As if growing up were not hard enough, there are inevitable events that might significantly disrupt your child's healthy sleep habits. Other special concerns, such as frequent injuries, may well be the result of unhealthy sleep habits. Here are some examples:
Changes with Daylight Savings Time
When you move the clock time an hour earlier or later, continue to sleep your child according to the new time. If her bedtime has been about 6:30 P.M., and you moved the clock forward an hour so her old 6:30 is now 7:30 P.M., still put her down to sleep at the new clock time of 6:30 P.M. The reason you can ignore the time change is because a lot of social cues in the family such as active or quiet times, meals, bathing, outdoor play time is adjusted with the time change, and these social cues help regulate your child's sleep schedule.
New Sibling
If you are expecting another child, it is best to maintain as much regularity as possible during the pregnancy and not move your young child to a bed until the new baby is about four months old, if then. Toward the end of the pregnancy, the mother is more tired and the older child becomes aware that her mother has less energy or patience. Receiving less attention or not as prompt a response is something that she will have to get used to. So don't kill yourself putting forth a heroic effort; it will only delay your older child's learning to adapt to the inevitable: a decrease in parental attention. When the newborn is about four months old, the developing biological rhythms in the baby permit a new and stable social rhythm in the household. The older child now knows that there are approximate times when her mother is feeding the baby or putting it to sleep. The stability of these events makes the older child feel more secure.
If you need to move the older child from a crib to a bed, consider leaving the crib up and empty for a while before the younger child is shifted to it. The parents’ understanding is that she is graduating to a “big kid's” bed, but the child might not have the same opinion. Prepare yourself for the possibility that, either because of fearfulness in the big bed or because the child now realizes she can easily get out of bed to explore the house, you might have to return her to the crib. Sometimes a crib tent is necessary because your child is curious about the new baby at night but you do not have the energy to repeatedly do the silent return to sleep (see Chapter 7). Don't be inhibited because of a fear that you are causing a “regression” or sense of failure in your child. Under these circumstances, the baby might have to go to a portable crib, another crib if the children are close together in age, or maybe some temporary larger substitute for the bassinet.
Twins, Triplets, and More
Let's face it: Having a baby is a blessing and a bother. With two or three babies at the same time, the blessings are two-or threefold, but the bother is about ten or twenty times as great! The reason why the bother is so much greater is that you can't clone yourself. When one child is awake and wants to play but the other needs to be put to bed, or when one baby needs to be fed at the same time as the other needs to be changed, you've got a problem. Not everyone has family members or hired help to give them a break, and even if you are lucky in this regard, there are still times when both the mother and father are exhausted from not getting enough sleep. However, if you plan ahead and if the father is actively involved, as described in the story of Caleb and Ezra, then the duration of your sleep-starved state will be shorter.
CALEB AND EZRA
As much as it gave us great joy, the news that we were having twins shocked us as well. We hadn't had children yet, so how our lives would work with one baby was a big question, but two seemed to raise to an unimaginable degree the level of responsibility and the sheer amount of labor we anticipated. Eventually the shock faded, giving way to excitement tempered by trepidation, and we began facing the many tasks we had to do.
We had our share of endless nights, during which someone was up every hour with one fussy fellow or another—or both didn't fall back to sleep without being walked back and forth. In a sleep-starved daze, we both covered many miles during those nights. To keep track of who fed whom, Jen and I drew two clock faces, one for each boy, on which we would record the time we retrieved either Ezra or Caleb, how many ounces of formula he consumed, and what time he went back down. To maintain our sanity—or as a record of its fragility during these sleep-drained hours—we would amuse each other with humorous notations on the clocks.
During the day the boys would sleep with regularity; up for an hour or so and down for several. One thing we experienced in full force, when the boys were around six weeks old, was heart-wrenching, inconsolable, nonstop crying at the end of the day, starting around 6:00 P.M. and sometimes lasting until as late as 10:00 P.M. before the exhausted babies would relent and drift off to sleep. During their fifth and sixth months, they began to sleep through the night. On the rare occasion when we did hear one of them cry or yell out during the night, we would resist the urge to react, and within a few minutes the baby would soothe himself back to sleep. We took advantage of their ability to soothe themselves to catch up on our sleep, too—even with the rest, two babies are a lot of work and we need all the energy we can muster.
One of our concerns, specific to having twins who sleep in the same room, has been about one baby waking the other. When our boys were about seven and a half months old, Ezra was waking Caleb up consistently. We consulted with Dr. Weissbluth, who instructed us to keep a twenty-four-hour chart for each baby over the course of a week. We recorded, in half-hour increments, whether the boys were asleep, awake and crying, or awake and happy. With this information, Dr. Weissbluth was able to tell us that we should put Ezra and Caleb down for naps at 9:00 A.M. and 1:00 P.M., and that it was time to eliminate their third nap of the day. This approach smoothed out their sleep pattern.
Overall, we have simply had to revise our expectations of how much time we have available and what we can accomplish. Adhering to a schedule that dictates the amount of time the children will be awake has circumscribed our activities. This would be true for anyone who chooses to abide by Dr. Weissbluth's approach to sleep. But with twins, it's even more pronounced: Since the multiplied tasks of child care place a greater demand on our time, there's even less time left for the extras. We had adjusted to this in various ways, but the sacrifices we've had to make during these months have very clearly been worthwhile. We never cease to hear people comment when we go out: “Oh, look, twins!” and “They're so cute” (which I, of course, can confirm). More than that, we constantly hear remarks to the effect that the boys are so well behaved and remarkably calm.
Raising “multiples” requires an extra degree of forethought, communication, planning, and sheer work. Two parents for whom sleep is an enchanting memory have to struggle to find the energy it takes to do all the work, mental and physical, necessary to take care of twins. Having had this experience, it's clear to me that training a child to sleep well is an extraordinarily crucial component to child rearing, especially when you're having more than one.
Here is an account from a family where the twins initially were overtired.
NIKOLAI AND ALEKSANDER
Nikolai and Aleksander, our identical twin boys, were born six weeks early. For the first few weeks, the boys slept soundly and cozily together in their crib. We had been instructed by the hospital to wake them at night for feedings, which we did happily. As they gained weight and their actual due date neared, they became more and more alert, much to our delight. Perhaps due to their early sleepiness, it didn't even occur to Mike and me to put the boys on any kind of schedule, or to protect the sleep. We both just assumed they would fall asleep when they were tired. When Nik or Aleks started to cry after two or three hours of wakefulness, we chalked it up to fussiness. When they took only a few very brief naps a day, we assumed they weren't sleepy children, and that most babies were like that. We told our friends and family that the boys could barely sleep an hour or two at a time at night, and they advised us to keep them up during the day so they would be tired at night. When that didn't work, we relied on reports that things would improve when they hit the three-month mark. We took the nights in shifts—I would sleep from 8:00 P.M. to 1:30 A.M., and then take over so Mike could get some rest—and gritted our teeth, waiting for the day they would be three months old, at which time they would embrace naps and bedtimes with sweet smiles and contented sighs.
