HEALTHY SLEEP
Are your child's sleep patterns healthy? There are five elements of healthy sleep for children:
1. Sleep duration: night and day
2. Naps
3. Sleep consolidation
4. Sleep schedule, timing of sleep
5. Sleep regularity
When these five items are in proper balance, children get the rest they need. Let's first take a look at each one separately. Later, we will see how each element is not really independent from the others but simply part of a package called “healthy sleep.”
As we consider the biological development of these five factors, please remember that parenting practices such as feeding do not influence how the brain develops. There are five turning points in the sleep maturation process: six weeks (night sleep lengthens), twelve to sixteen weeks (daytime sleep regularizes), nine months (disappearance of night waking for 14 feeding and a third nap), twelve to twenty-one months (disappearance of the morning nap), and three to four years (afternoon nap becomes less common).
As your baby's brain matures, the patterns and rhythm of sleep change. If you always adapt your parenting practices to these changes, your child will sleep well. Those parents who do not see these changes or make these adjustments have babies who become overtired. The biological development causing all these changes is under the control of two regulatory mechanisms. Understanding these controlling mechanisms will help you organize your thoughts and plan your actions to ensure healthy sleep for your child.
The first regulatory system controls the body's need for sleep and has been called the “homeostatic control mechanism.” In a nutshell, this means that the longer you go without sleep, the longer you will subsequently sleep. If you lose sleep, the body tries to restore it. The body tries to make sure you are getting enough sleep. This automatic process reflects an internal biological mechanism that we do not control. It is similar to the body wanting to control its temperature; when we get hot, we automatically sweat. If we do not drink enough fluid, then we cannot sweat, and we suffer the ill effects of dehydration. However, if we drink too much caffeine and deprive the body of sleep, we also cause harm. Unfortunately, our baby's biological need for sleep is always changing, so we have to be on our toes in order not to miss shifts in sleeping requirements.
The secondary regulatory system has been called the “circadian timing system.” It is also called the “internal timing system” and can be thought of as a dedicated regulatory program that switches specific genes on and off in response to the light-dark cycle. This regulatory apparatus built to turn on and off is a molecular clock that is genetically specified and it is set to the proper time by sunlight. This mechanism automatically tries to ensure that the body is sleeping at the right time, and that when you are asleep, the timing and amounts of different stages and types of sleep are correct. Signals come from a specific area within the brain to make us feel sleepy or wakeful. The pattern of these signals changes over weeks, months, and years as the baby grows into an adult. The pace of these changes is especially quick during the first several months, so it is easy for a parent to get a little off tempo. Just when you think you have figured out when your baby needs to nap or be put to bed at night, the times change!
IMPORTANT POINT
The Internal Timing System is under genetic control so there is individual variation. It takes time for the Internal Timing System to express itself.
Sleep Duration: Night and Day
If you don't sleep long enough, you feel tired. This sounds very simple and obvious, but how much sleep is enough? And how can you tell if your child is getting enough sleep?
Under three or four months of age, infants’ sleep patterns seem mostly to reflect the development of the child's brain. During these first few weeks, in fact, sleep durations equal sleep needs, since infant behavior and sleep durations are mostly influenced by biological factors. But after about three or four months, and perhaps even at about six weeks (or six weeks after the due date, for babies born early), parenting practices can influence sleep duration and, consequently, behavior. As I will discuss later in more detail, I believe parents can promote more charming, calm, alert behaviors by becoming more sensitive to their growing child's need to sleep and by helping to maintain healthy sleep habits. The goal is to recognize and respect your child's need to sleep and not do things that interfere with the natural sleep process.
Newborns and Young Infants
During their first few days, newborns sleep about sixteen to seventeen hours total each day, although their longest single sleep period is only four to five hours. It makes no difference whether your baby is breast-fed or bottle-fed, or whether it's a boy or a girl.
PRACTICAL POINT
Nursing mothers often worry unnecessarily that long sleep periods deprive their baby of adequate breast milk. Weight checks with the doctor will reassure you that all is well.
Between one week and four months, the total daily sleep duration drifts down from sixteen and a half to fifteen hours, while the longest single sleep period—usually the night—increases from four to nine hours. We know from several studies that this development reflects neurological maturation and is not related to the start of feeding solid foods.
Some newborns and infants under the age of four months sleep much more and others much less. During the first few months, you can usually assume that your baby is getting sufficient sleep. But if your baby cries too much or has extreme fussiness/colic, you might assist Mother Nature by trying the helpful hints for “crybabies” described in Chapter 4.
PRACTICAL POINT
When they are one or two weeks old, many infants begin to have several hour periods of increasingly alert, wakeful, gassy, and fussy behavior. This continues until about six weeks of age, after which they start to calm down. This increasingly irritable and wakeful state is often misinterpreted as resulting from maternal anxiety or insufficient or “bad” breast milk. Nonsense! The culprit is a temporarily uninhibited nervous system that causes excessive arousal. Relax; this developmental phase will pass as the baby's brain matures. It's not your fault.
Young infants are very portable. You can take them anywhere you want, and when they need to sleep, they will. I remember when, as a medical student at Stanford University, I was playing tennis with my wife one day and my first child was sleeping in an infant seat near the fence. A huge dump truck came crashing down the narrow street, making an awful racket. We ran over to our son, only to be surprised that he remained sweetly asleep. After six weeks of age, he became more socially aware of people around him; after about four months of age, he, like all children, became interested in barking dogs, wind in the trees, clouds, and many other curious things, all of which could and did disturb his sleep.
For some infants, the time when the baby first makes a socially responsive smile (usually at six weeks of age, or six weeks after the due date, for babies born early) is when social curiosity or social learning begins. However, under about three or four months of age, most infants, like my son, are not much disturbed by their environment when it comes to sleeping. When their body says it's time to sleep, they sleep. When their body tells them to wake up, they wake up—even when it is not convenient for their parents! This is true whether they are fed on demand or according to a regular schedule. It is also true even when they are continuously fed intravenously because of birth defects of the stomach or intestines. Hunger, in fact, seems to have little to do with how babies sleep. A much more likely candidate for influencing a baby's sleeping patterns is the hormone melatonin, which is produced by the baby's brain beginning at about three to four months of age. This hormone surges at night and has the capability to both induce drowsiness and relax the smooth muscles encircling the gut. So around three or four months of age, so-called day/ night confusion and apparent abdominal cramps (colic) begin to disappear.
Furthermore, infants raised in an environment where the lights are constantly on evolve normal sleep patterns, just like babies brought up in homes where the lights are turned on and off routinely. Another bit of evidence to suggest that environment has little effect on sleep patterns in children under three or four months of age comes from infants born prematurely. A child born four weeks before his due date, for example, reaches the same level of sleep development as a full-term baby four weeks later than the child born on time. Biological sleep/wake development does not speed up in those preemies who are exposed to more social stimulation.
What we can conclude, therefore, is that, for infants under three or four months of age, you should try to flow with the child's need for sleep. Don't expect predictable sleep schedules, and don't try to enforce them rigidly. Still, some babies do develop regular sleep/wake rhythms quite early, say at about six to eight weeks. These babies tend to be very mild, cry very little, and sleep for long periods of time. Consider yourself blessed if you are one of these lucky parents.
Older Infants and Children
As children age, the amount of time they sleep tends to decrease. Figures 1 through 3 describe how much daytime sleep, night sleep, and total sleep occur at different ages for older children. The bottom curve in each graph means that 10 percent of children sleep less than the amount shown, while the top curve means that 90 percent of children sleep less than the amount shown for each age. These curves were generated by my own research using data collected from 2,019 children, mostly white, middle-class residents of northern Illinois and northern Indiana in 1980. These graphs can help you tell whether your child's sleep is above the ninetieth percentile or below the tenth percentile. (Other studies have used only the fiftieth percentile, or average values, and do not tell you whether your child's sleep duration is slightly below average or extremely below average.) Interestingly, the results of studies of similar social classes in 1911 in California and in 1927 in Minnesota, also involving thousands of children, were the same as those in my study. In addition, studies in England in 1910 and Japan in 1925 showed identical sleep curves.
So it seems that despite cultural and ethnic differences, social changes, and such modern inventions as television, DVDs, and computers that shape our contemporary lifestyles, the age-specific durations of sleep are firmly and universally rooted in our children's developing biology.
An exception to this generalization is that adolescents in the United States are now getting less sleep. During the second half of the twentieth century, a trend toward earlier start times for high school developed. This forced children to get up earlier during the school week and reduced the total number of hours available for sleeping. At the same time, it became more popular for teenagers to hold part-time jobs after school, so they were going to bed later. Also, the amount of homework has increased.
After about four months, I think parents can influence sleep durations, and as you will see, sleep durations for these older infants and toddlers are especially important.
I studied sixty healthy children in my pediatric practice at five months of age and then again at thirty-six months. At five months of age, the infants who were cooing, smiling, adaptable, and regular, and curiously approached unfamiliar things or people, slept longer than infants with opposite characteristics. These easy and calm infants slept about three and a half hours during the day and twelve hours at night, or a total of fifteen and a half hours. Infants who were fussy, crying, irritable, hard to handle, irregular, and more withdrawn slept almost three hours less overall, almost a 20 percent difference (three hours during the day and nine and a half hours at night, or twelve and a half hours total).
In addition, for all the five-month-olds studied, persistence or attention span was the trait most strongly associated with daytime sleep or nap duration. In other words, children who slept longer during the day had longer attention spans.
As I will discuss in a later chapter, infants who sleep more during the day are better able to learn from their environment; this is because they have a better-developed ability to maintain focused or sustained attention. Like a dry sponge in water, they soak up information about their surroundings. They learn simply from looking at the clouds and trees, touching, feeling, smelling, hearing, and watching their mothers’ and fathers’ faces. Infants who sleep less in the daytime appear more fitful and socially demanding, and they are less able to entertain or amuse themselves. Toys and objects are less interesting to these more tired children.
By three years of age, the easier to manage children in my study who were mild, positive in mood, adaptable, and approachable toward unfamiliar people slept twelve and a half hours total. The difficult to manage children—those who were intense, more negative, less adaptable, and withdrawing—slept about one and a half hours less, almost the equivalent of a daytime nap.
An important conclusion is that three-year-olds who nap are more adaptable than those who do not. But napping did not affect the length of sleep at night. Comparing nappers and non-nappers, night sleep duration was ten and a half hours in both groups. Those who napped, however, slept about two hours longer during the day, so their total sleep was twelve and a half hours. Therefore, it simply is not true that children who miss naps will “make up” for it by sleeping more at night. In fact, the sleep they miss is gone forever.
PRACTICAL POINT
Missing a nap here and there will probably cause no harm. But if this becomes a habit, you can expect your child to lag further and further behind in his sleep and to become increasingly difficult to handle in this over-fatigued state.
All in all, at age three, the children who slept more were more fun to be around, more sociable, and less demanding. The children who slept less not only tended to be more socially demanding, bratty, and fussy, but they also behaved somewhat like hyperactive children. Later, I will explain how these fatigued, fussy brats are also more likely to become fat kids.
One recent study examined the effects of a single night of sleep restriction in a group of children between ten and fourteen years old. The researchers noted that there were impairments in verbal creativity, abstract thinking/concept formation, and in complex problem solving. These higher cognitive abilities appear to be essential for academic performance and success. In contrast, there were no deficits on rote performance or less-complex memory and learning tasks. The ability to maintain routine performance despite being sleepy is familiar to every adult who sometimes gets very tired but nevertheless is able to perform the routine aspects of his or her job fairly well. My interpretation of this study is that chronic sleepiness in infants and young children impairs cognitive development, but this will not become apparent until the child is much older and challenged by more complex tasks. Of course, cognitive development starts in babies, not at ten to fourteen years of age, but the deficits from sleep deprivation remain hidden in young children. When younger, the challenges are at a much lower level, and these chronically sleep-deprived children may still do well with spelling, writing, reading, and simple arithmetic. Later, when older, the more demanding academic challenges unmask the cognitive deficits.
Looking at our sleep curves again, we see that throughout early and middle childhood, the duration of sleep declines until adolescence, when the curve shown in Figure 1 levels off and then slightly increases. This increase has been noted in other studies and suggests that teenagers need more sleep than preteens. Yet academic demands, social events, and school sports combine during adolescence to pressure teenagers to stay up later and later. Also, there are biological shifts in adolescents that seem to encourage more wakefulness in the evening. This is the time when chronic and cumulative sleep losses begin to take their toll, and can make a normally rough period in life unbearably rocky.
Naps
Having grown up in a highly achievement-oriented society, most American adults are likely to view naps as a waste of time. We tend to think that the adults who nap are lazy, under-motivated, ill, or elderly. In turn, we do not attach much positive benefit to daytime sleep in our infants and young children. Let me explain why naps are indeed very important for learning, or cognitive development, in children.
Naps are not little bits of night sleep randomly intruding upon children's awake hours. Actually, night sleep, daytime sleep, and daytime wakefulness have rhythms that are partially independent of one another. During the first three to four months of life, these rhythms develop at different rates, so they may not be in synchrony. Only later do these sleep/wake rhythms become linked with fluctuations in body temperature and activity levels.
For example, most of us have experienced drowsiness in the afternoon. This sensation is partially related—but only partially—to how long you have been up and how long you slept the night before. Our mental state fluctuates during the day between alert and drowsy, just as fluctuations occur during the night between light and deep sleep stages. As adults, an afternoon nap is most refreshing when we take it at the time when we are biologically most drowsy. Here is how to figure out your best nap time. Take the midpoint between the time when you most easily fall asleep at night (example: 10:00 P.M.) and most comfortably awaken naturally in the morning (example: 8:00 A.M.). Then, twelve hours from the midpoint is your best naptime (example: 3:00 P.M.). If you lived in the siesta belt, you might rest or take a nap, but in the United States, it's a coffee break.
There is an important reason, though, why some adults do not nap: sleep inertia.
Sleep Inertia
Sleep inertia is a feeling of disorientation, confusion, pain, discomfort, impaired mood, and the inability to concentrate or think well that occurs upon awakening, especially from naps. In children, sleep inertia appears to be more severe and more prolonged for those who are more overtired. It appears that sleep is intruding into wakefulness and this overlap state is painfully uncomfortable. One mother described it as a “fugue” state, another as a “demonic” state. The children are out of control, panicky, crying, or screaming hysterically. Parents would often call me after three-day holiday weekends, during which their children became severely overtired, and tell me that they were sure their child had a painful ear infection because their child awoke crying. They often added that they were sure their child was not overtired because the child had just completed an extra-long nap! The ears were perfect. The children had simply missed some naps or had been allowed to stay up too late during the holiday.
Understanding that the rhythms of night sleep, daytime sleep, and daytime wakefulness are somewhat independent from one another leads to two important ideas.
First, in a child under three or four months of age, these rhythms are not in synchrony with each other, and the baby may be getting opposing messages from different parts of the brain. The sleep rhythm says “deep sleep,” while the wake rhythm says “alert” instead of “drowsy.” Wakeful but tired, the confused child cries fitfully; we might call this behavior colic or fussiness. Opposing messages from different parts of the brain may cause ambiguous stages such as sleep inertia. In research with adults and animals, this has been called “dissociated states of wakefulness and sleep,” or “Status Dissociatus.” For example, some birds can swim or fly when they are completely asleep! Narcolepsy is the intrusion of REM sleep into wakefulness. Sleepwalking, night terrors, and crying out at night occur during the overlap state of wakefulness and non-REM sleep. Because adult wake/sleep states may overlap, be incomplete, or switch rapidly between states, it is entirely possible that during the first four months, when sleep states are developing, partial states express themselves out of phase and with other states, creating overlap problems that we refer to as fussiness, colic, or sleep inertia. For example, it is known that babies can suck, smile, and cry with their eyes open during REM sleep, so while they appear to be awake, they are actually asleep. We can call this “indeterminate sleep” or “ambiguous sleep,” which reflects the immaturity of the young brain. After about four months of age, these ambiguous states are less common.
Second, if these sleep/wake rhythms are somewhat independent, they may have different functions: learning for the wake cycle, physical and emotional restoration for the sleep cycle. Daytime sleep and nighttime sleep may be different in this regard. I believe that healthy naps lead to optimal daytime alertness for learning—that is, naps adjust the alert/drowsy control to just the right setting for optimal daytime arousal. Without naps, the child is too drowsy to learn well. Also, when chronically sleep-deprived, the fatigued child becomes fitfully fussy or hyperalert in order to fight sleep, and therefore cannot learn from his environment.
Not only are naps different from night sleep, but not every nap is created equal. There is more REM sleep in the morning nap compared to the afternoon nap. Research suggests that high amounts of REM sleep, under the influence of low melatonin levels, help direct the course of brain maturation in early life. Also, adult studies have suggested that REM sleep is especially important for restoring us emotionally or psychologically, while deep, non-REM sleep appears to be more important for physical restoration. Let's get all the REM sleep we can for our babies!
Because naps have their own function and do their job best when they occur at the right time, I suggest that if a nap has been missed, try to keep your child up until the next sleep period in order to maintain the timeliness of the sleep rhythm. This suggestion has to be balanced with the general theme of avoiding the overtired state, so the next sleep period (nap or night) might begin a little earlier.
