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Sleep matters for health visitors: evidence and best practice

Health visitors can play a central role in supporting sleep-deprived families. A recent Netmums survey1 of over 11,000 parents revealed that health visitors and online support were the most popular sources parents turned to for help, with friends and family a close second. The recent Bedtime Live series on Channel 42 illustrated the critical role health visitors can play in supporting families who have sleep and settling issues.

Effective assessment of sleep and settling difficulties are a fundamental precursor in identifying causes of sleep issues before any sleep intervention can be started. The cause of the settling or sleep problem needs to be understood by both the practitioners and the parents if any intervention is to be successful. A partnership approach3 to working with parents is essential if the issues are to be resolved. Parents need to feel supported, listened to and comfortable with their sleep training intervention for a successful outcome.

Effective sleep interventions
There are a number of different sleep training methods parents can use which are based on behavioural methods of intervention.

Before any sleep intervention is commenced it is important to exclude any medical or physical causes and to bear in mind there may be relationship issues affecting attachment and bonding. Be mindful that prolonged crying is reported more frequently by depressed mothers and makes them more susceptible to broken nights and infant crying.4 For all of the sleep training programmes a consistent, positive bedtime routine is needed and the child put to bed drowsy but awake.

Controlled checking
It is important to differentiable between 'controlled checking' and 'crying it out,' as the two are often confused and misunderstood. Crying it out involves leaving a baby to cry unattended for long periods and is not recommended, as it can be harmful. This is very different to controlled checking, also called gradual extinction, which involves the parent returning at frequent intervals to check the baby. Controlled checking does not prevent crying but the fact that the parent is returning at frequent intervals reassures the baby that he or she has not been abandoned and that they are being attended to, which reinforces their sense of security.

The use of controlled crying is controversial and often elicits an emotive response. The Harvard Centre on the Developing Child5 makes the distinction between moderate short-lived stress that can actually promote growth, and toxic stress, which is the strong, unrelieved activation of the body's stress management system, which elicits a toxic stress response that is harmful.

Research5 shows that controlled crying is not harmful if followed correctly for a maximum of two weeks in a baby aged over six months old, provided the baby gets lots of love and attention in the day from a sensitive attuned parent. Practitioners will need to use their professional judgement in assessing the sensitivity of the parenting and the needs of the infant before suggesting controlled checking. Many parents are opposed to this form of sleep training, and their parenting style and wishes need to be respected and kept in mind when discussing which sleep interventions may be suitable.

Gradual retreat
This is a very gentle form of sleep training which may take a longer time but involves less crying. The parent starts off by settling the child to sleep in their cot or bed but stays with them while they go to sleep. They may need to have physical contact with the child while they go to sleep to start off with. As the child learns to settle with the parents close by, the parent starts to gradually distance them self from the child so they get used to falling asleep without physical contact from the parent but with the reassurance of the parent close by.

Over time the parent withdraws further and further away until they can be at the door while the child goes to sleep. Eventually the child can start to settle with the parent at the door, and later out of sight but close by. During this whole process, the parent does not interact with the child. This method works well for children with separation anxiety. Parents will need a chair in the room or a cushion to sit on if there is no room for a chair.  

Pick-up, put-down
This method was popularised by Tracey Hogg6 and is a variation of gradual retreat. The is useful for babies over six months old who won't settle on their own or wake in the night, This training works well for children with separation anxiety as it is gentle and encourages self-settling with support from the parent. It needs to be adapted for babies who can stand in their cot; once they are out of a cot it is not suitable.

The baby is put to bed when they are drowsy. If the baby cries at this point they can be picked up and reassured by having a key phrase such as, “shh, I'm here, it's OK”. When this has been said they are put back down. If they start to cry on the way down they are still put down. If they continue crying they are picked up again. If they are fighting or arching their back, they are put down after saying the key phrase, and then they are picked up again if still crying. As soon as the crying stops they are put down again, the parent repeats this as many times as necessary.

As soon as the crying stops, the parent leaves the room. It can take 100-150 or more 'pick-up, put-downs' before they settle, and it may take an hour or more. It is very tiring and many parents lose faith in the approach. Physically, a strong back is also needed to do this.

Separation anxiety
Dawes7 and Sadeh8 have both identified bedtime separations of babies and parents as key issues. Separation from a 'secure base', the attachment figure (usually the mother), and the fear and anxiety that can ensue is well-documented in attachment theories by Bowl9 and Ainsworth,10 and others since. Many children do go through stages of separation anxiety and it is a normal part of their development. It usually starts from about seven months onwards when babies start to develop stranger discrimination.

