 10.1002/car
Most infants who cry a lot gain weight satisfactorily, are not
unwell and do not have long-term problemsCopyright 2007 John Wiley
& Sons, Ltd.
Helping Parents to Manage Infant Crying and Sleeping
49
Likewise, most infants and young children with sleeping problems
are not unwell or likely to have longer-term health, growth or
developmental problems, other than with sleeping at night (Ferber,
1986; France, 1992; Richman et al., 1975; Wolke et al., 1995).
Instead, what characterises most of these cases is difculties with
settling at bed-time and, particularly, waking and crying out later
in the night (Anders et al., 1992; Messer and Richards, 1993).
Video-based studies have found that waking during the night is
normal, but most infants return to sleep without waking their
parents (Goodlin-Jones et al., 2000). The primary clinical
phenomenon is not infant sleeping problems so much as infant waking
and crying at night that disturbs parents. 1b. The Distinction
Between Crying and Sleeping Problems Although infant crying and
sleeping problems are often treated as synonymous, in practice they
present differently, at different ages, and often in different
infants. Infant crying, and parental complaint about it, peak at
around four to six weeks of age, and the crying clusters in the
daytime and, particularly, the evening (Barr, 1990; St
James-Roberts, 1989, 2001). In contrast, infant sleeping problems
occur at night, and concern parents when they occur after three
months of age (Messer and Richards, 1993). Most babies wake at
night for feeding during early infancy and parents expect this, but
about two thirds develop the ability to remain settled at night by
12 weeks of age (Anders and Keener, 1985; Moore and Ucko, 1957). It
is the failure to achieve this developmental milestone, so that a
child wakes and cries at night at later ages, which characterises
most infant (or child) sleeping problems. Underscoring these
distinctions, most one to three month old infants who cry a lot
have normal sleep-waking patterns (Kirjavainen et al., 2001, 2004).
Ironically, earlier reports that crying babies sleep less per 24
hours were due to the inaccuracy of parent reports about
non-criers, which inate the amounts these babies sleep because the
parents are not aware of periods when they are awake but settled
(Kirjaivanen et al., 2004). Lehtonens review of follow-up studies
of crying babies concluded that most of them slept normally at a
later age (Lehtonen, 2001). At ve months of age, Wolke et al.s
(1995) epidemiological study found that 11% of infants had sleeping
problems, ten per cent crying problems and just ve per cent had
both types of problems, while sleeping problems, rather than
amounts of crying at ve months, predicted later sleeping problems.
These distinctions point to the existence of at least three main
infant groups: (i) infants with unexplained crying in months one to
three; (ii) infants with night waking after 12 weeks of age; and
(iii) infants with multiple disturbances beyond 12 weeks of age.
The differences in timing and presentation of the groups
suggestCopyright 2007 John Wiley & Sons, Ltd.
About two thirds develop the ability to remain settled at night
by 12 weeks of age
These distinctions point to the existence of at least three main
infant groupsChild Abuse Review Vol. 16: 4769 (2007) DOI:
10.1002/car
50
St James-Roberts
different aetiologies, so that they will be examined separately
below. The third group lies outside the scope of this review, but
will be considered briey in making recommendations.
2. Concepts of Parenting
The parenting issue that most divides baby-care books, as well
as parents and professionals
There is considerable evidence that infants needs and
competencies change within the rst three months of age
The parenting issue that most divides baby-care books, as well
as parents and professionals, involves the distinction between
infantdemand and structured forms of care. On one hand, books such
as Liedloffs (1986) The Continuum Concept emphasise innate needs
and instincts which parents and babies inherit as a legacy of
evolution. Liedloff believes that parents can avoid crying and
sleeping problems by following natural instincts to respond
quickly, feed in response to babies cries, and to hold and sleep
with them, rather than consciously adopting care that is convenient
in an industrial society. Other terms, including Attachment
Parenting (Sears and Sears, 1999) and Proximal Care (Hewlett et
al., 1998), have different origins but likewise refer to forms of
parenting that aim to be responsive to infant expressed or inferred
need. On the other hand, books such as The New Contented Little
Baby Book (Ford, 2002) recommend imposing structured routines, such
as feeding and putting babies down to sleep at regular times. Some
commentators have expressed concern that the increased adoption of
structured care in modern society encourages parents to leave
babies to cry (AAIMHI, 2002; Meltz, 2004). One limitation of both
the infant demand and structured viewpoints is that they are
unspecic about how these forms of care affect infant behaviour.
Ford and Liedloff base their recommendations on personal experience
and neither proposes a fully-edged theory of how their recommended
form of care inuences the infant physiological or mental processes
that govern infant crying or sleeping. A further issue is that both
advocate a consistent form of parenting, rather than one which
adapts to infant development. Yet, there is considerable evidence
that infants needs and competencies change within the rst three
months of age. As others note (Herschkowitz et al., 1997; Prechtl,
1984), early infancy is best approached developmentally, as a
transition period involving major neuro-developmental
re-organisation. Because of evolutionary inuences, human infants
are born immature, with a set of reex behaviours which disappear as
cortical regulation of more complex abilities emerges during the
second and third month of age in typically-developing infants. It
is plausible that infants vary in how easily they complete this
normal developmental transition, that some forms of parenting will
be more effective than others in supporting infants through it, and
that different forms of parenting will be needed before and after
this developmental stage.Child Abuse Review Vol. 16: 4769 (2007)
DOI: 10.1002/car
Copyright 2007 John Wiley & Sons, Ltd.