My studies show that at four months of age, most children take either two or three naps. The third nap, if taken, tends to be brief and in the early evening. But by six months of age, the vast majority of children (84 percent) are taking only two naps; by nine months of age virtually all children are taking just one or two naps. About 17 percent of children have started taking only a single nap by their first birthday, and this percentage increases to 56 percent by the age of fifteen months. By twenty-one months, most children are down to just a single nap.
The morning nap develops before the afternoon nap, but it also disappears before the afternoon nap. The single nap that is present by twenty-one months and resurfaces in adolescence or adulthood is always the afternoon nap. Infants and young children have much more REM sleep at night than older children, and the morning nap has more REM sleep than the afternoon nap; this suggests that in some infants, the morning nap may be viewed as a sort of continuation of night sleep. Later I will discuss how we can help babies sleep better by keeping the interval of wakefulness between the wake-up time and the start of the first nap very short. This strategy may work because we are really allowing night sleep to continue longer.
Another thing that I've discovered is that up until about twenty-one months of age, some babies are born to be short nappers and some are inherently long nappers.
IMPORTANT POINT
Not all sleep periods are created equal!
Parents can interfere with a child's long naps by messing up the child's schedule, but they cannot make short nappers into long nappers. Here are some important facts about short nappers: At six months of age, 80 percent of babies nap between two and a half and four hours total each day. Napping more than four total hours each day occurs in 15 percent of babies. However, in 5 percent of babies, the total daytime sleep each day is less than two and a half hours. If you look at brief naps slightly differently and include babies who sleep a total of two and a half hours or less each day, then 18 percent of babies fall into this category. These short nappers tend to keep this pattern for the next twelve to eighteen months! This truth is especially frustrating to mothers whose first child was a long napper and they remember having long breaks during the day to do whatever they wanted. If their second child is a short napper, they may incorrectly think they are doing something wrong.
If parents can cause problems that interfere with good naps, why can't parents make their babies sleep longer? This question provides a good example of the asymmetry between sleep and wakefulness. Sleep is not the absence of wakefulness; rather, the brain automatically and actively turns on the sleep process and simultaneously turns off wakefulness. You, and your child, can force wakefulness upon sleep, but you cannot force sleep upon wakefulness. You, and your child, can motivate or force yourself and him into a more wakeful or alert state, but you cannot will anyone into a deeper sleep state. So sleep and wake states are different but not opposite. Parents have the opportunity to permit the maximum amount of sleep to occur; this amount reflects their child's actual need for sleep. As stated before, a baby's nap pattern is largely an individual trait that stays stable until about twenty-one months.
Evidence of the individuality of this trait comes from studies on twins and argues for a strong genetic component to the control of sleep in babies. An obvious example occurs when one twin is a short napper and the other twin is a long napper—more about that later. At twenty-one months, the average nap duration is a little less than two and a half hours, but the range is wide: between one and four hours. At this age, some of the children who initially took brief naps are now taking longer naps, and some who had been long nappers are now taking briefer naps. My interpretation is that by twenty-one months, biology is no longer the primary influence on napping; social factors begin to play a role. For example, events such as the birth of a sibling, an older sibling starting preschool, or the child herself now participating in organized and scheduled activities can cause children who have a biological need for longer naps to take shorter naps. Often, no problems occur if catch-up days are provided coupled with an extra-early bedtime.
The time of day when the nap occurs is also important. Some studies have suggested that an early nap, occurring in the midmorning hours, is different in quality from a later nap, which occurs in the afternoon. As mentioned before, there is more active REM sleep than quiet sleep in the first nap, and this pattern is reversed in the second nap. So naps occurring at different times are different! Even for adults, a nap earlier in the day is lighter and less restorative than an afternoon nap, which consists of deeper sleep.
Long naps occurring at the right time make the child feel rested. Levels of cortisol, a hormone that increases with stress, dramatically fall during a nap, indicating a reduction of stress in the body. Not taking a needed nap means that the body remains stressed. Brief naps or naps that are out of synchrony with other biological rhythms are less restful, less restorative. But a short nap is better than no nap. It still has a positive effect on alertness.
Children can be taught how to take naps. A nap does not begin and end the way an electric light can be turned off and on. In fact, a nap or night sleep involves three periods of time: the time required for the process called falling asleep, the sleep period itself, and the time required to wake up. One father complained to me, “I can't see the pre-Zs coming out of his head,” meaning he had difficulty seeing the lull in activity or quieting that precedes sleep. In later chapters I will show you how to recognize the “pre-Zs” and teach your children to fall asleep.
PRACTICAL POINT
Do not expect your baby to nap well outside his crib after four months of age. If you don't protect your baby's nap schedules, you can produce nap deprivation.
When children do not nap well, they pay a price. Infants between four and eight months who do not nap well have shorter attention spans or appear less persistent when engaged in activities. By three years of age, children who do not nap or who nap very little are often described as nonadaptable or even hyperactive. Adaptability is thought to be a very important trait for school success.
One mother of a nonadaptable child said with a laugh that every morning she prayed to the “nap god” to give her a break. In contrast, another mother described her son as a very easy child as long as she had a bed around. He was such a “rack-monster” that she decided he just liked his own company best. Another mother described her son, who napped well, as the “snooze king.”
Sometimes it appears that the older toddler needs exactly one and a half naps. While one nap is insufficient, two are impossible to achieve. These children are rough around the edges in the late afternoon or early evening, but parents can temporarily and partially compensate by putting the child to bed earlier on some nights.
An earlier bedtime may become a necessity when your child develops a single-nap pattern, between fifteen and twenty-one months. Earlier bedtimes help prevent bedtime battles, deter night waking, discourage extremely early morning awakenings, and regularize and prolong naps. Why, then, do many parents resist the notion of putting their children to sleep when they first appear tired at night, even though it is clear that the brain is sleep-sensitive? First, parents naturally want to be with their children and play with them. Second, there is a powerful inhibitory fear that if their child is put to bed very early when tired, she will get up extra early the next day. Third, because I recommend that, along with an earlier bedtime, the parents not go to the child at night, except for feeding, parents are naturally frightened about the possibility of prolonged crying when they put the child to bed or in the middle of the night. This fear of possible crying discourages parents from trying for an earlier bedtime.
Here is an example of how a family started early, at eight weeks of age, to focus on an earlier bedtime. The baby was not overtired and did not have extreme fussiness/colic, so the transition went smoothly. For 20 percent of babies with extreme fussiness/colic, this easy change to an earlier bedtime at eight weeks of age is not realistic.
JADEN'S STORY
When our daughter Jaden was born, we were anxious to start off on the right foot with her sleep habits. We immediately focused on no more than two hours of wakefulness with a bedtime around 10:00 or 11:00 P.M., which was very easy to accomplish. After a few weeks, though, we still weren't really seeing very long nighttime stretches. When Jaden was eight weeks old, we visited Dr. Weissbluth to discuss her sleeping pattern. Dr. Weissbluth told us that at six weeks, we should have incorporated an early bedtime in addition to keeping shorter periods of wakefulness. We left wondering whether an early bedtime would really work for someone so young. We really expected that Jaden would be up within an hour or two after we put her down. We started off with a 7:00 P.M. bedtime. She still woke up in the late evening to eat, but we put her promptly back to bed. There were a few bumps in the road for the first couple of nights—sometimes she would wake up a few times and cry—but we kept at it. After a few days, Jaden went from sleeping a four-to five-hour stretch in the evening, to seven, then eight, then nine or ten hours a night. In fact, she seemed happy to be sleeping so much! If she woke up to nurse, she would eat and immediately fall back asleep as soon as we put her back in her crib. We couldn't believe how easy it was. The earlier we got her to bed, the better she slept. Her daytime naps even seemed longer and more restful. She is now seven months old. We now try to get her down between 6:00 and 6:30 each night, and she is extremely happy about it. (So are we!)
Over and over again I have seen children who are put to bed too late. It becomes a vicious circle: The child's nap schedule is messed up, and the child is fussy in the late afternoon or early evening. This fatigue-driven fussiness ends in a wired state at bedtime, which interferes with the ability to go to sleep easily. As a result, the parent keeps the child up until he crashes. The next day the child is still tired, the naps are messed up, and so on. The circle never ends.
The solution is obvious in Meg's story.
MEG'S EARLY BEDTIME
Our daughter Meg has been a good sleeper from the very beginning. Since she was six weeks old she has gone weeks when she would sleep through the night (from 10:00 to 6:00), and weeks when she would wake up twice to nurse.
At seven months, she began waking once a night for a bottle. This was fine until she turned eight months old. We had been told by a doctor that she should no longer need to eat in the middle of the night, but we thought we would wait until Meg's nine-month appointment with Dr. Weissbluth to address the problem.
We had never been very consistent with Meg's bedtime. We would put her to bed when she appeared tired (rubbing eyes, yawning), anywhere from 7:00 to 7:45, but occasionally even later. It usually took her between fifteen and thirty minutes of crying to fall asleep. I thought this was normal. She had always gone to bed rather late and she had always taken a while to fall asleep.
At Meg's nine-month appointment we asked Dr. Weissbluth about her night waking. He made a very simple suggestion. He told us that we should put Meg to bed twenty minutes earlier at night. He said that her night waking would disappear and she would still wake up at a normal hour in the morning. I told him that we had been putting her to sleep when she appeared tired at around 7:30, give or take thirty minutes. He said that once she appears tired it is too late and she should already be in bed.
The first night we put her to bed at 6:45. We were very skeptical. We were sad to put her down so early when she seemed so wide awake and happy. She cried for about five minutes and then fell asleep, and with no night waking! The same thing happened the next night—about five minutes of crying and then asleep until morning. Sometimes she would wake up as early as 5:30, but we would give her a bottle and she would fall back to sleep, sometimes until almost 8:00!
It has been almost four weeks since our nine-month appointment. Bedtime is an absolute joy. Meg eats dinner, takes a bath, and is in bed about 6:30. Sometimes I hesitate to put her down so early when she seems to be in such good spirits, but she cuddles with her blanket and her doll, sucks her thumb, closes her eyes, and sleeps till morning. It's the sweetest thing I have ever seen.
As Meg's parents said about my recommendation for a much earlier bedtime, “He made a very simple suggestion.” Sometimes simple approaches work better than complex solutions. Here's another example.
JARED'S SLEEP STORY
When we met with Dr. Weissbluth, Jared, now nineteen months old, was waking up every hour and a half to two hours during the night. He would have to fall asleep while we were walking and carrying him on our shoulder. When placed in the crib, Jared would awaken and abruptly “pop up.” He would only sleep in the bed “nest” we created for him on the floor of our family room. We endured three months of the night waking before we consulted Dr. Weissbluth.
We were instructed to place Jared in bed in an awake state between 6:00 and 7:00 in the evening and that we should leave him there until 6:00 in the morning. Our initial reaction was that Jared would carry on relentlessly when placed in his crib so early, and that the recommended approach was too strict and would never work. Much to our shock and delight, the first night we tried the new routine, Jared was asleep after five minutes of crying, and remained asleep for eleven hours, not waking until 5:30 the next morning. During the next two nights, Jared went to sleep on his own, with no episodes of crying. On the fourth night, he lay down in the bed with his favorite stuffed animal under his arm, as he has done since. Our baby was clearly overtired from going to bed at 8:30 and not being allowed to relax and go to sleep without interference. We never expected it to be so simple and provide such an immediate result. Jared wakes up happy, energized, and ready for a day full of adventures. Now, several months later, Jared is most happy when going to bed at 6:30, and will go to his bed himself if he is tired.
Probably the most common worry is that the earlier bedtime will produce an earlier wake-up time, as expressed by Anna's story.
ANNA'S TRANSITION FROM TWO NAPS TO ONE
At eighteen months it became apparent that Anna was ready to make the transition from two naps to one, but would need some help because she fought the morning nap. We began, as Dr. Weissbluth suggested in his book, by gradually delaying the morning nap till 11:00 A.M. or so. Over a two-week window we were able to continue to push back the nap to sometime between noon and 1:00 P.M.
In his book, Dr. Weissbluth suggested an earlier bedtime to help prevent night waking or early-morning waking. Anna was going to bed at 6:30 P.M. and sleeping until 7:00 A.M., SO we really questioned this theory. My husband and I agreed that Dr. Weissbluth's advice has always been right on the money, so we decided to put her down an hour earlier. We feared that she would wake up at 5:30 or 6:00 A.M. after her usual twelve or thirteen hours of sleep. To our surprise, she awoke at 9:00 A.M., and she was in the most cheerful mood to date!
Family, friends, even strangers constantly tell us what a happy, cheerful child we have. The reality is that she is a very well-rested child.
Not napping means lost sleep. Over an extended period of time, children do not sleep longer at night when their naps are brief. Of course, once in a while—when relatives visit or when a painful ear infection keeps the child awake—a child will make up lost daytime sleep with longer night sleep. But day in and day out, you should not expect to satisfy your child's need to sleep by cutting corners on naps and then trying to compensate by putting your child to sleep for the night at an earlier hour. What you wind up with is a cranky or demanding brat in the late afternoon or early evening. Your child pays a price for nap deprivation, and so do you.
PRACTICAL POINT
When your child does not nap well and you keep him up in the evening, he suffers.
Spending hours holding your child in your arms or in a rocking chair while he is in a light, twilight sleep also is lost sleep because you have delayed the time when he will fall into a deep slumber. It is similar to having a bedtime that is too late. It's a waste of your time as well. Brief catnaps during the day, “motion” sleep in cars or baby swings, light sleep in the stroller at the pool, and naps at the wrong time are all poor-quality sleep.
Here is an example of how one family learned to appreciate napping.
HOW CHARLEY'S PARENTS BECAME NAP ZEALOTS
I am aware that the practice of toting your baby along with you on every occasion is the new social thing. No doubt it stems from the “me” generation's philosophy that a baby should not be allowed to interfere with your lifestyle. So parents everywhere are seen with their infants: in grocery stores, restaurants, the homes of friends… and for the unflappable, at cocktail parties, dinner affairs, even cross-country trips. Although some of these examples may appear to be extreme, be advised, new mothers, that the pressure is on to be a “nouvelle” mom.
As with anything in vogue, you need the appropriate raw material to make it work. And the fact is, my husband, Tom, and I simply do not have the baby to make this new “porta-kid” trend work for us. Oh, we tried. But it was, and continues to be, completely futile. So we gave it up when Charley was three months old.
Charley is now seven months into his life. From the beginning, there has been only one of life's necessities that he requires as much as milk and oxygen, and that is sleep. In fact, we used to shake him when we first brought him home to make sure he was alive. The baby slept… serious sleep.
In the beginning he would sleep anywhere. After his second month, he would sleep only in his crib. And that's another subject. I maintain that the person(s) who decreed that a child's bed should be “stimulating” and full of colored linens and mobiles did not have a child of his/her own! If I had to do it all over again, I would buy a solid, dark-colored comforter and pads. After Charley's second month, he would spend hours on end trying to pick the red, white, and blue flowers off the sheet. This is no lie. And he would scream unmercifully for us to remove this distraction, which was preventing him from needed slumber!
Since his second month, Charley has slept through the night and half of the day. If we disallowed him this necessity, he became a different baby. “Crabby” did not do justice to his fatigue condition. Without this sleep, our peaceful, alert, sweet, and cuddly baby turned into a raging beast. We did this to him when we denied him sleep—not according to our expectations but according to his own internal requirements.
Charley gave us his cues, simply and clearly. He doesn't cry at first. He mumbles, then grumbles, and finally, if his unaware parents or sitters persist, he wails.
At first we couldn't believe he was tired so often. We changed his diapers a thousand times and force-fed bottles. We took him on endless trips in the buggy and walked him incessantly in the Snugli, trying to calm our “miserable” baby with the rhythm of our heartbeats. Nothing worked. Nothing, that is, until we finally, out of sheer nervous exhaustion, laid him in his bed to sleep.
Charley still naps four to five times during the course of a day. He's also a very happy child. When Tom and I go anywhere, we go alone, leaving our contented, sleeping son in the hands of a competent baby-sitter. Our friends, especially our childless friends, think we're overprotective. Well, thank God, Charley is not their baby. We are no longer concerned about our parental image; uneducated criticism doesn't count. If we cannot find a baby-sitter, we don't go. We simply would have a better time watching television … anything, even doing the laundry, beats the hell out of making your baby and yourselves crazy. And our family is now harmonious, having discovered the secret of sleep.
PRACTICAL POINT
When you maintain a healthy nap schedule and your child sleeps well during the day, jealous friends will accuse you of being overprotective. They'll say, “It's not real life” or “Bring her along so she'll learn to play with other children” or “You're really spoiling her.” Suggestion: Change friends, or keep your baby's long naps a family secret.
Sleep Consolidation
Consolidated sleep means uninterrupted sleep, sleep that is continuous and not disrupted by awakenings. When awakenings or complete arousals break our slumber, we call it disrupted sleep or sleep fragmentation. Abnormal shifts of sleep rhythms toward lighter sleep, even if we do not awaken completely, also cause sleep fragmentation. Ten hours of consolidated sleep is not the same as ten hours of fragmented sleep. Doctors, firefighters, and mothers of newborns or sick children who have their sleep interrupted frequently know this very well.