Not only did that day never come, but the older Aleks and Nik got, the worse their sleep patterns became. They could manage to sleep a couple of hours if they were cuddled up on Mike or me, but they did not sleep in their crib for longer than twenty minutes at a time. When I asked their pediatrician about it at their four-month checkup, he told me it was normal for infants to have such short, erratic sleep. When I left his office, I knew he was wrong. I sought out Dr. Weissbluth and his book, and was amazed by what I read! I had been doing all the wrong things with my children—keeping them awake for several hours at a time, rushing in to rescue them from their beds at the slightest peep, allowing them to “snack” on poor-quality stroller, swing, or car seat sleep all day! Was it possible that my kids did need sleep, and I just hadn't been providing the right conditions for it? I felt horribly guilty for torturing my poor boys!
We began trying to help Nik and Aleks improve their sleep habits immediately. It seemed logical to attempt to get the boys on the same sleep schedule. We decided to temporarily have the boys sleep in separate rooms, which was a difficult decision for me to make. I had very strong feelings about keeping the boys together from the time they were born. I felt they would feel safer, more secure, and comfortable if they could sleep together. I think I wanted them to continue what I considered to be an idyllic, symbiotic existence inside the womb. I still feel strongly about sleeping twins together, and wish that our circumstances hadn't forced our hand in this matter.
Our boys were incredibly overtired when we began to employ Dr. Weissbluth's ideas and, as a result, they were overly sensitive to outside stimuli. The slightest floorboard creak would wake them from sleep with a jolt, and they would scream at the top of their lungs. As one can imagine, if small household sounds woke them so easily, the ear-piercing wails of their brother would do the same. Having two screaming babies was inordinately stressful, and made it virtually impossible for them to settle down and fall back asleep. We didn't have much room in our apartment, so we chose to let Nik, who slept more soundly, sleep in our room in his crib, while Aleks stayed in his own room.
Mike and I continued our nightly “shifts” as we instituted Dr. Weissbluth's plan and set out to improve our children's sleep habits. I spent many difficult nights questioning myself and feeling bad for “making” my children cry. Although we saw improvement immediately, it took several weeks before Aleks and Nik had completely adjusted to the new sleep routine. I believe it really took them months to get over those first months of so little sleep. The transformation was slow, but nearly miraculous. Our sweet, dear boys, who had probably been getting no more than eight to nine hours of irregular sleep a day, were now sleeping up to sixteen and eighteen hours a day! I often wonder if I ever would have figured out on my own that my sons, who initially seemed to need so little sleep, were actually in need of the absolute opposite.
As the months passed, I began to see that Nik and Aleks were way at one end of the sleep continuum—they needed, and continue to need, a lot more sleep than the average child. Around the time they were a year old, they were actually falling asleep at around 4:30 or 5:00 in the afternoon, and sleeping until about 6:30 in the morning! Then they would take a nap at around 8:30 for one to two hours, and a nap at noon for another one to two hours. They didn't give up their third nap until just before their first birthday. Our realization that they required so much sleep was a revelation—we had finally found the “key” to unlock their sunny, curious, exuberant personalities. Having kids with such high sleep needs, however, hasn't been easy. On the contrary, it's been a real pain in the neck to protect their sleep so vigilantly. Before they were about two and a half years old, missing one nap would send our family into a tailspin—three to four days of fragmented nighttime sleep, resistance to their regular naps, crabbiness, et cetera. I can count on my hands the number of times we allowed them to miss a nap or stay up late before they turned three. The cost of such a move was so great that few things were worth the price.
When Aleks and Nik were thirty months old, Michael and I were preparing for the birth of our youngest son. My in-laws purchased two beautiful “big boy” beds for the twins, and we excitedly set them up and let them loose. The twins had escaped from their cribs on a couple of occasions, but had responded well to reprimanding. They were capable of sleeping safely in the twin beds, but did not seem able to follow instructions to stay in them. Looking back, I realize that attempting to make the move so early was a mistake. Bedtime became a circus, complete with two wild monkeys, jumping and running around their rooms each night. After two months of little improvement, one night they fell silent almost immediately after their bedtime routine. I was hopeful that all the bribes, cajoling, and scolding had finally worked, but I went in to check on them anyway. I walked in to find Nik standing on his bed, snapping the wood blinds from his window in half, carefully sliding them out of their frames and handing them over to Aleks. Aleks was sitting quietly, stacking my broken blinds on his bed. We dismantled the beds and put their cribs back up the next day.
We set the twin beds up again soon after the boys turned three. The first few nights were successful, but things began to deteriorate soon after. Even in their pitch-dark room, Aleks and Nik would run around their room, empty their dressers, jump on their beds, and stay up one to two hours past their normal bedtime. Within a few weeks they were engaging in the same kind of behavior at nap time, and Mike and I knew we had to make a change. This time, it was easy for me to make the decision to separate them. The difficulty was where to put them! We settled on putting Aleks to bed in our room. After their bedtime stories, Nik stays in his room, and we take Aleks to our bed where he sleeps until we're ready to go to bed. At that time, we carry Aleks back into his room. While the situation is not ideal, it has been very successful for us. At three years of age, the boys fall asleep between 7:00 and 7:30, wake up around 7:00 A.M., and take one nap a day from 1:00 to 3:00 P.M. Aleks is incredibly cuddly and happy to return to his bed each night, and it doesn't seem to affect his overall sleep habits. After feeling so strongly about keeping the twins in the same bedroom, I would be the first to give them their own rooms now if our house provided it. At this stage in their lives, I think it would be healthy for them to have a few hours to themselves after playing together all day. In addition, the separation relieves them of the pressure to perform for each other.
Tomas arrived when the twins were thirty-two months old. I never realized how difficult it was to have twins until he arrived! It's such a relief not to panic at every cry, for fear of waking the “other” baby. Of course, I have to admit that Tomas has made it really easy on us. He is even-tempered, sweet, and happy. He was practically sleeping through the night within a week of coming home from the hospital. In the first few months, we could tell when he was sleepy, as it would be the only time he'd cry. Now that he's nearly six months old, he continues to be patient and calm. I'm careful to maintain his nap schedule and to put him to bed early at night, and he wakes up happy and content, cooing and smiling. His sweet, gentle demeanor makes me wonder what Nikolai and Aleksander would have been like at his age if I had incorporated Dr. Weissbluth's ideas immediately after they were born!
There is ample evidence that genetics contribute significantly to shaping our sleep patterns. Identical twins sleep more like each other than fraternal twins. So there are limits on what we can do to modify their schedules if we attempt to synchronize them. As discussed previously, the regularity of the mother's activity/rest cycles and her sleeping and eating patterns before the babies are born may substantially contribute to the regularity or irregularity of her babies.
With twins, triplets, or more, the major principle is to start sleep training early.
Early sleep training means starting around the time the babies are born, or around the time of their due date for children born early (many twins or triples arrive before their due date). The first principle is to avoid the overtired state. Try to put your babies down for a nap, using Method A (see page 235), after a wakeful period of one or two hours. If they get overtired, it is harder for them to fall asleep. The more rested they are, the more adaptable they become later, and the more successful you will be in synchronizing their sleep schedules when they are older. Because the clock machinery is not really well developed during these first few weeks, you can't set their clocks to the same “time.”
Counting from the due date, over the next six weeks, you will notice more and more fussiness and wakefulness; by six weeks of age, it is mostly concentrated in the evening hours, about 7:00 to 10:00 P.M. During these increasing spells of agitated or fussy wakefulness, do whatever you can to calm and comfort your babies. Remember, you can't spoil your babies, so during these spells do all the holding, hugging, nursing, or whatever works to keep your infants comfortable.
