2013年10月19日 星期六


Proving the Risk of Harm in Early Sleep Training

原文出處: http://evolutionaryparenting.com/proving-the-harm-in-early-sleep-training/
作者:Tracy G. Cassels
A new review paper out in the Journal of Developmental and Behavioural Pediatrics[1] has me hearing choirs, seeing the clouds part, and sun shining down (and I live in Vancouver, BC so it’s not something I see very often) over finally seeing someone address the issue of sleep training in young children by summarizing ALL the research (albeit only until six months of age).  This new review paper examines all articles from 1993 to August 2013 that examined the effects of sleep training on infants younger than six months of age.
一篇新的review paper(文獻探討)最近發表於Journal of Developmental and Behavioural Pediatrics[1] (發展與行為小兒科學期刊),它讓我聽見了唱詩班,看到飛雲散開,陽光照射而下 (因為我住在溫哥華,所以這不是我常看到的天氣。),終於有人發表早期睡眠訓練對於年幼孩童影響的研究總結 (雖然只有6個月大以下的部分)。這篇新的review paper檢視了從1993年到2013年8月的所有文章,來檢視早期睡眠訓練對於未滿6個月大的嬰兒有何影響

Just a reminder, in case people didn’t know, many doctors, sleep experts, sleep trainers, and clinics start to promote sleep training at month 3 or 4.  Some parents start even earlier.  And when those of us speak out against it’s promotion, arguing infants are in a sensitive period at that point (the fourth trimester so to speak) or have naturally developing circadian rhythms we don’t want to mess with, or that this type of training can harm breastfeeding success, we’re told it’s up to us to prove harm if we don’t want it *promoted*.  Well… here is that proof.  (Remember we’re talking about promoting something here, not speaking to parents who used methods without knowing anything or who were told by doctors, sleep experts, etc. to use these methods early.)
為了讓不瞭解的人知道,在此提醒一下,很多醫生,睡眠專家,睡眠訓練家,和診所開始推廣睡眠訓練對於3或4個月大的嬰兒,有些父母更早開始訓練。當我們這些發言反對睡眠訓練的人,主張嬰兒在這麼小的時候(可以說是第4個3個月) (譯註:指從懷孕開始算起)是處於敏感期,正在自然發展他的生理時鐘,我們不會想要弄亂它的,而且這種睡眠訓練會妨害親餵哺乳的成功,有人說如果我們不希望睡眠訓練被推廣我們要去證明它有害,恩...這篇就是個證明。 (記住我們是在討論推廣某件事,不是在針對先前不知道原由,被醫生或睡眠專家建議而使用這些方法的父母。)

Drs. Pamela Douglas and Peter Hill out of the University of Queensland in Australia (both of whom I’d like to buy drinks for) performed the review.  A total of 43 articles met the criterion for inclusion.  There were various sleep training techniques included in the review.  The usual suspects, as well as decoupling feeding from sleep and touch (i.e., never letting the baby fall asleep at the boob or in arms, teaching the child to “self-settle” without touch or food), scheduling the baby’s sleep whether tired or not, and decreasing daytime stimulation.  They looked at all of these for the outcomes associated with them on infants and mothers.
Drs. Pamela Douglas & Peter Hill來自於澳洲昆士蘭大學寫了這篇review。(我想請這2人喝飲料。) 總共檢視了符合標準的43篇文章,裡面包含了多種睡眠訓練技術。通常的作法是把餵奶和接觸與睡眠分開 (也就是說不讓寶寶在吸奶中或抱著時睡著,教嬰兒 “自我安撫”而不去接觸他或餵奶。),訂定嬰兒睡眠時間表不管他是不是累了,並減少白天刺激。他們找出嬰兒與母親受到的相關影響。