The effects of sleep fragmentation are similar to the effects of reduced total sleep: daytime sleepiness increases and performance measurably decreases. Among healthy adults, even one night of sleep fragmentation will produce decreases in mental flexibility and sustained attention, as well as impairment of mood. Adults with fragmented sleep often fight the ill effects of fragmented sleep with extra caffeine. Alcohol unmasks or uncovers the hidden fatigue and makes them “feel tired.” However, well-rested pre teens who are given the same amount of alcohol, during research studies, do not “feel tired.”
PRACTICAL POINT
Let sleeping babies lie! Never awaken a sleeping baby. Destroying sleep continuity is unhealthy.
Protective Arousals
Sometimes our brains awaken us in order to prevent asphyxiation in our sleep. These awakenings, or protective arousals, occur when we have difficulty breathing during sleep, which can be caused by large tonsils or adenoids obstructing the air passage. (I will discuss this problem in detail in Chapter 10.)
Arousals may also prevent crib deaths, or sudden infant death syndrome (SIDS), which kills young infants. This tragedy might be caused by a failure to maintain breathing during sleep or a failure to awaken when breathing starts to become difficult.
MAJOR POINT
Some arousals from sleep are normal.
Sleep Fragmentation
After several months of age—beyond the age when crib death is most common—frequent arousals are usually harmful, because they destroy sleep continuity. Arousals are complete awakening from either a light, deep, or REM sleep. Arousals can also be thought of as a quick shift from deep sleep to light sleep without a complete awakening.
FIGURE 4: AROUSALS DURING SLEEP
Figure 4 is a simplified illustration of the cycling from deep sleep to light sleep that normally occurs after about four months of age. During partial arousals, we stay in a light sleep state and do not awaken. But during complete arousals, or awakenings, we might become aware that we are looking at the clock, rolling over, changing arm positions, or scratching a leg. This awareness is dim and brief, and we return to sleep promptly.
As we can see, arousals come in several forms, and depending on which types occur, how many times they happen, and how long they last, we pay a price: increased daytime sleepiness and decreased performance. Some arousals, however, always occur naturally during healthy sleep. The brain, not the stomach, makes arousals. Please don't confuse arousals from sleep with hunger.
It's not just night sleep that can be fragmented. I believe naps can also be fragmented when parents rely on “motion” sleep in a baby swing or car, or when they allow catnaps in the stroller. Holding your dozing child in your arms in a rocking chair during the day also probably prevents good-quality day sleep. These naps are too brief or too light to be restorative. Stationary sleep is best. If you use a swing for soothing, turn it off once your baby falls asleep.
PRACTICAL POINT
After four months, naps of less than one hour cannot count as “real” naps. Sometimes a nap of forty-five minutes may be all your child needs, but naps of less than thirty minutes don't help.
By four to eight months of age, infants should have at least a midmorning nap and one in the early afternoon, and the total nap duration should be two to four hours. Night sleep is ten to twelve hours, with one, two, or no interruptions for bottle-feeding. If you are breast-feeding and using a family bed, you might feed your baby at night many times. In this situation, both mother and baby are often more asleep than awake during the feeding and neither suffer from sleep fragmentation. When children do not get healthy, consolidated sleep, we call the problem “night waking.” As I will discuss later, night waking itself is usually due to normally occurring arousals. The real problem is the child's inability or difficulty returning to sleep unassisted.
PRACTICAL POINT
Some arousals from sleep are normal. Problems occur when children have difficulty returning to sleep by themselves. They have not learned the process of “Falling asleep.”
Sleep Schedule, Timing of Sleep
Figures 5 and 6 show the times when most children awaken or go to sleep. These graphs are based on data from the same 2,019 children referred to in Figures 1 through 3 (see pages 21-23). Looking at the graphs, you can see, for example, that 90 percent of preschool children (those under the age of six) fall asleep before 9:00 P.M., and 10 percent of children between the ages of two and six fall asleep before 7:00 P.M.
MAJOR POINT
Junk food is not healthy for our bodies. Neither is a “junk sleep” schedule. You try not to let your child become overly hungry, so don't let your child become overly tired.
When sleep/wake schedules are not in synchrony with other biological rhythms, attentiveness, vigilance, and task performance are measurably decreased and moods are altered. Jet-lag syndrome is one example of this. Another is the poor sleep quality some shift workers suffer due to abnormal sleep schedules. Shift workers complain mainly of headaches and stomachaches. These are the most common complaints of older children with unhealthy sleep schedules. So if your child doesn't appear to be very sick but has frequent headaches or episodes of vague abdominal pain, especially near the end of the day, ask yourself if he might be overtired. A clue would be that he no longer has the energy or drive that he once had.
When thinking about sleep schedules in babies and toddlers, consider sleep to be “food” for the brain, just as breast milk or formula is food for the body. You don't breast-feed on the run while doing errands; instead, you find a reasonably quiet space. Same for naps. You don't withhold feeding because it is socially inconvenient; you anticipate when your child might become hungry. Same for naps. You don't try to force-feed your baby when she's not hungry; you know a hungry period will naturally come. Same for naps. A parent coming home late from work would not starve his baby by withholding food until he arrived and could feed the child. Same for the bedtime hour; don't “sleep starve” your baby's brain by keeping her up too late.
Night Sleep Organization
Before six weeks of age, the longest single sleep period, unfortunately, is randomly distributed around the clock. In some babies, this longest sleep may actually be only two to three hours! But by six weeks of age (or six weeks after the due date, for babies born early), the longest single sleep period will predictably occur in the evening hours and last three to five hours.
PRACTICAL POINT
During these early weeks, you may find breast-feeding too demanding or too frequent, and think that you might want to quit so that you can get some rest. On the other hand, you also may want to continue nursing. Hang in there until your baby is past six weeks of age. Then you, too, will get more night sleep.
After six weeks of age, babies sleep longer at night. So do moms! Also, babies start social smiling at their parents, and they then become less fussy or irritable. Life in the family definitely changes after six weeks. One exception is the premature baby, whose parents might have to wait until about six weeks after the expected date of delivery. Another exception is the extremely fussy/colicky baby, whose parents might have to wait until their child is three or four months old.
Daytime Sleep Organization
At about three to four months of age, daytime sleep is organized into two or three long naps instead of many brief, irregular ones. Mothers, especially nursing mothers, should learn to nap when their baby naps. You never know what the night will bring; you might be up a lot holding, walking, or nursing.
Abnormal sleep schedules usually evolve in infants and young children when parents keep them up too late at night. Parents do this because they (1) enjoy playing with their baby, (2) cannot put the child to sleep, but wait for their child to crash from total exhaustion, or (3) both. Some parents leave work late, have a long commute to the day-care site to pick up their child, and then arrive home even later. This lifestyle is extremely difficult for the child if naps are not regular at the day-care center and he is put down too late to sleep at night. Unfortunately, if both parents are working outside the home, then naps may suffer on weekends because the parents do too many errands with the child or attempt to spend too much time playing with their child to make up for the minimal time together during the week. Sleeping well during the day may also suffer when parents skip naps in favor of organized, scheduled preschool activities. These baby classes are usually fun for both child and parent, but if they take up too much time, the child becomes overtired.
One common mistake is keeping bedtime at exactly the same hour every night. Usually this hour is too late and is based more on the parents’ wishes than the child's sleep needs. It is important to have a fairly regular routine of soothing events before putting your child to sleep, but it makes biological sense to vary the bedtime a little. The time when your child needs to go to sleep at night depends on his age, how long his previous nap lasted, and how long his wakeful period was just before the bedtime hour. The time when he wants to go to sleep may be altogether different! Obviously, the bedtime hour is not fixed or unchanging. If your child is unusually active in the afternoon or if she misses a good afternoon nap, then she should be put to sleep earlier.
This is true even if a parent, returning home late from work, does not get to see her child. If one parent is arriving home late, then she or he might walk in the house and immediately begin a twenty-to thirty-minute soothing-to-sleep routine without playtime. If the parent returns very late, the child should be put to bed as usual; keeping a tired child up to play with a tired parent does no one any good. At the cost to the parent of having less time with his child, the benefit is no bedtime battles, no night-waking habits, no early-morning arousals, good-quality naps, a well-rested child, a well-rested spouse, and relaxed private time for the parents in the evening. Usually under these circumstances there is morning time to spend together and relaxed weekends for the family because everyone is well rested.
The completely opposite scenario occurs when one parent, usually the father, demands that the other parent, usually the mother, keep their child up late so that he can play with him or her. Not only does the child suffer, but it is the mother who is the unappreciated victim, because she is trying to maintain marital harmony and trying to keep her child well rested—and she can't do both. Obviously this is not simply a child's sleep problem but a family problem.
PRACTICAL POINT
To establish healthy sleep schedules at four to eight months of age, become your infant's timekeeper. Set his clock on healthy time.
Allowing brief naps in the early evening or long late-afternoon naps in order to keep a child up late at night will eventually ruin healthy sleep schedules. If your child misses his early-afternoon nap, in order for him to be able to fall asleep close to his biological bedtime hour and avoid the overtired state, it is better to have no nap and an early bedtime than a late nap and a late bedtime. Similarly, you may occasionally need to wake your baby in the morning in order to establish an age-appropriate midmorning nap that is needed to set the sleep schedule for the rest of the day.
Sleep Regularity
The best time for your child to fall asleep at night is when she is just starting to become drowsy, before she becomes overtired. For young children in day care, dual-career families with long commutes, older children with scheduled activities, or teenagers with tremendous amounts of homework, it may be impossible to catch that magical drowsy state. These children will be better off if the bedtime is occurring at approximately the same time every night. For teenagers, this might mean consistent bedtimes throughout the week with later times on the weekends. In one study, regularity of the bedtime schedule was assessed in 3,119 high school students. They discovered that a more irregular sleep schedule was associated with more daytime sleepiness. These teenagers had lower grades, more injuries associated with alcohol or drugs, and more days missed from school. Going to bed around 11:00 P.M. compared to sometimes 10:00 P.M. or midnight might produce the same amount of sleep, but the more regular schedule is probably better.
Another report examined the sleep of 202 children between four and five years of age. Here, too, variability in bedtime was associated with daytime problems described as “less optimal” behavioral adjustments in preschool. For example, these children did not “comply with teacher's urging to join an activity,” “show enthusiasm for learning something,” and they argued and fought more than other children. The authors thought these children with chronically variable sleep schedules might experience states similar to jet-lag syndrome characterized as nagging fatigue and cognitive disorientation. This particular study examined the role of family functioning as well as school behavior and concluded that the link between sleep behavior and school adjustment was not a common by-product of family stress.
A bedtime that never varies, for example, always putting your preschool child to sleep at exactly 7:00 P.M., does not take into account the biologic variability, from day to day, of activity levels or lengths of naps. So it makes sense to vary the bedtime by thirty to sixty minutes based on how your child looks and behaves during the late afternoon. On the other hand, for older children who are not napping, having bedtimes that are hours earlier or later from day to day has been shown to be unhealthy.
PRACTICAL POINT
Even if the bedtime is too late, a regular bedtime is better than an irregular bedtime.
Biological Rhythms
To better understand the importance of maintaining sleep schedules, let's look at how four distinctive biological rhythms develop. First, immediately after birth, babies are wakeful, then fall asleep, awaken, and fall asleep a second time over a ten-hour period. These periods of wakefulness are predictable and not due to hunger, although what causes them is unknown. Thus a partial sleep/wake pattern or rhythm emerges immediately after birth. Second, body temperature rhythms appear and influence sleep/wake cycles. Body temperature typically rises during the day and drops to lower levels at night. At six weeks of age, temperature at bedtime is significantly higher than later in the night. After six weeks of age, as temperatures fall more with sleep, the sleep periods get longer. By twelve to sixteen weeks, all babies show consistent temperature rhythms. It is exactly at six weeks of age when evening fussiness or crying begins to decrease from peak levels and night sleep becomes organized, and it is at twelve to sixteen weeks when day sleep patterns become established.
A third pattern is added by three to six months of age, when the hormone cortisol also shows a similar characteristic rhythm, with peak concentrations in the early morning and lowest levels around midnight. (This hormone is related to both mood and performance and will be discussed further in Chapter 3.) Interestingly, a part of the cortisol secretion rhythm is related to the sleep/wake rhythm and another part is coupled to the body temperature rhythm. I wish Mother Nature were simpler!
Melatonin rhythmicity is a fourth pattern to consider. Initially, a newborn has high levels of circulating melatonin, which is secreted by the mother's pineal gland and crosses the placenta. Within about one week, the melatonin that came from the mother has disappeared. At about six weeks of age, melatonin begins to reappear as the baby's pineal gland matures. But the levels are extremely low until twelve to sixteen weeks of age. Then melatonin begins to surge at night, and the hormone appears to be associated with evolving sleep/wake rhythms by about six months of age. (Melatonin supplements should not be given to babies or young children to make them sleep better; there is no evidence that it is safe.)
Even at only a few months of age, then, interrelated, internal rhythms are already well developed: sleep/wake pattern, body temperature, and cortisol and melatonin levels. In adults, it appears that a long night's sleep is most dependent on going to sleep at or just after the peak of the temperature cycle. Bedtimes occurring near the lower portion of the temperature cycle result in shorter sleep durations.
Shift work or jet travel in adults, or parental mismanagement in children, might cause disorganized sleep. What is “disorganized sleep”? When you are awake but your body clock is in the sleep mode or when you crash from exhaustion when your body clock is in the awake mode, then your wakeful-ness or sleep is occurring out of phase with many biological rhythms. The result is poor-quality sleep or poor-quality wake-fulness. Imagine the sound from an orchestra if the violin section started to play their part after the woodwinds had already started!
Many studies have been conducted with shift workers and in sleep labs on the internal desynchronization of circadian rhythms, the uncoupling of rhythms that are normally closely linked, and shifting rhythms that are out of phase with one another. The most common complaints in these adults are headaches and abdominal pain. Such people appear healthy and can function reasonably well except for the fact that they have pain in their head and/or stomach.
REMINDER
Never wake a sleeping baby.
There is a large pediatric literature on headaches and recurrent abdominal pains; also, this is very familiar territory to parents of school-age children who have highly scheduled, busy lifestyles. Additional consequences of disorganized sleep include fatigue, stress, and perhaps chronically elevated cortisol levels. Once in place, a pattern of disorganized sleep sets in motion other specific sleep disturbances, such as night waking or an inability to fall asleep easily. Furthermore, recent research has shown that the hormones that are important to regulate sleep are also involved with the immune system, which helps us to fight infections. And research has shown that even modest sleep loss can impair cellular immune function. An article published in Science News in 2002, “Missed ZZZ's, More Disease: Skimping on sleep may be bad for your health” describes how “poor sleep habits are as important as poor nutrition and physical inactivity in the development of chronic illness.” They specifically cite obesity, diabetes, and cardiovascular disease. Although this article addressed adult health concerns, there is a growing concern that too many of our children are becoming more overweight or obese. So remember what our grandmothers used to say: “Early to bed, early to rise, makes you healthy …”
I often tell parents to become sensitive to their child's personal sleep signals. This means that you should capture that magic moment when the child is tired, ready to sleep, and easily falls asleep. The magic moment is a slight quieting, a lull in being busy, a slight staring off, and a hint of calmness. If you catch this wave of tiredness and put the child to sleep then, there will be no crying. I like the analogy of surfing, because timing is so important there, too—you have to catch the wave after it rises enough to be recognized but before it crashes. But if you allow a child to crash into an overtired state, it will be harder for him to fall asleep, because he is trying to fall asleep out of phase with other biological rhythms. His ride to sleep then will not be easy or pleasant. Timing is most important! Remember, not every sleep wave is the same, and not every child learns quickly how to ride his sleep wave. But as with everything else, after practice it occurs effortlessly.
Cumulative Sleepiness
It's been known for many years that the effect of lost sleep accumulates over time. When you constantly have insufficient sleep, the sensation of sleepiness when you should be awake increases progressively. Let me explain what this means by giving an example. When adult volunteers have their sleep shortened by a constant amount, impairments in their mood and performance can be measured during the day. If the sleep disruption is repeated night after night, the actual measured impairments do not remain constant. Instead, there is an escalating accumulation of sleepiness that produces in adults continuing increases in headaches, gastrointestinal complaints, forgetfulness, reduced concentration, fatigue, emotional ups and downs, difficulty in staying awake during the daytime, irritability, and difficulty awakening. Not only do the adults describe themselves as more sleepy and mentally exhausted, they also feel more stressed. The stress may be a direct consequence of partial sleep deprivation or it may result from the challenge of coping with increasing amounts of daytime sleepiness. Think how hard it would be to concentrate or be motivated if you were struggling every day to stay awake.
If children have constant amounts of sleep deficits, do they show these same escalating problems during the day? Yes! I believe the young child's brain is as sleep-sensitive as, if not more so than, an adult's. It is also possible that severe or chronic sleep deficits occurring early during the period of rapid brain growth might hard-wire circuits to produce permanent effects. This would be difficult to prove, because young children cannot report how they feel and we assume it is “natural” for them to have difficult temperaments, have tantrums, get frustrated, become easily angry, and so forth. In addition, in older children we have learned to accept as “normal” vague neurological differences—learning difficulties or attention deficit hyperactivity disorder (which, oddly enough, we treat with stimulant medications).