The next step in early sleep training, at about six weeks after the due date, means trying to control the wake-up time in the morning with the goal of partially synchronizing the babies’ sleep/wake cycles. The earlier we start the process and the more rested our children are, the more likely it is we will succeed.
So, around six weeks after the due date, when one baby awakes in the morning, you declare that the day is starting and night sleep has ended. This will usually occur between 5:00 and 8:00 A.M. At that time, awaken the other baby or babies. Remember, we are doing this at a few weeks of age to help synchronize their sleep schedules, but this maneuver of controlling the wake-up time may also be applied to older twins and triplets. If you are experienced parents, you might want to try to control the wake-up time when the children are much younger. If you are good at reading the babies’ cues and you have identical twins, then you might be able to synchronize their schedules when they are very young.
After both children are up in the morning, the next step is to keep the following interval of wakefulness ultra-short. We are going to try to put both children down for the first nap—together, in the same room or crib—after only one hour of wakefulness. Try as best you can to change, feed, and soothe them back to sleep within a total time of one hour. This means that you will probably have no time to play with them during this brief morning wakeful period. During this hour of wakefulness, if there is bright natural sunlight, open all your shades and expose them to this light, because exposure to bright morning light helps to set the sleep/wake clock.
Let's stop for a quick review: start early, avoid the overtired state, use Method A, control the wake-up time, allow a very brief interval (only one hour) of wakefulness, and exposure to bright light.
Now comes the hard part, especially if you are an inexperienced parent. Our hope is that your children will be able to learn some self-soothing skills even at this very young age. The most important point is to put your babies down to sleep after several minutes of soothing whether or not they are in a deep sleep state. This simply means that your children may be fully asleep, completely awake, or in a state between wakefulness and sleep at the time when you put them down.
If one or both babies cry as you walk away, leave them alone—but look at a clock so that you will know when they have been alone for five to ten minutes. Here are two common scenarios: Your babies cry very hard for a few minutes, then cry quietly for several minutes, and then fall asleep. Or possibly your babies cry hard for several minutes and do not appear to be able to fall asleep. Of course, one child may go one way and the other child another way. Your goal is to get and protect the morning nap for one or both children.
If your baby does fall asleep, don't be surprised if the duration of the nap is brief; naps tend to lengthen only at twelve to sixteen weeks of age, counting from the due date. Within any subsequent two-hour interval, try to put both children back down for a nap. This is because most young babies do not comfortably tolerate more than two hours of wakefulness.
If your baby does not fall asleep, rescue your baby or babies. You now have two choices. First, you may sense that after several minutes of hard crying your baby will now be able to fall asleep, so you repeat the process of soothing back to sleep. Or else the crying was so stressful for all of you that you will quickly go out for a walk, enjoy playing with and comforting your baby, and try this maneuver again another day. Remember, you want to give your babies the opportunity to learn how to soothe themselves to sleep. You are practicing consistency in how you soothe the baby to sleep and timing to avoid the overtired state.
If you had only one child, you might decide to always hold or nurse that child until he or she was in a deep sleep state and then either put the baby down alone or sleep with the baby in your bed or sofa (Method B, see page 236). The simple truth is that you cannot be consistent with Method B if you have twins or triplets. So stick with Method A. Because the process of falling asleep is learned behavior, your babies will learn faster if you are consistent in how you soothe them to sleep.
At night, an early bedtime is helpful because it regularizes and lengthens naps. Here, too, consistency in the style of soothing to sleep is helpful.
If you have older twins or triplets, between four and fifteen months of age, control the wake-up time, expose them to bright light in the period after they wake up, and practice consistency in how you soothe your babies to sleep. Now your goal is to put them down for naps at about 9:00 A.M. and 1:00 P.M., and not to let them sleep at other times during the day. Expect your babies at fifteen to twenty-one months of age to need a single nap between noon and 2:00 P.M.
Here is the story of one mother who started sleep training her twins at eleven months of age.
CAROLINE AND LAURA
As a new mom, I was very reluctant to let my babies cry when they reached the four-month mark. Although my rational side (smaller every day, due to sleep deprivation) believed that children would sleep better if they learned to soothe themselves to sleep, I was filled with anxiety that I might be doing the wrong thing … they would be emotionally scarred, feel abandoned, or at a minimum be in pain and need our care. My husband, convinced that life must get better, had to force me to stay in our bedroom while the girls learned to soothe themselves to sleep. They cried for only about fifteen minutes, but it seemed like days.
They cried less each day for three or four days and rarely cried at nap time after they learned to soothe themselves to sleep. I no longer spent hours every day rocking them to sleep. What a relief. We also found that sleep begets sleep … the better they napped, the better they slept at night.
I now have six-month-old Peter, who has been a joy in every way, starting with the fact that he was not part of a set. With two “guinea pigs” before him, I don't need to try all the tried-and-true sleep remedies. I now know what works and what doesn't. When he was fourteen weeks old, I started him on a 9:00 A.M. and 1:00 P.M. nap schedule with a 6:00 P.M. bedtime. Starting a predictable schedule at fourteen weeks was much better than waiting for eleven months for some organization in my chaotic household. When he was four months old, I let him learn to soothe himself to sleep. He cried on only four different occasions, for no more than ten minutes each time. Starting a schedule and self-soothing are proving much easier at such a young age.
The plan to have the babies asleep and awake at about the same time may initially fail, because there is a strong genetic component that influences how long babies sleep, how regular are the times when they need to sleep, and how self-soothing they are when put down to sleep. Therefore, you may be more successful in synchronizing sleep schedules with identical twins than with fraternal twins. But even identical twins can have their own personality! Prepare yourself for the possibility that one twin may be a good sleeper (self-soothing, long sleep durations, regular sleep patterns) and the other twin is the opposite.
As I mentioned, in the beginning, place your babies together in the same room, or even the same crib. Many of these babies seem to enjoy touching each other and sometimes appear to help the other one sleep by stroking, petting, or even putting a hand or finger in the mouth of the other. Later, if it becomes apparent that one twin or triplet is interfering with the sleep of another, then you have to try to separate the “bad sleeper” from the “good sleeper.” Sometimes this is easier said than done because of the number of rooms in your house. Be creative. You might temporarily put one child in your bedroom for naps, or perhaps you have a large walk-in closet, or maybe there is some attic or basement space where you can create a nest for naps. This temporary separation might be needed until the “bad sleeper” settles down to a regular nap pattern, which usually evolves between twelve and sixteen weeks after their due date. Also, please do not be surprised if the twins do a flip-flop and the one who had been a “good sleeper” becomes a “bad sleeper” and vice versa. The truth is that during the first few months, there is a lot of shifting around in daytime sleep patterns. All children sleep better during the day around three or four months of age, so be patient.
When I discussed the problem of trying to synchronize sleep schedules when one twin naps better than the other with mothers and fathers at a support group for parents of twins, some said they would wake up the good sleeper, go out to have fun, and then put them both down together for the next sleep period. The risk is that the good sleeper might become overtired because the child's needs are not met. Other parents let the good sleeper finish the nap and later put them down together. Here, the risk is that the bad sleeper becomes very overtired from being up too long. The mother of Ezra and Caleb, currently two excellent sleepers, really summed up the majority sentiment when she said, “You just have to compromise.” Sometimes letting the good sleeper snooze a little longer before waking him up is all it takes to produce some regularity in the sleep routines.