Helping Parents to Manage Infant Crying and Sleeping
51
Instead of dividing these forms of parenting into infant-demand
and structured care, recent studies have developed alternative
concepts that translate more readily into testable hypotheses about
the inuence of parenting on infants physical and psychological
systems. The rst is the idea of parenting as an external regulatory
environment for infant physiological homeostasis. The second is the
notion of parenting as a scaffold that supports infants autonomous
learning. The idea of parenting as an external regulatory
environment can be traced back to Harlows studies, which showed
that infant monkeys chose to cling to a cloth rather than wire
surrogate parent, indicating that some types of environment
provided more comfort than others (Harlow and Harlow, 1962). More
recently, similar ideas have emerged from studies of infant pain
and the role of environmental factors in inuencing infant arousal
and respiratory control in relation to Sudden Infant Death Syndrome
(SIDS) (McKenna, 2006). For example, human infants cry less if they
are held during an inoculation, presumably because body contact
helps them to regulate their response to pain (Gray et al., 2000).
Based on animal studies, Hofer (2001) has argued that early crying
evolved as a reex that serves dual functions: a communicative
function, which encourages maternal contact, and a homeostatic
function by raising body temperature and preventing hypothermia.
The concept of external environmental regulators allows
evolutionary ideas to be translated into, and tested, at a
physiological and behavioural level. Their importance here is to
highlight parental care as an external regulator of the infant
physiology that underlies crying and sleeping behaviour, and to
raise the question of whether different environmental inuences are
needed before and after the period of reex behaviour in early
infancy. As well as an external regulator, the second function of
parenting emerging from developmental studies is the idea of
parenting as a scaffold which supports autonomous infant
learningthe learning needed to function independently (Wood et al.,
1976). The acid test for whether a form of parenting is superior in
this respect involves comparing it with alternatives on measures of
behaviour change. If a form of parenting supports effective infant
learning, it should lead to systematic reductions in infant crying,
or distressed night waking, over time. The concepts of parenting as
an external regulator and as a learning scaffold are not sufcient
to describe all aspects of parenting; for instance, they give
parental love and anxiety short shrift. However, from the infant
point of view, these two functions seem to encompass the essence of
the parenting role in early infancy. Compared with the notions of
structured versus infantdemand parental care, their advantage is
that they can be translated into testable hypotheses about
measurable effects in infants.Copyright 2007 John Wiley & Sons,
Ltd.
The idea of parenting as an external regulatory environment can
be traced back to Harlows studies
Emerging from developmental studies is the idea of parenting as
a scaffold which supports autonomous infant learning They can be
translated into testable hypotheses about measurable effects in
infantsChild Abuse Review Vol. 16: 4769 (2007) DOI: 10.1002/car
52
St James-Roberts
3. Parenting Versus Other Causes of Crying and Sleeping Problems
3a. Crying in One to Three Month Old Infants
Both infant crying and parental concern about it, peak at around
ve weeks of age in Western cultures
Cows milk protein intolerance and other digestive disturbances,
cause crying in only about one in 100 infants
The unsoothability of the crying is thought to be its most
salient feature, since this makes parents feel out of control
As noted above, both infant crying and parental concern about
it, peak at around ve weeks of age in Western cultures. Prevalence
estimates for crying as a problem vary widely, depending on whether
parental complaint or amount of infant crying is used to dene the
problem (Canivet et al., 1996; Reijneveld, 2001). Rates dened by
clinical contact will necessarily vary according to the adequacy of
the services. As a rule of thumb, around nine to 12% of infants
meet denitions based on amounts of crying, while 14 28% do so if
problem rates are dened by parental concern or complaint (Canivet
et al., 1996; Rautava et al., 1993; Reijneveld et al., 2002).
Prolonged crying in early infancy has traditionally been attributed
to infant gastrointestinal disturbance and pain, leading to the
term infant colic (Illingworth, 1985). In particular, intolerance
of cows milk protein has been singled out (Lothe et al., 1982). In
practice, as noted earlier, careful reviews of the evidence have
concluded that organic disturbances, including cows milk protein
intolerance and other digestive disturbances, cause crying in only
about one in 100 infants, and one in ten cases where parents seek
professional help (Gormally, 2001). Since breastfeeding is often
considered more physiologically natural than bottle feeding, it is
worth noting that this distinction does not predict prolonged
infant crying reliably (Barr, 1989). As well as querying the
gastrointestinal origins of most crying in early infancy, recent
studies have challenged the assumption that the crying signals pain
(St James-Roberts, 1999; St James-Roberts et al., 1995a, 1996).
Instead, the features found to disturb parents most are the
prolonged length of the infants cry bouts, the relatively high
intensity of the crying (i.e. a high cry: fuss ratio), and the
resistance of the crying to consoling manoeuvres that usually
soothe babies crying (St James-Roberts et al., 1996). The
unsoothability of the crying is thought to be its most salient
feature, since this makes parents feel out of control. Alongside
this, studies have found that normal infants share the crying peak
and many other features of clinically-referred cases, suggesting
that many referred infants are at the extreme of the normal
distribution for crying amount and intensity, rather than unwell
(Barr, 2001). In conjunction, these ndings have shifted the search
for the main cause of the crying from gut pathology to the
neuro-developmental changes that normally take place in early
infancy. Three studies have found that infants who cry a lot at
home are highly reactive when handled by researchers, implying
thatChild Abuse Review Vol. 16: 4769 (2007) DOI: 10.1002/car
Copyright 2007 John Wiley & Sons, Ltd.