The problem with concluding that constant sleep deficits are associated with these problems is that early nighttime sleep deficits may be mild and masked by long naps. If the brain has been permanently changed due to severe or chronic sleep loss, then, when the naps disappear and school requires more mental vigilance and focused attention, preexisting problems may appear. It is not simply academics that might suffer. We do not know the contribution of healthy childhood sleep toward creativity, empathy, a sense of humor, or adult mental health. Part of the problem is, of course, that we don't have yardsticks to measure items such as creativity or empathy, so we do not yet have a way to measure the contribution that healthy sleep during childhood might make.
I do know that many parents keep their child up an extra twenty or thirty minutes at night to have fun, and notice no problems in the beginning. Later they call and ask why their “good sleeper” is now resisting bedtime or is cranky in the morning for “no obvious reason.” Because the change in routine was small and in the past, they don't even think about it. But during our conversation they will recall that because of the longer spring and summer days, or because “it didn't seem to cause any problems,” they pushed the child's bedtime back. The interval between allowing the too-late bedtime and the emergence of sleep-related problems was months in young children who had always in the past been well rested and were taking good naps, or weeks in children who were always on the edge of being overtired anyway. When such parents were asked if they thought their child appeared able to go to sleep twenty or thirty minutes earlier, the answer was almost always yes.
MAJOR POINT
Small but constant deficits in sleep over time tend to have escalating and perhaps long-term effects on brain function.
In older children who have outgrown naps, the interval before the effects of cumulative sleepiness show themselves may be very long because of high motivation in the child and many exciting parent-directed events such as classes, lessons, or excursions, which help mask impaired vigilance or performance. The right bedtime is based on your child's age (see previous graphs for age-appropriate norms) and your child's behavior, mood, and performance, especially in the late afternoon.
Twenty-five-Hour Cycles
Although harmonious biological rhythms promote healthy sleep, random bad days are bound to occur. One explanation for “off” days, when the child's sleep is irregular for no apparent reason, is that our basic biological clocks have about twenty-five hours in their cycle, not twenty-four. In other words, without time cues, our free-running sleep/wake rhythms appear to complete one full cycle every twenty-five hours. As long as we train our children to match sleep/wake rhythms to night and day, problems are usually avoided. Other babies appear to get off schedule every few weeks and parents then must work to keep them well rested. I suspect that babies, like adults, differ in their individual ability to adjust their twenty-five-hour biological rhythms to society's twenty-four-hour clocks. Most parents, however, find that the effort to reset a baby's clock is worth it, because otherwise the child becomes increasingly tired and crabby.
When parents make the effort to help the child get needed sleep, the child becomes better rested, and it becomes easier for her to accept sleep, to expect to sleep, to take long naps, and to go to sleep by herself. Some parents always have to endure days of disruption following trips, illnesses, or immunizations because any irregularity of schedule upsets sleep rhythms.
Here is one family's account.
SUSAN'S NIGHT WAKING
Last summer, Susan's night waking had become so frequent that she was basically awake more than she was asleep. We had been instructed by a pediatrician at the parenting class we attend to “meet our child's needs.” So we were getting up as frequently as she asked and rocking her back to sleep. This happened three or four times a night and often took thirty to sixty minutes. A part of me wanted to do this. Needless to say, however, after months of this nighttime routine, my husband and I became quite exhausted and began to resent our child. I knew I was in trouble when I would get up and go into the baby's room and yell at her and then begin crying myself. The point I'm trying to make is simple: When a problem like a child's sleep habit gets out of hand, the parents are partially responsible.
Finally, on our own, we decided to let her cry it out. By the way, my husband had a much easier time psychologically with letting her cry. He knew it was in her best interest and was able to remain unemotional about it. It took about a week, and she cried for about two hours for quite a few of those nights. Finally it seemed that she had gotten the idea.
Unfortunately, the next week we were scheduled to go on our summer vacation. We didn't want to cancel the trip, but we knew we were taking a chance on destroying the results of our hard work. We stayed at an inn, and there were no cribs, so we made a sleeping area for Susan in the corner of the room. She'd wake up in the middle of the night and think it was playtime.
When we got back from the trip we tried to get into the routine of letting her cry it out, but by that time we didn't have the energy to go through a week of crying again. So we fell back into a poor nighttime routine. Another month went by, and we knew we could not go on. We discussed it with the teacher at our parenting class, and she finally recommended the process of just letting Susan cry it out. This time it took about five days before she was back to sleeping through the night. The improvement lasted about a month.
Susan received a vaccination shortly after that. I went into her room for only a moment to check on her one night. Then she began waking each night, and we were into our old routine. We repeated the process yet one more time. I think it took about five nights to get her to sleep through the night again. After that, Susan slept through the night regularly for months. She eventually asked to be put down before she was asleep at night rather than being rocked to sleep. She began taking long naps this spring, which seemed slightly strange.
This summer when we went on vacation Susan slept in a crib in our room. She'd awaken in the night and again think it was playtime. It didn't take long for her to get back into her old bad habits. We had hoped we were beyond that, since she had been sleeping through the night for so many months … but since our trip she's been up at night practicing long dialogues, and it looks like we'll have to go through this one more time.
This sounds like the story of a child who is always on the edge of being overtired and in whom natural disruptions are not easily tolerated. Slightly overtired children are more easily thrown off balance and take longer to recover. Well-rested children tend to be more adaptable and take occasional changes of routine in stride.
PRACTICAL POINT
A well-rested baby with a healthy sleep habit awakens with a cheerful, happy attitude. A tired baby awakens grumpy.
Sleep Positions, SIDS
A common myth held by Western parents is that all children sleep better on their stomachs. Yet a Chinese mother whose baby preferred to sleep on her stomach said she knew something was very wrong with her infant, because all Chinese babies sleep on their backs! She truly worried that stomach sleeping was unhealthy.
The truth is that some babies seem to sleep better and fuss or cry less when asleep on their backs. Contrary to many parents’ fears, sleeping on the back does not cause a misshapen skull. In the past, tradition and social circumstances dictated which sleeping position most parents selected. Now it appears that sleeping on the back is healthier because it helps prevent sudden infant death syndrome.Fortunately, most babies sleep equally well on their backs as on their stomachs.
A variant of the myth that babies sleep better on their stomachs is that when the child at five months rolls over, away from the sleeping position selected by the parents, the parent has to intervene and roll the child back. Actually, leaving the child alone allows the child to learn to sleep in different positions. If you roll your child back and he instantaneously returns to sleep, obviously there is no problem. On the other hand, going to your child to roll him back can become a game for the infant by five months of age. Games should occur at playtime, not when it's time to sleep. Remember, not going to your baby allows him to learn to roll back alone, learn to sleep in the new position, and learn to remember the next night not to roll in the first place.
Likewise, when the older child pulls herself to a standing position in her crib, parents do not need to help her get down. A child might fall down in an awkward heap, but she will not hurt herself. Next time she will think twice about standing up and shaking the crib railings, or she'll be more careful when letting go.
Parents who rush in to roll the baby over or to help a child down run the risk of reinforcing this behavior, encouraging it to be repeated night after night. Children are very crafty and learn quickly how to get parents to give them extra attention. Don't deprive your child of the opportunity to learn how to roll over or sit down unassisted at night.
The Benefits of Healthy Sleep:
Sleep Patterns, Intelligence, Learning,
and School Performance
Do sleep patterns really affect learning in children? Yes! Different studies of children at different ages all agree on this point. Focusing on perfectly normal, healthy children, let's consider the data by age groups: infants, preschoolers, and school-age children.
Infants
A study at the University of Connecticut showed that there was a strong association between the amount of time infants were in REM sleep and the amount of time they spent when awake in the behavioral state called “quiet alert.” In the quiet alert state, babies have open, bright eyes, they appear alert, their eyes are scanning, their faces are relaxed, and they do not smile or frown. Their bodies are relatively quiet and inactive. One mother described her four-month-old, who was frequently in this quiet alert state, as “a looker and a thinker.” She's right! These infants don't miss a thing. A study of sleep development at Stanford University showed that environmental factors, not simply brain maturation, are responsible for the proportion of time infants spend in REM sleep. Unfortunately, the exact environmental factors were not identified, but presumably parental handling could influence all of these items: sleep patterns, the proportion of REM sleep, and the amount of time the child is in the quiet alert state.
Infants who are notoriously not quiet alert are those with colic or a difficult temperament. Their fussy behavior may be due to imbalances of internal chemicals such as progesterone or even cortisol. High cortisol concentrations in infants have been shown to be associated with decreased duration of non-REM sleep. So, even in infants, as in adults, there seem to be connections between internal chemicals, sleep patterns, and behavior when awake. Also, these fussy children tend to have irregular schedules and short attention spans. Among two-to three-month-old infants, one study showed that the more irregular and impersistent the child was, the slower the rates of learning. Looking ahead to Figure 9 (see page 395), you can see how colicky or difficult-temperament children, who sleep for brief durations and have irregular schedules and short attention spans, might not learn quickly to fall asleep unassisted. Thus they easily could become sleep-deprived, fatigued, and hyperactive older children. (This concept of increased alertness, wakefulness, and irritability due to chemical imbalances will be discussed in Chapter 3.)
I think naps are especially important for infants. In my own studies, I've found that how long the infant sleeps during the day is strongly associated with persistence or attention span. Infants who take long naps have longer attention spans. They spend more time in the quiet alert state and seem to learn faster. Infants who do not nap well are either drowsy or fitfully fussy, and in either case they do not learn well.
PRACTICAL POINT
Naps promote optimal alertness for children. Children who nap well spend relatively more time in the quiet alert state when awake.
It is a myth that long naps interfere with acquiring socialization skills or infant stimulation. While it's true that “rack-monsters” are less available for all the classes or activities that abound today—swim-gym, Mom-Tots, Pop-Tots, or infant-stimulating groups—is that so bad? Do infants suffer because they don't participate in so many activities? Are they less likely to get into the right preschool, which feeds to the right nursery school, which feeds to the right private school? No.
Please do not confuse the quantity of time spent in these organized activities with the high-quality social awareness that well-rested children exhibit. The truth is that these infant-stimulation groups are often not important for infants but instead serve legitimate parental needs by allowing mothers and fathers to meet other parents and escape from their isolation at home.
Preschool Children
Three-year-old children who nap well are more adaptable. (Adaptability means the ease with which children adjust to new circumstances.) Adaptability is the single most important trait for school success. The briefer the naps, the less adaptable the child. In fact, the major temperament feature of three-year-olds who do not nap at all is nonadaptability. It is exactly these non-napping, nonadaptable children who also have more night wakings!
My research has shown that when infants who are easy at five months of age develop into crabbier, more difficult three-year-olds, it is because they have developed a pattern of brief sleeps. In contrast, difficult infants who mellow into easier three-year-olds have developed a pattern of long sleeps. I think that parents’ helping or hindering regular sleep patterns caused these shifts to occur.
School-Age Children
In 1925, the father of the Stanford-Binet Intelligence Test, Dr. Lewis M. Terman, published his landmark book, Genetic Studies of Genius.He compared approximately 600 children with IQ scores over 140 to a group of almost 2,700 children with IQ scores below 140. For every age examined, the gifted children slept longer!
Two years later, about 5,500 Japanese schoolchildren were studied, and those with better grades slept longer!
Even seventy-nine years later, Dr. Terman's study stands apart in design, execution, and thoroughness. A 1983 scientific sleep laboratory study from Canada has provided objective evidence confirming Terman's result, that children of superior IQ had greater total sleep time. Both studies agreed that brighter children slept about thirty to forty minutes longer each night than average children of similar ages.
Another study from the University of Louisville School of Medicine examined a group of identical twins that were selected because one twin slept less than the other. At about ten years of age, the twin with the longer sleep pattern had higher total reading, vocabulary, and comprehension scores than the twin with the shorter sleep pattern.
PRACTICAL POINT
Please don't think that it has no lasting effect when you routinely keep your child up too late—for your own pleasure after work or because you want to avoid bedtime confrontations—or when you cut corners on naps in order to run errands or visit friends. Once in a while, for a special occasion or reason, it's okay. But day-in, day-out sleep deprivation at night or for naps, as a matter of habit, could be very damaging to your child. Cumulative, chronic sleep losses, even of brief duration, may be harmful for learning.
Children diagnosed with attention deficit hyperactivity disorder or learning disabilities have been shown to have sleep-related difficulties, though we don't know which came first. Nevertheless, one careful intervention study showed that improvements in sleep dramatically improved peer relations and classroom performance.
Research on creative adults supports the concept that originality of ideas and the quality of experiences suffer when you cut back on sleep. What you lose in waking time is made up in terms of a richer life. Have you ever nodded off at an evening event that you really wanted to attend but were too tired to fully enjoy?
There are many other studies that show an association between sleeping and school performance, but these involve children with allergies or large adenoids. (These problems are discussed in Chapter 10.)
SLEEP STRATEGIES
Drowsy Signs
As your baby shows signs of becoming drowsy, you should begin a soothing-to-sleep routine. These signs usually start within one or two hours of wakefulness. About 20 percent of babies have colic and they may not show these drowsy signs, so you have to watch the clock more carefully. If your child often shows signs of fatigue, note how long she has been awake and next time begin the soothing process about twenty minutes earlier.
It is not necessary for your child to be drowsy and awake when you put him down or you lie down with him in your bed. Sometimes your baby goes from drowsy to sleepy very quickly, and there is no good reason why some books suggest that you should then wake up your baby before you put him down or lie down with him.
DROWSY SIGNS, SLEEPY CUES, SLEEP SIGNALS
Moving into the sleep zone
Becoming Drowsy
Decreased activity
Slower motions
Less vocal
Sucking is weaker or slower
Quieter
Calmer
Appears disinterested in surroundings
Eyes are less focused
Eyelids drooping
Yawning
FATIGUE SIGNS
Entering overtired zone
Becoming Overtired
Fussing
Rubbing eyes
Irritable
Cranky
Soothing to Sleep
What exactly is soothing? Soothing is restoring a peaceful state. To soothe your newborn is to render her calm or quiet, to bring her to a composed condition. You are attempting to establish a peaceful state of tranquillity by reducing the force or intensity of fussiness. Your goal is to soften, tone down, or render less harsh fussiness or crying. Soothing is pacifying or calming. You want to bring comfort to your baby and a cessation of agitation. Snuggling her close to your body, she feels your warmth and senses your affection and protection. Cuddling is the close embrace you do with someone you love. Sometimes you just want to nestle with her as you take a cozy position and press her close to you or lie down close to her. At best, when a child is tired, we hope to lull her into a relaxed sleepy state.
Bodily contact, sucking, and gentle rhythmic motions over long periods of time seem to work best. Sometimes loud mechanical sounds like the garbage disposal or hair dryer seem to help. Be careful, however, not to bombard your baby with stimuli. Initially, try to appeal to one sense at a time: tactile (massaging, rubbing, kissing, rocking, patting, changing from hip to shoulder), auditory (singing, humming, playing music, running the vacuum cleaner), sight (bright lights, mobiles, television), dim light or darkness when drowsy or rhythmic motion (swings, cradles, car rides, going for a walk). Sometimes, doing too many of these things simultaneously or with too much force has a stimulating rather than a relaxing effect. However, if your baby remains fussy, try combinations of these different modalities.
Try to synchronize your actions with your baby's rhythms. If he is tense, taut, with deep exhausted heaving sobs and little physical movement, try rubbing his back ever so gently or moving your cheek over his in a slow rhythm that coincides with his breathing pattern. If he is boxing with his fists, jerking his legs, and arching his back, maybe a ride on your shoulders will grab his attention and arrest the spell. You will find that after a while you become attuned to nuances within your baby's rhythms and respond accordingly.
Father Care: Our Secret Weapon for Soothing
Before your baby is born, fathers should make the decision to become involved in caring for the baby from the very beginning. Some fathers hold back initially, afraid they might “do the wrong thing” when holding, burping, bathing, changing, or feeding the baby. After mothers get their strength back, they should deliberately leave the house on a weekend for a few hours to visit a friend, hang out with the older kids, get their hair done, or go shopping at a time when they expect the baby to go through a cycle of feeding, changing, bathing, and putting to sleep. Guess who has to do the work then? Often a father will feel more comfortable doing these things when the “expert” is not looking over his shoulder. So the first point is for fathers to start early in practicing baby care.
Second, fathers should plan ahead for the six-week peak of fussing/crying that occurs in all babies. They should come home early or take a few days off from work if they are able. Make adjustments if your baby is born before or after the expected date of delivery, because the six-week peak is counted from this due date. At six weeks of age, babies fuss/cry more and sleep less. Less sleep for the baby means less sleep for the mother. All mothers need help in caring for their six-week-old and themselves. Fathers should give mothers a well-deserved break at this time by taking the baby out for long walks or car rides in the evening or night. The baby might not sleep well during these outings, but at least the mother gets a break.
