Dear Brian, There are, I’m told, long queues of parents outside your stall at the Brisbane Pregnancy Babies and Children Expo this weekend, waiting patiently for a Medicare-rebate-only consultation with you. You and I have had some communication in recent years, and I’ve aimed to maintain a positive relationship with you despite differences in perspectives. But as a fellow GP with a special interest in problems of infant crying, feeds and sleep, I find those long queues oddly disquieting. The queues are not only a measure of parents’ desperation for help. They are, most importantly, a measure of effective marketing of your research credentials and evidence-base. Your website tells us that your“sleep strategy combines medical research with practical routines that help parents overcome sleeping, feeding and growth issues in babies and children.” Unfortunately, various claims about this medical research on your web-site aren’t accurate. Is it OK to profit from Medicare through inaccurate advertising of research? I’d like to address a few of your claims. “[Dr Symon’s] study is one of only two accepted internationally as guiding advice on infant sleep based on Cochrane Collaboration criteria.” The Cochrane Review you’re referring to states that your 2005 study, a sleep intervention for babies 0-6 months, resulted in 29 more night-time minutes of infant sleep (or more accurately, of estimated time lying in cot without signalling to disturb the parents). Your approach belongs to a cluster of infant care interventions properly referred to as First Wave Behaviourism (FWB), since it arose in the 1950s and 1960s.1 The results of your intervention in this age group were not linked to improved maternal mental health. (In fact, postnatal depression is linked with a parent’s capacity to get back to sleep, not to the number of times she is woken by the baby.2) That same Cochrane Review found that your study had high attrition bias and high risk of other bias. It concludes: Education about sleep enhancement resulted in a mean difference of 29 more night-time minutes of infant sleep in 24 hours at six weeks of age … than usual care. However, it had no significant effect on the mean difference in minutes of crying time in 24 hours at six weeks and 12 weeks of age.… More and larger, well-designed studies are needed to confirm these findings. Importantly, two large, well-designed studies of FWB approaches for babies 0-6 months have now occurred. Both simply do not show positive effects of FWB strategies on crying and sleep when applied in to this age group.1, 3, 4 A systematic review by Associate Professor Peter Hill and me analyses 43 international studies of FWB interventions for babies 0-6 months, of which yours is just one, and shows that crying time is definitely not decreased, and possibly increases; that there is no evidence to suggest that FWB approaches help improve infant’s sleep behaviours in the long-term, or improve mother’s mental health in the short and long-term, in this age group. That is, there is no reliable evidence to suggest that training an infant 0-6 months to sleep for a slightly longer time at night without signalling improves a mother’s mental health.2 So is it accurate to state that your study is one of only two accepted internationally by the Cochrane Collaboration as guiding advice on infant sleep? I don’t believe so. “Dr Brian Symon presents a model of care which is proven by robust evidence(4) to improve infant sleep while simultaneously decreasing maternal scores for depression.” “Women report an 85% reduction in maternal depression. Dr Brian Symon, The Babysleep Doctor, British Medical Journal.” Your second study, which you are citing here, relates to babies between 6-12 months of age. This research, published in the BMJ Open (which is different to the BMJ itself, actually, because the BMJ Open requires authors to pay), shows that 35% of mothers of babies 6-12 months of age had mild or worse symptoms of depression on a DASS21 scale before your intervention, and this decreased to 5% after the intervention.5 It’s not that these mothers had a clinically diagnosed depression either – that’s quite a different thing. Your study wasn’t comparative, so any caring therapeutic intervention could have had the same effect or better – we don’t know. And without comparison we can’t know if the patient group who comes to see you already is a biased sample. So is this banner on your website stating that women report an 85% reduction in maternal depression