Helping Parents to Manage Infant Crying and Sleeping
53
some infants have difculty in regulating their responsiveness
under challenging conditions (Prudhomme White et al., 2000; St
James-Roberts et al., 1995a, 2003). These ndings suggest that much
of the explanation for prolonged crying in early infancy will
involve uncovering the processes of nervous system development that
take place around two months of age. Turning to the role of
parenting, two early studies reported reduced infant crying after
parents were given advice to change their forms of care, seeming to
imply that inadequate care caused the crying (McKenzie, 1991;
Taubman, 1988). These studies have been criticised for
methodological weaknesses (Wolke, 2001), but it is equally
important that reducing babies average amounts of crying is not the
crucial issue. Since infant crying in general often stops when
parents respond to it, reducing the average time parents take to
respond is likely to reduce the average amount of crying. But,
unless changes in parenting diminish the long bouts of unsoothable
crying in one to three month old infants which cause parental
concern, the changes are unlikely to resolve the parental problem.
More recently, the causal relationship between parental care and
infant crying has been examined using a variety of research methods
and designs, each with its own limitations. One strategy is to
observe the behaviour of parents of infants who cry a lot, compared
to the behaviour of other parents. In such a study, the parents of
67 babies selected because they fussed and cried for three or more
hours per day were compared with the parents of 55 moderate criers
and of 38 babies who did not cry a lot but showed a clear evening
crying peak (St James-Roberts et al., 1998a, 1998b). Each baby and
mother was observed at home for four hours at ve to six weeks of
age using reliable observers blinded to the infants group. Few
group differences in maternal behaviour were found at ve to six
weeks and, where found, these occurred in conjunction with infant
crying: mothers of the high criers spent more time carrying,
soothing and stimulating when their babies were crying. Using
Murrays (Murray et al., 1996) measures of maternal responsiveness
and sensitivity, a striking nding was that 31 of the 67 mothers of
the high criers achieved maximum, 100%, ratings for sensitivity and
responsiveness, even though their babies fussed and cried for an
average of 33/4 hours per day. Alvarez (2004) similarly, identied a
group of Danish infants who cried a lot in spite of sensitive care.
Because comparative studies of this type assess parenting only
after the onset of crying, they do not provide strong evidence
about causation. However, their implication is that most Western
babies who cry a lot do so in spite of care which is adequate for
most other babies. Bell and Ainsworths (1972) early study based in
attachment theory proposed that responsive parenting in the early
weeks produced less infant crying at a later age. In practice, as
Hubbard andCopyright 2007 John Wiley & Sons, Ltd.
Some infants have difculty in regulating their responsiveness
under challenging conditions
A striking nding was that 31 of the 67 mothers of the high
criers achieved maximum, 100%, ratings for sensitivity and
responsiveness
Child Abuse Review Vol. 16: 4769 (2007) DOI: 10.1002/car
54
St James-Roberts
These ndings provide some evidence of an effect of infant
characteristics on parents rather than the other way round
Is whether parenting which is substantially different from
Western norms might have a more substantial effect on early
cryingCopyright 2007 John Wiley & Sons, Ltd.
van Ijzendoorn (1991) and van Ijzendoorn and Hubbards (2000)
careful studies have shown, variations in how rapidly Western
parents in general respond to crying in one to nine week-old
infants do not predict amounts of crying at later ages. These
researchers found that responsive parenting early on was associated
with small increases in crying frequency in weeks nine to 27. But
these associations were modest and did not suggest any effect of
early parental responsiveness on the amounts infants cried later.
Another way of probing parenting is to examine parentinfant
interactions in clinical groups. Murray and Coopers (2001)
randomised controlled trial examined the effectiveness of an
eightweek supportive intervention programme in preventing
depression, improving mother-infant interaction and reducing infant
crying problems, in such cases. The depressed women considered the
intervention to help them, but they reported the same, high
(>40%) rate of crying problems at two months as depressed women
who did not receive the intervention. These ndings provide some
evidence of an effect of infant characteristics on parents rather
than the other way round. Arguably, the most powerful strategy for
assessing the effect of variations in care on infant crying is to
systematically vary parenting in a general community sample, using
a randomised controlled trial. Several studies have adopted this
approach, either by increasing (or decreasing) parental
interactions, or targeting specic aspects of parenting, such as
holding and carrying. The ndings are perplexingly inconsistent. For
example, Hunziker and Barr (1986) found that supplementary carrying
introduced at three weeks of age reduced the crying peak at ve to
six weeks in a community sample, but Barr et al. (1991b) found that
supplementary carrying was not effective as a treatment once crying
had begun. Two attempts to reproduce the original Hunziker and Barr
ndings (St James-Roberts et al., 1995b; Walker and Menahem, 1994)
did increase parental holding to the same amounts achieved by
Hunziker and Barr, but this did not reduce infant crying in either
of these studies. These inconsistencies are puzzling, but query
whether the differences in parenting achieved in these studies have
a strong inuence on infant crying. A question these ndings leave
open is whether parenting which is substantially different from
Western norms might have a more substantial effect on early crying.