The third point is that fathers can practice and learn how to help their baby fall asleep. For example, after nursing her baby, the mother could pass her son to the father, who then rocks his baby gently for a while and puts him down to sleep or lies down with him in their bed and they both snooze. (This may only occur on weekends when the father is around.) The participation of fathers in putting their babies to sleep will help them gain confidence in becoming a parent. If the mother is giving expressed breast milk in a bottle, fathers and babies may have an easier time accomplishing the feeding if the mother actually leaves the house. This is because the baby can smell the mother's presence and might resist taking the bottle if he knows his mother is home. So, maybe on weekends, when it's time for the baby's nap, mom leaves the house and has fun while dad gives the bottle and puts his baby down to sleep.
Fourth, fathers can learn how to soothe baby fussiness and crying and spend lots of time doing the soothing. For example, fathers can learn infant massage. Classes are offered everywhere; call your local maternity hospital or go on-line. Fathers can learn lullabies (your baby will not care how well you sing). A baby bath might be especially soothing, and fathers can spend time letting the warm water calm the baby. A father can learn to do everything a mother does to soothe the baby except breast-feed. For babies six months of age or older, fathers can attempt to help lengthen naps by responding immediately as a mininap nears its end (baby just begins to whimper or cry) by attempting to soothe the baby back to sleep for a nap extension. If mothers do this, it might be more stimulating than soothing.
Lastly, a father can request to help feed or soothe the baby in the middle of the night when the mother needs extra sleep. This is a little bit tricky because many mothers have the attitude that nobody can do the soothing as well as they can, and also that dads need their rest so they can go out to work well rested in the morning. With this attitude, the mother rejects or resists the idea that baby care in the middle of the night should be a shared experience. For some families, this might be the right course of action. But if the mother is distressed, exhausted, sleep-deprived, or going through baby blues, then extra help at night from the father is absolutely needed to give the mother a little more sleep. After all, no matter how stressful his job might be, the father at work always gets some breaks. A mother with a baby might not get any breaks during the day. In one study of children one to three years of age, sleep problems were solved when fathers took over the management of the bedtime routine and night awakenings. Dr. Klaus Minde observed that the fathers were “more forthright and authoritative” and the mothers felt tired in the evening and perceived their toddlers as particularly difficult at that time. In this study, the fathers used the “graduated extinction” or “controlled crying” method.
Fathers need to understand that when children are overtired and not sleeping well, it is sometimes useful to go to a temporarily ultra-early bedtime to repay the sleep debt. The child awakens better rested, then learns to nap better, and later is able to have a later bedtime. If fathers refuse to help prevent and solve sleep problems, then they have to accept responsibility for their overtired child's behavior—and not blame the mother!
Sucking Is Soothing
Anything you can do to encourage your baby to suck will help soothe her. Offering the breast, bottle, pacifier, finger, or wrist usually helps calm your baby. If you are breast-feeding, one way to help distinguish between sucking for soothing and sucking for hunger is that the sucking for soothing is often rapid, repeated sucks with very little swallowing. In addition, the fussy baby does not suck in a rhythmic steady fashion; instead, she starts and stops, twists and turns. If she is hungry, the pattern is usually a rhythmic suck-swallow, suck-swallow, and so forth. If you are bottle-feeding, do not assume that when your baby eagerly takes several ounces that this means she is hungry. Many babies with extreme fussiness/colic suck more than they need and spit up a lot.
Because sucking is such a powerful way to calm a baby and babies often fall asleep with sucking, I think it is unnatural and unhealthy for parents to deliberately do things that interfere with sucking. One popular book that promotes “no-cry sleep solutions” tells parents to remove the breast while he is sucking, before he falls asleep, and if the baby continues to want to suck after the removal, it tells parents to hold the baby's mouth closed to prevent the sucking. Another popular book describes sucking as one of the major ways that babies can calm themselves, but then goes on to recommend that you wake your baby up during sucking if he falls asleep at the breast. Furthermore, the author instructs you to begin this practice at one month of age! Both books make the assumption that if the baby falls asleep while sucking, you will be creating a sleeping problem. There is no good evidence to support this assumption. Mothers in my practice do not deliberately interfere with sucking at the time of soothing to sleep, and their babies sleep well. Both books also incorrectly assume that feeding and sleeping are tightly linked. So they both encourage you to force-feed your baby in order to help him sleep longer. Phrases like “cluster feed” or “top off the tank” to help him sleep or “He's awake when he's hungry and asleep when he's full” reveal a profound ignorance about how the developing brain, not the stomach, controls sleep/ wake rhythms. I believe it is much more natural to follow your baby's needs. If your baby is hungry, feed him. If your baby is fussy, soothe him. If your baby is tired, put him to sleep. If you're not sure what he needs, encourage sucking at the breast or bottle until he seems satisfied because he is full or calm or asleep.
Rhythmic Rocking Motions
Rhythmic motions are one of the most effective methods of soothing your infant. Use a cradle, rocking chair, baby swing, or Snugli; take the baby for automobile rides, dance with her, or simply walk with her. Rocking motions may be gentle movements or vigorous swinging, depending on what your child responds to. Gently jiggling or bouncing may calm your baby. Some parents claim that raising and lowering the baby like an elevator is effective. Perhaps these rhythmic movements are comforting because they are similar to what a baby feels in the womb.
Swaddling
Gentle pressure, such as that experienced when embraced or hugged, makes us feel good. Swaddling or gentle wrapping, sleeping in a car seat or being held in a soft baby carrier or sling are other ways to exert gentle pressure. Here, too, perhaps the sensation of gentle pressure resembles a state of comfort that the baby feels before he is born. Both rhythmic motions and gentle pressure may be effective because perhaps human babies are born too early. The theory is that human babies are born earlier compared to other primate babies because as the pelvic bones developed to support an upright posture, they became narrower. So human babies had to be smaller at the time of birth. If correct, then it is likely that rhythmic motions and gentle pressure exert their soothing effects because they partially re-create the sensations that the baby felt in the womb.
Massage
Massaging babies has been observed in many different cultures and has a long history. It is not just a new fad. One particular benefit from massaging your newborn is that the mother or father directly benefits from this activity. While lovingly stroking your baby, you smile at your baby, talk softly, or you might sing or hum. These efforts, while focused on your baby, also relax you! Since fathers cannot breast-feed their babies, I encourage them to develop an intimate bond with their newborn by practicing baby massage right away—even before any fussiness begins. Using a natural cold-pressed fruit or vegetable oil, gently stroke the skin and gently knead your baby's muscles. All the movements are performed gently—books with pictures and videos are available to assist you. Baby massage is not a gimmick or a cure for extreme fussiness. However, it does soothe babies. Equally important, it provides you with a singular opportunity to be completely focused on your baby—turn off the phones and pagers. You are doing something quite different from feeding, changing, and bathing. Comforting your baby this way will give you an inner calmness that will help you get through possible rough times when your baby is extremely fussy and not very soothable.
Respect Your Baby's Need to Sleep:
The One-to Two-Hour Window of Wakefulness
Immediately after the baby is born, you will see what people mean when they say “sleeping like a baby.” For a few days, babies sleep almost all the time. They barely suck and normally lose weight during this time. If your baby was born early, this very drowsy time might last longer; if your baby was born past the expected date of delivery, the drowsy period might be brief or nonexistent. A few days later, babies begin to wake up more. This increased wakefulness reflects the normal maturation of your baby's nervous system. I tell families that the brain wakes up after three or four days just in time to catch the breast milk that is just now available in ample amounts. He looks around more with wider eyes and is able to suck with more strength and for longer periods. Within days, the weight loss stops and a dramatic growth in weight, height, and head circumference begins. Also, longer periods of wakefulness begin to appear after a few days. Although your baby is intently interested in you and is quickly able to recognize your face and voice, he is not yet curious about objects such as toys or mobiles. He does not appear to care about the general buzz or noises, colors, or other activities surrounding him, and therefore, he falls asleep almost anywhere. The extremely fussy/ colicky baby is not like this and appears to have difficulty falling asleep and staying asleep even at only several days of age. All babies gradually seem to become more aware of action, motion, voices, noises, vibrations, lights, wind, and so forth as they become more curious. Now they often do not “sleep like a baby.”
During the day, within a one-to two-hour time “window” of wakefulness, your baby will become drowsy and want to go to sleep. I discovered this window during my research on naps. If you soothe a baby during the beginning of drowsiness, most will easily fall asleep. The exception is the extremely fussy/ colicky baby who might fall asleep but not easily; these babies need longer and more complex soothing efforts to help them fall asleep. The other exception is during the evening fussy periods and especially around six weeks of age.
Here are some ways to note that your baby is becoming drowsy. Watch for the drowsy signs—quieting of activity, less movement of the arms and legs, eyes that are not as sparkling, eyelids that droop a little, less-intense staring at you, and sucking that may be weaker or slower. If your baby is over six weeks old, you may notice less socially responsive smiling or your baby may be less engaging. This is the time to begin soothing to sleep. All babies become this way within one to two hours of wakefulness.
What happens if you miss this one-to two-hour window? Your baby will become overtired if she cannot fall asleep because of too much stimulation around her. When you or your baby becomes overtired, the body is stressed. There are chemical changes that then occur to fight the fatigue, and this interferes with the ability to easily fall asleep and stay asleep. Babies vary in their ability to self-soothe and deal with this stress, and parents vary in their ability to soothe their babies. So not all babies go bonkers if they are kept up a little too long. But you will have a more peaceful and better-sleeping baby if you respect his need to sleep within one to two hours of wakefulness. I consider this to be the beginning of sleep training for babies.
Sleep training begins with developing a sense of timing so that you are trying to soothe your baby at the time when your baby is naturally getting drowsy before falling asleep. Some young babies will need dark and quiet environments to sleep well and others will appear to be less sensitive to what is going on around them. Respect your baby's individuality and do not try to force him to meet your lifestyle. I like the analogy with feeding: We do not withhold food when our baby is hungry. We try to anticipate when he will be hungry, so he will be somewhere calm where we can feed him. We do not feed him on the run. The same applies for sleeping.
If your young baby does not sleep, continue trying to soothe. Do not let him cry or ignore him. You cannot spoil a baby. You cannot teach a baby a crying habit.
Other Soothing Methods
Be skeptical about the supposed miracles accomplished with crib vibrators, hot-water bottles, herbal teas, or recordings of heartbeat or womb sounds. There has been a great deal of nonsense written about burping techniques, nipple sizes and shapes, baby bottle straws, feeding and sleeping positions, lamb's wool pads, diets for nursing mothers, special formulas, pacifiers, and solid food. There is no good evidence that chiropractic spinal manipulation helps babies. These items have nothing to do with extreme fussiness, crying, temperament, or sleeping habits.
Many useless remedies can be purchased without a prescription. Antigas drops, such as simethicone, have not been shown to be more effective than a placebo in well-conducted studies. One popular pellet contains chamomile, calcium phosphate, caffeine, and a very small amount of active belladonna chemicals (0.0000095 percent). Another remedy contains natural blackberry flavor, Jamaica ginger, oil of anise, oil of nutmeg, and 2 percent alcohol. Maybe enough alcohol will sedate some infants! Please read labels carefully—any natural substance, flavoring agent, or herb can have pharmacological effects. Call a school of pharmacy or a medical school to find experts in pharmagnosy, the study of natural herbs and plants, to find out if a particular plant or herb is dangerous.
Beware of gimmicks. Newborns have been drowned in rocking waterbeds, strangulated by having their necks overhang a trampoline-like crib platform, and suffocated by burying their heads into pillows. Beware of prescribed drugs. The London Times headline of May 22, 1998, screamed, “Baby died after drop of medicine for wind.” A midwife had “diagnosed trapped wind” and prescribed what was thought to be peppermint water.
Also be cautious in using home remedies. One mother almost killed her baby by giving a mixture of Morton Salt Substitute with lactobacillus acidophilus culture, as prescribed in a popular book.
Everything Works … for a While
When you believe that something is going to calm your baby—herbal tea, womb recordings, lamb's wool blankets, you name it—often it appears to work, for a while. You are emotionally expecting relief because you trust the advice of an authority. Your fatigue may breed inflated hopes for a cure, and the day-by-day variability in infant crying creates the illusion that a particular remedy works. What is really happening is a placebo effect, the emotional equivalent of an optical illusion.
Mothers may fool themselves into believing their babies are better because of a new formula or special tea. Of course, reality sets in after a few days and shatters the illusion. Some mothers sincerely believe that their babies habituate to, or become accustomed to, the benefits from the new formula or tea much like a dope addict needs increased doses to produce the desired feeling. Some doctors believe the mothers’ reports and agree that the babies really did improve for a day or two because the babies received novel stimulation.
Novelty is unlikely to be important because parents report that upon reintroduction, weeks after the special tea or gimmick was discarded, they see no improvement. In other words, there was no placebo effect the second time around. Naturally, if the baby coincidentally outgrows extreme fussiness/colic when a useless remedy is introduced, the mother, the family, and even the doctor might become convinced that the useless remedy actually cured the extreme fussiness/colic!
Resources for Soothing
Some families have vast resources to invest in soothing their babies, but other families are not so fortunate. Twenty percent of babies have colic and require much more soothing, and families with a colicky baby and limited resources to soothe might easily become overwhelmed and frustrated. The other 80 percent of babies are more easily soothed and usually do not overly stress their parents. So you want to pay attention to whether your child has colic or not, and take some time to reflect on how able you will be to enlist help to soothe your baby. It is often more than a one-woman job! If you have a baby who fusses and cries a lot and is difficult to console, and your available resources for soothing are limited, you might modify some of the plans you made before your child was born regarding a family bed or crib.
Consider a balance between the baby's disposition to express distress and the parents’ capability to soothe their baby. Not only do babies vary in their expression but parents also vary in their capability to soothe. The resources for parents’ ability to soothe fussiness and crying and promote sleep in their baby include the following.
RESOURCES FOR PARENTS’ ABILITY TO SOOTHE
· Father involvement versus absent father
· Agreements or disagreements between parents regarding child-rearing such as breast-versus bottle-feeding or crib versus family bed
· Absence or presence of marital discord
· Absence or presence of intimacy between wife and husband
· Absence or presence of baby blues or postpartum depression
· Absence or presence of other children requiring attention
· Ease or difficulty in breast-feeding
· Absence or presence of medical problems in child, mother, father, or other children
· Number of bedrooms in the home
· Absence or presence of relatives, friends, or neighbors to help out
· Help or interference with sleep routines from grandparents
· Ability or inability to afford housekeeping help
· Ability or inability to afford child care help
· Absence or presence of financial pressures such as mother having to return to work soon
Bedtime Routines
Just as soothing helps your child feel safe and secure, bedtime routines help all children calm down before falling asleep, because both are associated with the natural state of relaxed drowsiness. As with soothing, bedtime routines should be started early, before sleepy signs change into overtired fussy signs. Older children and more regular babies will develop predictable sleep times, and these children might be “slept by the clock.” Pick and choose from the following list based on your child's age and your personal preference. Try to follow the same sequence at all sleep times.
BEDTIME ROUTINES
Before sleep times, reduce the amount of stimulation: less
noise, dimmer lights, less handling, playing, and activity
Bedroom should be quiet, dark (use room-darkening shades),
and warm, but not too warm
Bathe
Massage after bath with smooth, gentle motions
Dress for sleep
Swaddle if it comforts and relaxes your baby, use a warm
blanket from the clothes dryer
Lullaby, quiet singing or humming—be consistent
Favorite words, sounds, or phrases—be consistent
Feed
May put down drowsy but awake, but do not deliberately
awaken before sleeping. This often fails for colicky babies
and all six-week-olds in the evening
Do not rush in at the first sound your baby makes
In addition to being consistent in your bedtime routines, you must cultivate patience, because it may take time for your child to get the message that this is not the time to be playing. I would also add that, except for premature babies and trying to correct a sleep problem, you should never wake a sleeping baby.
Breast-feeding versus Bottle-feeding and Family Bed versus Crib
How you feed your baby and where you sleep with your baby might depend on many factors, including whether the baby is easy or difficult to soothe and whether you and your baby are well rested or not. Ask yourself these questions:
Do you spend a total of more than three hours per day soothing your baby to prevent crying? That is, when you add up the total amount of minutes spent walking, rocking, driving around in the car, swaddling, singing, humming, running water, offering the breast or bottle even when not hungry, using a pacifier, and so forth, does the total exceed three hours?
Do you behave this way more than three days per week?
Have you been doing this for more than three weeks?
If you answered “yes” to all three questions, then your baby has colic. There may be no crying because of your soothing effort, just endless fussing. Or, she might sometimes cry anyway despite your soothing efforts. If you answered “no” to some of the questions but your baby fusses often, especially in the evening and especially around six weeks of age, then your baby has common fussiness. If you answered “yes” to all three questions, please stop here and skip ahead to Chapter 4 to better understand the challenges you will be up against.