Here's the conflict: You want to avoid the overtired state and you want to synchronize their sleeping patterns. Sleep logs, as described on pages 118 and 221, are very helpful to get a handle on how to strike a good compromise.
Each family with twins and triplets has its own strengths, resources, and stresses; please consider reviewing your situation with other parents of twins and triplets or your pediatrician before sleep problems develop.
Moving
The only thing worse than moving is moving with children. You pack, they unpack. You clean up, they make a mess. Here is one account of how moving upset a child's routine.
“NICHOLAS KNEW THIS
WAS THE TIME TO
REALLY STICK IT TO ME”
Nicholas had an established sleep pattern before we moved, but after … !
Bill and I started packing up the apartment about two months before we moved; Nicholas's response to this preparation was to change his sleep pattern. But we weren't too worried, since we assumed it would change back once we were moved and settled. It didn't. We moved when he was about eight months old. Well, by the time Nicholas was nine months, I needed another chat with Dr. Weissbluth to discuss Nicholas's frequent night wakings.
My husband was with my father for the opening of trout season that weekend, and Nicholas knew this was the time to really stick it to me.
Nicholas had had a cold for weeks. Thursday night he cried from 7:00 until 11:00 P.M. I went in several times to try to calm him. I knew that what I should be doing was turning off, or down to a whisper, the intercom and letting him work it out, but I thought the cold had something to do with it. Dr. Weissbluth said the cold did have something to do with it—plain and simple. Nicholas needed more sleep to shake it, but just as important was the routine Nicholas had to learn (again). The doctor made me promise not to go in the room at all until between 5:00 and 7:00 A.M.: “Load him up with Desitin and hugs and kisses and close the door.” The first night the crying stopped after about an hour and a half, but by Saturday Nicholas cried for only five minutes. Now he will perhaps play for at least a few minutes, then before I know it, his head is down and we have a quiet, happy baby twelve hours later!
Your general goal is to maintain as regular and consistent a pattern as possible when preparing for and following a move. Resist the temptation to drag the baby to the home improvement store or garden shop when he should be sleeping. If your child is young, say less than a year old, quickly reestablish the bedtime rituals and sleep patterns that worked best before the move. Be firm, and after allowing a day or two for adjustment to the new surroundings, ignore any protest crying that may have evolved from the irregularity and inconsistency during the move. If your child is older, say a few years, go slower. Fears of newness, excitement over novelty, and uncertainty regarding further changes may cause new problems of resistance to naps, difficulty falling asleep at night, or night waking. Be gentle, firm, and decisive. Reassurance, extra time at night, night-lights, and open doors have a calming or soothing effect. Be somewhat consistent in controlling this extra comfort so that the child does not learn that it is completely open-ended. For the older child, consider using a kitchen timer to control the amount of extra time you are going to spend with her. The timer helps the child to learn to expect that mom or dad will leave for the night after a predictable time period. Place the timer under a pillow or cushion to muffle the sound.
Anxiety or fear in your child regarding a move is natural, normal, and not something that should unduly alarm you. After several days, start a deliberate process of “social weaning” to encourage a return to your old, healthy sleep habits by gradually reducing the duration on the timer. This should usually take no more than several days in most instances.
Vacations and Crossing Time Zones
Think of a vacation with your child as sort of a semiholiday. After all, you may spend a lot of time baby-sitting among the palms on sun-drenched beaches. I have spent many hours building simple sand castles, trying to keep one eye on the castle architecture and the other eye on a nonswimmer jumping over small waves. This intense concentration is not very relaxing!
Try to flow with your child; be flexible, forget schedules, try to have as much fun as possible, and don't worry much if your kids become tired. Irregularity and spontaneity are part of what makes vacations fun.
When you cross time zones, you might suffer the ill effects of jet lag. You are conditioned to sleep when it is dark, but activity/rest cycles and feeding habits also get messed up when you cross time zones. Children seem to be more sensitive to light, especially morning light, than adults are, so use this to help defeat the jet lag. The day after you arrive, or the next day for a very long trip—both at your destination, at the beginning of the trip, and home when the vacation is over—wake your child at the usual wake-up time.
Scenario one: You leave your home very early in the morning because of holiday traffic and the extra time required because of airport security. You arrive at your destination, and it is now very late at night. By the time you claim your luggage, rent a car, drive to your hotel and get settled, everyone is exhausted. It's been a long day! So everyone sleeps in late the next morning. If your child is napping, the late morning wake-up causes the nap(s) to be later. Therefore, wake up your child after a one-to two-hour nap in order to protect a reasonably early bedtime. The following morning, either wake up your child at his routine time to reestablish his regular sleeping schedule, or repeat the process of shortening the nap to more gradually get the bedtime to its regular early time. If your child is not napping, over the next day or days control the wake-up time by waking your child earlier either a lot or a little until you get to your normal wake-up time.
Scenario two: You arrive at your destination and get settled in by midafternoon or early evening. The day after you arrive, wake up your child at the usual time. That is, if you usually get up at 7:00, rouse your child at 7:00 local time, no matter what the time difference. Try to expose him to bright morning light. Continue with the schedule as if you had not taken a trip, using local time for naps and the night sleep. Naturally, there will be some irregularity, no matter how hard you try, so assume that when you return home, your child may be overtired.
Once you're home, it's boot camp again—back to the basics, with all the regular routines. Repeat the strategies described above. Within a few days, if you are firm, consistent, and regular, your child will learn quickly that the vacation is over. If your child was well rested prior to this vacation, expect only one rough, crazy recovery day of protest crying. Trying to gradually soothe your child back to her previous good sleep routine over several days often fails because the child fights sleep in order to enjoy your company.
You may avoid having a “reentry” problem by carefully planning ahead, as Claire's parents did.
CLAIR FIRST VACATION
Having spent our previous vacations as young marrieds, jaunting lightheartedly to Hawaii, the Canadian Rockies, England, Europe, and New England without an itinerary or reservations, it was with some trepidation that my husband, Tom, and I launched off on our first vacation as new parents with our eight-month-old daughter in tow. We chose a family-oriented beach resort (only one time zone away), which was conveniently located near a major city of historical interest that we had never visited. We decided to spend our money on above-average accommodations, knowing that with an eight-month-old we would be spending more time there and might as well make ourselves comfortable. We selected a two-bedroom/two-bath condo with a kitchen and large living/dining area, which ensured that Claire's naps and bedtimes wouldn't interfere with our activities and vice versa.
Our daily schedule certainly was not as hectic as when we were just a couple, but we did manage to relax more and have a great deal of fun. We tried to preserve Claire's two-nap-a-day schedule and approximate bedtime hour, but we wanted to be flexible, too. A typical day for us would begin with breakfast at the condo followed by a walk on the magnificent beach looking for shells and sand dollars. Because the sand is firmly packed there, we could push Claire's stroller right along on the beach, which allowed us to venture farther than if she'd been in the backpack. About midmorning we'd return to the condo for Claire's nap. One of us would lounge on the sundeck while Claire was sleeping, while the other would be free to go swimming, shopping, cycling, or whatever.