This proposal stems partly from the Barr et al. (1991a) study of
!Kung hunter-gatherer parents, which found that almost constant
holding (>80% of daylight hours), frequent (four times per hour)
breastfeeding and rapid response to infant fretting was associated
with low amounts of infant crying. In comparison, typical Western
care, as practised in London and North America, involves putting
babies down in cribs, cots or walkers, feeding every three to four
hours and delaying response toChild Abuse Review Vol. 16: 4769
(2007) DOI: 10.1002/car
Helping Parents to Manage Infant Crying and Sleeping
55
babies crying on about 40% of occasions (Bell and Ainsworth,
1972; Foundation for the Study of Infant Deaths, 2004; Hubbard and
van Ijzendoorn, 1987; I. St James-Roberts, unpublished work, 1990).
Drawing on the ideas outlined earlier, it is possible that
!Kung-like care acts as an external regulator of reexive infant
systems and so leads to reduced crying, particularly in reactive
babies. Until recently, attempts to extrapolate the !Kung ndings to
Western cultures have been constrained by the reluctance of Western
parents to adopt comparable forms of care. However, one study has
recently succeeded in matching some aspects of !Kung parenting (St
James-Roberts et al., 2006). The approach adopted was to recruit
normal community samples in London, and Copenhagen, and to compare
them on measures of parenting and infant crying with a group of
parents who decided before the birth of their baby to practise form
of infant-demand parenting, called Proximal Care. This term was
adopted from anthropological research to describe the key feature
of this form of parenting, extensive infant holding, in contrast to
the common Western practice of putting babies down. Each of the
groups included over 50 infants and infant and caregiver behaviour
was measured by validated behaviour diaries. In keeping with the
parents intentions, this study conrmed the existence of large
differences in parenting between the groups when the infants were
ten days and ve weeks of age. Proximal care parents fed their
babies more often (14 times per 24 hours, compared to ten to 12
times per 24 hours) and held their babies for an average of 1516
hours per 24 hours, about twice as much as London parents, while
Copenhagen parents fell in-between. Proximal care parents co-slept
throughout the night with their babies much more often than both
other groups. Compared to the Proximal care group and the
Copenhagen parents, parents in the London community sample had 50%
less contact with their babies, both when settled and when crying.
London parents also abandoned breastfeeding much earlier than both
other groups. These differences in parenting were associated with
substantial differences in amounts of infant crying. The London
babies fussed and cried 50% more than both other groups at both ten
days and ve weeks of age. Average amounts of fussing and crying
declined at 12 weeks in all three groups, but remained higher in
London infants. In contrast, unsoothable crying bouts were equally
common in all three groups. Likewise, infant colic, dened using a
modied version of the Wessel et al. (1954) denition, occurred
equally often, in ve to 13% of infants in each group, at ve weeks
of age. These latest ndings require cautious interpretation,
particularly because this was not a randomised controlled trial.
However, the studys features make it likely that the infant ndings
reectedCopyright 2007 John Wiley & Sons, Ltd.
One study has recently succeeded in matching some aspects of
!Kung parenting
This study conrmed the existence of large differences in
parenting
Unsoothable crying bouts were equally common in all three
groups
Child Abuse Review Vol. 16: 4769 (2007) DOI: 10.1002/car
56
St James-Roberts
Typical London parenting is adequate for most infants
parenting. First, the approaches to care were adopted before
birth, so that they preceded infant crying rather than being a
response to it. Second, the nding of reduced infant crying occurred
with two very different groups of parents, a general-community
sample in Copenhagen and a non-conformist, Proximal Care sample,
suggesting that features of care they had in commonthat is, high
amounts of holding and responsive contactwere responsible for the
similarities in their infants low overall amounts of crying.
Thirdly, the ndings are consistent both with the !Kung study
described above and with a previous Copenhagen study (Alvarez,
2004) in showing that high amounts of parent contact are associated
with low amounts of infant crying. Lastly, the ndings are
consistent with the evidence, cited above, that bouts of
unsoothable crying are common around ve weeks of age and due to
normal neuro-developmental processes. To sum up the evidence about
parenting and early infant crying, typical London parenting is
adequate for most infants and minor variations in such parenting do
not produce substantial differences in infant crying. Parenting
which involves much more holding and responsive contact appears to
reduce overall amounts of crying in one to three month-old infants
by 50%. However, it does not affect whether infants have
unsoothable crying bouts, or the number of infants who fuss and cry
for three or more hours per day at ve weeks of age. 3b. Sleeping
Problems in Infants and Children Beyond 12 Weeks of Age Like
prevalence estimates for crying problems, those for infant sleeping
problems vary widely according to the methods and denitions used.
As a rule of thumb, parents report that 1535% of children over
three months of age have such problems, with rates declining over
age (France, 1992; Goodlin-Jones et al., 2000; Messer and Richards,
1993). Conicts around bed-time add to the core problem of night
waking and crying as infants get older (Messer and Richards, 1993;
Scher et al., 2005). Rates of sleeping problems are relatively high
in children with organic disturbances (Stevenson, 1993; Stores and
Wiggs, 2001a), but such disturbances are too rare to explain most
sleep problems. Likewise, parasomnias (child sleep disorders due
primarily to organic disturbances) are rare (France and Blampied,
2004). It is well established that the most effective treatment for
childrens sleeping problems after they have arisen involves the use
of structured behavioural programmes (Ramchandani et al., 2000).
