How to Use This Chapter
I believe about 5 to 10 percent of babies are at risk for developing 90 to 95 percent of the severe sleeping problems that drive parents crazy. If your baby already has sleeping problems and you think you may have come down this path, this chapter will tell you the necessary corrections you need to make to solve the sleeping problem. However, you may be too exhausted to make it through the whole chapter, so you might benefit more by reading the summary and action plan at the end of the chapter. If you have not yet had your child, this chapter will help you later identify whether your baby is just starting on this path. Reading the entire chapter will enable you to prevent future sleeping problems.
This chapter is divided into four main sections. First, a detailed description of what is known about extreme fussiness/ colic and its relation to difficulties in sleeping during the first three to four months; second, what is temperament; third, how the fussiness/crying during months three to four is connected to temperament at four months of age; and fourth, postcolic. I also present data that connects these two ages and tells you how likely it is that your baby will develop on one path or another. You can skip the data if your child already has or had colic and go directly to the management sections or the summary and action plan if you just want to figure out what to do.
The section on postcolic is crucial to help prevent or solve any sleep problems in 20 percent of children.
Introduction
If your child suffered from colic during infancy—and 20 percent of all babies suffer from this mysterious condition—then you'll be most interested in learning how your child's colicky first months could have set the stage for unhealthy sleep habits and turned him into a “crybaby.” This chapter will be of interest to you even if your baby never had colic, though, because all babies experience unexplained fussiness and crying in their first weeks of life, no matter what your ethnic group, no matter what birthing method brought your child into the world, no matter if your lifestyle is that of jet-setter or stay-at-home.
All parents, too, tend to use the same techniques and strategies to successfully weather those first few months of life with baby, whether it's fair sailing for the most part or they feel storm-tossed by colicky waves of crying. Sleep problems arise when some parents don't change their techniques for coping with crying and fussiness at bedtimes and nap times after about three to four months of age, after their babies have become more settled. That's when unhealthy sleep habits and their resulting problems begin.
Sleep and Extreme Fussiness/Colic
For 20 percent of babies, I actually prefer the term “extreme fussiness/colic” instead of colic because fussiness is a bigger problem than crying. All babies have some fussing and crying, and for 80 percent of babies, I call this behavior common fussiness/crying. My idea is that extreme fussiness/colic is a sleep disorder. I also suggest that postcolic sleep problems occur after three to four months of age because some parents experience difficulty in establishing age-appropriate sleep routines. Let us look at the facts.
What Is Extreme Fussiness/Colic?
Dr. Wessel defined a colicky infant as “one who, otherwise healthy and well fed, had paroxysms of irritability, fussing or crying lasting for a total of more than three hours a day and occurring on more than three days in any one week … and that the paroxysms continued to recur for more than three weeks.” He added the criterion “more than three weeks” because nannies left families after about three weeks of crying. He thought nannies knew that if babies cried for more than three weeks, then the crying would continue. Because the mothers were now alone at night caring for their babies, they came to his office after three weeks complaining that their children were always crying. About 26 percent of infants in his study had colic. Dr. Illingworth defined colic as “violent rhythmical, screaming attacks which did not stop when the infants were picked up, and for which no cause, such as underfeeding, could be found.” Together, they studied about 150 infants.
The age of onset of these behaviors is characteristic. Both Dr. Wessel and Dr. Illingworth found that the attacks were absent during the first few days but were present in 80 percent of affected infants by two weeks and in about 100 percent by three weeks. Premature babies also start their attacks shortly after the expected due date, independent of their gestational age at birth. The time of day when these behaviors occur is another characteristic. During the first month, crying appears at any time of the day or night, but later it occurs predominantly in the evening hours. In 80 percent of infants, the attacks start between 5:00 and 8:00 P.M. and end by midnight. For 12 percent of infants, the attacks start between 7:00 and 10:00 P.M. and end by 2:00 A.M. In only 8 percent, the attacks are distributed anytime throughout the day and night. The age of termination of these spells is also characteristic. The attacks disappear by two months of age in 50 percent of infants, by three months of age in 30 percent, and four months of age in 10 percent of infants. The infant's behavioral stateis associated with colicky behavior. Among 84 percent of colicky infants, the crying spells begin when they are awake, 8 percent have spells start when asleep, and 8 percent under variable conditions. For 83 percent of infants, when the crying spells end, they fall asleep. It is now known that fussing as opposed to crying is the major feature of colicky behavior, and parental distress over colic may be the major factor in producing postcolic sleep problems.
What Causes Extreme Fussiness/Colic?
A recent study showed that colicky infants had higher levels of serotonin, a chemical found in the brain and in the gut. This supported Linda Weissbluth's theory that some features of colic might be caused by an imbalance between serotonin and melatonin, another chemical found in the brain and in the gut. Concentrations of serotonin are high and present in infants during the first month of life and decline after three months. Immediately after delivery, concentrations of serotonin are higher at night and lower during the day. Melatonin, flowing across the placenta from the mother, causes high concentrations immediately after birth, but they rapidly fall to extremely low levels within several days. Melatonin increases slightly between one and three months, and only after three months is there an abrupt increase in melatonin levels with higher levels at night and lower levels during the day.
Serotonin and melatonin have opposite effects on the muscle around the gut—serotonin causes contraction, melatonin causes relaxation. Linda Weissbluth's theory is that in some infants, high serotonin levels cause painful gastrointestinal cramps in the evening when serotonin concentrations are at the highest. The high nighttime melatonin levels opposes the intestinal smooth muscle contraction caused by serotonin. On the other hand, melatonin and serotonin might be directly affecting the developing brain. For example, high levels of melatonin at night might cause night sleep to become longer.
Other hormones might be involved. In one study, extremely fussy/colicky infants had a blunted rhythm in cortisol production while the control infants exhibited a clear and marked daily rhythm in cortisol that was not observed in the colicky infants. In addition, researchers in this study coded behavioral measures from videotapes and arrived at the same conclusion as have many other studies: The crying of these infants was not due to differences in handling by the mother; the colic was not simply a maternal perception.
Other studies have clearly shown that food hypersensitivity, gastroesophageal reflux, maternal anxiety, and so forth are not linked to infantile colic.
Crying
Some degree of irritability, fussing, or crying is universal—that is, crying for “unknown reasons” occurs in all babies. Dr. Brazelton reported that half of all babies cry for one and three quarter hours during the second week with a gradual increase to two and three quarter hours at six weeks, followed by a decrease in crying thereafter to one hour or less by twelve weeks of age. He called the fussiest infants “colicky.” They cried two to four hours per day every day, and their crying also increased between six and eight weeks of age.
The distress caused to parents because of their inability to deal with this crying cannot be overstated. Recent government data has shown infant homicides to increase after the second week and peak at the eighth week, and the researchers concluded that the “peak in risk in week eight might reflect the peak in the daily duration of crying among normal infants between weeks six and eight.”
There are no clear cut-off points in measurements of irritability, fussing, or crying, whether by direct observation in hospital nurseries, voice-activated tape recordings in homes, or parent diaries. Thus, extreme fussiness/colic appears to represent an extreme amount of normally occurring, unexplained fussing or crying that is present in all healthy babies.
Because the spells of irritability, fussing, or crying are universal, differing only in degree among infants; because the occurrence of spells peaks at forty-six weeks after conception and independent of parenting practices; and because the behaviors exhibit behavioral state specificity and a day-night rhythm, it is reasonable to believe that these behaviors reflect normal biological processes. One example is the normal biological process involving the development of wake/sleep control mechanisms. In all babies, the consolidation of night sleep develops during the second month (after the peak of crying occurs) and that periodic alternation of wake and sleep states is well developed by three to four months of age (when colic ends).
Fussing
Persistent low-intensity fussing, rather than intense crying, characterizes infants diagnosed as having colic. In fact, to emphasize fussiness instead of crying, the title of Dr. Wessel's paper was “Paroxysmal fussing in infants sometimes called ‘colic’” Fussing is not a well-defined behavior, and although not defined in Wessel's paper, it is usually described as an unsettled, agitated, wakeful state that would lead to crying if ignored by parents.Because sucking is soothing to infants, some parents misattribute the “fussing” state to hunger and vigorously attempt to feed their baby. These parents may misinterpret their infants as having a “growth spurt” at six weeks because they were “hungry” all the time, especially in the evening. They view their child as hungry, not fussy. Even if they spend more than three additional hours a day, more than three days a week, for more than three weeks “feeding” them at night to prevent crying, these parents do not think their baby is colicky because there is so little crying. Over a thirty-four-month period, at newborn visits, I routinely questioned every new parent who joins my general pediatric practice whether their child fulfilled Dr. Wessel's exact diagnostic criteria for colic. All families had been followed since the child's birth and received counseling regarding the normal development of crying or fussing. There were 118 extremely fussy/colicky infants out of 747 (16 percent). However, the vast majority of infants had little or no crying. Instead, they fulfilled Dr. Wessel's criteria because they had long and frequent bouts of fussing, which did not lead to crying because of‘intensive parental intervention.
Studies show that, between two to six weeks, there is an increase predominately in fussing, not crying. Furthermore, fussing and sleeping, but notably not crying, were found to be stable individual characteristics from six weeks to nine months of age. The amount of crying during the first three months did not predict crying behavior at nine months. Crying alone is not a prediction of sleep problems. Two separate and well-designed studies agree with Dr. St. James-Roberts that “high amounts of early crying do not make it highly probable that an infant will… have sleeping problems at nine months of age.”
Colic-Sleep
Dr. Kirjavainen asked parents to keep a daily diary and performed sleep recordings in the lab at night between 9:00 P.M. and 7:00 A.M. At about four and a half weeks, the total sleep time from the diary was significantly shorter in the colic group (12.7 versus 14.5 hours per day). The most dramatic decrease in sleep in the colicky babies occurred at night between 6:00 P.M. and 6:00 A.M. The diary data showed that by six months of age the extremely fussy/colicky infants slept slightly less than the noncolicky infants, but the group differences were small. The first sleep lab recording was performed when the infants were about nine weeks old. There were no differences in sleep characteristics between the groups in the night recordings. The second sleep lab recording was performed at about thirty weeks of age, and again, there were no differences in sleep characteristics between the infants formerly with and without extreme fussiness/colic.