After lunch—either a picnic by the park/playground near the condo or a meal at the snack bar by the pool—we'd pack up the car and head to a nearby attraction. Claire would promptly fall asleep in her car seat for her afternoon nap, a habit we never practiced back home, and be ready to go again after we reached our various destinations about an hour or so later.
We ventured out to dinner with Claire on several occasions, picking one of the resort's family-oriented restaurants and arriving early (both before the larger crowds and to be closer to her typical suppertime). After another walk on the beach, we'd follow Claire's bedtime routine and put her to sleep at about her normal hour in the rented full-size crib in her own room. We then had time to enjoy some wine, read, catch up on our conversation, or plan the next day's activities.
Yes, it was quite a different style of holiday for us! But the new scenery was fascinating, and with some advance planning (like arranging the crib rental and packing a special box with Claire's walker, backpack carrier, and favorite toys), we all were able to enjoy our first vacation as a family.
Frequent Illnesses
Night wakings routinely follow frequent illnesses. First, let's have a clear understanding of what is happening. Videotapes of healthy young children in their homes at night show that many awakenings occur throughout the night, but the children usually return to sleep without any help. Fever can alter sleep patterns and can cause light sleep or more frequent awakenings. So it is not surprising that a painful illness with fever, such as an ear infection, causes an increased number of night wakings. These more frequent and prolonged arousals often require your intervention to soothe or calm the child back to sleep. Your child might now begin to associate your hugging, kissing, or holding at night with returning to sleep. This learning process might then produce an alteration in the child's behavior or expectations that continue long after the infection passes. Now we have a night-waking pattern.
Actually, awakening at night is not the problem. As we have seen, spontaneous awakenings are normal, as are increased awakenings with fever. Naturally, parents should go to their sick children at night. The real problem once the child is healthy again and not bothered by pain or fever is his learned difficulty in returning to sleep unassisted.
How can you reteach your child to develop her own resources to return to sleep after awakening? Remember, parents are teachers and we teach health habits, even if the child might not initially cooperate or appreciate our efforts. Here are three options:
Option one: You might decide that since children are frequently ill and you can't let your child down when he needs you, you will always respond, and you will simply wait for the child to “outgrow” this habit. The problem with this option is that the awakenings initially tend to become more frequent, because your child learns to enjoy your company at night. After all, who wants to be alone in a boring, dark, quiet room in the middle of the night? Eventually, months or years later, the child sleeps through the night and the parents can congratulate themselves for always having attended to their child's crying at night. You have, however, paid a price. Parents following this course of action often become sleep-deprived or chronically fatigued, and occasionally feel resentful toward the child for not appreciating their dedicated efforts. In addition, the sleep fragmentation and sleep deprivation often produce a child who is more irritable, aroused, agitated, and hyperexcitable because the child is always fighting chronic fatigue and drowsiness.
Option two: You might try to go to your child at night only when she is really sick and to leave the child alone at night when she is healthy. This is a strategy that often fails, because you may often be uncertain whether an illness is serious or just a minor concern. After all, at 7:00 P.M., you might decide that your child has only a minor common cold and that you are going to ignore her crying, but by 2:00 A.M.you begin to worry about the possibility of an ear infection. Is it still reasonable to ignore the crying? What usually occurs is intermittent reinforcement: You sometimes go to your child and sometimes do not. This behavior generally teaches your child to cry longer and louder when she awakens at night, because she learns that only loud and persistent crying will bring her parents. Quiet or brief crying often fails to get the parents’ attention.
Option three: Work closely with your pediatrician to devise a reasonable strategy whereby frequent visits or phone calls permit a clearer distinction between nonserious common colds and more distressing or disturbing illnesses. Generally speaking, the child's playfulness, sociability, activity, and appetite during the day are good clues; common colds do not cause much change in your child's behavior when awake. Then, in a planned and deliberate fashion, your child is left alone more and more at night, so that she learns to return to sleep without your help. When an acute illness develops that is associated with high fever or severe pain, of course, do whatever comforts the child best, both night and day. But when the acute phase of this illness is over, start again to give her less and less attention at night. Remember, most children sleep through most common colds; with your pediatrician's help, you can learn to distinguish between “habit crying” that occurs with a common cold and the more painful crying that is associated with a serious and painful acute infection.
Research has shown that sleep loss itself can cause impairments in our immune system, which is the body's defense mechanism to prevent infections. So it's a vicious circle: Illnesses might disturb sleep, and not sleeping well makes us more vulnerable to becoming sick.
Mother's Return to Work
Some adults develop sensitivity to children's needs and appreciate the benefits of regularity, consistency, and structure in child care activities. Some do not. The quality of the caretaker is what is important, not whether the person is or is not the biological parent.
PRACTICAL POINT
Write down specific instructions for sleep rituals so that the baby-sitter, the nanny, or the day-care provider knows what soothes your child best.
Do not assume that when the mother returns to work outside the home, your child's sleep habits will suffer. Keep data: track the schedule of naps when she is cared for by someone else, ask the nanny to keep a sleep log so you know exactly what is going on, watch for signs of tiredness in the early evening that might suggest nap deprivation.
Sometimes a nanny is a very nurturing person who wants to hold your baby all the time. But at some point you'll want to be able to use Method A, which means putting your child down for naps after soothing whether or not she is asleep. If the nanny refuses to do this, then your child will not be able to learn to soothe herself to sleep.
PRACTICAL POINT
To help your child sleep better during natural room changes such as vacations, moves, or bringing her to your workplace, try to build an environment of familiarity by using certain cues only for sleeping:
The same bumper pads
The same music box
The same stuffed animal or blanket
A spray of perfume, used only at sleep times
The child will then learn to associate these sensations with falling asleep, and this will help reduce the disruptive effect of the novelty of any new surroundings. None of these items, however, will work in the absence of regularity and consistency of parent care.
Please don't let your guilt about being away so much during the day cause you to keep the child up too late, to reinforce night wakings for sweet nocturnal private time with your baby, or to induce nap deprivation on weekends when you cram in too many activities. And don't let household errands, chores, or nonessential social events rob you and your child of unstructured, low-intensity playtime. The most common mistake is to keep your child up past the time of tiredness; your child needs sleep just like she needs food. Don't withhold sleep any more than you would withhold food.
Home Office
Parents who work at home are closer to their children throughout the day, and some parents have a similar situation when they are able to bring their baby to their workplace. The general problem is that some parents try to schedule their child's sleep around their work. In the beginning, with a newborn baby who naturally sleeps a lot, parents sometimes have the illusion that it will be smooth going. This is especially true if you have an easy-temperament baby. Unfortunately, the ebb and flow of the baby's developing sleep rhythms cannot be molded to fit a work schedule. An exception might be made if both parents are working together and there is always one available to attend to the baby.
Let's say that you have a home office and have hired someone to assist you with the care of your baby. Please do not expect to work, care for your baby, and breast-feed on any regular schedule. Your baby can smell you; she will know you are there! When she is hungry and wants to be fed, even though she might not see you, she senses your presence and expects you to feed her—now, not later. If you decided to feed formula instead of breast milk, then others will be able to help out more with the feedings. Expect to make lots of compromises between your needs, the baby's needs, and the expectations of the person helping you care for your child.