These work by rewarding changes in infant behaviour, such that
night waking and crying are ignored, while remaining settled and
resuming sleeping are reinforced. In effect, the programmesChild
Abuse Review Vol. 16: 4769 (2007) DOI: 10.1002/car
Such disturbances are too rare to explain most sleep
problems
Copyright 2007 John Wiley & Sons, Ltd.
Helping Parents to Manage Infant Crying and Sleeping
57
provide a care scaffold which supports autonomous infant
learning of patterns of sleep and waking behaviour. Although they
are effective, an important proviso is that some parents will not
implement behavioural treatment programmes because they involve
leaving an infant or child to cry, which the parents consider to be
cruel (Morrell, 1999). Because of this, and for common sense
reasons, preventing sleeping problems appears to be preferable to
treating them. However, the use of structured behavioural
programmes for this purpose depends on the assumption that infants
can learn to remain settled for long periods at night at an early
age, and that structured parenting supports this learning. That
assumption has only recently been put to the test. In an initial
study, some 600 infants and parents were randomly assigned to one
of three main types of parenting when the infants were ten days
old: a structured behaviour programme; an information-oriented
group, where parents were given booklets about best practice
together with a back-up help line; and the basic UK services (St
James-Roberts et al., 2001). Importantly, although the behavioural
programme was highly structured, it did not involve leaving the
infants to cry. Validated behaviour diaries were used to conrm that
parents implemented the methods, and to measure infant crying and
sleeping. Parental questionnaires at nine months provided follow-up
data. The study found no group differences in night waking or
crying up to six weeks of age, which is what might be expected if
behaviour is largely reexive in this early period. After that, more
infants in the behavioural group slept through the night so that
about ten per cent fewer infants in the behaviour programme group
woke and cried at night by 12 weeks of age. Parents in the
behaviour programme group liked the programme and reported fewer
contacts with health services for infant crying and sleeping
problems up to nine months of age. The educational leaet programme
had no effect. This study provided evidence that structured
parenting helps infants to learn sleep-waking organisation after
six weeks of age, but about 70% of infants in the routine services
control group developed the same ability without a specic behaviour
programme. This gure is in keeping with general community study
ndings in Western cultures and may reect these parents tendency to
adopt structured care, but queries whether it would be worthwhile
for health services to introduce behaviour programmes routinely. To
address this, a second study based on the same data set was used to
detect whether the behaviour programme was particularly benecial
for infants who were at high risk of night waking and crying at 12
weeks of age (Nikolopoulou and St James-Roberts, 2002). Using the
control group data only, it was found that infants who had 12 or
more feeds at one week of age were particularly prone to night
waking and crying at 12 weeks of age. Next, infantsCopyright 2007
John Wiley & Sons, Ltd.
The programmes provide a care scaffold which supports autonomous
infant learning of patterns of sleep and waking behaviour
More infants in the behavioural group slept through the
night
Infants who had 12 or more feeds at one week of age were
particularly prone to night waking and crying at 12 weeks of
ageChild Abuse Review Vol. 16: 4769 (2007) DOI: 10.1002/car
58
St James-Roberts
Infant night waking was not a problem for many Proximal Care
parents
McKenna (2006) argues that cosleeping may help to prevent
SIDS
who met this risk criterion at one week, and who were assigned
at random to the behaviour programme, were compared with those
assigned at random to the control group. At 12 weeks of age, 80% of
the at-risk infants given the behavioural programme slept through
the night, compared to 60% of at-risk infants in the control group,
a 20% improvement, indicating that the behavioural programme was
particularly benecial for infants who were at high risk of
developing sleep problems. Since the Proximal Care infants
described earlier received infant-demand care, including 14 feeds
per 24 hours at ten days and ve weeks of age, it might be expected
that such infants would be especially likely to fail to sleep
through the night. The ndings show that this is the case (St
James-Roberts et al., 2006). Compared both to London and Copenhagen
babies, those whose parents used proximal care were more likely to
wake up, cry and disturb their parents at night at 12 weeks of age.
Whether this difference was maintained after 12 weeks is not yet
clear, although the provisional evidence indicates that this is the
case (Abramsky, 2004). Importantly, however, infant night waking
was not a problem for many Proximal Care parents, who considered
the overall benets of this approach to outweigh the night waking.