Therefore, among infants with extreme fussiness/colic, parent diary data showed shorter total sleep times compared with the age-matched control group at four and a half weeks, but that by nine weeks there were no group differences in sleep lab data obtained during the night. Also, this report suggests that over time, between ages five and nine weeks, the sleep duration increased among extremely fussy/colicky infants. Based only on the sleep lab data, the authors concluded that infantile colic was not associated with a sleep disorder. However, Dr. Kirjavainen told me that the lab data was questionable because all children slept poorly in the lab setting.
Dr. St. James-Roberts used the term “persistent criers” to describe extremely fussy/colicky infants. At six weeks of age, the extremely fussy/colicky infants slept significantly less than non-colicky infants (12.5 versus 13.8 hours per day). There were no group differences regarding time spent awake or time spent feeding. Extremely fussy/colicky infants slept less throughout the twenty-four-hour diary record. The clearest group differences for sleep were during the day. In fact, there were no group differences regarding sleep at night. In addition, at night, there were no group differences for cry/fuss behavior. The clearest group differences for cry/fuss behavior were in the daytime. The groups were similar in the timing and duration of the infant's longest sleep period. This analysis of sleep cycle maturation led to the conclusion that the “chief difference between them lies in amounts of daytime fuss/crying and sleeping, rather than in the diurnal organization of sleep and waking behavior.” In addition, at six weeks of age, the less a baby slept, the more amounts of fuss/crying were observed. Because the authors observed no deficit in calm wakefulness, only sleeping, they felt that there was a specific trade-off between fuss/crying and sleep. In other words, more fuss/crying behavior reduced sleep time only, not calm wakeful time. The researchers concluded that persistent crying is associated with a sleeping deficit.
Another study of extremely fussy/colicky infants using sensors embedded within a mattress to continuously monitor body movements and respiratory patterns showed that at seven and thirteen weeks of age, they slept less than common fussy infants. The extremely fussy/colicky infants had more difficulty falling asleep, were more easily disturbed, and had less quiet, deep sleep.
At about eight weeks of age, it was noted that colicky infants slept significantly less (11.8 versus 14.0 hours per day). The colicky infants slept less during the day, evening, and night; however, the big difference in sleeping was during the nighttime. Again, crying more was associated with sleeping less. The authors concluded that extreme fussiness/colic might be associated with a disruption or delay in the establishment of the circadian rhythm of sleep/wake activity. At four months of age, my study showed that the average total sleep duration based on parental reports of forty-eight infants who had had extreme fussiness/colic, based on Dr. Wessel's exact definition, was 13.9 plus or minus 2.2 hours, much less than those with common fussiness/crying.
In my general pediatric practice, where all parents receive anticipatory advice regarding sleep hygiene at every visit, parents of extremely fussy/colicky infants describe a late development of early bedtimes, self-soothing to fall asleep at night, longer night sleep periods, fewer night wakings, and regular, longer naps compared to common fussy/crying infants. This suggests that while extreme fussiness/colic may be associated with a delay in maturation of sleep/wake control mechanisms, the data shows that by six, eight, and twelve months there are no differences in duration of night sleep between extreme fussiness/colic and common fussy/crying groups.
However, night waking has been reported to be more common following extreme fussiness/colic at four, eight, and twelve months. This might be interpreted as a persistent impairment of the learned ability to return to sleep unassisted during a naturally occurring nighttime arousal from sleep.
Colic-Wakefulness
Parents of extremely fussy/colicky infants often report that daytime sleep periods are extremely irregular and brief. Also, some parents of extremely fussy/colicky infants describe a dramatic increase in daytime wakefulness and sometimes a temporary but complete cessation of napping when their infants approach their peak fussiness at age six weeks. It has been suggested that, before three to four months of age, the period of inconsolability in the evening hours, when the infant cannot sleep and cries, may reflect periods of high arousal similar to the circadian “forbidden zone.” In adults, the forbidden zone is a time period during which sleep onset and prolonged, consolidated, and restorative sleep states do not easily occur. In this context, it might be more appropriate to describe colic not as a disorder of impaired sleep but as a disorder of excessive wakefulness in the evening. This view is supported by recent sleep lab investigations showing that, in infants, a circadian forbidden zone does exist between 5:00 and 8:00 P.M.
Extreme Fussiness/Colic-Temperament
Temperament characteristics of mood, intensity, adaptability, and approach/withdrawal are related to one another, and infants who were described as negative in mood, intense, slowly adaptable, and withdrawing were diagnosed as having difficult temperaments because they were difficult for parents to manage. These infants were also observed to be irregular in all bodily functions. When parents performed a temperament assessment at two weeks of age and a twenty-four-hour behavior diary at six weeks of age, it was observed that more difficult temperaments at two weeks predicted more crying and fussing at six weeks. At four weeks of age, infants who were more difficult in general, more intense and less distractible (less consolable) in particular, cried more during their second month of life than other infants.
Another prospective study performed temperament assessments at the ages of three and twelve months. At three months, the extremely fussy/colicky infants were more intense, more persistent, less distractible, and more negative in their mood. However, at twelve months, ratings on the temperament questionnaire showed no group differences between the extremely fussy/colicky infants and the control group, but the general impression of the mothers of the colicky group was that they were more difficult.
Infants who had extreme fussiness/colic, using Dr. Wessel's criteria, are more likely to have a difficult temperament than noncolicky babies when the temperament assessment is performed at four months of age. Furthermore, this progression occurs even when extreme fussiness/colic is successfully treated with the drug dicyclomine hydrochloride. This drug may act centrally in the nervous system or relieve smooth muscle spasms of the gastrointestinal tract. Similar results were observed in another study: While behavioral management significantly reduced evening fussing and crying, there were no effects of successful treatment on later temperament ratings; the infants were still described as difficult. These results originally suggested to me that biological factors cause increased cry/fuss behavior during the first three to four months of age and subsequently lead to difficult temperament assessments. I then thought that colic-induced parental distress or fatigue was a much less important factor. Now I have a slightly different view that I will share later.
Extreme fussiness/colic does not appear to be an expression of a permanently difficult temperament. In one study of extremely fussy/colicky infants, subsequent measurements of temperament at five and ten months did not show group differences between formerly extremely fussy/colicky and common fussy/ crying infants.
Sleep Temperament
Continuous recordings of sleep patterns during the second day of life were linked with temperament assessments at eight months. It was observed that infants with the most extreme values on all sleep variables were more likely to have difficult temperaments.
Temperament assessments performed at a mean age of 3.6 months showed an association between problems of sleep/ wake organization, difficult temperament, and extreme crying. Mothers of crying infants scored high on depression, anxiety, exhaustion, anger, adverse childhood memories, and marital distress. The authors concluded that factors related to parental care, while not causing persistent crying, did function to maintain or worsen the behavior. The persistence of parental factors may explain why at one year there is reported to be more difficulty in communication, more unresolved conflicts, more dissatisfaction, and greater lack of empathy in families with an extremely fussy/colicky infant, and after four years, formerly extremely fussy/colicky children have been reported to be more negative in mood on temperament assessments.
In my study of sixty five-month-old infants, the infants rated as difficult had average sleep times substantially less when compared to the infants rated as easy (12.3 versus 15.6 hours). Although nine infant-temperament characteristics were measured, only five are used to establish the temperament diagnosis of difficult. Four of these (mood, adaptability, rhythmicity, and approach/withdrawal) were highly associated with total sleep duration.
When my original study of sixty five-month-old infants was extended to include 105 infants, those with difficult temperaments slept 12.8 hours and those with easy temperaments slept 14.9 hours. This observation was subsequently confirmed in another ethnic group with different parenting practices. It thus appears that infants who have a difficult temperament have briefer total sleep durations when assessed at four to five months of age.
Support for a sleep-temperament association is also based on a study where objective measures of sleep/wake organization, derived from time-lapse video recordings, were compared with parental perceptions of infant temperament at six months of age. Dr. Keener stated that “Infants considered [temperamentally] easy have longer sleep periods and spend less time out of the crib for caretaking interventions during the night.” However, the authors’ analysis also led them to the conclusion that the night waking is also caused by environmental (parental) rather that biological factors. This increased time out of the crib for temperamentally more difficult children at six months is similar to the observation that increased night waking occurs in formerly extremely fussy/colicky infants at four, eight, and twelve months.
Utilizing a computerized movement detector, it was observed that for twelve-month-old children, those with the temperament trait of increased rhythmicity went to sleep earlier and had longer sleep durations, and by eighteen months of age there was again the observation that both subjective and objective improved sleep measures were associated with easier temperament assessments.
The exact same sixty infants that I examined at four months of age were restudied at three years. Again, temperamentally easy children had longer sleep durations compared to children with more difficult temperaments. However, there was no individual stability of temperament or sleep durations between the ages of four months and three years. Thus, temperament ratings and associated sleep patterns at age four months do not predict temperament or sleep patterns at three years.
Postcolic Sleep
I did another study of 141 infants between four to eight months of age from middle-class families and showed that the history of extreme fussiness/colic was associated with the parents’ judgment that night waking was a current problem. The frequency of awakening was a problem in 76 percent of infants, the duration of awakenings a problem in 8 percent, and both frequency and duration a problem in 16 percent. The more often a child woke up the longer were the durations of the night wakings. Other studies also reported more night waking at eight and twelve months and ages fourteen to eighteen months in postcolic children. Among those postcolic infants, the total sleep duration was less (13.5 versus 14.3 hours). These group differences decrease as children become older.
There are studies suggesting that both infant irritability and sleep deficits are moderately stable individual characteristics during the first year of life and beyond. One study showed that children with extreme fussiness/colic had more sleeping problems and the families exhibited more distress than a control group at age three years. The trend of decreasing group differences with age regarding sleep between colicky and non-colicky infants and the normal sleep lab recordings of colicky infants at nine weeks of age suggest that it is not biological factors that contribute to enduring sleep problems beyond nine weeks of age, it is parenting practices.
It may be difficult for parents of postcolicky infants after four months of age to eliminate frequent night wakings and lengthen sleep durations. Because of parental fatigue, parents may unintentionally become inconsistent and irregular in their responses to their infant.
It cannot be overemphasized that, as stated by Dr. Parmelee, “Parents are never truly prepared for the degree to which the babies' sleep/wake patterns will dominate and completely disrupt their daily activities.”