accurate? Does it make it clear that the findings refer only to mothers with older babies? I don’t believe so. “[Dr Symon] represents one of many international care providers utilising a ‘behaviour modification’ approach as opposed to an ‘attachment parenting’ model. To suggest as your website does that there are two opposed infant sleep approaches available to parents, that is, either behaviour modification or ‘attachment parenting,’ is a significant misrepresentation of the complex scientific literature concerning infant sleep. To give one example, Dr Koa Whittingham and I have developed a new sleep program which draws heavily on behaviourism (Third Wave Behaviourism) and is not at all like what is popularly referred to as ‘attachment parenting’. Yet our evidence-based sleep program is also very different to the approach you are using.6 “The Babysleep Doctor strategy is designed to reduce infant crying and distress within 2 to 4 days, and to ultimately eliminate unnecessary crying and distress.” “Recently presented Australian research and papers at the RACGP conference in Adelaide(1,2) on the topic reports babies are commonly crying for 2 to 4 hours per day (24 hours). …These figures represent a common norm for Australian babies who have neither seen, nor heard of Dr Symon.” Despite your claims, which are proving a successful marketing strategy, your research does not demonstrate that your approach decreases crying behaviours in babies. Your first study on babies 0-6 months group showed no differences in crying time; your second study on babies 6-12 months did not measure crying.5, 7 You cite my own team’s publication, which I presented at the RACGP Conference last year, and misrepresent it. (The other presentation you refer to was neither a presentation of research nor a paper.) In that study, we showed that the Possums approach to unsettled babies in the first 16 weeks of life halves crying and fussing behaviours.8 We didn’t investigate average levels of infant distress. The parents who came to us were experiencing 6 hours of crying and fussing a day, which decreased to 3 hours after our assistance. As you know we don’t apply the FWB approaches that you recommend because they have been demonstrated to be ineffective in decreasing cry-fuss and sleep problems in the first 6 months, but our program showed excellent results. (This included substantially decreased Edinburgh Postnatal Depression Scale (EPDS) Scores, but since our study was preliminary, and since the EPDS may decrease with any kind and caring therapeutic intervention, we don’t overstate our findings.) Parent-baby sleep problems need time, and we would not dream of trying to meet families’ needs in a 20 minute consultation at a public Expo. It is fundamentally important to us that parents and babies are receiving care from health professionals that is based firmly on the latest evidence as reviewed by our peers in the medical literature. Dr Pamela Douglas MBBS FRACGP IBCLC PhD Medical Director, The Possums Clinic 1. Douglas PS, Whittingham K. Response to 'Sleeping like a baby? Infant sleep impact on care givers and current controversies'. Journal of Paediatrics and Child Health. 2015;51:234. 2. Douglas P, Hill PS. Behavioural 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. 3. Hiscock H, Cook F, Bayer J, Le HN, Mensah F, Cann W, et al. Preventing early infant sleep and crying problems and postnatal depression: a randomized trial. Pediatrics. 2014;133:1-9. 4. Stremler R, Hodnett E, Kenton L, Lee K, Weiss S, Weston J, et al. Effect of behavioural-educational intervention on sleep for primiparous women and their infants in early postpartum: multisite randomised controlled trial. BMJ. 2013;346:doi: 10.1136/bmj.f1164. 5. Symon B, Bammann M, Crichton G, Lowings C, Tucsok J. Reducing postnatal depression, anxiety and stress using an infant sleep intervention. BMJ Open. 2012;2:e001662. 6. Whittingham K, Douglas PS. Optimising parent-infant sleep from birth to 6 months: a new paradigm. Under review. 2014. 7. Symon B, Marley JE, Martin JA, Norman ER. Effect of a consultation teaching behaviour modification on sleep performance in infants: a randomised controlled trial. Med J Aust. 2005;182(5):215-218. 8. Douglas P, Miller Y, Bucetti A, Hill PS, Creedy D. Preliminary evaluation of a primary care intervention for cry-fuss behaviours in the first three to four months of life ("The Possums Approach"): effects on cry-fuss behaviours and maternal mood. Australian Journal of Primary Health. 2013;18:332-338.