Some games such as peek-a-boo and hide-and-seek with older children may help with separation anxiety. Books that deal with loss or a lost-and-found theme can help children come to terms with this. Books with liftable flaps can also be useful.
Other strategies that parents can try include practicing saying 'bye-bye' and waving them out of sight, before quickly returning with smiles. The parent can also leave the room but continue to talk or sing while out of sight, or to leave them for a few seconds initially and gradually extend this time.

The quality of the caregiving relationship and sensitive attuned responsive parenting are important, and the health visitor will need to assess these. The stress of separation is not necessarily harmful if it is managed in a thoughtful way, and parents may need help and support to manage this. The gentle sleep training methods may be more suited to children who have separation anxiety.

Scheduled waking
Scheduled waking is a technique that can be used to try and break a regular habit of waking at a certain time. Parents need to use a sleep diary to record the times night waking occurs. The child is woken thirty minutes before this time and then allowed to go back to sleep. It is best not to wake the child fully but just enough so that they open their eyes. This is done every night for at least a week, and then parents try a night of not waking to see if they stay asleep. Scheduled waking is often used to treat night terrors as this disrupts the sleep cycle and also needs to be done for at least a week. However evidence shows there is no direct information from randomised controlled trails about scheduled waking in the treatment of children with parasomnias. It would seem to be a promising treatment; however, high-quality trials are lacking.

Rapid return
Rapid return is used for older children who won't stay in bed at night or come into their parent's bed; it involves immediately silently returning the child to bed. This is repeated every time the child gets out of bed, and may have to be done fifty to one hundred times for very persistent children. Calmness and persistence from the parent is important returning the child to their bed with the minimum of fuss and attention. Parental body language and expression convey a lot, so quiet determination on behalf of the parent is fundamental to success.

Rewards, choices and consequences
Reward methods work well with older children; to be most effective children need to be three years old or over to fully co-operate with this. The idea is to focus and reward the desired behaviour rather than pay attention to undesired behaviour. A menu of small rewards helps to maintain interest and may be more effective than one large reward when they achieve the goal. It is best to break things down into small achievable steps the child can attain, otherwise they can become demoralised and loose interest. A reward system can be used alongside a sleep coaching programme.

Choices and consequences are another helpful way of encouraging children to co-operate and take responsibility for their behaviour. The age at which you can start using this approach will vary with the child's level of understanding. When used with young children, it will need to be kept simple and it may help to show the child the choices. Choices and consequences keep the adult in charge of the consequence while allowing the child control over the choices they make. It prevents a battle of wills as the child is fully aware of the positive and negative consequences that will flow from the choices they make. If children are not given a choice, they may feel powerless which can trigger other difficult feelings and may lead to misbehaviour.

Choices and consequences are used with great success in the Family Links Nurturing Progamme.11 The child is offered a limited choice and the consequence should logically flow from the behaviour, for example:

(child's name) you have a choice.
You can either: Lie quietly in bed.
(positive behaviour choice).
Or you can: Get out of bed/scream etc.
(negative behaviour choice).
If you choose: To stay quietly in bed.
(positive behaviour).
You will get: A sticker/I will sit with you.
(positive consequence).
If you choose: To scream or get out of bed
(negative behaviour).
You will not get: a sticker/I will leave the room.
(negative consequence).
It's up to you - it's your choice.

In this example the child is offered a limited choice that clearly spells out the positive and negative consequences from the choices they make. As this example illustrates the use of choices and consequences, it can be linked to a reward chart or other sleep training intervention. In this example, the desired behaviour is rewarded with a sticker or parental presence using the gradual retreat method with an older child. Children quickly learn that they have a choice and to gain what they want they need to co-operate.

Bedtime routines
A child's temperament plays a big part in their ability to settle and sleep. Some children require extra support than other more placid, easy-going individuals. For babies and children who are more sensitive than predictable, consistent positive routines day and night are helpful, as these help to set their body clock. Regular consistent routines day and night help children to feel safe and secure and provide boundaries. Knowing what is going to happen next and their lives following a predictable pattern is very reassuring for children coping with separation anxiety, and for those who are more sensitive.

Establishing a regular calm, relaxing bedtime ritual is helpful and it is important that the final part of the bedtime routine takes place in their bedroom, as babies and children need to associate getting ready for bed with going to bed. It is suggested that they are not allowed back into the main room to play after bath time or getting ready for bed. It is much more difficult to persuade a child to go to bed from the sitting room, which is a much more stimulating environment, than the bathroom and this is a useful transition point. Sleep experts suggest you should not allow children to watch television or have any screen time thirty minutes before bedtime as this alters the brainwave patterns, making sleep less likely and affects the quality of sleep. Parents may need to monitor what children are watching on television as some children's programmes can be disturbing. A relaxing story at bedtime is more beneficial and can take place in bed.