Copenhagen infants, who were put in cots to sleep for part of the
night, rather than co-sleeping throughout like Proximal Care
infants, equalled the London babies infrequent night waking (St
James-Roberts et al., 2006). Before summarising the evidence in
this area, it is important to consider McKennas (2006) argument
that co-sleeping protects infants against SIDS. He and his
colleagues found that bed-sharing mothers and infants aroused more
frequently (usually as a result of the others movement or sound),
and spent signicantly more time in lighter stages of sleep (Stage 1
and Stage 2), and less time in deeper stages of sleep (Stage 3 or
4), compared to infants sleeping alone (McKenna, 2006). Because
there is evidence that infants have greater difculty in arousing
from deeper sleep, McKenna (2006) argues that co-sleeping may help
to prevent SIDS. Since adopting a structured behavioural programme
involves putting babies down to sleep, McKennas ideas suggest a
conict between parenting designed to help infants to learn to sleep
through the night and parenting which seeks to provide external
regulation for infant physiology in order to minimise the risk of
SIDS. Because the peak age for SIDS is eight to 16 weeks (McKenna,
2006), it is plausible that co-sleeping might provide an external
regulator for infant respiratory physiology, while the evidence
that SIDS is caused by inadequate functioning of reexes designed to
overcome respiratory occlusion ts this view. However, the evidence
for McKennas proposal is far from clear. One consideration is that
SIDS rates tend to be highest in cultures where co-sleeping is
prevalent. McKenna (2006) attributes this to the high rates ofChild
Abuse Review Vol. 16: 4769 (2007) DOI: 10.1002/car
Copyright 2007 John Wiley & Sons, Ltd.
Helping Parents to Manage Infant Crying and Sleeping
59
other SIDS risk factors, such as parental cigarette smoking and
alcohol consumption, in communities where bed-sharing occurs,
pointing to low SIDS rates in bed-sharing communities without these
risk factors. In contrast, other experts have concluded that the
dangers of mother-infant bed-sharing outweigh the benets (Kemp et
al., 2000). A recent case-control study of 20 regions in Europe
(Carpenter et al., 2004) concluded that two week-old infants
sharing a bed with non-smoking parents were 2.5 times more likely
to die from SIDS, compared to infants sleeping separately.
Consequently, the Foundation for the Study of Infant Deaths (2004)
recommends that babies should sleep in a separate cot in their
parents bedroom. This advice has itself been queried (Wailoo et
al., 2004). However, providing infants settled in cots are placed
on their backs or sides, and are carefully monitored, there is no
reason to expect that using cots and a structured approach to
infant sleeping after about six weeks of age will increase the
likelihood of SIDS. In summary, the existence of randomised control
trials makes the evidence about preventing infant sleeping problems
particularly robust, while the ndings are consistent with evidence
about the causes and treatment of sleeping problems more generally
(GoodlinJones et al., 2000; Ramchandani et al., 2000). Unlike
crying problems, infant sleeping problems at night are prevented by
the learning scaffolds involved in the form of parenting provided
by structured behaviour programmes. Infants cared for using this
approach learn to remain settled through the night at an earlier
age and there is no evidence that it increases the likelihood of
infant SIDS.
Other experts have concluded that the dangers of motherinfant
bed-sharing outweigh the benets
4. Conclusions: Translating the Findings into Recommendations
for Practice and Research The reviewed ndings highlight
distinctions which are helpful in understanding infant crying and
sleeping problems and guiding service provision for parents. These
include the distinction between crying and sleeping problems,
between different types of crying behaviour, between the problem
identied by parents and the infant behaviour underlying the problem
and between the types of cases which present at different ages. In
considering the ndings implications, it is important to keep in
mind that research ndings need not translate directly into service
changes. Rather, their immediate impact may be to indicate the need
for more information, or to query current practice and stimulate
debate. Rather than applying the lessons emerging from research
universally, there is also a need for translational studies, which
use medium-scale community projects to evaluate the emergent
lessons under real-life health service conditions. Bearing these
considerations in mind, the aim below is to evaluate the ndings
implications.Copyright 2007 John Wiley & Sons, Ltd.
Learn to remain settled through the night at an earlier age and
there is no evidence that it increases the likelihood of infant
SIDS
Child Abuse Review Vol. 16: 4769 (2007) DOI: 10.1002/car
60
St James-Roberts
4a. Helping Parents to Prevent Infant Crying and Sleeping
Problems
The clearest evidence concerns sleeping problems
No evidence that differences in parenting affect whether infants
have bouts of unsoothable crying around about ve weeks
Less clear is whether these ndings justify advising London
parents in general to change their form of baby-care in the early
weeksCopyright 2007 John Wiley & Sons, Ltd.
1. The clearest evidence concerns sleeping problems. Randomised
controlled trials have produced compelling evidence that, after
infants are about six weeks of age, structured parenting prevents
infant sleeping problems at, and beyond, three months of age. There
is no evidence that such parenting increases the risk of SIDS and
it is worth reiterating that the structured behavioural approach
evaluated in the preventive studies does not require babies to be
left to cry. Indeed, these ndings highlight the distinction between
structured parenting and controlled crying care, which deliberately
leaves babies to cry (AAIMHI, 2002; Meltz, 2004). An important
proviso is that most infants who continue to wake and disturb their
parents at night do not have anything physically wrong with them.
To some extent, infant night waking is a problem for parents
because of cultural pressures toward dual employment and ofce
hours. For many parents, decisions about the use of structured care
involve balancing priorities and, for some, having an infant who
remains settled at night may not be their most important goal.
Where parents do wish to prevent night waking and crying after 12
weeks, introduction of structured parenting based on behavioural
principles from about six weeks of age is likely to help. By
providing parents with information and helping them to make
informed choices, professionals should be able to reduce infant
sleeping problems. 2. The evidence about preventing infant crying
problems is more complex, as is the question of benets and costs.
There is no evidence that differences in parenting affect whether
infants have bouts of unsoothable crying around about ve weeks of
age. These appear to be due to biological processes in infants.