They may become overindulgent and oversolicitous regarding night wakings and not appreciate that they are inadvertently depriving their child of the opportunity to learn how to fall asleep unassisted. Some mothers have difficulty separating from their child especially at night, while other mothers have a tendency toward depression, which might be aggravated by the fatigue that results from struggling to cope with a colicky infant. In either case, simplistic suggestions to help the child sleep better often fail to motivate a change in parental behavior. If a child fails to learn to fall sleep unassisted, the result is sleep fragmentation or sleep deprivation driven by intermittent positive parental reinforcement. This causes fatigue-driven fussiness long after the colic has resolved, which ultimately creates an overtired family.
Support for this view has come from research on infants at five months of age who were followed to fifty-six months of age. Dr. WoIke showed that “Long crying duration and having felt distressed about crying during the first five months were significant predictors of night waking problems at twenty months” but not at fifty-six months. In other words, the combined factors of long infant crying or fussing plus parental distress at five months of age make it more likely that a night-waking problem will develop. Even more powerful, later sleep problems are mostly related to the comorbidity or linking of crying with sleep problems at five months rather than to crying problems alone. Sleep problems at five months remain the best predictor of sleep problems, especially night waking, at twenty months. Dr. Wolke concluded that postcolic “sleep problems are likely to be due to a failure of the parents to establish and maintain regular sleep schedules. … This conclusion does not blame parents for sleep difficulties. Rather, it recognizes why many parents adopt strategies to deal with night waking in the least conflictual manner by night feeding or cosleeping. This may be especially true of parents who are dealing with a temperamentally more difficult infant.” The authors also concluded that postcolic sleeping problems are not due simply to increased crying per se, but appear to be the consequence of associated infant sleeping problems and altered caretaking patterns for dealing with night waking in infancy.
Dr. Bates and associates recently directly evaluated the interaction between family stress, family management, disrupted child sleep patterns (variability in amounts of sleep, variability in bedtime, and lateness of bedtime), and adjustment in preschool in children about five years old. Children with disrupted sleep did not adjust well in preschool. In their analysis, disrupted sleep directly caused the behavior problems. They did not find any evidence that family stress or family management problems caused both disrupted sleep and behavior problems. Dr. Bates concluded that “sleep irregularity accounted for variation in [behavioral] adjustment independently of variation in family stress and family management.” Dr. Bates agrees with my hypothesis that sleep modulates temperament and told me that “parenting responses to [sleep] issues would be involved in the continuity/discontinuity of temperament…. If parents make the effort to manage their kids’ sleep schedules consistently, I would think that over the years they are going to see less difficult and unmanageable behavior.” Another recent study examined sixty-four children, aged eight to ten years, who had, as infants, “persistent crying” defined as fussing or crying more than three hours on three days in the week. The authors concluded that they were at risk for hyperactivity problems and academic difficulties. In addition, at eight to ten years of age, the previous persistent criers took a longer time to fall asleep, suggesting to Dr. Wolke that “they were less effective in controlling their own behavioral state to fall asleep.”
Therefore, it appears that the increased crying/fussing behavior in infancy is associated with less infant sleep, and the crying/fussing alone does not directly cause later sleep problems. Although the postcolicky child's family may be stressed, it appears that it is the failure to establish age appropriate sleep hygiene that specifically leads to later disrupted sleep and behavioral problems.
Summary
During the first four months, colicky infants, by definition, exhibit more cry/fuss behavior. Data from parent diaries obtained at four and a half, six, seven, and eight weeks of age show that extremely fussy/colicky infants sleep less than common fussy/crying infants (about 12-12.5 versus about 14-14.5 hours), but there is disagreement as to whether the decreased sleep occurs predominately during the day or night hours. By nine weeks of age, sleep lab data does not show group differences regarding sleeping between extremely fussy/colicky and common fussy/crying infants. Group differences in sleeping duration between these two groups of infants, while present even at four months of age, disappear by six to eight months. This raises the suggestion that parenting practices might be especially important in affecting sleep patterns after nine weeks, especially regarding the development of a night-waking habit. Also, by six months of age, researchers are more apt to describe parents contributing to sleeping problems, especially night waking.
There appears to be agreement that infant crying alone does not predict the development of sleep problems. Rather the comorbidity of crying plus parental distress at five months or crying plus sleep problems at five months predicts night waking at twenty months, but not at fifty-six months.
Temperament assessments at two and four weeks of age showed that infant difficultness predicted increased crying/ fussing at about six weeks of age. Infants with extreme fussiness/colic are more likely to have a difficult temperament when assessed at four months of age, but not at twelve months. A difficult temperament is associated, at many ages, with problems in sleeping, such as shorter sleep durations and night waking, but this association is not predictive of later sleep problems. At four to five months of age, infants with a difficult temperament have total sleep durations of about thirteen hours versus about fifteen hours for infants with an easy temperament.
The association of difficult temperament and sleeping problems during and shortly after four months occurs despite successful treatment of colic. My revised view is that it is exactly those parents who have the willingness and resources to invest heavily in soothing during periods of fussing, who are able to prevent some of the fussing escalating into crying and to prevent some postcolic sleep problems. On the other hand, some parents are unable to manage severe infant fussing and become overwhelmed by crying. They feel they cannot influence their child's behavior regarding crying and, later, sleeping.
It is important for parents to help postcolicky infants establish healthy sleep habits. Some of these children have difficulties falling asleep and staying asleep. At about four months they have not developed self-soothing skills, perhaps because parents had invested constant soothing to prevent fussiness developing into crying, or perhaps the inability to self-soothe is an integral component of colic. A successful intervention effort to help families cope with infant crying during colic will reduce parental distress. Continued age-appropriate sleep hygiene after colic ends is likely to prevent sleep problems persisting beyond four months. Unsuccessful intervention increases the likelihood that temperament issues, family stress, and sleeping problems will persist beyond four months.
Here is one vivid personal account of extreme fussiness/ colic.
A FATHER REMEMBERS COLIC; OR, Is THE FRENCH FOREIGN LEGION ACCEPTING APPLICATIONS?
Sleep? Hmmm … Oh, yes! I remember that! We used to do that frequently before Michelle was born.
Two years and another baby later, I still replay Michelle's birth in my mind at least daily. I joked in the delivery room that the newborn was “ugly,” but it was just a ruse to help me hold back the tears. A healthy, normal baby! The demons of the past nine months disappeared in a flash.
The first few days were spectacular. While my wife and baby recovered in the hospital from a long, tough, toxemic labor; I played the role of red-eyed, tired-but-ecstatic new father to the hilt. I showed up at work the next day, ostensibly to guard against using up a vacation day, but actually to show off the Polaroid pictures I had carried home with me in the wee hours of that postpartum morning to avoid waiting an ungodly twenty-four hours for the 35-millimeter prints to be developed.
Everything was perfect. I was getting the house in shape, making the phone calls, bringing goodies to the hospital. Nursing was starting off fine for my wife, Sharon, and our new baby was peaceful and thriving.
The false security even lasted through the first few days Sharon and Michelle were home. Michelle would wake up about every three or four hours and, with a tiny, delicate cry, let us know that it was time to nurse again. We marveled at the fact that no matter how soft the cry or what room it came from, we could always hear it. Isn't parenthood amazing? And as Michelle nursed, she would usually doze off again. When Sharon was finished, she'd put the baby back in her crib, and we would just stare down at her, enjoying the peaceful sight of our sleeping baby.
Just as Michelle crossed the boundary into her second week of life, the scene started to change. Same little cry. Same nursing routine. But then, when the nursing stopped, a new cry would start. This one was different. Louder. More agitated. More demanding. I rather enjoyed it at first, because it gave me a role—I could pick her up—and with a few minutes of rocking and patting, the crying would stop. It was my first fleeting sense of competence as a father.
But the crying grew worse and worse. Five minutes of rocking were replaced by hour-long midnight jaunts in the stroller. On rainy nights I'd carry her around the kitchen-to-dining-room-to-living-room-to-kitchen circuit so many times that I actually started to vary my route for fear of embedding a path in the carpet. The left shoulder of every T-shirt I owned had spit-up stains on it. I switched to the football carry: Holding Michelle facedown on her tummy with my fingers supporting her chin, I would swing from my hips, back and forth, back and forth, back and forth. At 3:00 A.M. I would strap on the Snugli and set off for another trek with my frantic daughter.
Each of these strategies worked for a short time. But Michelle had become a motion junkie. Absent motion, she would shriek and scream violently and tirelessly, literally for hours at a time. She would become hoarse, but even that failed to deter her.
Everyone we knew had a theory, even people we had only just met in the supermarket checkout line. All the advice was offered freely and generously, but never without the subliminal undercurrent that the real problem was our incompetence as parents. The baby was nursing too much. She wasn't getting enough food from nursing, so we should give her formula. Mix some cereal in with the formula. Wait four hours between feedings. Put her on a schedule. Relax, she senses your stress. And on and on and on. There was no end to the advice, all of it contradictory, much of it accusatory, and none of it helpful.
Michelle got worse and worse. And we got more and more tired, more and more frazzled, and more and more testy. Then we got the swing.
The swing was one of those windup numbers where you place the baby in the seat, turn the crank fifty times, and the seat swings back and forth with a mechanical click.
The swing was the true definition of a mixed blessing. While it was in action, clicking away, Michelle was quiet and often fell asleep. But within two minutes after the final click, Michelle would stir, stretch her arms, fill her lungs, and scream.
One good cranking would last about twenty minutes. So we organized our lives into neat, twenty-minute intervals, always trying to catch the sound of lessening momentum so we could crank up the swing again before Michelle got cranked up. And it worked.
It worked so well that Michelle would accept no substitute. Unless she was hungry, there was no longer any time that we could hold our child without her screaming. All of our fears, all of the subliminal messages we had received, were coming true. We were rotten parents. A mechanical swing could calm our child, but we could not. We hated the swing, but we dared not, could not, put it away.
Dr. Weissbluth gave us a copy of his book Crybabies. Sharon and I each devoured the book in one sitting. One section was particularly important and encouraging to us. It was a bell-shaped curve. Along the horizontal axis was the amount of what was laughingly called “unexplained fussiness.” “Unexplained fussiness” is medical jargon for unending, sharp, fierce shrieks that push parents to the edge of insanity.
