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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

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Helping Parents to Manage Infant Crying and Sleeping: A Review of the Evidence and its Implications for Services
Infant 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: i.stjamesroberts@ioe.ac.uk 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

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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.

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 problems
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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 suggest
Copyright 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 groups
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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.
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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 infants
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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 that
Child Abuse Review Vol. 16: 4769 (2007) DOI: 10.1002/car

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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 and
Copyright 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

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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 crying
Copyright 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 to
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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 reected
Copyright 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

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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 programmes
Child Abuse Review Vol. 16: 4769 (2007) DOI: 10.1002/car

Such disturbances are too rare to explain most sleep problems

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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, infants
Copyright 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 age
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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 of
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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.
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Learn to remain settled through the night at an earlier age and there is no evidence that it increases the likelihood of infant SIDS

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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 weeks
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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 supports
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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). Copenhagen
Copyright 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

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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.
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Parental complaints are the presenting phenomenon

Health services need effective means of identifying and treating these special cases

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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 should
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Empowering parents and reframing the rst three months as a challenge which they can overcome

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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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Child Abuse Review Vol. 16: 4769 (2007) DOI: 10.1002/car