Letter to and answer from the Danish National Board of Health

Letter to the Danish National Board of Health   

Information on the study of guidance on children’s sleep

Cry it out-sleep training (CIO) is a series of different methods in which the cries of babies and toddlers are ignored for shorter or longer periods of time with the aim of teaching the child to fall asleep alone. In Denmark, the “good night and sleep well” method (comparable to the Ferber-method, red.) from the bestselling book on sleep training Godnat og sov godt: Lær dit barn gode sovevaner (“Duérmete, niño” by Estivill / de Béjar (Sleep, Child. red.)) is one of the most common forms of CIO.

Proponents of the method believe the use is evidence-based, while other researchers and professionals point out methodological weaknesses in the studies of the various forms of cry it out, controlled crying and other forms of sleep interventions. The weaknesses include lack of control groups, or lack of control over whether the control groups also practiced various forms of sleep interventions. The method is debated and some would say controversial.
(For more information go to The reason cry it out-sleep training (CIO) should be discouraged)

Because of this, the NGO ‘Sleeping Children’ (Sovende Børn, red.) conducted a comprehensive study of the actual sleep guidance professionals, especially health visitors, provide to parents in 2019-20. The study reveals that among health visitors there is great variation in the individual practice of the guidance given to parents, including, but not limited to, guidance in leaving and / or ignoring a crying child.

Current counseling sets a framework for evening and night care that is in direct contrast to the research-based knowledge that exists about the toddler’s sleep and the need for sensitive response during sleep and the nocturnal awakenings. This applies to public and / or health professional advice, including the Danish National Board of Health    , and deals with knowledge about children’s biologically normal sleep, attachment theory, as well as children’s cognitive and emotional development.

Our study consists of a voluntary questionnaire for parents in Denmark, the Faroe Islands and Greenland about the recommendations and guidance they have received in regard to sleep. The questionnaire was answered by 3627 respondents, and 2711 of the responses concerned children born in 2017-2019, which is the primary period of the study.

In addition, we have asked for access to documents and asked questions to all the leaders of all 98 Danish municipalities’ health visitors about counseling in children’s sleep and sleep training. As part of this, we have read all written material about children’s sleep from the health visitors in Danish municipalities, which access to documents, inquiries and review of websites allowed us access to. We have also read those of the Danish National Board of Health’s publications that are relevant in Relation to children’s sleep, as well as other public or health professional websites with advice on baby and children’s sleep.

Our study highlights the discrepancies between current practice and the evidencebased knowledge about children’s sleep and at the same time the study points to a required action:

1. 1. Parents are recommended Cry-It-Out sleep training by professionals, especially health visitors
      312 respondents (12%) who had children born in 2017-2019 had received advice on cry it out-sleep training from at least one professional, with health visitors, doctors and childcare professionals accounting for the majority of these recommendations. We have identified that the health visitors have recommended cry it out-sleep training in 67% of the surveyed geographical areas, which were the 98 Danish municipalities as well as Greenland and the Faroe Islands in the years 2017-2019. 25% of the parents who received guidance in cry it out-sleep training from their health visitor received the guidance when the child was 0-3 months old.
      (For more information go to Information on guidance in sleep training from Danish municipalities and Questionnaire on sleep guidance)
   2. Parents are given outdated advice in baby and child sleep, which is in contrast to existing research-based knowledge about and in relation to sleep
      This includes, but is not limited to, guidance in interpreting the child’s crying as ‘protests’, instructions against sensitive response, recommendation to separate food and sleep, using fear based appeals in the guidance on eg cot death (SIDS) and bedsharing, and advising parents from a norm of solitary sleep, despite a myriad of leading researchers, biologists and anthropologists pointing out that this is in stark contrast to the biologically normal sleep of children. In addition, there is a lack of information about the consequences of following current guidelines, such as. involuntary breastfeeding discontinuation.
      (For more information go to Major discrepancies between research into children’s sleep and the advice parents receive)
   3. It is necessary for the Danish National Board of Health to immediately initiate work to update, nuance and elaborate on the board’s recommendations and guidelines so that they reflect the latest research
      It is essential that professionals – especially health visitors – get more information and updated tools to help parents make informed choices for their children, themselves and their family. It is necessary that the revised material is subsequently distributed to the relevant authorities, ie. municipalities and health professionals.

We turn to the Danish National Board of Health, as it is the Board that publishes the publications that form the basis for guidance in the area.
We ask for the Danish National Board of Health’s comment on the three points.

We must point out that we plan to publish the study around 20 January 2021 and would be grateful if we can get the Board’s concrete comments on the three points before 10 January 2021.

In addition, we state our most important recommendations for the updated guidelines, cf. point 3 above:

1. 1. That the Danish National Board of Health’s material on children’s sleep is based on the latest research-based knowledge about and in relation to children’s sleep, development and attachment, and that these are presented in the board’s publications to both professionals and parents.
   2. That the publications from the Danish National Board of Health inform about the importance of sensitive response at all hours of the day, do not contain elements of sleep training and contain specific methods as an alternative to sleep training.
   3. That the Danish National Board of Health re-evaluates their position in relation to bedsharing, including cot death (SIDS), and in the future includes guidance in safe bedsharing as part of the standardized guidance given to parents, on the basis of updated research in the field.
   4. That the Danish National Board of Health nuances and broadens the concept of what is considered ‘normal’ with regard to baby and child sleep, so that it reflects the real variation in the area to a greater extent.
   5. That the Danish National Board of Health initiates an active effort to distribute these updated publications to the relevant professionals, especially health visitors, so that they have common standards to ACT within.
   6. That the Danish National Board of Health immediately, before the new publications are available, instructs health professionals and other relevant professional groups to refrain from recommending and / or advising sleep training, including cry it out-sleep training, and to dissuade parents from using the same.

Sleeping Children is happy to provide further information about the study, general elaborations or input in connection with changes to the recommendations and guidelines of the Danish National Board of Health.

The Board will find our survey is attached, for confidential consideration, so that the agency has the opportunity to comment on it.

We request the Board to provide a receipt of this letter as well as the attached appendices.

Kind regards

Mette-Sophie Lassen and Mia Bernscherer Bjørnfort
Mail: info@sovendeboern.dk
Phone.: +45 61704702

Detailed information about the study can be read in the attached appendices:

1. 1. Summary: Study of guidance and practice in relation to child sleep and sleep training in Denmark, Greenland and the Faroe Islands​
   2. The reason cry it out-sleep training (CIO) should be discouraged
   3. Major discrepancies between research into children’s sleep and the advice parents receive
   4. Review of the Danish National Board of Health’s guidelines for sleep
   5. Health visitors information on sleep in their pamphlets and on their websites (Appendix)
   6. Summary review of municipal websites, pamphlets and municipalities’ references to other sources
   7. Questionnaire on sleep guidance
   8. Information on guidance in sleep training from Danish municipalities
   9. What guidance on children’s sleep can be found on the Internet?
   10. What guidance on children’s sleep can be found on the Internet? (Appendix)
2.