Significant sleep benefits were observed in both graduated extinction and bedtime fading above sleep education control, yet these interventions conveyed no adverse stress responses or long-term effects on parent-child attachments or child emotions and behavior. This according to a randomized controlled trial of 43 infants aged 6 to 16 months (63% girls) randomized to receive either graduated extinction (n=14), bedtime fading (n=15), or sleep control (n=14). Sleep measures included parent-reported sleep diaries and infant actigraphy. Mothers completed assessments 12 months after intervention:

• Significant interactions were found for sleep latency, number of awakenings, and wake after sleep onset.

• There was a large decrease observed in sleep latency for graduated extinction and bedtime fading groups, and large decreases in the number of awakenings and wake after sleep onset for the graduated extinction group.

• Small-to-moderate declines in graduated extinction and bedtime fading groups showed with salivary cortisol vs controls.

• Mothers’ stress showed small-to-moderate decreases for the graduated extinction and bedtime fading conditions over the first month, yet no differences in mood were detected.

• At 12-month follow-up, no significant differences were found in emotional and behavioral problems.

Citation: Gradisar M, Jackson K, Spurrier NJ, et al. Behavioral interventions for infant sleep problems: A randomized controlled trial. [Published online ahead of print June 1, 2016]. Pediatrics. doi:10.1542/peds.2015-1486.

Commentary: Graduated extinction, also called the Ferber Method, involves leaving the child to cry themselves to sleep for longer and longer times each subsequent night. Usually after a few nights, the child begins to be able to fall off to sleep on their own without crying out for their parent. In the fading bedtime routine, children are kept awake to later than their normal bedtime, given a positive routine like dimming the lights and soothing music or a bedtime story, and allowed to fall asleep. The fading part describes that once this routine is established, the bedtime can be gradually made earlier until their target bedtime is reached. The important take-home point from this article is that there are evidence-based effective options for helping children establish productive, predictable sleep behaviors. —Neil Skolnik, MD