Breast-feeding versus Bottle-feeding
Breast-feeding is considered best for baby and mother. The decision on how to feed your baby may be influenced by the support or lack thereof from your husband, your mother, or other family members. However, many babies are bottle-fed because of adoption, prematurity, or medical problems with the baby or mother. Bottles can contain expressed breast milk or formula, so “bottle-feeding” may include feeding breast milk. Formula-fed babies grow up to be just as healthy as breast-fed babies. Many studies have shown that breast-feeding does not prevent extreme fussiness/colic, does not prevent sudden infant death syndrome, and does not prevent or cause sleeping problems. At night, breast-fed babies are often fed more frequently than formula-fed babies, but it is not known whether this is caused by the breast-feeding mother responding more promptly to her baby's quiet sounds or whether breast milk digestion causes the baby to wake up more often. In general, research has shown that sleep/wake rhythms evolve at the same pace whether the baby is breast-fed, formula-fed, demand-fed, schedule-fed, or whether cereal is given in the bottle or by spoon. Some babies with a birth defect of the digestive system are fed continuously by vein or tube in the stomach. Because of the constant feeding, they are never hungry. These babies develop the same sleep/wake rhythms as all other babies. This is why I tell parents that “Sleep comes from the brain, not the stomach.” Although there are rare medical exceptions, changing formulas will not reduce fussiness/crying or promote better sleeping.
Of course, if your baby is not being fed enough, then she might be too hungry and fuss/cry or not sleep well. In this situation, the child will not be gaining weight and some help will be needed to establish a better breast milk supply or evaluation for medical problems that are causing poor weight gain. In my practice, I encourage first-time mothers to give a bottle of expressed breast milk or formula once per twenty-four hours when their baby is two to three weeks old. This allows fathers and other family members to have the pleasure of feeding the baby, as well as giving the mother a mini-break once a day to rest and allow for the healing of cracked or painful nipples. It also gives the parents the chance to have a date to recharge their energy. Fathers can be more helpful during fussy/crying periods or middle of the night feedings to allow mothers a little more sleep. Some experienced mothers, who have previously breastfed successfully, give the single bottle sooner. They have confidence in their ability to breast-feed and either give formula in the hospital or start pumping sooner. They know that the single bottle does not confuse the child or interfere with breastfeeding. The reason the bottle is given every twenty-four hours is to keep the baby adapted to taking the bottle. Some babies do well with less frequent bottles, but others will reject all bottles if days go by without having had one.
Family Bed versus Crib
Our goal is a well-rested family, and a family bed—sometimes described as cosleeping or bed sharing—may be right for your family. The decision to sleep with your baby might be made before the child is born because this is what you want for your family. You might decide that unrestricted breast-feeding day and night, always caring for your baby, and sleeping with your baby at night or day and night will promote a tighter or more sensitive bond between you and your baby. Parents then begin the practice of cosleeping as soon as the baby is born. Researchers use the term early cosleepers to describe these children. Alternatively, you might not have thought about or not really wanted to have a family bed, but you discovered that because your baby was so fussy/colicky, or when your child was older and not sleeping well, that the only way anyone got any rest was to sleep with your baby in your bed. Researchers use the term reactive cosleepers to describe these children. Scientific studies have shown that cosleeping in infancy is often associated with the later development of sleep problems. I suspect that the majority of these problems occur among the formerly “reactive cosleepers.” In other words, some parents find that the family bed is a short-term and partial solution to sleeping problems, and that the sleeping problem continues long after the child has been moved to his own crib or bed.
About a third of white urban families frequently sleep together in a family bed for all or part of the night. By itself, this is neither good nor bad. Studies in the United States suggest that the family bed might encourage or lead to a variety of emotional stresses within the child; opposite results were found in studies conducted in Sweden. This probably reflects differences in social attitudes toward nudity, bathing, and sexuality. Think of it as a family style, one that does not necessarily reflect or cause emotional or psychological problems in parents and children.
But when someone is not getting enough sleep, either parent or child, the family bed can cause potential problems. I suspect this often develops in older toddlers because by the age of one to two years, sleeping together is often associated with night waking. Once there is a well-established habit, the child is unwilling to go to or return to his own bed.
So if you want to enjoy a family bed, fine. But understand that your cuddling in bed together may make any future changes in sleep arrangements difficult to execute. Remember, while it sounds like an easy solution to baby's sleep problems, you may wind up with a twenty-four-hour child even when he gets older.
In contrast, many families use a family bed overnight only during the first few months, and then shift baby to her own bed for overnight sleep. Then at 5:00 or 6:00 A.M., parents might bring their older infant or child into their bed for a limited period of warm cuddling.
Sleeping with your baby might include day and night or just night, all night or part of the night, in your bed or using a small crib attached to your bed, with other children in your bed or other children in your bedroom but not in your bed. All of these variations are collectively called “family bed.” In many cultures, families sleep together because of tradition or a limited number of bedrooms. It is rare in Japan or in traditional or tribal societies for children to sleep apart from their parents. There is a great appeal for sleeping together. A powerful word to describe soothing is “nestling,” and this easily brings forth the image of creating a nest for your baby in your bed.
Both the U.S. Consumer Product Safety Commission and the American Academy of Pediatrics actively discourage the family bed because of the risk of entrapment between the mattress and the structures of the bed (headboard, footboard, side rails, and frame), the wall, or adjacent furniture. There is the hazard of suffocation or overlying by an adult who is in an unusually deep sleep caused by alcohol or mind-altering drugs. Also, soft surfaces or loose covers can cause suffocation. They point out that there is no evidence that bed-sharing protects against sudden infant death syndrome. Also, there is no evidence that bed-sharing prevents extreme fussiness/colic.
So, if you want to use a family bed, try to make it a safe environment by not drinking or taking drugs at night and making sure your baby is always sleeping on his back. Also, fill in the spaces between the bed and any walls or furniture and eliminate loose bedding.
Different Decisions for Different Babies
Research—both my own and others’—has shown that about 80 percent of babies have common fussiness and 20 percent have extreme fussiness, also called “colic.” What happens to these babies over the first four months? At four months of age, some children are super-calm, regular, smiling all the time, and good sleepers, while other babies are the opposite. The good sleepers are described as having an “easy” temperament; the opposite have a “difficult” temperament. Some children are more in-between and are described as having an “intermediate” temperament. How you care for your baby influences the temperament at four months of age.
These temperaments are explained in detail in Chapter 4. For now, I will just lead you through a numerical exercise involving a hypothetical group of a hundred babies. The reason this exercise is useful is because it might:
1. Help you set your expectations on what you will need to do with your baby, both during the first several weeks (for soothing) and the following several months (to prevent sleep problems)
2. Help you decide whether you will breast-feed or bottle-feed
3. Help you decide whether you will use a family bed or crib
Out of a group of one hundred babies, 80 percent (eighty babies) will have common fussiness, and 20 percent (twenty) will have extreme fussiness/colic. My research has shown that these two groups of babies differ in how their temperaments develop.
Consider the eighty common fussy babies at four months of age:
1. 49 percent, or thirty-nine babies, are temperamentally easy
2. 46 percent, or thirty-seven babies, are temperamentally intermediate
3. 5 percent, or four babies, are temperamentally difficult
Consider the twenty extremely fussy/colicky babies at four months of age:
1. 14 percent, or three babies, are temperamentally easy
2. 59 percent, or twelve babies, are temperamentally intermediate
3. 27 percent, or five babies, are temperamentally difficult
Of the original hundred babies, the largest temperament group is “intermediate.” Forty-nine babies (49 percent) are in the temperamental category of intermediate. Temperament measurements form a gradation and the temperament categories represent arbitrary cut-off points. So it is possible that the thirty-seven babies in group B, who had common fussiness, tend toward being temperamentally easier and the twelve babies in group E, who had extreme fussiness/colic, tend toward being more difficult. I suspect that the parents of the twelve babies in group E had to put forth much more soothing effort into this intermediate temperament group than the parents of the thirty-seven babies in group B.
Of the original hundred babies, the next largest temperament group is “easy.” Forty-two babies (42 percent) are in the temperamental category of easy. Of these, thirty-nine babies in group A were born mellow, self-soothing, and calm, and/or their parents were unusually skillful in soothing and/or their parents had vast resources to help them soothe their babies. Not so with the three babies in group D. These babies had extreme fussiness/colic at birth. They were not born mellow, self-soothing, or calm. I think these lucky three babies had super-hero parents who put forth enormous effort to soothe and probably also had lots of other resources to help them maintain this effort over four months.
The smallest temperament group is “difficult.” Only nine babies (9 percent) of the original hundred are in this temperament category. The four babies in group C had common fussiness, but they may have been almost, but not quite, extremely fussy/colicky. Remember, the measurements used to determine whether a baby has common fussiness or extreme fussiness/ colic are graded, and arbitrary cut-off points are used to make the determination. Alternatively, for these four common fussy babies, maybe something went wrong with the parents’ ability to soothe. Why might parents be unable to really soothe their baby? Some reasons may include maternal depression, an un-supportive husband, too many other children to care for, illness, financial problems, stress from the extended family, and marital problems between husband and wife. The five babies in group F may have overwhelmed all the resources that the parents could bring to bear on soothing their baby. This implies that factors within the baby were so powerful that no matter what the parents did, the baby's extreme fussiness/colic led to a difficult temperament at four months of age. It is also possible that the difficult temperament evolved because there was a combination of factors within the baby in addition to the problems within the parents or family that conspired to create an overtired child. Preexisting problems such as marital discord only get worse when parents are trying to cope with an extremely fussy/colicky baby. Parents’ inability to soothe may grow out of, or be a response to, the fatigue, frustration, and exhaustion of trying, without much success, to soothe an extremely fussy/colicky baby.
I believe that how babies sleep influences the development of temperament at four months of age. And how babies sleep during the first few months is a combination of both factors within the child and the parents’ ability and skill at soothing. It is also my belief that at four months of age, the difficult temperament represents an overtired baby and the easy temperament represents a well-rested baby. The temperament that your baby has at four months of age is not permanent. Temperament changes over time as babies develop and parents change how they soothe their children. Stability of individual temperament measures does appear to develop during the second year of life or shortly after the second birthday. If you are reading this book before you have had your baby, be prepared to invest enormous efforts in soothing and consider yourself unlucky if your child is among the 20 percent of extremely fussy/colicky babies. However, if you have already had your baby and you are in the midst of suffering through four months of extreme fussiness/colic, reevaluate some of your decisions, if necessary, regarding how you soothe your baby and what is best for your baby and family. Be optimistic because everything settles down at about four months. Everyone gets a second chance at about four months to help their child sleep better.
Common Fussiness
Eighty percent of babies have common fussiness, and the parents of these babies are lucky. These babies do not require a lot of parental soothing. They tend to be self-soothing, mild, and calm; they fall asleep easily and sleep for long periods.
Breast-feeding these babies is relatively easy because the mothers tend to be better rested and the babies tend to be more regular. The duration of a breast-feeding, how long you nurse, may be relatively short and infrequent because nursing is mainly for satisfying thirst and hunger. When these babies are fussy, methods of soothing other than breast-feeding often work. In fact, the popularity of many techniques or strategies for soothing babies is due to the fact that, for these babies, most everything works well!
Bottle-feeding these babies either formula or expressed breast milk with or without breast-feeding is a family decision that is usually easily made. Some considerations are to allow the father or other children the pleasure of feeding the baby, thus enabling the mother to get some needed extra sleep at night, to return to work by continuing to pump her breasts at work, or to make it easier for the parents to arrange an evening for an old-fashioned date.
Before your baby is born, you might decide that you want to sleep with your baby or that you want to use a crib or bassinet. For 80 percent of all babies, those with common fussiness, it doesn't matter, they are fairly adaptable and self-soothing. You can sleep with your baby at both naps and at night, or only at night. Or, you might sleep with your baby when she first falls asleep, put her down in her crib, and then at the first night feeding, bring her into bed with you. Or, you might have a cosleeper attached to your bed and use it for part or all of the night. You can put your baby to sleep within one to two hours of wakefulness. Watch for drowsy cues that are usually obvious in these babies, then any soothing-to-sleep method is likely to work and the baby and parents usually sleep well. Parents are at a low risk for feeling distressed, and I think maternal depression is not very likely. Some of these common fussy babies, however, will occasionally behave like the extremely fussy/ colicky baby and your plans might have to be altered. Only about 5 percent of these babies seem to develop into overtired four-month-olds.
During the first four weeks, your baby is really “sleeping like a baby.” Elliot, my first son, described his first son as having a look on his face like “I didn't do it,” or seeming almost intoxicated during this time. Sleeping with your baby in your bed or placing your baby in the crib is usually a piece of cake. During weeks four through eight, your baby will become more wakeful and alert and have more evening fussiness. Elliot said that his son now had a more quizzical look, like “Who are you?” and “Give me back my pacifier.”
Extreme Fussiness/Colic
Twenty percent of babies have extreme fussiness/colic, and the parents of these babies are unlucky. These babies require a lot of parental soothing. They tend not to be self-soothing and they often appear intense, agitated, and have difficulty falling asleep and staying asleep.
Breast-feeding these babies is often difficult because the mothers tend to be exhausted or fatigued from sleep deprivation and the babies tend to be irregular. The duration of the breast-feeding, how long you nurse, may be long and frequent because in addition to satisfying thirst and hunger, much of the nursing is for reducing fussiness. When these babies are extremely fussy, methods of soothing other than breast-feeding often do not work. Frustration or despair is common because many of the popular techniques or strategies for soothing babies fail, even though many other mothers (80 percent) swear by them.
Some considerations going through the mind of the mother are whether something is wrong with her breast milk, whether her breast milk is sufficient, or whether her diet or the current formula is causing the extreme fussiness/colic. Because soothing at the breast often seems to work when other soothing methods fail, the mother does not want to give it up. But painfully dry or cracked skin around the nipple may make breast-feeding an ordeal. The discomfort and pain associated with breast-feeding, plus unrelenting exhaustion from sleep deprivation, may conspire to cause so much stress that the breast milk supply becomes insufficient. Mothers who have enormous support—a dedicated husband who spends a lot of time soothing, housekeeping help, or baby care help—can get through this difficult time much easier than mothers who lack a support system. Mothers who have other children to care for, pressure to return to work, medical problems, baby blues, or postpartum depression may find the additional stresses associated with breast-feeding these extremely fussy/colicky babies to be overwhelming.
Bottle-feeding these babies either formula or expressed breast milk can be a benefit to some mothers or create more stress in others. The benefits of complete or partial bottle-feeding is that the mother might get more rest because others can feed her baby, and the parents are calmer because they know for certain that their baby is not hungry because they can see how much the baby is swallowing. In other mothers, giving bottles can create the feeling of having failed as a mother. Recognizing that bottles are not as soothing as the breast, these mothers feel guilty because they think they are causing their babies to fuss/cry more, and they worry that something in the formula is causing the fussiness/crying. If you want to breast-feed, a compromise position is to have someone else give a single bottle of expressed breast once per twenty-four hours. This will not cause “nipple confusion” or interfere with lactation. It will give the mother a mini-break, will allow her to get a little more sleep, and it will allow the parents a night out.
Before your baby is born, you might decide that you want to sleep with your baby or that you want to use a crib or bassinet. But for 20 percent of babies, those with extreme fussiness/colic, the plans that you made for sleeping with your baby might have to be altered because these babies tend to be difficult to soothe and have difficulty falling asleep and staying asleep. Watching for drowsy cues is usually frustrating in these babies because they are not obvious, and even if you keep the intervals of wakefulness less than one to two hours, it is still difficult to soothe them. When they finally do fall asleep, they do not stay asleep for long. As a result, parents are often sleep deprived. Parents are at a high risk of feeling distressed and I think that maternal depression is more likely to occur.
Because these babies are difficult to soothe, breast-feeding in the family bed may be the best or only strategy that works. Although the mother's sleep may be fragmented by frequent feeding for both nutrition and soothing, this is probably the most powerful soothing method for these babies. During the first four weeks, your baby is not really “sleeping like a baby.” Placing your baby in the crib is usually stressful. During weeks four through eight, your baby will become even more wakeful and alert and have more evening fussiness, causing the parents to be at an even greater risk for distress. About 27 percent of these infants are at risk for becoming overtired four-month-olds.
There is some research to suggest that parents who made the commitment to use the family bed from day one, and stick with it, will wind up with better-rested babies than those families who initially wanted to use the crib but later brought their baby into their bed because it was the only way the parents could get any sleep. In the former group, sleep problems are less likely to develop as the children get older. But in the group where it was used only in response to soothing or sleeping difficulties, the family bed appears to be a short-term solution, but in reality it creates a long-term sleep problem. What really is happening is that parents who are overwhelmed by the fussy/crying behavior and have limited resources for soothing their baby, reluctantly use the family bed to gain some relief, but the limited resources for soothing persist and may often cause sleeping problems in older children. (This will be discussed more in Chapter 5.)
Breast-feeding the Fussy Baby
by Nancy Nelson, RN, IBCLC
One of the most difficult things for many breast-feeding mothers is not knowing how much milk your baby is getting. When you are the mother of a “fussy baby” it can be even more of a concern. When a baby is crying, most well-meaning observers will comment that the baby must be hungry. As the mother, these comments may cause you to feel frustrated and guilty. After all, you are responsible for feeding the baby! To allay your fears, keep track of the baby's output of urine and stool. After the sixth day of life, your baby should be producing six or more wet diapers and one or more stools in a twenty-four-hour period as a sign of adequate intake of breast milk. Babies usually need to feed eight to twelve times in a twenty-four-hour period during the first few weeks of life. In the beginning they may cluster feed. This means they may want to feed very frequently for a few hours and then go into a sleep stretch of four or five hours. As they become more efficient, they decrease the number of feedings. The baby should be back to birth weight by two weeks of age and should gain a minimum of five ounces a week for the next two to three months.