The point is this: All newborn babies cry a lot. A portion of that crying is for no good reason, as far as we in the grown-up world can tell. If you normalize the daily variations in the amount of this crying, what you find is that it keeps going up for the first six weeks of life, then gradually falls off over the next six weeks. Then it's gone.
We weren't sure it was true, but we decided to delay our mutual suicide pact for twelve weeks to see if it was. As Michelle reached her eighth week of life, we started to notice a strange phenomenon: There were brief periods of time when she was awake and not crying! And those periods of calm were starting to increase! We were believers.
Of course, nothing kids do ever conforms entirely to what the books say. Getting Michelle settled down to sleep remained a long, drawn-out ritual well past her twelfth week. And getting her to sleep through the night was still an impossible dream. We were still tired (especially Sharon, who had gone back to work but still nursed her at night and expressed milk for Michelle to take during the day), but we were no longer frantic and frazzled. We had regained a sense of time, a sense of day and night. We no longer felt like miserable failures at the baby business.
We let it ride until Michelle reached five months. Then, after another series of consultations with our doctor, we decided to aggressively manage Michelle's sleep patterns so that both she and we could get some meaningful rest.
The theory was that Michelle was waking up at night at various times just as we all do. But instead of turning over and going back to sleep, she was demanding food and attention from us. She no longer needed the food, and the attention was robbing both her and us of a satisfying night's sleep.
The first rule was no more middle-of-the-night feedings. And because of that, we decided that Sharon should not go to the baby at all during the night, since the sight and smell of her would be too tempting for Michelle. When she cried, I would go in and rock, cuddle, sing, or swing … whatever it took to get her back to sleep.
The next phase was no more talking. Now when I was summoned to her room for a soiree, I would just lean over her crib and pat her on the back until she was fast asleep. In fact, anything short of a full five minutes would lead to a revival meeting shortly thereafter.
A few days later we held our final strategic planning session with our pediatrician. He suggested that we make the room as dark as possible, put Michelle in her bed, and not open the door until morning. He recommended that Sharon spend the night with a friend, and promised us that this final step would not take more than three nights of prolonged screaming. Very encouraging.
Sharon decided to gut it out with me. When the designated time approached, we started the bedtime ritual. Then we put Michelle in her crib, turned, marched out of the room, and shut the door. The crying started immediately. But it lasted only ten minutes. Ten minutes! That was it.
Neither of us slept well that night. We kept straining our ears to hear the cries. But there were none. When daylight came, we rushed into Michelle's room and, lo and behold, she was fine.
And that was it. Ten tough minutes, and the three of us were free from this five-month ordeal. As the days passed, we noticed some very positive side effects. Just like us, Michelle was becoming much more pleasant and fun now that she was well rested. She was thriving, and we were loving it. Life has resumed.
While this father's story may sound extreme, it is actually typical of die lengths parents will go to help their babies through their crying spells. I would like to emphasize that soothing a fussy or crying child is something both parents can do. Even if she is breast-feeding, it is not solely die mother's responsibility.
Fathers can, and in my opinion should, help with their children. If a father can be at home to help the mother for a time after she arrives home from the hospital and again for a period when the baby is about six weeks old, then the mother will be able to adjust to die changes in her baby. One father called this “tag-team parenting” because whenever one parent became exhausted, the other one took over for car rides, walks, or trips in the stroller to let the other get some much-needed rest. Two exhausted parents don't make a good couple!
Although many remedies have been suggested for extreme fussiness/colic, including catnip or herbal tea, papaya juice, peppermint drops, heartbeat or womb recordings, hot-water bottles, or trying new baby formulas, only three maneuvers have been found to calm fussiness and crying. Additional treatments such as simethicone drops and chiropractic spinal manipulation have been proven to be completely ineffective. Gastroesophageal reflux disease is the newest popular diagnosis in fussy and crying babies, but research has shown it to be a coincidental finding and not die cause of irritability in babies. The three manuevers are:
1. Rhythmic motions: rocking chairs, swings, cribs with springs attached to the casters, cradles, carriages, and strollers; walking, taking ceiling tours, using your baby for curling exercises to strengthen biceps, and taking car rides. Maybe all rhythmic rocking soothes babies by encouraging regular breathing, thus taking away the need for the baby to “make” colic in order to breathe well. However, avoid water beds, which are dangerous because they may cause suffocation. Other dangerous colic “treatments” include certain herbal remedies, which have caused poisoning; beanbag pillows, which have caused suffocation; and trampolinelike devices suspended in the crib, which have caused strangulation. Tryptophan was once used to help babies sleep well, but we now know that this is dangerous; similarly, melatonin should not be given to babies.
2. Sucking: at breast, bottle, fist, wrist, thumb, or pacifier.
3. Swaddling: wrapping the child in blankets; snuggling, cuddling, and nestling. After the first few weeks, however, this maneuver is often less effective.
You should avoid trying gimmick after gimmick; it will only make you feel more frustrated or helpless as the crying continues. You may also feel resentment or anger if your child, perhaps unlike your friend's child, doesn't seem to respond well to home remedies.
PRACTICAL POINT
Feelings of anger toward your crying child are frightening—and normal. You can love your baby and hate her crying spells. All parents sometimes have contradictory feelings about their baby.
Take breaks when your baby is crying. This will enable you to better nurture your child; it's a smart strategy for baby care, not a selfish idea for parent care.
You may feel, during the first few months, that you are not influencing your extremely fussy/colicky child's behavior very much. And you are right, but consider this period to be a rehearsal. Your hugs, kisses, and loving kindness are expressing the way you feel. Practice showering affection on your baby, even when he's crying. This loving attention is important for both of you.
However, unceasing attention showered on a fussing or crying baby, whether he is extremely fussy/colicky or just common fussy, during the first few months can have complications if you continue this strategy of intervention for the older, post-colic child at bedtime and nap times. Thus, after the extreme fussiness/colic passes, the older child is never left alone at sleep times and is deprived of the opportunity to develop self-soothing skills. These children never learn to fall asleep unassisted. The resultant sleep fragmentation or deprivation in the child, driven by intermittent positive parental reinforcement, leads to fatigue-driven fussiness long after the biological factors that caused the extreme fussiness/colic have been resolved.
Temperament at Four Months
When the excessive crying and fussiness of your baby's first few months have passed and the child seems more settled, what next? After about four months of age, most parents have learned to differentiate between their child's need for consolidated sleep and the child's preference for soothing, pleasurable company at night. Most parents can learn to appreciate that prolonged, uninterrupted sleep is a health habit they can influence; they can quickly learn to stop reinforcing night wakings and irregular nap schedules that rob kids of needed rest. A process of “social weaning” from the pleasure of a parent's company at nap times and bedtimes is underway. As one young mother said, “I see—I should now forget the company she [the baby] wants.”
But parents of postcolic children still have a few challenges to face. That's because children who have had extreme fussiness/colic appear more likely than other babies to develop a difficult temperament, shorter sleep durations, and more frequent night wakings between four and eight months of age. My research also has shown that parents of postcolic kids are more likely to view frequent (instead of prolonged) night wakings as a problem. Furthermore, boys are more likely than girls to be labeled by their parents as having a night-waking problem. Let's see how these patterns could have emerged.
Dr. Alexander Thomas, a pioneer in child development, described temperament differences among babies. In a study based on both his own careful observations and parent interviews, Dr. Thomas noted interrelations among four temperament characteristics: mood, intensity, adaptability, and approach/ withdrawal. Infants who were moody, intense, slow to adapt, and withdrawing in Dr. Thomas's study were also rated as irregular in all bodily functions. Thus they were diagnosed as having “difficult” temperaments because they were difficult for parents to manage! We don't know why these particular traits cluster together, but we do know that infants with “easy” temperaments had opposite characteristics. In Dr. Thomas's study, four additional temperament characteristics were described: persistence, activity, distractibility, and threshold. (Threshold means how sensitive or insensitive the child appears to be to noises or changes in lighting.) These four temperament characteristics were not part of either the easy or difficult temperament clusters.
The term “temperament” means behavioral style or the manner in which the child interacts with the environment. It does not describe the motivation of an action. All parents naturally make their own assessment of their babies’ temperaments. You may be surprised to know that there is a standardized system for evaluating infant temperament. It is not absolutely objective, and it has a number of limitations that I will point out later, but it has proved over the years to be very useful.
The researchers who developed this system did not have extreme fussiness/colic anywhere in their minds. There is not even a crying dimension in their system. No one connected temperament, as rated on this scale, with extreme fussiness/ colic until much later. However, as you will see, the connection proved to be striking.
Infant Temperament Characteristics
Activity (General Motion, Energy)
Does your baby squirm, bounce, or kick while lying awake in the crib? Does she move around when asleep? Does she kick or grab during diapering? Some infants always appear to be active, others only in specific circumstances, such as bathing. Activity levels in infants have nothing to do with “hyperactivity” in older children. I have examined a few babies who previously had been referred to a pediatric gastroenterologist because of extreme fussiness/colic. When he recognized that there were no gastrointestinal problems, he decided that the problem was “hyperactivity.” This diagnosis was made on the false motion that wakeful, reactive, or difficult infants are hyperactive. There is no proven association between high activity levels in infancy and hyperactivity when older.
Rhythmicity (Regularity of Bodily Functions)
Rhythmicity is a measure of how regular or predictable the infant appears. Is there a pattern in the time he is hungry, how much he eats at each feeding, how often bowel movements occur, when he gets sleepy, when he awakens, when he appears most active and when he gets fussy? As infants grow older, they tend to become more regular in their habits. Still, some babies are very predictable at age two months, while others seem to be irregular throughout the first year.
Approach/Withdrawal (First Reaction)
Approach/withdrawal is a temperament characteristic that defines the infant's initial reaction to something new. What does he do when meeting another child or a baby-sitter? Does he object to new procedures? Some infants reach out in new circumstances—accept, appear curious, approach—others object, reject, turn away, appear shy, or withdraw.
Adaptability (Flexibility)
Adaptability is measured by observing such activities as whether the infant accepts nail cutting without protest, accepts bathing without resistance, accepts changes in feeding schedule, accepts strangers within fifteen minutes, and accepts new foods. It is an attempt to measure the ease or difficulty with which a child can adjust to new circumstances or a change in routine.