One of the most disturbing revelations is that articles promoting sleep training in the early months don’t actually have scientific backing for it.  What many of them found was simply that sleep consolidates rapidly during the first four months postpartum and that because it does this, it is assumed to be evidence that sleep training will prevent later problems in sleep-wake cycles for infants.  But when they actually looked at outcomes for infant and mother (as this is who has primarily done the sleep training in the research they found), they find the following:
最惱人的真相是這些推廣早期月份睡眠訓練的文章,實際上並沒有科學根據來支持,它們很多是只發現在出生後4個月內睡眠被快速穩固了,這是因為訓練的作用,所以它假定這能證明睡眠訓練將會預防嬰兒之後的 “睡眠-清醒”循環的問題。但是當他們實際檢視嬰兒和母親的結果,他們有以下發現:
  • Sleep training in the first 12 weeks does result in longer sleep durations but does not reduce infant crying, which is the main concern for parents seeking sleep training.
  • 在最初12週的睡眠訓練導致較長的睡眠期間,但並沒有減少嬰兒哭泣,而這是父母尋求睡眠訓練的主要考量。
  • Increased night wakings in breastfed babies was not associated with any long-term sleep or behavioural problems despite many suggesting long-term problems associated with infant night wakings.
  • 親餵寶寶的夜間醒來次數增加,並沒有和任何長期睡眠或行為問題有關聯,僅管很多人暗示嬰兒夜間醒來會造成長期問題。
  • Infants who show night wakings or other sleep disturbances at six months (without intervention) have completely normal mental health in young adulthood, meaning those who suggest a link to later problems don’t have a leg to stand on.
  • 六個月大會夜間醒來或有其他睡眠擾亂的嬰兒 (未被訓練),在年青成年期時心智完全正常,表示將睡眠醒來或擾亂連結到往後問題的說法沒有根據。
  • For those who worry about moms with depression, sleep training prior to six months was not found to decrease maternal depression at all.  And in fact, mom’s sleep problems do not correlate with infant sleep but rather are due to the depression, not the infant.
  • 對於擔心媽媽會沮喪的人,六個月大前的睡眠訓練未發現有減少母親沮喪的作用。事實上,媽媽的睡眠問題和嬰兒睡眠無關,而是和自己的沮喪有關。
  • In fact, it was maternal depression that predicted longer infant awakenings at night (though not frequency), not the other way around.
  • 事實上,母親沮喪能引起嬰兒更長的醒來時間(不是頻率)。
  • Mothers who breastfeed wake more to feed babies but report better sleep quality and lower rates of postpartum depression.
  • 親餵媽媽晚上更常醒來親餵寶寶但有較好的睡眠品質,產後憂鬱的機率也較低。
  • The few studies that reported a decrease in maternal depression due to interventions were incredibly complex interventions with many elements (including support for mother) and the lowered depression cannot be said to be due to sleep training.
  • 少數研究宣稱睡眠訓練介入能使母親沮喪減少,但其實是有許多複雜的干預因素 (包含母親得到的支持),沮喪降低並不能算是睡眠訓練的作用。
  • Decoupling feeding from sleep in infants younger than six months was associated with increased breastfeeding failure.
  • 未滿六個月的嬰兒睡覺時不讓他喝奶與breastfeeding失敗增加有關。
  • Rigid, scheduled sleep and care in the early months is associated with three times the risk of behavioural problems at six months and twice the amount of crying as infants with cue-based care.
  • 在早期月份時固定依時間表睡眠與照護,可能造成六個月大時發生行為問題的風險增為3倍,而且其哭泣時間是依需求來照護的寶寶之2倍
  • Placing an infant in a dark room during the day under the guise of them needing sleep or crying from being “overstimulated” or “overtired” actually inhibits the consolidation of night sleep (meaning more night wakings) and increases the risk for SIDS.  It also reduces the ability of mom to develop a good daytime biorhythm with the baby which reduces maternal mental health.
  • 在白天把嬰兒放到黑暗房間,假借他們需要睡眠並需要在 “過度刺激”或 “過度疲勞” 時哭泣,實際上妨害了夜間睡眠穩定 (意指夜間更常醒來) 並增加了SIDS (嬰兒猝死症)的風險。它也減少了母親配合寶寶發展良好日間生理節律的能力而對母親的心理健康有害
  • The focus of sleep interventions – namely the amount the baby has slept, how long between sleeps, number of wakings, etc. – actually increases parental anxiety.  It can also result in worse sleep for baby.
  • 睡眠介入的關注重點-那就是寶寶睡眠時數,睡眠與睡眠間的間隔時間,醒來幾次…等等-實際上會增加育兒焦慮,這會導致寶寶睡得更差。

Perhaps most interesting of all, though not an outcome, most families don’t report any issues with infant sleep in the first six months.  Most people are being told to use behavioural techniques as preventative measures for later problems.  Only there’s no evidence that this works and as we’ve just read, actually can pose more problems for the family both in the short- and medium-term.  And none of these studies even looked at any longer-term social or emotional issues that can arise from sleep training so young, thus the question of what the risk of long-term harm is still remains.
或許最有趣的地方在於,雖然並非結果,大部分家庭並沒有反映寶寶最初6個月有任何睡眠問題,大部分父母被教導使用行為技術訓練,是作為往後可能發生問題的預防措施, 但如同上述所言並沒有證據顯示它有效,反而對家庭造成短期和中期的問題。而且這些研究都沒有去看早期睡眠訓練可能帶來的長期的社會或心理影響問題,因此關於長期傷害的風險疑問還是存在的

What to do?  As the authors here suggest, treatments need to be holistic.  In the minds of these authors and researchers, early treatment of any problem should avoid sleep training and all behavioural techniques in favour of education about cue-based care, parent-child synchrony, healthy daytime biorhythms, and addressing parental anxiety about sleep and normal crying.  Further, feeding difficulties should be examined as one of the potential causes of unsettled infant behaviour, thus parents should be given all the assistance they need to address any feeding issues.
該做什麼?如同作者在此建議,治療需要是全面的。這些作者及研究者認為,任何問題的早期治療應該避免睡眠訓練及所有行為技術,並支持關於cue-based (訊號需求基礎) 的照護、parent-child synchrony(父母-孩子同步)、健康的日間生物節律的教育,並處理父母對於睡眠及正常哭泣的焦慮。此外,餵奶困難應該被檢視為造成嬰兒行為不穩定的潛在原因之一,所有父母應該得到全面協助來處理任何餵奶問題。

Isn’t it sad that we needed 20 years of studies to prove harm?  Couldn’t we have not promoted this and saved these families the anxiety, stress, and problems that came with promotion of something that hadn’t been proved to do no harm despite countering all biological norms?

So… sleep trainers, baby “experts”, doctors, and anyone else promoting sleep training in young infants.  What are you doing to do now?
那麼…睡眠訓練家,寶寶 “專家”,醫生,以及其他推廣對年幼嬰兒實施睡眠訓練的人,你們現在要怎麼做?

[1] Douglas PS, Hill PS.  Behavioral sleep interventions in the first six  months of life do not improve outcomes for mothers or infants: a systematic  review.  J Dev Behav Pediatr 2013; 34: 497-507.

[Image Credit:  Unknown]

感想:看了這篇,以及之前的網誌 <為什麼Cry It Out及睡眠訓練技術對寶寶有害 (百歲法、費伯法等) > ,你是否更瞭解,為什麼百歲醫師這本書中,有一頁是作者聲明,其中寫到作者有免責權,不需為讀者直接或間接採用本書作法所導致的後果負責。


◎Attachment Parenting 101: Ten reasons "crying it out" is bad for babies
10個Cry It Out (哭泣式睡眠訓練)對寶寶有害的理由:例如得到ADHD〔注意力不足過動症〕的機率增加、影響大腦發展、平均智商(IQ)下降、情緒控管能力變差等,網頁中有列出研究資料來源

◎Evidence Mounts Against Letting Babies 'Cry It Out' as New Research Says it Stresses Them Out
研究顯示,經過Cry It Out睡眠訓練後,嬰兒變得不哭了,但是他的可體松濃度依然升高,表示寶寶仍然感到高度壓力,雖然他已經不哭了。

◎Educating the Experts – Lesson One: Crying
 1. 寶寶的需求被滿足了,這是最佳的情況。
 2. 哭泣會造成體溫上昇,當體溫過高時寶寶會減少或停止哭泣。
 3. 寶寶因為被訓練而放棄哭,或者他學到了沒有人會來幫助他。 簡而言之,不回應寶寶的溝通嘗試,會使他放棄哭並可能顯現出長期性習得的無助感(long-term learned helplessness)這種類型的停止哭泣會傷害寶寶的長期心理健康,無論它對於父母帶來多棒的立即好處。寶寶不哭了絕對不是因為他學會了訓練專家說的 “自我安撫”。
(註: “教導訓練專家” 系列文一共 5篇,以科學的角度指正一些嬰兒訓練書籍的錯誤資訊,其中點名了《Secrets of the Baby Whisperer》《超級嬰兒通》” 這本書,這本看似為溫和派的訓練書籍,因為違反學理且實行上常造成不良結果因此負評很多,AMAZON書評平均分數為 3.7星。對照組:Dr. Denmark Said It!》,台灣名書《百歲醫師...》的資料來源,Dr. Denmark即為百歲醫師,這本書的評分為 3.8星,也是因為違反科學且對嬰兒有害,因此負評很多。)

◎Educating the Experts – Lesson Four: Self-Soothing


◎ Educating the Experts – Lesson Five: Schedules
強迫寶寶在不想睡覺時要他睡覺,或是在他想睡覺時讓他撐久一點讓他清醒,會傷害親子關係造成寶寶更愛哭鬧,並且有造成SIDS (嬰兒猝死症)機率增加的風險。此外,比起依訊號餵奶 (feed on-cue,意思同feed on demand,即想喝就餵餓了就餵,但feed on-cue一詞有強調觀察寶寶餓了的cue=訊號之意思。),依照Schedule (時間表)定時餵奶的寶寶,其喝奶量較少,體重成長較慢,並且不利於母乳產量 (親餵次數頻繁,並在晚上寶寶醒來時餵奶,有助於奶量增加),而在另一篇網誌 “瓶餵與親餵的不同 & 如何改善瓶餵”中也有提到,研究指出餓了就餵的寶寶比起依時間表餵奶的寶寶,有較好的認知發展與智商。



為什麼Cry It Out及睡眠訓練技術對寶寶有害 (百歲法、費伯法等)