One thing you can do to make it easier is to start early to respect your child's need to sleep, and be very careful to avoid the overtired state. Starting as soon as you come home from the hospital is the best. The reason for starting early is that a well-rested baby is more adaptable to schedule changes that might occur when you try to coordinate baby care and working in your home office. Second, if you are breast-feeding, introduce a single bottle per day of expressed breast milk or formula at about two weeks of age. It does not have to be at the same time each day. If you do this, your baby will be able to take a bottle. If you wait a longer time to introduce a bottle, your baby may decide that he will take only the breast, and you lose some flexibility. The single bottle will not confuse your baby or cause weaning to occur.
Here is one mother's account of how starting a bottle early and establishing a schedule really helps.
“MOMMY WORKS AT HOME”
In some ways, working from home proved to be much more challenging that I had expected. The hardest part of being at home was hearing my new baby cry and realizing that my caregiver was unable to quiet her as quickly as I could. The urge to go to Katherine was incredibly strong, and many times I had to force myself to stay at my desk and allow the caregiver to find her own way of comforting the baby. While I knew intellectually that she needed to bond with Katherine, it was very hard to fight the maternal instinct.
I also found that the noise a two-year-old makes carries quite easily up two flights of stairs and through two closed doors! My oldest child, Caroline, became an unexpected participant this way on many phone calls with my clients and coworkers. I quickly learned to plan important phone calls around nap times, or go into the office on busy days to avoid the distraction.
It's not easy being a parent; it's harder when you have to work outside the home. The home office option is not available to everyone, but with planning and an attitude of flexibility and willingness to compromise, many mothers and fathers find the rewards are more than worth the effort.
Even when children outgrow naps, the home office is a possibility. Charlie's mother describes the lifestyle of a parent who works out of her home.
NEW ARRANGEMENT
I've had a home office for five years, ever since my son Charlie was born. Before Charlie entered our lives, I had a fast-paced job at a public relations agency, which I thoroughly enjoyed. But as my maternity leave progressed, I lost my appetite for going back to the grueling hours that were expected at the office. What kind of time or energy would be left for my son? Not surprisingly, the agency didn't have much sympathy for my point of view. I was lucky, however, because my biggest client suggested I work for them from home, and they were willing to accept a part-time arrangement. I know full well how fortunate I am; in fact, I wish I had a nickel for every person who has told me that I have the best of both worlds.
From my perspective as a home-office veteran, there are many, many benefits. For example, working from home allowed me to nurse my son for thirteen months. A home office setup also makes it much easier to establish good sleeping habits for your child. First, you have more opportunity to get tuned in to your baby's need for sleep, especially during that first year. When he gets tired, you're able to pick up signals—which can be subtle—and you can put him down before he gets overtired. It used to amaze me how much sleep my son needed once he got past that newborn, semi-colicky period; a couple of hours awake, and then it was back to bed. He took three naps a day until he was nine months old.
I sympathize with parents who don't get home from work until 6:00 P.M. and then, quite naturally, want to spend time with their children. Early bedtimes have to be tough. But if you're already home, you can give your child dinner at a reasonable hour and get him to bed when he's ready to sleep, not when it's convenient for you. When our son was going through the transition period from two naps to one, he needed to go to sleep by 6:30 P.M. at the latest. Instead of all of us gobbling down our food, I gave Charlie an early dinner, and when my husband got home, he would give him a bath. My husband and I would eat later in peace and quiet. This was only a temporary period, and in a few months, we were back to eating dinner as a family again, which we felt was important.
For most of the time that I've had a home office, I've had a baby-sitter come in two or three days a week. On the days that she's off, I'm on my own. I used to relish nap time because I could get so much accomplished. When Charlie was taking two naps, I would have uninterrupted blocks of one to two hours, both in the morning and in the afternoon. A friend of mine used to warn me darkly that this two-naps-a-day stuff wouldn't last, and, of course, it didn't. But I've also discovered a side benefit to working at home, which is that you tend to become very productive. No meetings, no interruptions from colleagues, no hanging out in the break room. When I am in my office, I work.
I routinely work at night, after Charlie goes to bed. He is asleep by 7:30 P.M., which pretty much leaves the whole evening. That's another benefit of early bedtimes! Sometimes I have to work very late to make a deadline, and then I'm tired the next day, but I'm willing to pay this price.
Home offices are not a perfect arrangement. You miss out on the office gossip, so you have to make an effort to stay connected. Another problem is that things come up unexpectedly, and I have to scramble if my baby-sitter isn't here. Yet the best thing about a home office is the flexibility. I used to think that I'd probably go back to work when Charlie got a little older, but now I'm not so sure. I like being able to participate in his school activities, and I like being here when he gets home. My home office represents freedom, and I can't imagine trading that in, even for a regular paycheck.
Some parents try to set up a mini-nursery or nest in their offices or stores for their babies to sleep. The truth is that it is difficult to answer phones or do business with clients at the same time your baby needs your attention. Perhaps for a few months, your child might seem to fit in, but it will become increasingly more difficult as he becomes more social, more alert, and more needy for your attention. Again, an exception might be when both parents are working together, so that one is always available for the baby.
Dual-Career Families
When both parents are working outside the home, the major problem is that the child tends to be put to sleep too late. Sometimes this occurs because, by the time the child is picked up from day care and brought home, it is already past the child's biological time for night sleep to start. Occasionally this is further complicated by the day-care facility not being able to maintain a routine and environment conducive to good-quality day sleep. At other times, both parents return home late from work and they naturally want to play with their child before feeding, bathing, and bedtime.
If the child goes to sleep past the time of biological sleep onset, then the child gradually becomes overtired. If the child is young, naps might be extra long in order to partially compensate for going to bed too late. Later, the older child begins to outgrow naps, and then the problems associated with the too-late bedtime begin to develop. But research has clearly shown that even with a fixed amount of sleep deficit, the child's irritability, fussiness, and short temper do not stay fixed; rather, they increase. Everything gets worse, but this process may develop very slowly. Eventually bedtime battles and night waking emerge, perhaps for the first time. Many parents assume that there is some other problem, such as teething pain, separation anxiety, insecurity from the mother returning to work, the “terrible twos,” nightmares, or the stress of a move or new sibling. Parents often do not see that the child has simply, slowly become overtired because several months before, the bedtime was allowed to become later.
MAJOR POINT
Constant sleep deficits cause increasing amounts of impaired functioning during wakefulness.
Q: When should my child go to sleep at night?
A: Before she becomes overtired.
If you think your child might be overtired in the late afternoon or early in the evening, try putting her to sleep twenty minutes earlier than is your current custom. If she falls asleep at this earlier time, then you will know that you have been putting her to bed too late. After several days, consider moving her bedtime another twenty minutes earlier if she still looks overtired. Remember, the way your child behaves or appears to you is more important than any recommended sleep duration or bedtime for “average children.”