If you are concerned that your baby is fussy because you have a low milk supply, it would be helpful to see a lactation consultant who will do a feeding observation. This includes a study of your baby's ability to transfer milk from your breast by a strong nutritive suck followed by audible swallows. A pre-and postfeeding weight should be included in order to get an idea of how much milk the baby is taking in during the feeding. The baby should be weighed both before and after the feeding with a diaper on so as not to lose the weight of urine or stool that may have been produced during the feeding. This can be reassuring if the baby gains between two and four ounces during the feeding. If the baby gains less, it might alert you to a problem with either the baby's method of transferring the milk or your milk supply. If the milk supply is low or the flow is too slow, a supplemental feeding system may help to improve the suck and give the baby the additional calories he needs. Use of a hospital-grade electric breast pump can augment the breast milk supply as well. Some mothers may decide to feed the baby additional pumped breast milk by bottle or feed formula if they are unable to pump enough milk to meet the baby's needs.
Occasionally breast engorgement may cause the baby to be fussy at the breast. To deal with engorgement, use warm compresses or take a warm shower prior to feeding the baby. Use breast massage as well. You may be able to express some milk by hand or with a good-quality breast pump to take out a little milk and make the breast softer and easier for the baby to latch on to. Do not pump too much milk because it could continue an oversupply problem and prolong the engorgement. In between feedings, use cold compresses on your breasts to decrease the swelling and give pain relief. Engorgement may occur within the first week after your baby is born or later when the baby begins to skip feedings as he gets older.
A baby can be fussy at the breast if the mother has flat or inverted nipples. Breast shells may be worn in between the feedings in order to evert the nipples. Using a breast pump for a few minutes prior to putting the baby to the breast will help to pull the nipples out and also start the flow of milk so the baby will get milk right away and be more likely to continue sucking instead of pulling off the breast and crying. Occasionally, nipple shields may help to keep the baby at the breast until the nipples are more everted. This should happen after about two to four weeks of breast-feeding. Seek the help of a lactation consultant as soon as possible if you are having difficulty with the feedings because of flat or inverted nipples.
A baby may be fussy at the breast because of poor positioning. Both mom and baby may be uncomfortable, which can lead to inadequate letdown and poor milk production. With a fussy baby, the football or the cross-cradle holds work best because you have more control over the baby's head. You can direct him to the breast and keep him there with these two positions. The baby's nose and chin should indent the breast. Babies usually nurse better when they are held more firmly by the mother. A firm pillow that supports the baby at the level of the breast is preferable to a soft pillow. A chair that gives good support is better than a soft couch. I cannot emphasize enough that a fussy baby will respond better to being held tightly and close in to the breast. Contact a lactation consultant if you are uncomfortable during breast-feeding. This may be the reason why your baby is fussy.
Almost all babies have some degree of gastroesophageal reflux. This is a medical term and simply means that the sphincter muscle, which leads to the stomach, is immature and may not close completely all the time. This allows some milk, along with stomach acid, to come back up into the esophagus, leading to a feeling we call “heartburn.” As anyone who has experienced this can attest, it is quite uncomfortable. Just as sitting upright can help an adult with heartburn feel better, holding the baby upright usually helps the baby feel better, too. Sometimes these episodes can occur during breast-feeding. Holding the baby more upright during the feeding or interrupting the feeding for a short time to comfort the baby by holding him in an upright position should help. Using a swing or a car seat may also help. As the baby matures, so does the muscle, and the episodes become less frequent. Sometimes a baby has a severe problem with reflux and is unable to feed well at all. This may be a case where prescription medication will be needed. Your health care provider should be consulted.
All new babies experience gassiness. When the baby begins to feed, it sets off a reflex that produces gas so that the baby will be able to pass whatever waste products are produced during the feeding more quickly. This avoids problems with constipation. Because breast milk needs little digestion it moves through the baby's system very quickly. You can often hear the sounds while the baby is still feeding. Although all babies are gassy, some babies are not as upset by it as others seem to be. The time of day may be a factor as well. It often seems as if this gas problem becomes worse at the end of the day. This is often called the traditional “fussy” time of the day. Babies seem to want to stay at the breast constantly and this may exacerbate the gas problem. The baby may need comforting or some cluster feeding. It is a good idea to pump a bottle of breast milk in the morning when the baby is calmer and not feeding so often. Have this milk available during this fussy time to allow another family member to feed the baby so you can get a break. As babies mature this problem resolves.
The milk at the beginning of the feeding from the breast is higher in lactose. This is called the “foremilk.” The milk that comes after ten to fifteen minutes of nursing from that same breast is called the “hindmilk.” It is higher in fat and balances out the lactose so as not to produce so much gas. If the baby takes in too much foremilk and no hindmilk, it may result in lactose overload and more gas production. Try to keep the baby on one breast for at least twelve to fifteen minutes in order to get the hindmilk. As the baby gets older and becomes more efficient at nursing, he will be able to get to the hindmilk in a shorter period of time. Hindmilk can have a sedating effect on the baby and help a fussy baby to fall asleep. Most new babies will naturally fall asleep at the end of a feeding because of the sedating effects of the hindmilk. Recently there has been advice given to awaken the baby at the end of the feeding in order to allow them to fall asleep in the crib on their own. I feel that as babies get to be three or four months old, they will remain more awake at the end of the feeding. This is the time for them to learn how to put themselves to sleep. This pattern should be allowed to develop naturally.
When the baby is just learning how to breast-feed, the letdown reflex may be overwhelming and lead to gagging and choking. This may cause the baby to pull off the breast and become fussy. Put firm pressure over the breast for a minute to stop the rapid flow and put the baby back to the breast. Try to pump a little milk prior to the feeding to see if you can elicit the letdown before the baby goes to the breast. This may not help too much because usually the baby will elicit a more forceful letdown, but it is worth a try. The football hold or holding the baby in a sitting position on your lap might help. The baby straddles your body with his legs and faces you directly. As the baby gets older, he will be able to handle the letdown reflex without a problem in any feeding position.
Allergic reactions to foods in the mother's diet are rare but sometimes occur. The most common cause of allergy is cow's milk. Besides extreme fussiness with feeding, there is frequent spitting up, blood in the stool, and poor weight gain. The baby's health care provider should be contacted if these symptoms occur. If you must go on an elimination diet, make sure that you get information about how to supplement your diet so that you remain in good health and can continue to produce enough breast milk for your baby. It usually takes at least two weeks to see results from an elimination diet.
Rarely will soaps or creams being used on the breast or nipples cause the baby to fuss and pull off the breast. If you have started using something new on your skin and the baby fusses, clean it off and start over.
Yeast infections can occur in the baby's mouth or on the mother's nipples. You might see white patches in the baby's mouth. The baby may also develop a diaper rash. Your nipples could be very red or itchy. There is a burning sensation of the nipples following the feeding. Your baby may be fussier during his feedings. See your health care provider. If a yeast infection is diagnosed, both you and the baby should be treated. If the baby is using bottle nipples or pacifiers, these should be replaced with new ones. They should be washed daily with hot soapy water and allowed to air dry. Change your diet by eating more yogurt or drinking acidophilus milk daily.
Some babies become fussy if they are overstimulated. They may have better breast-feeding sessions if the lights are dim and they are allowed to feed with only ambient sounds.
If you have implemented these suggested techniques and you still have a fussy baby, it may be that the baby is not hungry. She may be drawn to the breast for comfort, but once she starts to nurse does not really need to feed at that time. Remember, a baby under twelve weeks of age does not have much ability to self-soothe. As parents, we need to meet these needs just as much as we need to provide them with the other necessities of life. Many of the things that seem to help soothe them are measures that imitate the in utero environment. Make sure that the baby is comfortable—not too warm or too cold. A clean diaper should be provided. The baby may be comforted by being held tightly and cuddled or rocked. Besides cuddling and rocking, swaddling, or ongoing sounds like music, dryers, or fans may help. Perhaps a pacifier will give your baby some additional soothing. The use of a soft side or front carrier will give you the chance to get other things done while you are providing comfort for your baby. Another person—the father or a grandparent—may be enlisted to calm the baby without the baby being stimulated by the smell of the breast milk that envelops the mother. This also gives the mother a chance to get a little time for herself. Try to take a nap or get some exercise. These activities will help you feel refreshed. Later, after the baby has been calmed by other methods, the mother will be ready to breast-feed more calmly.
It takes time and the trying of different techniques to find out what your baby needs and how best to meet those needs. Feel free to experiment. The baby may respond to certain things at one time and to other things at another time. Remember, it is a learning process, so don't expect you or the baby to be perfect.
Take good care of yourself during this time. Eat well. Take your prenatal vitamins. Stay well hydrated and get some outdoor exercise, if not daily at least five days per week. Try to use relaxation techniques—yoga, meditation, massage, or a warm bath—to help you get through the difficult times. Share your feelings with the baby's father or other family members and let them take turns walking, rocking, and cuddling the baby. Set small goals for yourself—like reading one chapter in a book or taking a fifteen-minute walk.
New-mother support groups help a lot because you learn that other mothers and babies are going through the same adjustment period that you are. Most reasons for infant fussiness will be worked out within the first six weeks of life. A few may take a little longer, but by three months of age it is usually resolved. Remember, overall, this is a very short time in the life of you and your baby. Try to hug and cuddle your baby as much as you can in order to help him get through this rough time. Together you can do it.
As discussed by Nancy Nelson, lactation consultants can be very helpful and I would encourage you to seek one who has been certified by the International Board of Lactation Consultant Examiners (IBLCE) and is entitled to use the title International Board Certified Lactation Consultant (IBCLC). In general, successful breast-feeding will require the family to make adjustments to fit the needs of the baby, and breastfeeding may not work well if the parents attempt to force the baby to fit into the family's schedule, especially if the baby has extreme fussiness/colic.
Keep reminding yourself that extreme fussiness/colic is not indigestion. It is not caused by formula or breast milk. Switching from one formula to another will not stop the crying. Some manufacturers of infant formula try to sell their product by claiming that their product will reduce fussiness. The so-called research they cite to support their claims is weak, unconvincing, and has not been reproduced.
Do not let extreme fussiness make you give up breastfeeding if you want to continue. Your baby is still getting all the benefits of breast milk, even if she seems at times not to appreciate them. If you stick with it, you can look forward to many calm, pleasant months of nursing once the extreme fussiness has run its course.
Still, nursing an extremely fussy baby is undeniably a challenge. When nursing, infants with extreme fussiness/colic tend to be gulpers, twisters, and forceful suckers. Sometimes they seem to reject the breast entirely. The determined nursing mother is in a bind; it is difficult to nurse a tense, twisting infant, but nursing is one of the few maneuvers that appear to calm such a child (at least temporarily). Non-nutritive nursing, using your breasts as pacifiers, may calm baby, but it is no picnic for mother! Here is a description of the nursing predicament by the mother of one of my young patients.
The first three weeks of Michael's life led me to believe that having a baby would be a breeze. His behavior was almost identical from day to day. He was very calm, and so were my husband and I. Michael would eat—breast-feeding about eight to ten minutes on each side. He had no problems burping after each meal. Then I'd either hold him for a while, lay him on his back, and talk or play with him. The usual schedule, from the time he got up until he went to sleep, would be one to one and a half hours. He would usually sleep anywhere from two and a half to four hours. Everyone said to me, “Boy, are you ever lucky to have such a good baby.”
As the fourth week approached, Michael's behavior changed dramatically. He no longer wanted to sleep during the day. I felt like all he wanted was my breast. I concluded that he either was continually hungry or had strong sucking needs.
By the middle of each afternoon, I was exhausted. Almost every hour I found myself breast-feeding. Sometimes I could put him off for two hours, but he'd cry a lot. I'd change his diaper, walk him, hold him, tilt him, sing to him, change his position and so on. Nothing would please him except my breast, which was terribly tiring, to say the least. The thing that saved our lives is that he slept long hours through the night—probably from exhaustion after being up all day. The worst times were midafternoon, and again between 5:00 and 10:00 P.M., after which he would sleep for around five hours straight. He would fuss and cry and nothing would calm him except when he was nursing.
If your situation is similar to this mother's, give yourself some relief by trying the following suggestions:
1. Space feedings a few hours apart. One mother said, “I must have Chinese breast milk; he gets hungry just one hour after nursing.” If you last nursed your baby well less than two hours ago (not a snack or a sip), there is no room in his stomach for more milk and your breasts contain little or no milk for him. Nursing too frequently is pointless, and if it causes you pain or exhaustion, it is destructive. See if the baby will accept a pacifier instead.
2. Ask your doctor about hydrocortisone ointment. A famous pediatric dermatologist who nursed her own children suggests treating cracked nipples with 1 percent hydrocortisone ointment. It is safe for both mother and baby, and seems to work better than any other treatment. Many of my patients’ mothers have reported rapid healing of sore nipples by using this treatment. After nursing, allow your breasts to air dry. Then apply a thin film of the 1 percent hydrocortisone ointment to the dry or cracked areas. Make sure you use ointment, not cream; the cream might cause a painful burning sensation. When you are about to nurse again, do not wipe or wash off any of the ointment. Most of it will have been absorbed into your breast skin and the small amount the baby absorbs will cause no harm. Basically, the skin of the breast can become very dry, cracked, or fissured from being wet or damp for prolonged periods of time.
3. Don't exhaust yourself. The mother of an extreme fussy infant stored breast milk so her husband could feed the baby once during the night and her mother could handle a similar daytime feeding. In this way, she was able to get some extra rest. When the baby was several weeks old, the baby's grandmother went home and the father returned to work. Now, all alone and very busy, the mother saw her previously ample supply of breast milk dwindle to almost nothing. We discussed how she had decreased her fluid intake, how she was worried about her mother's departure, and how she was generally under strain. I reassured her that while it was important to continue having the child suck at her breasts to stimulate milk production, a single bottle of formula for one or two days would not harm the baby or inhibit lactation. She increased her fluid intake, rested more, and after four to five days was again nursing with more than ample milk production. Throughout this period, the child continued to have extreme fussiness/colic spells with periods of inconsolable crying. But this mother now knew that the crying was not related to nursing.
Another mother of one of my patients felt especially bad when nursing failed to calm her baby.
It's early evening and my daughter is screaming and restless. Nothing seems to calm her, not even nursing. I didn't think Chelsea was colicky, but she sure was fussy. Although her fussiness wasn't an everyday occurrence, it persisted from her second or third week of life until about two months of age.
At first I thought something I was eating was giving her gas. Then I thought her behavior was due to my inexperience as a mother. As these episodes continued, I began to feel desperate, sad, and exhausted.
I felt inadequate as a parent. I didn't know how to comfort my child, or whether what I was doing was right. I especially felt inadequate when Chelsea rejected my breast. It seemed as if nothing could console and comfort her.
We had visions of a child who could be comforted at the touch of her mom or dad. Soon all the sleepless nights and exaggerated feelings of incompetency led to exhaustion. Would this cycle ever end? Well, it finally did. With the help of our pediatrician, we soon began to realize that this behavior was normal and would not last indefinitely. I also found that her fussiness was neither caused nor enhanced by my behavior. Along with this realization came the light at the end of the tunnel. I then knew her fussiness would not last forever.
I became aware of certain behavioral changes that manifested themselves either before or after each fussy period. She would startle easily, have difficulty falling asleep, and then sleep for shorter periods of time. Also, during her fussy periods, she exhibited different behavioral characteristics. She was restless and would scream with a quivering chin. She would become stiff or have rigid movements. She would not nurse, and when she did she would suck frantically. She would become overtired but would not sleep. Sometimes she would be wide awake one moment and sound asleep a second later.
Chelsea is now three months old. Her fussy periods have ceased and she wakes in the morning with a smile that lasts all day. We really love our “perfect” child.
Sometimes a nursing mother notices that the baby seems calmer in her husband's arms than in her own. She may feel that her husband does a better job of soothing the baby, that perhaps the baby “prefers” him to her. What is really happening is quite simple. The baby recognizes that his mother is the source of milk. When she holds him, he quite naturally squirms and twists, rooting around, looking to suck, even when he's not hungry.
I want to encourage every mother's desire to nurse her extreme fussy/colicky baby. It is an important accomplishment for both of them. One mother called me when her extremely fussy/colicky baby was exactly three months old. She was determined to continue nursing and to start working part-time. Her husband was a fireman and found it very difficult to be around a crying baby on his days off. She was under enormous stress. All her friends claimed that if she would feed her baby formula, the crying would disappear. She wanted to—and did—keep on nursing after the extreme fussiness/colic disappeared to show them, and herself, that nursing was not the cause of the crying. Here is a report from the mother of another one of my patients; persevering with nursing helped her maintain her confidence and self-esteem.