Intensity
Intensity is the degree or amount of an infant's response, either pleasant or unpleasant. Think of it as the amount of emotional energy with which they express their likes and dislikes. Intense infants react loudly with much expression of likes and dislikes. During feeding they are vigorous in accepting or resisting food. They react strongly to abrupt exposure to bright lights; they greet a new toy with enthusiastic positive or negative expressions; they display much feeling during bathing, diapering, or dressing; and they react strongly to strangers or familiar people. One mother described her extremely fussy/colicky baby's intense all-or-nothing reactions: “Her mood changes quickly; she gives no warning—she can go from loud and happy to screaming.” Intensity is measured separately from mood. Infants who are not intense are described as “mild.”
Mood
If intensity is the degree of response, mood is the direction. It is measured in the same situation described above. Negative mood is the presence of fussy/crying behavior or the absence of smiles, laughs, or coos. Positive mood is the absence of fussy/ crying behavior or the presence of smiles, laughs, or coos. Most intense infants also tend to be more negative in mood, less adaptable, withdrawn. Most mild infants also tend to be more positive in mood, more adaptable, and approaching.
Persistence
Persistence level, or attention span, is a measure of how long the infant engages in activity. Parents may value this trait under some circumstances but not under others. For instance, persistence is desirable when the child is trying to learn something new, like reaching for a rattle, but it is undesirable when the infant persists in throwing food on the floor. Unfortunately, some babies persist in their prolonged crying spells and their prolonged wakeful periods. One father described his persistently crying baby as follows: “We have a copper-top, alkaline battery-powered baby and we're powered by regular carbon batteries. He outlasts us every time.”
Distractibility
Distractibility describes how easily the baby may be distracted by external events. Picking up the infant easily consoles a distractible infant's fatigue or hunger; soothing can stop fussing during a diaper change. New toys or unusual noises easily distract the infant. Distractibility and persistence are not related to each other, and neither trait is related to activity or threshold levels.
Threshold (Sensitivity)
Threshold levels measure how much stimulus is required to produce a response in the infant in specific circumstances, such as loud noises, bright lights, and other situations previously discussed. While some infants are very reactive or responsive to external or environmental changes, other infants barely react.
Difficult Temperament
As previously mentioned, while observing many children and analyzing many questionnaires, Dr. A. Thomas and Dr. S. Chess noticed that four, and only four, of these temperamental traits tended to cluster together. In particular, infants who were extreme or “intense” in their reactions also tended to be slowly adaptable, negative in mood, and withdrawn. This appeared to be a personality type.
According to their parents’ descriptions and direct observation by the researchers, these infants seemed more difficult to manage than other infants. Consequently, a child whose temperament scores fall into this pattern is said to have a difficult temperament. One mother referred to her infant as a “mother killer.” Infants with the opposite temperamental traits are said to have easy temperaments. These are sometimes called “dream” babies. One father described his “easy” infant as a “low-maintenance baby.” The difficult temperament and the easy temperament are only descriptions of a behavioral style. Temperament research usually does not ask why a child behaves in a particular way. There is no scientific basis for labeling a child with a difficult temperament as a “high needs” child. In fact, there is no scientific support for labeling a child a “high needs” child under any circumstances.
Later, I will explain why so many so-called “high-needs” children are really very overtired children/difficult temperament children.
Of the original group of infants Thomas and Chess studied, about 10 percent fell into the difficult temperament category. These infants also tended to be irregular in biological function such as sleep schedules and night awakenings. They were more likely to have behavioral problems—particularly sleep disturbances—when they grew older. One of the most interesting differences between difficult and easy babies is the way they cry when they are past the extreme fussiness period—that is, when they are three or four months old. Published research found that mothers listening to the taped cries of infants rated difficult (not their own babies), described the crying as more irritable, grating, and arousing than the crying of easy infants. They said that the first group sounded spoiled and were crying because of frustration rather than hunger or wet diapers. An audio analysis of cries helped explain why this should be. The crying of the difficult infants was found to have more silent pauses between crying noises than that of the easy babies. These silent pauses caused the listener to repeatedly think that the crying spell had ended. Also, at its most intense, the crying of difficult infants was actually pitched at a higher frequency. These two differences can make the crying seem much more frightening, piercing, and annoying.
What causes the difficult temperaments? Do they learn to be this way? Is it genetically prewired or are they overtired?
Here's how child development specialist Laya Frischer described a postcolicky baby.
JANE AT AGE FOUR MONTHS
Jane is difficult and unpredictable, with less than average sleep and cuddling and more than average crying. Observations over five weeks have revealed an extremely sensitive infant. For a period of time, she could not even tolerate touches on her abdomen. Swaddling helps a little, and the rhythmic swing movement gives her some relief. If these things fail, the parents walk her around. Sometimes these efforts quiet her fussiness, but at other times it escalates to panic crying. Jane seems to have no capacity to console herself, and very little capacity to be consoled by usual methods of touch. The pacifier has been helpful, but not always successful. Jane does not have good state regulation. She can be in a panic cry state when she seems to be asleep.
Jane goes from sleep to distress in seconds. She becomes overtired and cannot sleep, which contributes to her irritability. She does not habituate easily to sensory stimulation of light and touch. Jane requires a very protective environment, which puts great stress on her parents, particularly her mother. Her cries are very hard to read; her parents feel she is unpredictable, and often uncommunicative.
Connecting Sleep, Extreme Fussiness/Colic, and Temperament
Different Approaches for Different Babies
As you read earlier, for every hundred babies, about 80 percent will have common fussiness, and of these, 49 percent (thirty-nine babies) will have easy temperaments, 46 percent (thirty-seven babies) will have intermediate temperaments, and only 5 percent (four babies) will have a difficult temperament. However, for that 20 percent of babies who had extreme fussiness/ colic, the outcome at four months is quite different. In this group, only 14 percent (three babies) will have easy temperaments, 59 percent (twelve babies) will have intermediate temperaments, and 27 percent (five babies) will have difficult temperaments. It is important to recognize that the largest group is the intermediate temperament group comprising of forty-nine babies, or 49 percent of the total. Some of these babies will be closely but not quite resembling easy-temperament babies or difficult-temperament babies. So, for almost half of all babies, the advice regarding common fussiness leading to an easy temperament and extreme fussiness leading to a difficult temperament fits only approximately. So please read the entire section and take out of it only that which applies to your baby.
The risk of developing sleeping problems after four months of age probably looks something like this:
LOWEST RISK FOR SLEEP
PROBLEMS AFTER FOUR MONTHS
39 percent of common fussy babies who develop easy temperaments
3 percent of extremely fussy/colicky babies who develop easy temperaments
37 percent of common fussy babies who develop intermediate temperaments
12 percent of extremely fussy/colicky babies who develop intermediate temperaments
4 percent of common fussy babies who develop difficult temperaments
5 percent of extremely fussy/colicky babies who develop difficult temperaments
HIGHEST RISK FOR SLEEP
PROBLEMS AFTER FOUR MONTHS
Different temperaments and perhaps different paths to these temperaments will lead to different sleep strategies for each child. It appears to me that the difficult temperament at four months mostly represents an extremely overtired baby while the easy temperament represents an extremely rested baby. But keep in mind that biological factors within the baby, such as elevated serotonin levels or immature development of sleep/wake rhythms, may contribute to a baby's behavior during the first four months. It is equally important to remember that there is enormous variability regarding the resources with which parents are able to soothe their babies. These are factors within the mother (for example, baby blues or postpartum depression), the husband (forcing a too-late bedtime, not helping to soothe the baby), the marriage (disagreements regarding family bed or breast-feeding), and the family (too many conflicting time pressures regarding other children, career events, not enough bedrooms, ability to hire housekeeping or baby care help, and so forth). So it is important to look at the big picture, your baby and your total soothing support structure, and resources that you have available. What will work for one family may not work for you. The goal is to develop a caring environment for the family, not a cure for extreme fussiness/ colic.
“No Cry” versus “Let Cry”
Some parents are strong believers in only one approach to soothing to sleep. They believe there should never be any crying and that by always holding their baby, frequently nursing their baby, and sleeping with their baby, they can prevent extreme fussiness/colic from occurring and prevent sleep problems. They characterize their approach as “gently to sleep,” “attached parenting,” a gentle, warm, child-centered style that enhances a sense of security because the baby is taught that the mother is always there. They characterize other approaches as “cry it out,” “detached parenting,” a cold, rigid, parent-centered style that creates a sense of abandonment because the baby is taught that the mother is unresponsive. These parents say that when the baby stops crying and sleeps, he “has given up” trying to communicate with his mother. This stark contrast in parenting styles is supposed to produce differences in babies and differences in the bonding between the child and her parents. However, there are some major problems with this way of thinking. First, there is no evidence that one style or another produces a specific outcome. Second, babies themselves contribute a lot to what will easily work or not work. Third, fathers, siblings, and real-life family issues help shape your ability to soothe, comfort, and put your baby to sleep. Fourth, there are methods in between always attending to night crying and never attending to night crying such as “check and console” or “controlled crying,” whereby the child is allowed to cry for only short periods of time (see page 104).
“Attachment parenting” may or may not be your decision, but it may work well for 39 percent of babies who had common fussiness and developed an easy temperament. For these babies, everything you read in popular books about soothing and sleeping will likely “work.” This might even be true for the 40 percent (3 percent plus 37 percent) of babies in the next two groups of babies at a low risk for developing sleep problems. So, perhaps the majority of families (39 percent plus 37 percent) will have a fairly smooth course to easy soothing and sleeping, and an additional 3 percent will struggle to get to a place where sleeping becomes easy at four months of age. Perhaps, for the majority of parents, the path does not involve any crying. There is no reason to be judgmental and criticize other parents who are not so fortunate.
There is an unfortunate minority (9 percent) of families whom I believe become distressed or overwhelmed with the arrival of their baby because they lack sufficient resources to soothe the baby and/or the baby has extreme fussiness/colic so she develops into an overtired four-month-old with a difficult temperament. These parents may have started out with the crib and decided later to use the family bed for soothing and sleeping, and were still frustrated later because after four months the baby still did not sleep well. Flexibility and sensitivity to your own baby and your own family situation is key.