The most common inhibiting fear in putting your child to bed early are that he will start the day too early and he will love you less because you are spending less time with him. Not true! Because sleep begets sleep, if your child becomes better rested, he will be better able to fall asleep and stay asleep. He will not get up earlier and earlier because of an earlier bedtime. You will prevent or correct bedtime battles and night waking for attention. Naps will tend to become longer and more regular if your child goes to bed earlier. One common scenario is that because of a too-late bedtime, the child takes a too-long morning nap, which causes him to be extremely tired by 4:00 or 5:00 P.M. A temporarily very early bedtime will often shorten the morning nap so that the child is able to take a restorative afternoon nap between noon and 2:00 P.M. and subsequently be able to stay up a little later.
REMEMBER
Sleep begets sleep. It's not logical that earlier bedtimes allow children to sleep in later in the morning, it's biological.
Q: I miss my baby so much during the day, why can't I spend more time with her at night? The only time I have to love my baby is late at night. Won't she miss me?
A: If she becomes overtired, her company will not be much fun. She will not enjoy or benefit as much from your social interaction because both of you will become increasingly fatigued. Her evolving bedtime battles and night waking will eventually produce an overtired family. At the price of seeing her less at night, she will stay better rested, more charming, more sweet, and you will mutually enjoy each other's company more in the morning and on the weekends.
Sometimes parents have to allow the sitter or the parent who comes home early to bathe, feed, and dress the child for bed; immediately after the arrival of the parent who comes home late, the child is quietly soothed to sleep. With our busy lifestyles, it may be difficult to coordinate a work schedule with a child's biological needs. If this is the case for you, your baby's needs must come first. You would not withhold food when the body needs it because it is inconvenient to feed your child, and you try to anticipate when your child will become hungry in order to feed her before she becomes overly hungry. Similarly, try not to withhold sleep when the brain needs it, and try to anticipate when your child will become tired before she becomes overtired.
Occasionally it happens that, during the week, a sitter or day-care center is protecting and maintaining naps, but on weekends everything falls apart. Dual-career families might try to do too much playing with their children on weekends to compensate for being with them less during the week, or they may simply not respect the child's need to nap because there are so many errands that have to be done. Either way, these children are often so overtired that they appear to be in pain. Every pediatrician gets some of these calls Sunday night or Monday morning because the parents often believe there is a painful ear infection. Severe sleep inertia can cause a child to awaken from a nap, which might be extra long, and scream as if in severe pain. Also, night terrors are often more common when children become severely overtired. On busy weekends, you should not feed your baby on the run; you need to find a quiet time to feed. Same thing for naps; don't nap on the run.
Adoption
Infants’ sleep patterns are influenced by powerful biological or genetic forces when they are very young, but as they become older, their sleep patterns begin to reflect more of the social circumstances of their family and their culture. The child's biological sleep needs may or may not be met by their experiences. The following story illustrates how experienced parents were able to help their new child learn to sleep better, even though she hadn't slept well for nine months.
“WITHIN ABOUT A WEEK OR SO, SHE
WAS ON A REASONABLE SCHEDULE”
With our son, we had followed Dr. Weissbluth's method since the get-go, and Charlie developed excellent sleep habits. As a kindergartner, he's no longer napping, but per Dr. Weissbluth, it's lights off by 7:30 P.M., and he's happy as a clam. As an infant and a toddler, Charlie very much needed consistent nap times and an early bedtime. Without that structure, he tended to fall apart. There was absolutely no question that Carina, our adopted daughter, would follow the “Weissbluth method,” too. She just didn't know it yet. As it turned out, there was plenty we didn't know yet either.
The big moment finally arrived, and we met Carina. (No, I didn't fall in love immediately.) At the time, she was nine and a half months—old enough to be wary of strangers, which is what Bill and I were. She clearly preferred her foster family, as we had anticipated and understood. They got to the hotel about an hour and a half later than originally planned, and I naively asked if they were late because she was napping. Well, no, that wasn't the reason; in fact, she hadn't had a nap that day.
We arrived back home late that night, and for the first time in her short life, Carina slept in a crib. She cried for a little while, but she managed to sleep pretty well, probably out of sheer exhaustion. The next day was a blur. We called Dr. Weissbluth, who arranged for Carina to have a battery of tests performed right away at Children's Hospital. Blood and stool tests are typically recommended for international adoptions, and we were concerned about the parasite issue. The good news is that she turned out to be perfectly healthy, and the lab could find no signs of parasites.
The next day we paid a visit to Dr. Weissbluth's office, and he advised us how to get Carina on schedule. Put her down at 9:00 A.M. for a morning nap, he said. Ideally, she should sleep an hour and a half. If she cries, pick her up after an hour. After lunch, try again. Put her down at 1:00 P.M., and if all goes well, she'll sleep until 2:30 P.M. If not, don't let her cry more than an hour. Bedtime should be between 6:00 and 7:00 P.M.
That sounds pretty simple. It wasn't. Carina didn't like her crib, she didn't like her room; she just didn't want to be alone. And she let us know it—vociferously. The trick was keeping her awake until bedtime. I'd learned from Charlie that those little catnaps can wreak havoc with sleep schedules.
Then, once Carina went to bed, there was no guarantee she would stay asleep. Bill and I were so tired and so tense, and we kept asking each other if one of us should go back into her room. But we honestly didn't think it would help, and besides, Dr. Weissbluth had said to leave her alone. She finally stopped crying at about 2:45 A.M.
The next night was much better, and believe it or not, within about a week or so, she was on a reasonable schedule. It wasn't perfect. Sometimes she would take a good morning nap, and then her afternoon nap would be restless. Sometimes she would wake up in the middle of the night. But as time went on, her sleep rhythms seemed to consolidate, and she became much more predictable.
We thought all our problems were solved until we went through a period where she was waking up in the middle of the night. I was convinced that she was missing her foster father and that she was grieving for everything she had left behind in Guatemala. I felt so tormented by this that I went into her room and snuggled with her. This did not help at all. In fact, one night after I had supposedly soothed her, she cried for two more hours. I gave up on sleep and went downstairs to cut out coupons from the Sunday paper.
I mentioned my “grieving” theory to Dr. Weissbluth, who politely discounted it. He said that when babies wake up in the middle of the night, they are in a twilight state between sleep and waking. They aren't likely to be grieving or doing much else. Obviously, if a baby has an ear infection, she might be in pain, but this wasn't the case here. He suggested putting her to bed fifteen minutes earlier—at 6:45 P.M.instead of 7:00 P.M. Even with all our good efforts, Carina might still be overtired. Well, no one ever said that it was easy being a parent.
Carina has been with us now for nearly four months. She takes good naps in the morning and in the afternoon, and she sleeps about twelve hours at night. She is very happy to get into her crib and snuggle into her special corner. Occasionally she will wake up in the middle of the night, but we have learned to leave her alone. We have also learned to recognize the noises she makes when she's settling back to sleep, and these are very different from cries of pain or hunger.
Have these healthy sleep habits produced a happy child? You bet. Carina is a joy to be around. As we've all gotten to know each other better, she has become much more affectionate. She is clearly crazy about Charlie, and he is very proud to be a big brother. As for me, I fell in love. And despite all my trepidation, it really didn't take that long.
Injuries
Injuries occur to children of all ages. Some can—or should—be prevented, but some cannot. Examples of preventable injuries include leaving a four-month-old infant alone on a changing table from which she falls, poisonings occurring when safety seals are not used or medicines are left lying around, or electrical shocks from uncovered wall sockets. A nonpreventable injury is truly an accident—for example, those resulting from an earthquake or a lightning bolt.