Hence, rather than attempting to prevent these bouts there is a
need to focus on parental containment and coping strategies (see
section 4b). In relation to overall crying amounts, comparative
studies have found that infant-demand parenting from birth is
associated with low 24 hour total amounts of fussing and crying,
particularly in the newborn period and rst 12 weeks of age, while
the form of parenting typical in London and North America leads to
50% more infant crying. Less clear is whether these ndings justify
advising London parents in general to change their form of
baby-care in the early weeks. Weighing against this are: (a) some
remaining uncertainty about causation; (b) the evidence that many
babies do not cry a lot in spite of typical London care; (c) the
evidence that infant-demand care does not prevent the unsoothable
bouts of crying which most concern parents during early infancy;
and (d) the evidence that most infants who cry a lot in early
infancy lack long-term disturbances. Here too the implication is
that health professionals will serve parents and babies best by
providing information which supportsChild Abuse Review Vol. 16:
4769 (2007) DOI: 10.1002/car
Helping Parents to Manage Infant Crying and Sleeping
61
parental choice. So far as parents wish to minimise infant
crying overall, the best evidence-based advice is that an
infant-demand form of care in the early weeks should help to do so.
Parents can also be advised that unsoothable crying bouts in one to
three monthold babies are not their fault. A related implication,
particularly, of the marked differences in parenting between
Copenhagen and London is to draw attention to the broader question
of the two societies values and wishes for parents and infants.
Indeed, these parenting differences are provocative in their own
right and support some healthcare experts concern that many London
parents are leaving their babies to cry. To the extent that parents
approach to childcare reects their societys norms and customs, the
broader question is whether our society wishes to support parenting
of infants differently than is currently the case. Alvarez (2004)
has described the more extensive support available to parents in
Denmark. The implication of the Copenhagen: London differences in
parenting is to highlight the need for a policy debate. 3. It seems
likely that many parents will want to adopt the compromise between
infant-demand and structured care which minimises early crying but
helps babies to learn to remain settled at night. Indeed, the
reviewed ndings may explain why the merits of these two forms of
infant care have been debated for so long. Rather than one or other
proving better, they appear to have different benets, and costs:
infant-demand parenting is associated with low amounts of fussing
and crying in the rst three months of age, but with night waking
which continues beyond three months, whereas structured care leads
to more fussing and crying during the rst three months, but reduced
night waking and crying after that. Unfortunately, little or no
research to date has directly examined the question of the optimum
way of arranging these alternative parenting strategies. There is a
need for such research. Assuming that the developmental view
advanced here is correct, parenting which changes from an
infant-demand approach in the early weeks to a more structured
approach at some point after six weeks of age may be the most
effective way of minimising early crying while helping infants to
remain settled at night by 12 weeks of age. On the best available
evidence, Copenhagen parents seem to have got this arrangement
about right. Notably, it does not require the almost constant
holding which denes proximal care. Rather, it involves levels of
holding and responsive involvement which are substantially greater
than are typical in London. Rather than co-sleeping with infants
throughout the night, Copenhagen parents used cots for infant
sleeping, as well as taking babies into their own beds for part of
the night. This has the added benet of complying with Foundation
for the Study of Infant Deaths recommendations for minimising the
risk of SIDS (FSID, 2004). CopenhagenCopyright 2007 John Wiley
& Sons, Ltd.
Parents can also be advised that unsoothable crying bouts in one
to three month-old babies are not their fault
The reviewed ndings may explain why the merits of these two
forms of infant care have been debated for so long Parenting which
changes from an infant-demand approach in the early weeks to a more
structured approach at some point after six weeks of age
Child Abuse Review Vol. 16: 4769 (2007) DOI: 10.1002/car
62
St James-Roberts
Copenhagen parents were also almost as successful as Proximal
Care parents in continuing breastfeeding until 12 weeks of age
parents were also almost as successful as Proximal Care parents
in continuing breastfeeding until 12 weeks of age, and this was not
associated with increased infant night waking and crying.
Continuation of breastfeeding in this way meets British Medical
Association recommendations about healthy feeding for infants (BMA,
2004). Although further information is needed, health professionals
may wish to draw parents attention to Copenhagen parents approach
to baby-care. 4b. Helping Parents to Treat Crying and Sleeping
Problems 1. For professionals who deal with established crying and
sleeping problems, parental complaints are the presenting
phenomenon. Such complaints involve a subjective judgement, while
parents vary in their knowledge of normal infant behaviour and in
their tolerance. It follows that measurements which accurately
assess actual infant behaviour are an essential rst step in
understanding what the problem is. Instruments for measuring infant
sleeping and crying have been developed for research and can be
adapted for routine health service practice. Behaviour diaries,
such as the Baby Day Diary (Hunziker and Barr, 1986) are the most
accurate method. Where parents cannot keep them, summary
questionnaires such as the Crying Patterns Questionnaire (St
James-Roberts and Halil, 1991) can be used. Both questionnaire and
diary methods exist for measuring infant sleeping (Sadeh, 2001;
Stores and Wiggs, 2001a). There is a need for translation studies,
which evaluate the use of these procedures under routine healthcare
service conditions. 2. Because some parents will be particularly
vulnerable to infant crying and night waking, collection of
information to identify maternal depression, social supports,
single parenthood and other sources of parental vulnerability
should be a core part of the primary workup, so that services can
be targeted towards need. 3. In about one in ten cases, persistent
crying in one to three month old infants reects an organic
disturbance. Health services need effective means of identifying
and treating these special cases. Gormally (2001) and Treem (2001),
two paediatric members of an expert panel on infant crying and
colic, recommended the use of the following inclusion and exclusion
criteria to identify organic cases: high pitched/abnormal sounding
cry; lack of a diurnal rhythm; presence of frequent regurgitations,
vomiting, diarrhoea, blood in stools, weight loss or failure to
thrive; positive family history of migraine, asthma, atopy, eczema;
maternal drug ingestion; positive physical exam (including eyes,
palpation of large bones, neurological, gastrointestinal and
cardiovascular assessment); persistence past four months of
age.Child Abuse Review Vol. 16: 4769 (2007) DOI: 10.1002/car
Parental complaints are the presenting phenomenon
Health services need effective means of identifying and treating
these special cases
Copyright 2007 John Wiley & Sons, Ltd.