Common Fussiness: Low Risk for Sleep
Problems After Four Months
Breast-feeding becomes much easier around four months of age or sooner for these babies because everyone is better rested and life is more predictable. At three to four months, your baby will start to show drowsy signs earlier in the evening. Instead of becoming sleepy at 8:00 to 10:00 P.M., she will become sleepy at 6:00 to 8:00 P.M. Respect her need to sleep and begin the soothing process at night at the earlier hour. If you are using a crib, simply put her to sleep earlier; but if you are using a family bed, you have to make some choices. The first is to go to bed much earlier yourself, but this is not usually practical. The second would be to lie down with her in your bed and create a safe nest or use a cosleeper where she will sleep, and then leave her after she has fallen asleep. The danger in this is that she might roll off the bed and injure herself. The third is to transition her to a crib for the beginning of night sleep and until she awakens for her first night feeding, and then bring her to your bed for the remainder of the night. Because these are well-rested four-month-old babies, they are more adaptable and easy to transition to a crib. One strategy is to breast-feed at night, pass your baby to his father, who soothes him in his arms, and then puts the baby down in the crib. This breaks up the previous pattern of mother-breast-feeding-sleep in parents’ bed. If your baby cries, soothe him without picking him up. But if this fails, pick him up and, after soothing, try again.
If you are bottle-feeding (formula or expressed breast milk) or breast-feeding and using a crib around four months of age, expect to feed your baby about four to six hours after her last evening bottle and again early in the morning around 4:00 to 5:00 A.M. until about nine months of age. Some bottle-fed babies are fed only once, around 2:00 or 3:00 A.M. If you are breast-feeding and using a family bed, you might feed your baby many times throughout the night.
If you are using a crib, there is more social stimulation as you pick up the baby, more time required to prepare the bottle, and more handling as you put the baby down to sleep again. Under these circumstances, feeding your baby more than twice at night after four months is likely to create a night-waking habit. If you are breast-feeding, the obvious question is whether the awakenings at night, other than the two times mentioned, are due to hunger. If your breast milk supply has not kept pace with your baby's needs or has decreased, then your baby will awaken more at night because of thirst and/or hunger. Are you thirsty throughout the day? If so, you are not drinking enough fluid. Are there some unusual stresses in your life such as an important trip that you have to take, are you worried about balancing child care and working, or worried about returning to work and continuing to breast-feed? Is your baby producing less urine? Has the volume of your expressed breast milk decreased? When offered a bottle of expressed breast milk or formula, does your baby now take a much larger feeding? Does he sleep better or longer after taking a bottle? If you think your child is hungry and you want to continue breast-feeding, then contact a lactation consultant through your pediatrician or maternity hospital.
If you are using a family bed, feeding often throughout the night is not likely to create a night-waking habit. This is because your baby is partially asleep or barely awake when fed. Therefore, the risk of sleep fragmentation for both mother and baby from too much social stimulation is low. With early bedtimes in place, the family bed does not create any sleep problems, and in fact, the family bed may have been part of the soothing solution during the first few months.
After the development of an earlier bedtime, the next sleep change is the evolution of a regular nap around 9:00 to 10:00 A.M. This nap may initially be about forty minutes, but it will lengthen to one or two hours. The rest of the day may be snatches of brief and irregular sleep periods. After the morning nap develops, when the baby is a little older, the next regular nap occurs around noon to 2:00 P.M. This nap will also lengthen to become about one to two hours. There may be a third mininap that is irregular and brief in the late afternoon.
These sleep rhythms are maturing for night sleep and day sleep. A common mistake is to approach the timing of naps and night sleep by strictly enforcing a “by the clock” (BTC) routine. A temperamentally very regular baby might appear to be sleeping BTC, but watching your baby's behavior for sleepy signs is more important than watching the clock.
Consider our original group of one hundred babies. At four months, of the forty-nine babies with an intermediate temperament, thirty-seven babies (about 76 percent) had common fussiness when younger. Also, at four months, of the forty-two babies with an easy temperament, thirty-nine babies (about 93 percent) had common fussiness when younger. So, out of the original eighty babies with common fussiness, the vast majority, seventy-six (thirty-seven plus thirty-nine), or 95 percent, is at a low risk for developing sleep problems because:
Parents are not likely to be stressed
Infant is likely to be well rested
Infant is likely to be able to self-soothe
At night, consolidated sleeping (long sleep duration) develops early
During the day, regular and long naps naturally develop
early, without parental scheduling
If sleep problems exist, “no cry” solutions usually work
Extreme Fussiness/Colic: High Risk for
Sleep Problems After Four Months
Consider our original group of one hundred babies. Out of the original twenty babies with extreme fussiness/colic, a minority of only five, or 20 percent, is at risk for developing sleep problems. However, at four months, of the nine babies with a difficult temperament, five babies, or a majority of 56 percent, had extreme fussiness/colic when younger. Another way to look at this is that only nine out of the original hundred babies, a tiny group, or 9 percent, develop a difficult temperament and subsequent sleep problems because:
Parents are likely to be stressed
Infant is likely to be overtired
Infant is likely to be only parent-soothed
At night, fragmented sleep (night waking) persists
During the day, irregular and brief naps persist
If sleep problems exist, “let cry” solutions might be
necessary
I believe it is in this small percentage of babies that you have the most severe and hard-to-solve sleep problems. There are two reasons for this. The first is that the biological factors that led to extreme fussiness/colic in the first place in five of the nine babies might persist and frustrate parents’ best efforts to solve sleep problems. The second is that the social or family factors that led to parents’ distress and difficulty in soothing for four of the nine babies who had common fussiness might persist and interfere with establishing healthy sleep habits. These social or family issues of course might also be a factor for those babies with extreme fussiness/colic, either caused by the extreme fussiness or independent of the extreme fussiness/colic.
Breast-feeding these babies may be difficult because everyone is tired. As the biological need for an earlier bedtime develops, the best strategy is to temporarily try to do whatever it takes to maximize sleep and minimize crying. The plan is to keep your child as well rested as possible in order to buy time for the development of more mature sleep/wake rhythms. Once these rhythms are developed, they may be used as an aid to help your child sleep better. For example, the breast-feeding mother might have to take the baby into her bed and nurse her to sleep at the earlier bedtime. However, real life events, such as returning to work or caring for other family members, might not permit the luxury of always sleeping with our baby whenever he appears to be sleepy.
You may have wanted to practice “attachment parenting” and spend much of the first four months soothing your baby, but now, she is heavy when you carry her all day. More important, she is more alert and curious and able to resist and fight sleep for the pleasure of your company even when she needs to sleep. This “natural” desire for social contact may interfere with the “natural” development of healthy sleep habits. It is difficult to have clarity of thought and purpose when everyone is tired. As outlined in Chapter 1, it is not always clear what really is “natural” or “unnatural.”
It is “natural” for all babies to fuss or cry, for all mothers to want to soothe their babies and to be distressed by their babies’ fussiness or crying, that the more fussiness/crying for the baby means less sleep for the mother, that mother's distress increases with her own sleep loss, and that in some tribal cultures other people are available to help care for the baby. It is “natural” to breast-feed, to change when soiled, to feed when hungry, to soothe when fussy, to sleep when tired, to sleep with your baby, and to carry your baby everywhere in most, but not all, tribal cultures. In some tribal cultures, for example Yemen, mothers leave their baby totally alone all day while they work.
It is “unnatural” to have urban stimulation (noises, voices, shopping trips, errands), day care (naps not occurring when sleepy, too late a bedtime at night), mother working outside the home (returning late causing a late bedtime), or social isolation (mother is alone and becomes exhausted with too many things to do). It is “unnatural” to deliberately wake your baby and remove your breast before putting him down to sleep “awake.” It is “unnatural” to try to force-feed your baby at night to try to make him sleep better. Is all this brand new? Probably not. We know that during the Egyptian and Roman empires, wealthy women did not breast-feed their babies but instead hired wet nurses.
Can you change your lifestyle so that your child will receive the soothing to sleep at those times when she needs to sleep? Can you avoid too much social stimulation from interfering with sleep even if it means ignoring your child's crying only at those precise times when she needs to sleep? These are difficult questions that many families never have to confront. Many popular books on children's sleep give simple answers or easy solutions that often fail for this group of 9 percent of infants.
Recent research on an initial group of 1,019 families supports my idea that at four months of age there are two subgroups of overtired children who appear to have a difficult temperament. Many mothers dropped out of the study, but the 560 mothers who stayed were more likely to be married, have completed more formal education, have higher household incomes, be nonsmokers, breast-feed, and have “higher levels of social support.” They noted that at three months of age there were thirty-five children who were crying enough to be called colicky. Of these, eighteen (51 percent) had been this way at six weeks of age (typical colic) but seventeen (49 percent) had not (“latent colic”). They felt that these represented two subgroups of colicky infants and went on to describe a third subgroup (14 percent of colicky infants) that continued to cry substantially past three months of age. The authors considered this to represent a “persistent mother-infant distress syndrome.” Comparing this study to my analysis, I would say that at four months of age there are about 9 percent of overtired children with difficult temperaments representing two groups of whom five out of nine, 56 percent, were formerly extremely fussy/ colicky babies (similar to the “typical colic”) and four out of nine, 44 percent, had common fussiness/crying (similar to the “latent colic”). I believe that those families with limited resources for soothing their babies are at greater risk for the overtired/ fussy/crying state to persist. However, I do object to the term “mother-infant distress syndrome” because of the blame it directs to the mother. Obviously, fathers, grandparents, financial factors, and so forth can stress a family independent of the mother's capabilities to nurture her child.
Postcolic: Preventing Sleep Problems
After Four Months of Age
After extreme fussiness/colic winds down around four months of age or sooner, a child may be overtired, not sleeping well, and difficult to manage. But not all difficult to manage four-month-olds had colic. I suspect there are two groups of children at four months of age, both of whom have difficult temperaments.
The first group with a difficult temperament comes from the large group (80 percent) of infants with common fussiness/ crying. Only about 4.5 percent of these children, or four infants out of a hundred, fall into this category. I think they are less overtired than the second group. When parents put forth great effort to help them sleep better, there is relatively fast improvement. They are more adaptable and it is easier to change their sleep routines. “No cry” sleep strategies are likely to work well.