Calming, relaxing music can help. Research suggests that music by Brahms and Bach is helpful and has a calming effect, and many schools use it to calm children down. Lullabies, gentle songs stories, rhymes and poetry also help to soothe and relax infants and children. Relaxation and visualisation exercises can help older children to sleep and there are lots of tailor-made ones for children that can be found on the internet and on parenting sites.

Diet, fizzy drinks and some additives in food can affect sleep, drinks or foods high in sugar or caffeine. Sweeteners added to some soft drinks and sweet foods can reduce tryptophan levels, which are essential in producing serotonin.12 Low levels of tryptophan are associated with hyperactivity and aggressive behaviour.12

To induce sleep in children at bedtime give foods rich in tryptophan at suppertime and avoid high-protein bedtime snacks that are known to activate dopamine which is a brain stimulant. Giving foods rich in carbohydrates in the evening activates tryptophan in the brain and helps to aid sleep.12 Calcium is also said to have calming effect so warm milk makes the perfect bedtime drink.

Helping parents to cope with and overcome sleep and settling issues
A stressed or anxious parent dealing with a screaming or upset child will have difficulty settling them, as the parents need to be able to calmly contain the child's feelings. Helping parents to support one another or enlist help from elsewhere is useful. Explore with parents strategies and techniques they can use to calm themselves down. Deep abdominal breathing is useful as is listening to calming music or doing relaxation and/or visualisation exercises can help.

Discover what things the parents find calming and relaxing and help them to compile a list of things they can do in the evening or during the night. At bed time, listening to relaxing music via headphones and deep breathing can help then to relax so they are better able to settle their child when they go into them.
A 'compassionate mind approach' as advocated by Gilbert13 can be very helpful for parents in understanding how their mind works, and may enable them to take control of it to calm and soothe themselves. The Netmums website14 has a helpful introduction to this, with ideas and strategies parents can use to help them when they are feeling stressed.

The role of health visitors in supporting families with sleep issues
Health visitors can play a central role in accurately assessing and successfully supporting families to manage sleep and settling issues. Netmums, along with the Institute of Health Visiting (iHV), conducted a survey with health visitors to determine their training needs with regard to sleep. To date over 852 health visitors have responded, and of this number only 4% felt 'expert', with 41% reporting to not being 'at all confident' or only 'fairly confident.'

Almost half (46%) had never had any training on the prevention and management of sleep problems. Of these, 23% had less than one hours' training, and just over 27% had less than three hours. More than a third (35%) were asked about sleep between two and four times a week, with a further 31% dealing with such issues weekly. These results highlight how frequently health visitors are asked about sleep issues in practice, yet many feel lacking in expertise and knowledge to support families effectively. Over 88% of the health visitors surveyed said they would like further training on sleep issues.

In the UK there is no evidence-based guidance on managing infant sleeping difficulties, yet it is a serious public health issue. Training for health visitors is often inconsistent or lacking. The iHV have recognised this unmet public health need and are offering evidence-based training to health visitors to address this gap in knowledge and provision. For more details please contact the iHV.15 Health visitors are in a prime position to help and support families and offer consistent evidence based information and support.

1. Netmums National Sleep Week. Netmums sleep survey results. 2012. Available at:
2. Channel 4. Bedtime Live. Available at:
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5. Centre on the Developing Child. Harvard University. Available at:
6. Hogg T. Top Tips from the Baby Whisperer: Sleep: Secrets to Getting Your Baby to Sleep Through the Night. London: Vermillion Publishing; 2005.
7. Dawes D. Through the Night: Helping Parents with Sleepless Infants. London: Free Association Books; 1989.
8. Sadeh A. Sleeping Like a Baby: A Sensitive and Sensible Approach to Solving Your Child's Sleep Problems. New Haven and London: Yale University Press; 2001.
9. Bowlby J. Attachment and loss, Vol. 1: Attachment. New York: Basic Books; 1969.
10. Ainsworth M, Blehar S, Waters M, Wall E. Patterns of attachment: A psychological study of the Strange Situation. Hillsdale New Jersey: Erlbaum; 1978.  
11. Hunt C. The Parenting Puzzle Family Links. 2003. Available at:
12. Sunderland, M. What Every Parent Needs to Know: The incredible effects of love, nurture and play on your child's development. London: Dorling Kindersley; 2007.
13. Gilbert P. The Compassionate Mind. London: Constable; 2009. Available at:
14. Netmums. The Compassionate Mind Approach. Available at:
15. The Institute of Health Visiting. Institute of Heath Visiting. Available at: