Finding the right infant sleep aid:

A parent's evidence-based guide

© 2008 Gwen Dewar, Ph.D., all rights reserved

Looking for an effective infant sleep aid? This article offers evidence-based tips for helping your baby fall asleep--and stay asleep.

As I note below, some infant sleep aids have given rise to safety concerns. For instance, under certain conditions swaddling can increase a baby’s risk for hip injuries, respiratory infections, and sudden infant death syndrome. If you choose to swaddle your baby, it’s important to follow safety guidelines.

Similarly, white noise machines--the sort that play back recordings of the ocean and other soothing sounds--can be hazardous to infant hearing if played too loud.

Other tactics pose no health risks but remain controversial. Many babies around the world are soothed to sleep during feeding sessions. Is that a bad thing? Your answer will depend on your values, cultural expectations, and goals.

Here I explain these controversies and concerns, and, where possible, discuss the evidence for the effectiveness of a given infant sleep aid.

I cover tangible tools for better sleep -- like infant sound machines. But I also talk about the sort of parenting behaviors that require nothing more than a little patience, emotional availability, and time.

As we'll see, the most important determinant of better sleep is probably not a device or baby product, but your own physical and emotional responsiveness. If you're feeling frustrated, exhausted, and out of ideas, take heart: Recent research suggests you can get your sleep-inducing mojo back with some stress management and renewed sense of confidence in your ability to soothe.

Swaddling: An ancient infant sleep aid

Swaddled babies are wrapped in cloths or blankets that restrict movement. As a result, they can’t jerk and startle as violently during sleep. Does that help them stay asleep?  Research supports the idea.

In three different experiments, infants who were swaddled and place on their backs showed improvements in sleep. They experienced fewer startles, awoke less often, and spent more time asleep (Gerard et al 2002; Franco et al 2005; Meyer and Erler 2001).

So swaddling can be an effective infant sleep aid. But depending on the details, it can also be dangerous.

It’s crucial to avoid swaddling a baby’s chest so tightly that she can’t inhale deeply. Tight swaddling has been linked with higher rates of respiratory infections. There is also the potential for overheating, particularly if the baby’s head is covered, or if the baby has a fever.

But the most persuasive, and worrying evidence, concerns swaddling methods that put babies at increased risk for hip dysplasia and sudden infant death syndrome (SIDS).

To minimize the risk of hip injury, it’s crucial that swaddling not interfere with a baby’s ability to rotate her hips and flex her knees. And perhaps the most important precaution is to place your swaddled baby on his back – never his stomach. Swaddled babies lying on their stomachs are at special risk for asphyxiation and SIDS. For this reason, experts recommend that you stop swaddling once your baby is capable of turning himself over.

So it seems to boil down to this: Don’t wrap your baby very tightly, don’t cover the baby’s head or otherwise overheat him, don’t constrict the baby’s hips or prevent the baby from bending his knees, and make sure the swaddled baby remains on his back. For tips on safe swaddling, watch this instructional video.

The bedtime routine

Many Western sleep experts suggest that parents develop a regular bedtime routine for their infants. This might include about 20 minutes of quiet, calming, low-key activities like bathing, reading a bedtime story, and singing a lullaby.

In theory, such bedtime rituals help babies wind down, and make the transition from waking to sleeping more pleasant. If your baby still resists falling asleep, you might want to consider delaying the bedtime routine until later at night (when your infant shows signs of drowsiness). For more information on this infant sleep aid, see my article on gentle methods of infant sleep training.

Circadian cues: An essential infant sleep aid

The “inner clock” of a newborn baby is out of sync with the 24-hour day. Over time, babies develop circadian rhythms—-the cyclical, physiological changes that keep us tuned into the natural progression from morning to night (Rikvees 2003). But babies—like adults—can also get their clocks out of whack, and this can cause sleep problems.

You can keep baby’s clock in sync by providing her with strong cues about time of day. Expose her to sunlight in the morning and afternoon, and include her in the hustle and bustle of daytime life. In the evenings, shift to low-key activities and dim lighting. At night, keep lights out—-even while you soothe or feed her.

I’m not sure if this tactic should be described as an infant sleep aid, but it’s important for maintaining regular sleep patterns. One study has reported that newborns who were active at the same time of day as their mothers quickly adapted to the daily schedule (Wulff and Siegmund 2002). And a study of older babies showed that infants exposed to afternoon sunlight slept better at night (Harrison 2004).

White noise as an infant sleep aid

White noise is a proven infant sleep aid. In an experimental study of newborns, 80% of infants assigned to hear playbacks of white noise fell asleep spontaneously within 5 minutes. Only 25% of control infants fell asleep spontaneously (Spencer et al 1990).

If you want to try this infant sleep aid, I’d invest in a machine that produces several different kinds of natural “soft sounds,” including the sounds of ocean waves breaking on the beach (which is suggestive of slow breathing) and the sounds of an adult’s heart beat. Other good sounds include that of a waterfall, a stream, and the rain.

Some products have timers on them, so you can set the sounds to turn off after a fixed period. But I think it makes more sense to leave the sound on throughout the night. If the baby begins to associate the white noise with falling asleep, he may be more likely to soothe himself back to sleep at night.

The pacifier as infant sleep aid

Is the pacifier an effective sleep aid? The evidence is mixed.

On the positive side, pacifiers soothe babies. When infants sucked rapidly on pacifiers during a painful medical procedure (a heel prick to draw blood), they appeared to experience less pain (Blass and Watt 1999).

An earlier study reported similar effects, and also noted that infants using pacifiers had lower heart rates (Campos 1994).

If pacifier use helps reduce the perception of pain, it makes sense that it might also soothe babies to sleep. But there’s a catch: The pain-reducing effect seems to work only as long as the infant is actually sucking on the pacifier. When babies stopped sucking, they cried as much as the control infants did (Campos 1994).

This may be the problem with using a pacifier as an infant sleep aid. When the pacifier falls out of the baby’s mouth, the soothing effect ends. And the pacifier will fall out of the baby’s mouth. In a study that recorded the sleep patterns of babies aged 6-18 weeks, almost two-thirds of infants lost their pacifiers within 30 minutes of falling asleep (Franco et al 2004).

Nevertheless, pacifier use seems to have other important beneficial effects on sleep. Infants who use pacifiers have a reduced risk for sudden infant death syndrome, or SIDS. Possibly, the protective effect has something to do with the fact that babies who use pacifiers are lighter sleepers: One study reports that infants who use pacifiers arouse more easily to disruptive sounds (Franco et al 2000). For more information about the link between sleeping “light” and reduced SIDS risk, see my article on baby sleep patterns.

Rocking baby to sleep: A controversial infant sleep aid

Is rocking an effective infant sleep aid? It might work well for some babies. But parents should consider two potential problems.

The first is that rocking a baby in your arms might actually be too stimulating (France and Blampied 1999). For instance, a study of newborns investigated the potential painkilling effects of rocking. During a painful medical procedure (the heel prick described above), newborns were either held and rocked or given a pacifier to suck. The infants who were rocked showed reduced rates of crying. However, compared with the infants given pacifiers, the rocked infants were more likely to stay alert than to fall asleep (Campos 1994).

The other potential problem concerns rocking babies to sleep in cradles. Cradle-rocking is a widely practiced infant sleep aid, and many parents report that it helps babies fall asleep. But some sleep researchers are concerned that babies will come to associate falling asleep with being rocked in the cradle. As a result, when these babies experience arousals during the night (as all babies do) they won’t be able to go back to sleep without being rocked again. So they wake all the way up and cry for help.

Although this sounds very plausible, I haven’t found experimental support for this claim. However, a survey of Thai infant sleep patterns has reported that infants who sleep in swinging or rocking cradles are more likely to experience frequent night wakings (Anuntaseree et al 2007).

Massage as an infant sleep aid

Although a variety of cultures practice infant massage, there has been little scientific research on its effectiveness an an infant sleep aid. However, the limited evidence suggests that massage may help babies adapt to the 24-hour day (Ferber et al 2002). In a study of newborns, babies who received 14 days of massage therapy (beginning in the second week of life) showed more mature sleep patterns later. At 12 weeks, the massaged infants had higher levels of nocturnal melatonin-—the “drowsy hormone” (Ferber 2002). These results may, in part, reflect the soothing effects of skin-to-skin contact (see below).

Skin-to-skin contact: Another ancient infant sleep aid

In modern-day hunter-gatherer societies, babies are often carried in slings against their mother’s naked skin, and they also sleep with their mothers at night (Konner 2007). As a result, these babies get lots of skin-to-skin contact during the day. Does this skin-to-skin contact function as an infant sleep aid?

Scientific studies of Western infants show that skin-to-skin contact, also known as “kangaroo care,” has a painkilling effect on babies (Gray et al 2000). It is also likely to boost an infant’s levels of oxytocin, a hormone with sedative effects (Uvnas-Moberg 2003). In addition, a study of hospitalized, preterm babies reports that kangaroo care increased infant sleep time and reduced agitation, rapid heart rate and apnea (Messmer et al 1997). So it seems plausible that giving your full term baby a little kangaroo care before bedtime might help her sleep better, too. However, as of January 2008, I haven’t found any experimental studies testing this hypothesis.

Aroma therapy as an infant sleep aid: Does it work?

If you trawl the internet for the perfect infant sleep aid you might find claims about lavender oil.

A number of studies have shown that people exposed to the scent of lavender feel more relaxed and spend a greater percentage of time in deep sleep (e.g., Goel et al 2005).

There is also a recent study reporting that mothers who bathed their young infants in water scented with lavender-scented bath oil were more relaxed, touched their infants more often, and smiled at their infants more often (Field et al 2007). The infants, in turn, looked at their mothers more. They cried less often and spent more time in deep sleep after the bath. Both mothers and infants showed reduced levels of cortisol (the stress hormone) after bath-time.

These results make lavender sound like a great infant sleep aid, but it’s not clear that the lavender is directly responsible for the soothing effects. A study published in the British Journal of Health Psychology tested the possibility that lavender aromatherapy works because people like the smell and expect it to relax them (Hughes and Hughes 2007). Before exposing people to the scent of lavender, researchers either told them that lavender was relaxing or stimulating. The results showed that people became more or less relaxed as a function of what they were led to expect.

This study doesn’t prove that lavender is an ineffective infant sleep aid, but it suggests that at least some of the reported effects of lavender are driven by people’s expectations. For instance, babies may have slept better after their lavender-scented bath because their mothers believed in the soothing effects of lavender. As a result, moms were more relaxed, and they behaved in ways that made their babies more relaxed, too.

So should you run out and by lavender-scented products? If you find the scent soothing, it might be a good idea. After all, if the baby bath study hints at anything, it’s that relaxed, responsive mothering is correlated with more relaxed babies.

But there is reason to be cautious about applying lavender oil directly to your baby’s skin. Lavender oil contains estrogen-mimicking compounds, and there is some clinical evidence (based on three case studies) suggesting that the topical application of lavender oil may cause breast growth in preadolescents (Henley et al 2007).

Snuggly toys and blankets: Do they promote better sleep?

Babies under 12 months shouldn't sleep with pillows, stuffed toys, or other soft objects. They can pose an asphyxiation hazard. But what about older children?

To help babies fall asleep on their own, parents may give babies soft toys or favorite blankets to cuddle up with. Such “transitional objects” (so-called because they are supposed to help the baby make the transition from waking to sleep) have been used so frequently in the United States and parts of Western Europe that many people may think of them as a natural part of childhood.

But the cross-cultural evidence suggests that transitional object use is a local phenomenon. In cultures where babies and children sleep with their parents, transitional objects are relatively rare (Gaddini et al 1970; Hong and Townes 1976; Jenni and O’Connor 2005).

Do transitional objects work--in the sense of helping babies soothe themselves to sleep?

One study tracked infants in four age groups (3, 6, 9 and 12-month olds) over a period of 3 months (Burnham et al 2002).

Infants were videotaped in their own homes while they slept, and researchers scored infants as “self-soothing” when infants were aroused during the night and went back to sleep without parental intervention. A baby was scored as using an infant sleep aid if she voluntarily touched, held or sucked on an object. Sleep aids included pacifiers, toys, blankets and the babies’ own hands. None of the babies slept in their parents beds. About one-fourth of them slept in their parents’ rooms. Three-fourths slept in alone in a separate room. Here are the results of the study:

• Over the 3 months of the study, 90% of infants used an object as an infant sleep aid at least occasionally

• Most 3-month old babies sucked on their fingers, thumbs, and hands. However, few babies over 6 months old did.

• Babies placed in their cribs while still awake were more likely to use sleep aids than were babies placed in their cribs while asleep, BUT

• There was no significant correlation between self-soothing and using an infant sleep aid.

Why didn’t transitional objects work? Perhaps they did for some infants. In previous studies, transitional objects have been associated with higher rates of self-soothing—-at least in infants 8 months or older (Anders et al 1992). And it’s possible that transitional objects are more likely to help infants soothe when they are older—-over 12 months old (Burnham et al 2002).

Feeding: The ultimate sleep aid?

It's highly effective...

Throughout human history, babies have been nursed to sleep. And bottle-fed babies frequently drowse off during feedings as well.

Why is feeding such an effective infant sleep aid? To some degree, it’s obvious. If a baby is no longer hungry, she feels more comfortable and relaxed. But there is more to it than that.

Newborns cry less and seem to experience less pain when they receive small amounts of milk, formula, or sucrose (see review by Shaw et al 2007; also Blass 1997a; Blass 1997b; Blass and Watt 1999; Barr et al 1999). Moreover, the act of sucking—-even sucking a pacifier-—has a calming effect (Blass and Watt 1999).

Breastfeeding in particular seems to be a powerful painkiller, stress reducer, and infant sleep aid. When newborns were subjected to a painful medical procedure (a heel prick to collect blood), they cried and grimaced much less if they were breastfed during the procedure. Compared to control infants (who were swaddled and not breastfed), they also showed a less pronounced increase in heart rate (Gray et al 2002).

Breastfeeding sessions may boost a baby’s levels of oxytocin, the “feel good” or bonding hormone that promotes calm restfulness (Uvnas-Moberg 2003).

Why is it about breastfeeding that triggers these effects? To some degree, breastfeeding is restful because it involves skin-to-skin contact—another established painkiller and natural sedative (Gray et al 2000; Uvnas-Moberg 2003). In addition, breastfeeding boosts the mother’s oxytocin levels, which enhances her maternal feelings and gives her a sense of calm (Keverne 1996). As a result, moms may be more successful at soothing their infants.

Breastfeeding may also have the added advantage of helping babies produce their own surge of melatonin (the “drowsy” hormone) at night (Cubero et al 2005).

Breast milk contains tryptophan, an amino acid that is used by the body to synthesize melatonin. Maternal tryptophan levels peak late in the day, and when infants consume tryptophan before bedtime, they fall asleep faster (Steinberg et al 1992). Is the tryptophan responsible? One study tested this hypothesis by feeding infants formula fortified with varying concentrations of tryptophan. When infants were given low levels of tryptophan during the day and high concentrations at night (mimicking the natural fluctuations of breast milk), infants fell asleep faster at night and got more sleep overall (Cubero et al 2007).

...but feeding is a controversial infant sleep aid

Given the various ways that feeding helps infants sleep, it might seem surprising to learn that many Western sleep researchers and pediatricians discourage parents from using feeding as an infant sleep aid.

Their objections are two-fold. First, there is the question of feeding frequency.

Some researchers believe that frequent feedings may prevent babies from learning to “settle,” that is, to sleep for lengthy periods during the night. In one study, newborns who were fed frequently during the first week postpartum—more than 11 times during each 24 hour period—were 2.7 times more likely than were other infants to have problems settling at 12 weeks (Nikolopoulou and St James-Roberts 2003).

Research also suggests that many young babies can be trained to awaken less frequently when their night-time feedings are delayed (Nikolopoulou and St James-Roberts 2003; Pinilla and Birch).

However, these studies are difficult to interpret, because the babies who experienced delayed feedings were subjected to other interventions as well. For instance, parents were instructed to provide their babies with strong cues about day and night. As a result, we can’t be sure which intervention was more important in reducing night wakings—-delayed night-time feeding or circadian cues.

Nor do these studies prove that frequent feedings cause sleep problems. It may be that some infants are needier than others—-and that those who need to feed frequently during the first week postpartum continue to need frequent night feedings later on.

More generally, these studies shouldn’t be interpreted as evidence that newborns should go for long periods between feedings.

The World Health Organization (WHO 1998), La Leche League, and the American Academy of Pediatrics (Work Group on Breastfeeding 1997) all recommend that newborns get fed at least 8-12 times per 24 hours. In fact, these organizations advise parents to awaken sleeping newborns if they haven’t fed for four hours or more. Older babies can go longer between feeds, but each baby’s situation is different.

Before attempting to curtail your baby’s feedings, you should check with your pediatrician.

The other major objection to using feeding as an infant sleep aid concerns self-soothing.

As noted above, Western sleep researchers often advise against letting babies fall asleep in their parents’ arms. Instead, they recommend that babies be put to bed while still awake. If babies cry, parents should resist the temptation to soothe them—at least for a few minutes. By holding back, parents will force babies to acquire their own “self-soothing” skills, and babies will learn to fall asleep by themselves. When babies experience arousals during the night, they will soothe themselves back to sleep without awakening their parents (France and Blampied 1999; Ferber 2006).

There is strong evidence to support these claims. Babies who are put to bed before they fall asleep are indeed more likely to soothe themselves back to sleep when they awaken again during the night (e.g., Anders 1979; Anders et al 1992; Ferber 1986; Goodlin-Jones et al 2001).

But does this mean you shouldn’t allow your baby to fall asleep during a feeding? Maybe not. Feeding appears to be a natural infant sleep aid, and soothing babies to sleep is the norm for our species. In many parts of the world, babies routinely fall asleep at the breast, and their parents don’t perceive this to be a problem (for more details about using parenting soothing as an infant sleep aid, see my article on baby sleep patterns). Moreover, some researchers are concerned about the physiological and psychological effects of strictly-imposed, solitary sleep regimens.

Typically, babies don’t adjust to such regimens without experiencing transitional distress. Does this distress cause long-term problems? Only a few studies have attempted to answer this question. They report no negative effects on daytime behavior, but the studies lumped babies together with children over 2 years old (France 1992; Eckerberg 2004). As a result, it’s unclear how babies fared as a subgroup.

Meanwhile, even those who advocate sleep training for babies warn that “cry it out” methods are inappropriate for babies less than 6 months (France and Blampied 1996; Owens et al 1999).


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