The second group with a difficult temperament comes from a small group (20 percent) of infants with extreme fussiness/ colic. About 27 percent of these children, or five infants out of a hundred, fall into this category. I think they are more overtired than the first group. When parents put forth great effort to help them to sleep better, there is relatively slow improvement. They are less adaptable and it is more difficult to change their sleep routines. “No cry” sleep strategies are not likely to work and parents have to consider “let cry” sleep strategies.
Here is a practical example of how different these babies are. Read the following advice on how to move your baby out of your bed. If you had decided that you wanted a family bed before your child was born, you might decide to continue the family bed for a long time, and when you move your baby out, the transition might be very easy if your baby had common fussiness/crying and now has an easy temperament. On the other hand, if your decision for a family bed was in reaction to extreme fussiness/colic and your child now has a difficult temperament, the transition might be very stressful for the entire family.
Transition from Family Bed to Crib
Q: I am breast-feeding and my child sleeps with us, but I want to move him out of our bed. How do I do this?
A: There is no one right way to do this, but however you do it, do it gradually and slowly over several weeks or a few months. Make the move when both parents agree that it is the right time. Always be mindful for your baby's safety. Initially, respond promptly when your baby calls for you. Later, you might delay your response. A baby might be placed in a crib secured to the side of your bed with the railing down. Later the railing is placed up and the crib is moved a few inches from your bed. Gradually, the crib is moved farther away until it is in baby's room. An older child might sleep on a mattress on the floor in your room, with or without the parent. Later, the mattress is moved to the child's room, with or without the parent. Sometimes you might just want your child to be in her crib or bed but in your room. If you are going to use a separate room and your child is older, announce the planned move in advance, make the room very attractive, or let her help decorate her room. Alternatively, move your baby into the room or bed where the siblings are sleeping. Some parents will begin the night together in the parents’ bed and then move the child to a crib after she has fallen asleep.
Q: Do I have to wean my baby from breast-feeding before I move him out of our bed?
A: I think the answer depends on your resources for soothing other than breast-feeding, especially the assistance of the father, plus your desire to continue or discontinue breast-feeding. I see no reason why weaning from breastfeeding has to precede or accompany your moving the baby.
The observation that brief and interrupted sleep often follows extreme fussiness/colic might suggest that some congenital, biological factors lead initially to extreme fussiness/colic, and that they are still present in the baby after the colicky period has passed. This is supported by the observation (mentioned earlier) that despite successful drug therapy that eliminated or reduced colicky crying, brief sleep periods were still the norm at four months of age. In addition, some, but not all, postcolic infants continue to behave as if they had heightened activity levels and excessive sensitivity to environmental stimuli.
Here is another example of sensitivity to environmental stimuli from my own experience. When my first son had colic, I had to keep the crib railing up and locked in place, because the clunk of the spring lock would always awaken him. This makes it awkward for me to place him in his crib, but fortunately I was limber from college gymnastics. For my wife, it was an impossible situation until we got a sturdy stool for her to stand on—but it still hurt our backs!
Interestingly, these two temperament characteristics (high activity and high sensitivity) are not part of the diagnostic criteria for babies who fall into the difficult temperament category. But some of these postcolic infants were exquisitely sensitive to irregularities in their nap or night sleep schedule. Disruptions of regular routines due to painful ear infections or holidays and trips subsequently caused extreme resistance to falling asleep and frequent night waking, lasting up to several days after the disruptive event. These prolonged recovery periods might reflect easily disorganized internal biological rhythms caused by enduring congenital imbalances in arousal/ inhibition or wake/sleep control mechanisms. Alternatively, parents who put their baby to sleep slightly too late, or who often cause their children to skip naps after four months of age, keep their postcolic infant close to the edge of overtiredness. What happens when some natural disruptive event occurs is that the child falls into the abyss of severe agitated wakefulness and irritability and the child is unable to easily get back into a regular sleep pattern.
Some postcolic kids have boundless energy. “She crawls like lightning” was how one mother described her baby. These babies are constantly on the move. They would rather crawl up mom's chest to perch on her shoulder than sit quietly in her lap. But once having reached the shoulder, they immediately want to get down and check out that dust ball or some equally exciting object off in the corner. They appear easily bored; they also seem very stimulus-sensitive, especially to mechanical noises such as those of a vacuum cleaner, hair dryer, or coffee grinder (which may have seemed to calm them down during colicky spells when they were younger). It's as if they have a heightened level of arousal, activity, and curiosity. When overtired, they are always crabby and socially demanding, needing mommy's presence and wanting to be held all the time. They also are quick to fuss when mom leaves the room for only a minute. But when they are well rested, it's a different story.
When they've had enough sleep, these same babies appear to have boundless curiosity, actively seeking opportunities to learn. Maybe these are very intelligent children who are so alert, curious, and bright that they have difficulty controlling their impulses to explore or investigate the world. No data support the conclusion that postcolic kids in general are more intelligent, but there may be a small number who are so exceptionally bright that they gave birth to this myth. One study of infants published in 1964 connected increased crying (induced by snapping a rubber band on the sole of the foot at age four to ten days) to increased intelligence at three years of age. Whether this artificially induced crying and its link with intelligence can be generalized to colicky crying is an open question.
When you become your child's timekeeper and program her sleep schedules, she will be able to sleep day and night on a regular schedule. For most parents, this is a relatively easy adjustment to make. But for postcolic infants, expect to put forth a greater effort to be regular and consistent. Your effort to keep the child well rested will be rewarded by a calmer, happier, more even-tempered child. One family that was finally able to permanently decrab their baby explained, “The ‘other’ baby is back!”
Here is a story of a child who probably had extreme fussiness/colic, even though the parents wanted to call him sleep-deprived. There was no quick sleep solution, but improvement did come slowly. Patience is always rewarded if you are reasonably consistent.
When Jackson was four months old, he had never been on any kind of sleep schedule. He seemed to cry all the time and would only sleep about four hours at a time (if we were lucky!). My husband and I would spend hours on end, holding, rocking, bounding, singing, playing, doing anything we could think to do to get him to stop crying. Our pediatrician said that he had colic and there was nothing we could do about it but to wait it out. Looking back on it all now, I am convinced that he didn't have colic at all, but was just plain sleep-deprived. At first we were hesitant to allow Jackson to cry without holding him. Given that we are both psychologists, we were scared that leaving him alone to cry would be emotionally scarring and would affect his attachment and self esteem. But we were both sleep-deprived ourselves, stressed out, and desperate to try anything. Dr. Weissbluth's belief that to not allow him to learn to soothe himself to sleep was damaging in and of itself was what allowed us to finally take the plunge. The first time I put him to sleep in his crib for a nap, I left the room and he screamed bloody murder. I sat at the top of the stairs and just cried and cried. I was convinced I was the worst mother in the world. After twenty minutes (which felt like an eternity), he finally fell asleep and slept for two hours. Unfortunately, later naps did not prove to be so easy. There were times in which he screamed for the whole hour (and I cried for the whole hour) and we would get him and try again later. Jackson was a bit resistant to the whole idea, and even though we were very consistent, he always put up a good fight. Even now, at nine months old, Jackson will still cry before most naps and bedtime. Sometimes it's thirty seconds, sometimes it's thirty minutes. He sleeps so much better and longer than he ever did. We calculated that before he was averaging ten hours of sleep per day, and after just a few weeks he was sleeping around seventeen hours a day. The best part of all was that he learned how to sleep through the night. Now, he goes to bed most nights between 6:00 and 7:00 P.M. and he wakes up usually between 6:00 and 7:00 A.M. He takes two naps per day, one around 9:00 A.M. and the other in the early afternoon. My husband and I finally got the sleep we needed and the stress level went down dramatically. We have our evenings together back, which we desperately needed. And Jackson's temperament is dramatically improved. I would still say he is a highly active baby, but would no longer say he is fussy. Before, I was certain we would never have another child because it was just too much on us emotionally. But now we are planning to conceive again within the next year.
Without your effort to maintain sleep schedules, a child will have a tendency to sleep irregularly and become unmanageably wild, screaming out of control with the slightest frustration, and spending most of the day engaged in crazy, demanding, impatient behaviors. The majority of postcolic infants do not fit this extreme picture, but they do require more parental control to establish healthy sleep schedules, compared to noncolicky infants. Thus it appears that after about four months of age, poor sleep habits are learned, not congenital.
PRACTICAL POINT
For all postcolic infants over four months of age, my clinical observations are that frequent night wakings may be eliminated and sleep durations lengthened if, and only if, parents establish and maintain regular sleep schedules for their child.
It appears that most postcolic sleep problems are not caused primarily by a biological disturbance of sleep/wake regulation; rather, the problem is parents’ failure to establish regular sleep patterns when the colic dissipates at about four months of age. Both obvious and subtle reasons can be cited as to why parents have difficulty in enforcing sleep schedules when colic ends.
Three months of crying sometimes adversely and permanently shapes parenting cycles. An inconsolable infant triggers in some parents a perception that their baby's behavior is out of their control. They observe no obvious benefit to their extremely fussy/colicky child when they try to be regular according to clock times or to be consistent in bedtime routines. Naturally, they then assume that this handling will not help their postcolic child, either. Unfortunately, they do not observe the transition, at around four months, from colicky crying to fatigue-driven crying.
Alternatively, some parents may unintentionally and permanently become inconsistent and irregular in their responses to their infant simply because of their own fatigue. The constant, complex, and prolonged efforts they use to soothe or calm their extremely fussy/colicky baby are continued. But these ultimately lead to an overindulgent, oversolicitous approach to sleep scheduling when the colic has passed. Their nurturing at night, for example, becomes stimulating overattentiveness. In responding to their child's every cry, the parents inadvertently deprive her of the opportunity to learn how to fall asleep unassisted. The child then fails to learn the important skill of self-soothing, which she will need her entire life.
In addition, my studies have shown that when daytime sleep is interrupted, the same consequences occur. The nap-deprived infant develops a short attention span. Remember, other studies have shown that the difficult child is irregular. It is exactly these two temperament traits, short attention span and irregularity, that have been shown to interfere with a child's ability to learn—beginning with learning how to fall asleep without his parents’ help.