The truth is, though—and I realize this sounds harsh to many parents’ ears—that most so-called childhood accidents are really preventable injuries that occur because of parental neglect or the lack of parental forethought. These injuries can be one consequence of home routines that create tired children—and tired families.
But is there such a thing as an accident-prone child? To determine if traits within a child can cause him to suffer frequent injuries, various studies have examined babies before injuries start to occur. (After a child has had several injuries, a “halo” effect develops and adults are more likely to perceive traits in the child—clumsiness, lack of self-control, and so on—that “explain” why he has had so many injuries.)
One study included two hundred babies who were evaluated between four and eight months of age. Some of the infants were difficult to manage. As we saw earlier, these infants were called “difficult” because they were irregular, low in adaptability, initially withdrawing, and negative in mood. During the next two years, difficult babies were much more likely to have cuts requiring suture than were babies with the opposite or easy to manage temperaments. This study showed that during the first two years of life, about one third of the difficult children had cuts deep or severe enough to require stitches, while only 5 percent of easy babies had similar cuts.
Remember also my data: At four to eight months of age, difficult babies slept about three hours less than easy babies, and at age three, the difference was about one and a half hours. By age three, the briefer the sleep, the more active, excitable, impulsive, inattentive, and easily distracted the child appeared—the perfect description of an accident-prone child. Little wonder, then, that these tired children fell more often, sustaining deep cuts.
Obviously, for both the “difficult” kids and all other children, chronic fatigue can lead to more injuries, such as cuts and falls. More sleep is the remedy.
Another study that supports this fatigue-injury connection included more than 7,000 children who were one to two years old. Researchers compared children who frequently woke up at night with those who slept through the night. Among the night wakers, 40 percent had injuries requiring medical attention, compared to only 17 percent of the good sleepers. The parents of the children who were night wakers reported that they immediately went to their child when they heard a cry in order to prevent further crying. There was a tendency for the mothers of night wakers to feel more irritable in general and “out of control.” One sign of family tension was that these mothers felt unable to confide in their husbands; the association of marital difficulties with disturbed sleep has been mentioned in many studies.
Maybe the parents who don't supervise sleep patterns so that the child can have his sleep needs met are the same ones who don't supervise children at play in order to protect their physical safety. The message is clear: If your child is often injured, it's not necessarily because he is careless or clumsy—he may be exhausted instead.
I have seen many children who were so overtired that they fell down only a stair or two or fell from a very low height. But because they hit their head and were later noted to be sleepy or wobbly, the parents worried about a head injury or concussion. What these children needed was more sleep, not a CT scan!
Falls from bunk beds can be serious, but most can be prevented by always using side rails in the upper bed and removal of the bed ladder when not in use.
Overweight, Exercise, and Diet
Difficult to manage children fuss and cry a lot. One way to respond to their demands is to put food in their mouths. This certainly quiets them. Coincidentally, their fussiness might also have some evolutionary value, ensuring their survival in times when food is scarce. This was shown to be the case among the Masai of East Africa during drought conditions in 1974. But in a study conducted in a white, middle-class Pennsylvania pediatric practice, the more difficult babies tended to be fatter babies. Perhaps this connection between fussiness and being fed sets the stage for obesity in later years.
In my own pediatric practice, fat babies are almost always overtired babies. That's because their mothers have incorrectly attributed their babies’ crying to hunger instead of fatigue. These mothers are always feeding their babies, then telling me that their babies can't sleep because they're always hungry! The major point here? Overfeeding the crying child to keep him quiet could cause unhealthy obesity.
This overfeeding habit may actually begin innocently enough in some children at three to four months of age, when nutritional feedings in the middle of the night give way to recreational feedings. Later, the bottle or breast is used as a pacifier and the frequent sipping and snacking causes excessive weight gain. Please try to become sensitive to the difference between nutritive and non-nutritive feeding. Overdoing milk or juice bottles is a common way babies learn to not “like” eating solids. After all, they are getting calories, so they have no appetite to motivate them to eat solid foods when they are older. For children between five and seven years, we now have direct evidence that the more tired the child is, the more likely it is that he will be overweight or obese.
Q: If I give my child a bottle at naps or at bedtime, will I make him fat? When should I not include a bottle in the bedtime ritual?
A: Sucking or sipping a bottle before falling asleep comforts most babies and even older children. There is no harm in doing this and there is no particular age when you should stop as long as (a) you prop the baby, not the bottle, so he drinks in your arms, (b) the rate of weight gain is not too fast, and (c) frequent or prolonged feedings are not part of a sleep problem.
The effects of exercise on sleep are hard to prove, even though most people assume that muscular fatigue induced by exercise will produce better sleep. Another possibility is that exercise reduces anxiety. However, strenuous exercise, especially common among teenagers, might mask an underlying problem of chronically insufficient sleep. The chronically or severely overtired adolescent is sometimes described as living in a “twilight zone”: frequent episodes of drowsiness, “micro-sleeps,” lethargy, depression, apathy, cognitive impairment, and proneness to accidents. Counteracting measures that fight the fatigued state are internal stimulation (heightened emotionality such as anger or elation) or external stimulation such as exercise. So, exercise may be helpful, but it will not solve an underlying sleep problem.
Diet should influence sleep, because food provides the chemical building blocks for the brain's neurotransmitters. But studies in infants and adults do not show support for any strong link between sleep and diet.
Child Abuse
Let's get one ugly fact out in the open: When we are very, very tired of hearing our baby cry to fight sleep at night, we would like to shut her up. We don't act on our feelings; we don't harm our baby. But at nighttime, the thought might have occurred to us: “What if I weren't in so much control, might I… ?”
The tired, difficult to manage infant whose howling at night will not stop can become a target for abuse or infanticide. Crying is the behavior that seems to trigger child abuse in some parents, and crying at night instead of sleeping is the historical setup for infanticide.
So when your baby gets all cranked up late at night, with desperate, angry, or relentless screaming when she should be asleep, and you feel like a tightly wound spring, don't be surprised if you feel you want to “get even” or “shut her up for good.” If you and your child don't get the sleep you need, you may have experienced these intense feelings of anger, resentment, or ill will toward your child.
Contact the following organizations, social workers at local hospitals, or your pediatrician if you feel the need for help.
National Committee to Prevent Child Abuse
1-800-244-5373
Parents Without Partners
1-800-637-7974
It's difficult to see how we can help solve sleep problems when we ourselves are extremely sleep-deprived. This is the time to call for help.
Atopic Dermatitis and Eczema
Atopic dermatitis is a chronic skin condition that causes severe itching. Itching of the skin can cause restlessness during sleep because a lot of the scratching goes on during light and REM sleep. As a result, children wake frequently throughout the night. Some studies have shown that these children have difficulty waking up for school, difficulty staying awake in the afternoon, and major discipline problems. However, one study that used sleep lab recordings and videotapes during sleep of atopic children showed that the sleep abnormalities of frequent arousals actually did not occur with the act of scratching. This study was performed when the skin condition was in remission, so it is possible that, during flare-ups, there might be more intense itching that interfered with sleep consolidation. If your child is often scratching his skin, the best idea is talk to your pediatrician or ask for a referral to a dermatologist.