Helping Parents to Manage Infant Crying and Sleeping
63
Gormally and Treem do not identify treatments, but the
implication is that such cases will usually be referred to
paediatric specialists. 4. Except where organic disturbances exist,
the available evidence provides no basis for advising parents in
general that changes in their care are likely to resolve crying
problems in one to three month old infants once they have arisen.
This is particularly true of the prolonged, unsoothable crying
bouts which seem to be central to parents concerns in early
infancy. Instead, once organic disturbance is ruled out and the
infants healthy growth and development are conrmed, the focus of
intervention should be on containing the crying and providing
parents with information and support. Important elements advocated
by an expert group (Barr et al., 2001) are: Examining the notion
that crying means that there is something wrong with a baby of this
age. Introducing alternativese.g. that it signals a reactive or
vigorous baby. Viewing the rst three months of infancy as a
developmental transition, which all babies go through more or less
smoothly. Reassuring parents that it is normal to nd crying
aversive and discussing the dangers of shaken baby syndrome.
Discussing ways of containing/minimising the crying, and
highlighting positive features of the baby. Considering the
availability of supports and the development of coping strategies
which allow individual parents to take time out and recharge their
batteries. Empowering parents and reframing the rst three months as
a challenge which they can overcome, with positive consequences for
themselves and their relationships with their babies. Continuing to
monitor infant and parents.
The focus of intervention should be on containing the crying and
providing parents with information and support
Following on from these principles, the American National Center
for Shaken Baby Syndrome has begun a Period of Purple Crying
campaign designed to raise parental awareness about the crying peak
and the associated danger of shaking babies (Barr et al., 2003).
Dias (2003) reported that raising awareness and asking all parents
to sign contracts not to shake babies produced signicant reductions
of Shaken Baby Syndrome cases in a multi-centre trial. It is not
clear whether campaigns of this sort would be generally effective,
but the principle of increasing knowledge about crying and its
impact on parents appears sound. 5. There is clear evidence that
structured behavioural programmes provide effective treatments for
infant sleeping problems after three months of age, so that this
has become the recommended approach (Ramchandani et al., 2000).
Although there is evidence that children benet from these methods,
as well as parents (France, 1992), a substantial minority of
parents continue to nd them hard to implement, emphasising the
advantages of prevention over cure. As with crying, organic cases
are rare but history taking shouldCopyright 2007 John Wiley &
Sons, Ltd.
Empowering parents and reframing the rst three months as a
challenge which they can overcome
Child Abuse Review Vol. 16: 4769 (2007) DOI: 10.1002/car
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St James-Roberts
Structured behavioural approaches provide the most effective
treatment, even in organic cases
A substantial unmet public health need and a priority for
research and healthcare services
identify them. Stores and Wiggs (2001a) provide guidelines for
distinguishing such cases. In keeping with the recommendations
here, Wiggs and Stores (2001) conclude that structured behavioural
approaches provide the most effective treatment, even in organic
cases, although the approach needs to be tailored to such childrens
abilities and circumstances. 6. Although outside the scope of this
review, an important development in recent research has been the
delineation of cases where crying and other multiple disturbances
occur beyond three months of age (Wolke et al., 1995; Papousek and
von Hofacker, 1998; Papousek et al., 2001). Preliminary gures
suggest that this may happen in about six per cent of infants, with
about half of these cases having their onset beforehand (Clifford
et al., 2002). Because this group is particularly likely to have
extensive, severe and longterm problems (Wolke et al., 2002; Rao et
al., 2004), much more needs to be known about the age of onset,
course of development and distinguishing features of these cases.
The ndings highlight these cases as a substantial unmet public
health need and a priority for research and healthcare services. 7.
As Stores and Wiggs (2001b) point out in relation to infant
sleeping problems, the ndings reviewed here highlight the dearth
and patchiness of healthcare services for infant crying and
sleeping problems, compared with the commonness and cost of these
problems. Recent developments in UK policy, such as the National
Service Framework for Children (Department of Health, 2003) offer
the sort of inter-disciplinary framework needed to tackle this
Cinderella area, so that the promise exists for major progress over
the next few years in how to help these infants and parents.
Acknowledgements This review was written while the author was
supported by Wellcome Trust Project Grant No. 065486.
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