Effective behavioral therapy to establish healthy postcolic sleep patterns by teaching the child how to fall asleep and stay asleep may or may not be acceptable to you, depending on your ability to perceive and respond to the sleep needs of your infant. (A variety of ways to achieve healthy sleep will be discussed in detail in the chapters that follow.)
Other parents, usually mothers, have extreme difficulty separating from their child, especially at night, as will be discussed in Chapter 12. They may have some difficulty themselves being alone at night because their husband's work requires frequent or prolonged absences, or because nights have always been lonely times for them. They perceive every cry as a need for nurturing. These women are wonderful mothers, but they may be too good. The infant's every need is anticipated and met before it is experienced; in doing so, the mother unintentionally thwarts the development of her child's capacity to be alone. For example, she may block her infant's attempts to provide himself with a substitute (such as thumb sucking or use of a pacifier) for her physical presence.
These parents perpetuate brief and fragmented sleep patterns in their children. Their infants become, according to Dr. Ogden, a child psychiatrist, “addicted to the actual physical presence of the mother and [can]not sleep unless they are being held. These infants are unable to provide themselves an internal environment for sleep.” Although the child has disturbed sleep, here the focus of the problem and the key to its solution lies with the parent.
WARNING
Persistent sleeping problems in children have been linked to psychiatric symptoms in adolescents, hyperactivity in children, and depression in their mothers.
Extreme fussiness/colic certainly does not cause the parents to have difficulty separating from their child! But it is more than a sufficient stimulus to cause them to regress toward the least adaptive level of adjustment. The result is severe, enduring sleep disturbance in the child. In this setting, simplistic suggestions to help the child sleep better often fail to motivate a change in how the parents approach the problem. Thus, while it is the wakeful child who may be brought for professional help, it is often the parent who has the unappreciated problem.
Extreme fussiness/colic is the most obvious example of extreme crying, but please remember that any painfully overtired infant or child might cry. In some nonindustrial societies, babies rarely cry, because they are always held close to the mother in a carrier. However, even in cultures where there is constant holding and unrestricted breast-feeding throughout the day and night, babies still cry and fuss. Here, too, the crying and fussing peak at about six weeks of age! Of course, these babies are less likely to have any congenital tendency toward fussiness exacerbated by overtiredness. These mothers do not drive cars, wear watches, or keep many daily appointments to which they must drag their infants. Also, there is less environmental stimulation, so the baby might sleep well outdoors when the mother is planting rice or cooking. Our lifestyles are different, and may cause our children to be overtired more often.
IMPORTANT POINT
Because all babies fuss and cry, some a little and some a lot, it's best to think of colic as something a baby does, not something a baby has. It's a stage of life, not a medical problem.
Summary and Action
Plan for Exhausted Parents
Sleep and Extreme Fussiness/Colic
All babies fuss and cry for no apparent reason during the first several weeks.
Babies who require more than a total of three hours a day of soothing to prevent crying, for more than three days in a week, for more than three weeks have extreme fussiness/colic. Fussing occurs more than crying. Fussiness is a precry state that will often change into crying if parents are unable to soothe their baby; some fussing leads to crying despite parents’ soothing efforts.
Twenty percent of babies have extreme fussiness/colic.
· It starts around a few days of age
· It occurs in the evening
· It ends around three to four months of age
· They start to fuss/cry when awake and stop when asleep
Unfortunately, many extremely fussy/colicky infants do not show drowsy signs.
During the first few months, these babies not only fuss and cry more, they also sleep less. Soothing these babies might lead to less crying, but not necessarily more sleeping. Review “Drowsy Signs” on page 63.
Review “Soothing to Sleep” on page 63.
You cannot spoil your baby, so do whatever you can to maximize sleep and minimize fussing and crying.
Unfortunately, for extremely fussy/colicky babies, many simple soothing methods do not work. Constant holding, breast-feeding, and sleeping with your baby may be required for soothing.
Review “Resources for Soothing” on page 73.
Make plans to enlist extra help from family, neighbors, and relatives.
If sleeping with your baby is the only way to soothe him and get some sleep, then sleep with him, even if you did not want to do so, for four months.
It is far better to let your baby cry than it is to shake him, so if you are completely exhausted and in pain from sleep deprivation, take a break to recharge your battery … even if your baby is crying.
Maternal depression, anxiety, exhaustion, and marital stress are likely to develop.
Extremely fussy/colicky infants are more likely to develop a night-waking habit after four months.
Extremely fussy/colicky infants are more likely to develop a difficult temperament after four months.
RISK FACTORS FOR ENDURING SLEEP PROBLEMS
1. Extreme fussiness/crying plus maternal distress about fussing and crying at five months of age.
2. Extreme fussiness/crying plus sleep problems at five months of age.
Extreme fussiness/crying alone is not a risk factor for enduring sleep problems.
Temperament at Four Months
How does your child interact with the environment? If he is intense, slowly adaptable, negative in mood, withdrawn, and irregular, then he is difficult to manage. He has a difficult temperament. At four months of age, I think this represents an overtired child. Sleep modulates temperament, so helping your child sleep well will make him easier to manage.
Connecting Sleep, Extreme Fussiness/Colic, and
Temperament: Different Approaches for Different Babies
Plan for your baby's tendency to fuss/cry and your baby's temperament
For a hundred babies:
· At birth, 80 percent of babies have common fussiness. Of these, 49 percent (thirty-nine babies) will become easy, 46 percent (thirty-seven babies) will become intermediate, and 5 percent (four babies) will become difficult.
· At birth, 20 percent of babies have extreme fussiness/ colic. Of these, only 14 percent (three babies) will become easy, 59 percent (twelve babies) will become intermediate, and 27 percent (five babies) will become difficult.
Match your parenting decisions to your baby's evolving temperament
· 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—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 parent's 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/crying babies are overwhelmed because they may have limited resources for soothing. For babies whose parents 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 not because of the family bed but because of limited resources for soothing to continue.
· Breast-feed: All the time, part-time (expressed breast milk versus formula), never.
For about 80 percent of babies—the common fussy/ crying 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 being sleep-deprived. The stress from loss of sleep might inhibit lactation. Breast-feeding may be difficult because breastfeeding 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 she doesn't have enough breast milk or that 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.
· Sleep Training: Start early, drowsy cues, one-to two-hour window, consistent soothing style for naps, quiet and dark place to sleep, earlier bedtimes, synchronize soothing with drowsiness, by the clock. “No-cry,” “maybe-cry,” or “let-cry” sleep solutions depend on your baby's tendency to fuss or cry, your baby's temperament, and your resources for soothing.
Postcolic: Preventing Sleep Problems After
Four Months of Age
· 49 percent of babies have an intermediate temperament (thirty-seven had common fussiness; twelve had extreme fussiness/colic)
· 42 percent of babies have an easy temperament (thirty-nine had common fussiness; three had extreme fussiness/ colic)
Parents are not likely to be stressed
Infant is likely to be well rested
Infant is likely to be able to self-soothe
At night, consolidated sleep (long sleep duration) develops early
During the day, regular and long naps naturally develop
early, without parental scheduling
If sleep problems exist, “no cry” solutions usually work
· 9 percent of babies have a difficult temperament (four had common fussiness; five had extreme fussiness/colic)
Those four babies who had common fussiness/crying might have been kept up too late, missed naps, or received too much attention at night. Or perhaps die families had limited resources for soothing and/or were overwhelmed by the demands of parenting. Reflect on how you handled sleeping during the first four months and how you might be able to get more help in caring for your baby.
Parents are likely to be stressed
Infant is likely to be overtired
Infant is likely to be only parent-soothed
At night, fragmented sleep (night waking) persists
During the day, irregular and brief naps persist
If sleep problems exist, “let cry” solutions might be
necessary
Different sleep styles work better for different temperaments.
What will work for one family may not work for you and your baby.
Concentrate on caring for your baby, not looking for a cure for extreme fussiness/colic.
1. Watch for an earlier sleep time at night developing and soothe your baby to sleep earlier.
1. For the family bed, lie down in your bed and use a safe nest in your bed, a cosleeper, or a crib only for sleep onset at the earlier bedtime.
2. If you use a crib, fathers can help put their babies to sleep; at the first night feeding, return her to her crib or bring her to your bed for the remainder of the night.
2. If you use a crib, try to feed your baby no more than two times at night; otherwise, you might create a night-waking habit.
1. For the family bed, breast-feed as often as you wish.
1. The morning nap develops first, around 9:00 to 10:00 AM. Use this nap rhythm as an aid to help your baby fall asleep.
1. Extremely fussy/colicky infants might have to go down for their first nap after only one hour of wakefulness.
2. The afternoon nap develops second, around noon to 2:00 P.M.
1. Extreme fussy/colicky infants might have to still be put down to sleep after one to two hours of wakeful ness following their morning nap.
2. Switching from “sleepy signs” to sleeping “by the clock” (BTC) may occur in common fussy babies who are temperamentally very regular at three to four months of age.
3. For extreme fussy/colicy infants, the development of nap rhythms and long naps occurs when they are older.
1. Try the “Fade procedure” described on page 295 and 346 at four months.
2. Try to “focus on the morning nap,” described on page 251 at four months.
3. Plan to switch from “sleepy signs” to “BTC” only when much older.
Different Postcolic Groups
After extreme fussiness/colic winds down—around four months of age or sooner—your child may be overtired and not sleeping well and difficult to manage. But not all difficult to manage four-month-olds have colic. I suspect that there are two groups of children at four months of age, both of whom have difficult temperaments (see page 175).
The first group with a difficult temperament came from the large group (80 percent) of infants with common fussiness/ crying. Only about 4.5 percent of these children, or four infants out of a hundred, fall into this category. I think they are less overtired than the second group. When parents put forth great effort to help them sleep better, there is relatively fast improvement. They are more adaptable and it is easier to change their sleep routines. “No cry” sleep strategies are likely to work well (see page 103).
The second group with a difficult temperament came from a small group (20 percent) of infants with extreme fussiness/ colic. About 27 percent of these children, or five infants out of a hundred, fall into this category. I think they are more overtired than the first group. When parents put forth great effort to help them sleep better, there is relatively slow improvement. They are less adaptable and it is more difficult to change their sleep routines. “No cry” sleep strategies are not likely to work and parents have to consider “let cry” sleep strategies.