Both my husband and I questioned our best judgments and our ability to care for Lisa. At one point I questioned my ability to nurse and felt that I was literally poisoning my baby. Her screaming episodes came a predictable ten minutes after every feeding. At times I felt tortured. I consider myself a rational and caring person, yet often found myself crying in the shower or praying that my husband could somehow relieve the tension, anger, and helplessness that I felt.
At six weeks, Lisa seemed to be easing into patterns and appeared to be getting good, deep sleep. Her smiling times were numerous, but she still had hours of screaming. I overcame my fear of nursing and decided to continue weeks after I had planned to stop. Nursing became the one pleasurable experience the baby and I had together. When I finally did wean Lisa, it was a sad time; we were separate after being together for so long.
Six weeks of age or six weeks after the due date is truly a magic turning point for many babies.
Solid Foods and Feeding Habits
Do you remember how drowsy you feel after eating all that Thanksgiving food? Big meals make us sleepy, so shouldn't solids make babies sleep better? Wrong. Feeding rhythms do not alter the pattern of waking and sleeping.
Sleeping for long periods at night is not related to the method of feeding, whether it be breast or bottle. This is a fact; check out some of the studies cited at the end of this book (see page 458). The studies I think are the most convincing involve comparing the development of sleep/wake rhythms of infants fed on demand with those who are continuously fed intravenously because of birth defects involving their stomachs or intestines. The babies who were fed on demand cycled between being hungry and being full. The other babies were never allowed to become hungry. The objective recordings in sleep laboratories show that there were no sleep differences between these groups of infants. Other studies involve the introduction of solid foods; they all show that solid food, such as cereal, does not influence nighttime sleeping patterns. No published studies have ever shown that the method of feeding (breast milk versus formula, or scheduled feedings versus demand feedings) or the introduction of solids affects sleep.
Some studies, however, do indicate that formula-feeding is more popular than breast-feeding among mothers who are more restrictive. Mothers who feed their babies formula tend to be more interested in controlling their infant's behavior and like being able to see the number of ounces of formula given at each feeding. These parents are more likely to perceive night waking in a problem/solution framework and consider the social wants of the child instead of nutritional needs. In contrast, the nursing mother, perhaps more sensitive to the health benefits of nursing, might respond to night waking more often or more rapidly because she perceives herself as primarily responding to her infant's need for nourishment. After awhile, of course, the child learns to enjoy this nocturnal social contact. Over time, the baby learns to expect attention when he awakens.
This explains why there is no difference in night waking between breast-and formula-fed infants at four months, but by six to twelve months, night waking is more of an issue among breast-fed babies.
The bottom line is that cereal does not make babies sleep better. Formula may appear thicker than breast milk, but both contain the same twenty calories per ounce. Giving formula to breast-fed babies or weaning diem also will not directly cause longer sleeping at night, although it is possible that attitudes toward breast-feeding may indirectly foster a night-waking habit. Here is one family's account of how breast-feeding led to a night-waking habit.
MAREN'S WAKE-UP FOR BREAST-FEEDING
Maren was born July 18, 1984, after an uneventful pregnancy and an easy Lamaze delivery, three days past term.
We were committed to breast-feeding, with no preconceived expectations of its duration. Maren behaved as a normal infant for about two weeks, at which point persistent crying jags began to occur daily. Though we were assured real colic was worse, we came to refer to these spells as “Maren's colic.” We endured the inconsolable crying without much complaint. Although her crying mostly lasted one to two hours, the worst individual days would include unabated crying spells lasting for eight to ten hours. Various experiments were tried to ease the colic suffering, including having Maren sleep with us, having her sleep on a hot-water bottle, et cetera. Predictably, none worked. At two months, the colic ended relatively abruptly.
From two months on, a very happy, trusting relationship developed between Maren and me. For about seven months, Maren was fed virtually exclusively on breast milk. From seven to ten months, increasing amounts of solid food were introduced at breakfast and lunch. Maren has always been a happy, bubbly, joyful child. The breast-feeding seemed to contribute to this sunny disposition. Maren's nap patterns were completely normal. Generally, I would sleep with her in the morning. Part of the feeding ritual for these ten months included twice-nightly breast-feedings for Maren, interrupting my sleep.
Massive campaigns were mounted by both sets of grandparents to convince me that breast-feeding needed to end. These began at two months and reached fever pitch around seven months. We listened politely. Except for a brief experimental period at around eight months, I didn't attempt to pump my breasts to permit me extra sleep. This was a conscious decision; direct feeding was easier and more satisfying for both of us.
Breast-feeding, in addition to the satisfaction it provided, was an indispensable part of the sleeping ritual. From birth to eleven months, Maren expected to be held, fed, and gently rocked or lulled to sleep in the pleasant company of her mother. At around nine months, Maren's rapid growth was taking its toll. There was more solid food in the daytime now. After nearly a year without a full night's sleep, I was beginning to reach a whole new level of fatigue.
New attempts were begun to get Maren to sleep without my direct attention. Her father would give her a bottle, rock her, sing to her, et cetera. Female friends of the family, familiar to Maren, would do the same. Maren was a good sport about these experiments but preferred my attention. At eleven months, we agreed it was time to wean Maren to a bottle.
Maren didn't like the plan much. She obviously disliked formula as much as I disliked feeding it to her. For nearly a week she rejected cow's milk. I ended the morning nap breast-feeding ritual first. Juices (orange, apple, pear) in the morning or during car rides helped to improve Maren's familiarity with bottles. They also allowed my husband, Larry, to feed her while I rested later in the mornings. Putting cow's milk in a special bottle (formed and painted to look like a dog) allowed this unpleasant white stuff to become gradually more acceptable. After a few days, Maren started to respond more favorably to her “pooch juice” and the games I created and associated with it.
I experienced some depression with the cessation of breastfeeding. As that special link came to an end, my contribution to Maren's development suddenly seemed more mundane, repetitive, and less satisfying. This depression came on and off for two months. It was a strange feeling, since it was offset at all times by the joy that comes from having a developing child.
Maren was fully weaned at eleven months. The last feeding to change over was at bedtime. But even if she was given milk at bedtime, Maren continued to wake up once or twice per evening, crying to be fed. The next step was to get her to sleep through the night. We were repeatedly advised to let her cry herself to sleep. The phrase “even for five or six hours” was used, a reminder of colic days. We considered this proposition, but continued to feed Maren warm milk, sing lullabies, and rock her to sleep, once or twice per night. The big question: What was waking her up?
We decided it was mostly habit, and that she just wanted the comfort of our company. A new go-to-sleep ritual was introduced: After much playing and affection, Maren was put to bed with her favorite doll, not rocked to sleep. If she woke, warm milk was provided, but Maren was purposely not picked up. Maren cried ten minutes when left alone the first night, then rested her head on top of her favorite doll and drifted off to sleep. After expecting possibly an hour or more of crying, this was an unbelievable, almost anticlimactic relief to us. After two or three nights of feeding without picking her up, Maren began sleeping through the night.
At the end of month eleven, the go-to-sleep is routine. Maren rarely cries at all. Key elements: a big dinner, a bath, gentle play, eight ounces of warm milk, hugs, and her favorite doll. Even a baby-sitter can do it. At one year, Maren had finally learned to sleep eight hours straight.
We did a few things we are sure were right. For us, especially me, we sensed Maren's needs and delivered them unasked. This created an extraordinary self-assurance in her, and led to a happy household. Maren seemed to cry less than other children and to be a bright, curious, quick learner. Other things we are happy about: lots of new games all the time; plenty of visual stimulation; rough-housing motions and playing; exposure to music, texture, any stimulation we could dream up. It all seemed to add to her alertness, her trust in us, and the regularity of her sleeping.
There are also some things we may not have done so well. We may have gone too long before we tried to put her to sleep alone. Our parents continuously warned us we were being too indulgent. They may have been right. But then, first-time parents are like that.
Solutions to Help Your Child Sleep Better:
“No Cry,” “Maybe Cry,” or “Let Cry”
There are many ways to help your child sleep. You should choose the solution that works best for you and your child. Some do not work well for the extremely fussy or colicky baby, some will be difficult to use because of limited resources for soothing, and some are appropriate only for older children. Also, one method may be more powerful in the hands of some families than in others. Often I will refer to ignoring all crying or extinction as the preferred solution to help your child sleep better because I think this works best for the 20 percent of babies who have extreme fussiness/colic; after four months of age, I think they represent the largest group of children with sleep problems or have more severe sleep problems. However, I understand that this is probably the hardest sleep solution for parents and you should always first consider trying other sleep solutions that involve less crying. This is especially true if your child does not have extreme fussiness/colic.
“NO CRY” SLEEP SOLUTIONS
Start early, when you come home from the hospital, to
avoid the overtired state by trying to soothe your baby
to sleep within one to two hours of wakefulness
Always hold your baby, always respond and soothe your baby
as long as needed to induce sleep, sleep with your baby
Always respect “drowsy signs” so your baby never be
comes overtired
Always try to put your child to sleep drowsy but awake
Motionless sleep
Establish and consistently practice bedtime routines
Practice scheduled awakening, also known as focal feeding
Get fresh air in between naps, go for a walk Control the wake-up time
Slowly and gradually give your child less attention around
falling asleep or during the night, a fade procedure
White noise
Room-darkening window shades
Relaxation
Stimulus control
“MAYBE CRY” SLEEP SOLUTIONS
Father puts baby to sleep
Make bedtime earlier
Focus on the morning nap
Sleep rules
Silent return to sleep
Day correction of bedtime problems
“LET CRY” SLEEP SOLUTIONS
Ignoring all crying or extinction
Ignoring some crying, also known as controlled crying, or
graduated extinction
Check and console
Crib tent
MAJOR POINT
Babies need to sleep after one to two hours of wakefulness.
Parents have told me the first solution needs to be emphasized because it is not intuitively obvious that babies, who sleep so much, need to return to sleep after only one to two hours of wakefulness. In addition, this pattern of brief intervals of wake-fulness appears to help many babies avoid sleep problems throughout the first four months.
Prevention versus Treatment of Sleep Problems
There sometimes appears to be a contradiction between whether or not to let your child cry. For 80 percent of babies who have common fussiness, if the parents have ample resources for soothing, sleep solutions that involve no crying, such as the “one-to two-hour rule,” should work to prevent sleep problems. A few, about 5 percent, of common fussy babies do become very overtired four-month-olds. To treat or correct the sleep problem, some crying might occur. However, in this group, improvement in sleep patterns and improvement in the child is often dramatic and rapid.
For 20 percent of babies with extreme fussiness or colic, however, if the parents have enormous resources for soothing, sleep solutions that involve no crying, such as “Always hold your baby, always respond and soothe your baby as long as needed to induce sleep, sleep with your baby,” might work to prevent sleep problems. But about 27 percent of these extremely fussy/colicky babies do become very overtired four-month-olds. Treatment to correct the sleep problem might involve more crying, and improvement in sleep patterns and inprovement in the child is often slow and not dramatic. This is especially hard for parents because they have already endured four months of sleep deprivation associated with the child's constant fussiness, crying, and not sleeping.
Rarely, some parents want to let their child cry to help him sleep after the peak of fussiness and crying has passed at six weeks of age, but he is under four months of age. One example is the mother who has to return to work and desperately wants to see if her child will sleep better at night with less attention. Another example is the exhausted and overwhelmed mother who is becoming depressed or getting angry or resentful toward her baby. Under these and similar circumstances, I usually try to enlist the assistance of the father to help his wife put the baby to sleep, to feed and soothe the baby at night, and to try to give the mother a well-earned break by making her go somewhere for several hours or a night to get some uninterrupted sleep. Obviously, these suggestions are impractical for some families. Nevertheless, the instructions are to give the child less attention at night, perhaps feeding only twice at night, and ignoring crying for either brief or long periods of time and to do this for only four or five nights. Sometimes the crying quickly diminishes, especially in the child who had common fussiness. Sometimes the crying does not decrease, especially in the child who had extreme fussiness or colic, and the plan is abandoned. Parents then resort to whatever method maximizes sleep and minimizes crying until the child is older.
Action Plan for Exhausted Parents
Healthy Sleep
Think of “healthy” sleep as a collection or group of several related elements grouped together to form a “package.” All must be present to ensure good-quality or healthy sleep. The five elements of healthy sleep are:
1. Sleep Duration: Night and Day
Does your child sleep as long as she needs at night and for naps?
How long your child needs to sleep depends on her age and temperament. Restricted sleep impairs mood, performance, development, and cognitive ability.
2. Naps
Is your child taking naps or do you sometimes skip naps?
If a nap has been missed, try to keep your child up until the next sleep period in order to maintain the timeliness of the sleep rhythm. Move the next sleep period a little earlier before your child becomes extremely overtired. If the naps are too long because your child has become overtired; you might have to wake him from a nap in order to maintain the timeliness of the sleep rhythm at night. The morning nap develops before the afternoon nap and disappears before the afternoon nap. Not all naps are created equal. Babies are born to be short or long nappers. An earlier bedtime may be required when two naps are needed but you can get only one.
3. Sleep Consolidation
Is the sleep interrupted (fragmented) or uninterrupted (consolidated)?
Some arousals from sleep normally occur. Some arousals are protective. Too many arousals fragment sleep and this causes impairments in mood and performance.
4. Sleep Schedule, Timing of Sleep
Do naps start and bedtimes begin just when your child is becoming drowsy?
A bedtime that is too late will produce an abnormal daytime sleep schedule. Variability in activity and length of naps causes some variability in the bedtime. Watch your child more than the clock.
5. Sleep Regularity
Do naps or bedtimes occur at approximately the same times?
Even if the bedtime is a little too late, regular bedtimes are better than irregular bedtimes.
Back Sleeping Is Best to Prevent SIDS
Learn to recognize drowsy signs—study the box on page 63.
If your baby is colicky, begin the soothing to sleep after one to two hours ofwakefulness. Soothing to sleep involves:
Getting dad to help out
Encouraging sucking—do not worry if
your baby falls asleep while sucking
Rhythmic rocking motions
Swaddling
Massage
HEALTHY SLEEP IMPROVES
Mood, temperament, cognitive development, and performance.
Resources for Soothing
Consider a balance between the baby's disposition to express distress and the parents’ capability to soothe their baby. Not only do babies vary in their expression of fussiness/crying, but parents also vary in their ability to soothe. The resources for parents’ ability to soothe fussiness and crying and promote sleep in their baby include those shown in the box on page 74.
Never wake a sleeping baby.
Bedtime Routines
Study the list on page 75.
Breast-feeding versus Bottle-feeding
and Family Bed versus Crib
· Breast-feed: All the time, part time (expressed breast milk versus formula), never.
For about 80 percent of babies, the common fussy babies, mothers are better rested and feeding is mostly for nutrition. Breast-feeding is usually easy.
For about 20 percent of babies, those with extreme fussiness/colic, mothers are fatigued from sleep deprivation. The stress from loss of sleep might inhibit lactation. Breast-feeding may be difficult because it is used for nutrition and soothing. Nursing more frequently and for longer durations might cause more discomfort or pain if the skin of the breast becomes cracked or dry. The mother might worry that not enough breast milk or her diet is causing the breast milk to upset the baby because of the extreme fussiness/crying. Consider a single bottle of expressed breast milk given once per twenty-four hours by someone else.
· Family Bed: All the time, part time, never, with or with out a cosleeper.
For about 80 percent of babies, those who have common fussiness, an early commitment to a family bed usually works well. Sleep problems later are unlikely.
For about 20 percent of babies, those with extreme fussiness/colic, an early commitment to a family bed may be associated with sleep-deprived parents for several weeks, but the strong soothing power of bodily warmth, close physical contact, sounds of breathing, or hearing a heartbeat when sucking at the breast, or the smell of breast milk may make the effort worth it. Sleep problems later might occur if the child is allowed to stay up too late when about four months old.
During the day some parents with extremely fussy/colicky or common fussy babies are overwhelmed because they may have limited resources for soothing. For parents who initially did not want to have a family bed but later made that decision because of its soothing power, sleep problems are more likely to occur. The sleep problems are more likely to occur and persist not because of the family bed but because of the limited resources for soothing to continue.
Solutions to Help Your Child Sleep Better: “No Cry,” “Maybe Cry,” or “Let Cry”
Start early, when you come home from the hospital, to put your child to sleep within one to two hours of wakefulness.
Study the list of sleep solutions on pages 103-104.
Different solutions are needed for different babies.
Does your baby require soothing more than three hours a day because he fusses or cries?
Does this occur more than three days a week?
Has this been going on for more than three weeks?
If you answered “yes” to all three questions, your child has extreme fussiness or colic. Enlist all the soothing resources you can to help soothe your baby. If you want to, or if you need to, consider sleeping with your baby day and night for several weeks or months. Always hold your baby and always respond to her. Drowsy signs may be absent, so try to soothe her to sleep after one to two hours of wakefulness. Soothe your baby as long as needed to induce sleep. Motion may be needed during sleep to help your baby sleep longer.
If you answered “no” to any of the questions, your child has common fussiness. Watch for drowsy signs developing within one to two hours of wakefulness. Soothe your baby and put her down or lie down with her when she is drowsy but awake. Motionless sleep may work well.