Our goal is to establish sleep habits, so we don't want to get sidetracked by worrying too much about crying. When your two-year-old cries because he doesn't want his diaper changed or your one-year-old cries because he wants juice instead of milk, don't let the crying prevent you from doing what is best for him. Establishing healthy sleep habits does not mean that there will always be a lot of crying, but there may be some in protest. If you find this to be unacceptable when your child is four months old, then please reconsider this chapter when he is nine or ten months old.
Months Five to Eight: Early Afternoon Nap
Develops at 12:00 to 2:00 P.M. Variable Late
Afternoon Nap at 3:00 to 5:00 P.M.
As months three to four blend into months five to eight, behavior does not change sharply. Nonetheless, a distinct shift occurs at about the age of four to five months. Increased sociability permits more playfulness and gamelike interactions between you and your infant. Your child may roll over, sit, imitate your voice with babbling, or respond quickly to your quiet sounds. This increased social interaction certainly makes having a baby more fun.
Infants really do enjoy their parents’ company; they thrive in response to your laughter and smiles. However, your baby is not like an empty vessel you can fill with love, warmth, hugs, kisses, and soothing until it is full, thus leading to satisfaction, blissful contentment, or undemanding repose. The more you entertain her, the more she will want to be amused. So it is natural and reasonable to expect your baby to protest when you stop playing with her. In fact, the more you play with your child, the more she will come to expect that this is the natural order of things. Nothing is wrong with this, except that there are times when you have to dress your baby or leave her to amuse herself for a while, and she will probably resist the partial restraint or curtailment of fun and games. When this happens, please remember that leaving your baby alone protesting for more fun with you while you get dressed is not the same thing as abandonment. Similarly, leaving your baby alone protesting for more fun when she needs to sleep is not neglect. You have become sensitive to your child's need to sleep, and she is now old enough to set her clock at a healthy sleep. Our goal is to synchronize caretaking activities with her need to be fed, to be kept warm, to be played with, and to sleep.
After four months of age, an infant's sleep becomes more adultlike. Infants younger than this enter sleep with a REM sleep period, but around this age they begin to enter sleep with a non-REM sleep period, like adults. Sleep cycling, from deep to light non-REM sleep with interruptions of REM sleep, also matures into adultlike patterns around four months of age.
As discussed previously, the five elements of healthy sleep are (1) sleep duration (night and day), (2) naps, (3) sleep consolidation, (4) sleep schedule, and (5) sleep regularity. Now let's look at Figure 7. This circle graph is a navigational aid for parents to help them understand sleep/wake rhythms. Although I designed this graph, I did not create it any more than a mapmaker creates the shape or location of an island. As your child gets older, the times when he will become sleepy are becoming more predictable. Another way of saying this is that the biological sleep/wake rhythms mature. This allows you to change your strategy for keeping your child well rested. Previously, the focus was on brief intervals of wakefulness to avoid the overtired state; now you can begin to use clock time as an aid to help your child sleep well. Some parents call this sleeping “by the clock,” or BTC. Stated simply, you are using your child's natural sleep rhythms to help him fall asleep. Let's start in the morning and go around the clock.
FIGURE 7: HEALTHY SLEEP SCHEDULE FOR INFANTS FOUR TO EIGHT MONTHS OLD
How to Teach Your Baby to Sleep or to Protect His
Sleep Schedule
You are now about to learn how to help your child learn to sleep well and to protect a naturally developed, healthy sleep pattern.
The Wake-up Time
Some babies tend to wake up early, 5:00 or 6:00 A.M., and return to sleep after a brief feeding or diaper change. This is a true continuation of night sleep and not a nap. Other babies wake up later but start the day then. Most children will awaken to start the day about 7:00 A.M., but there is a wide range (between 6:00 and 8:00). In general, it is not a good idea to go to your child before 6:00 A.M., even if he is crying, because if you do, he will begin to force himself to wake up earlier and earlier in order to enjoy your company. The natural wake-up time seems to be an independent, neurological alarm clock in these young infants that is somewhat independent of the part of the brain that puts them to sleep or keeps them asleep. In fact, despite what is commonly believed, you cannot change the wake-up time by keeping your baby up later, feeding solids before bedtime, or awakening your baby for a feeding before you go to sleep. The last seems insensitive, anyway. How would you feel if someone woke you from a deep sleep and started to feed you when you weren't hungry? The sleep strategy called “Scheduled Awakenings” will be discussed later.
Morning Wakeful Time
Let's focus now on how brief intervals of wakefulness develop into “windows” of clock time. These are periods during which you will watch your baby and the clock to determine the time when it is easiest for your child to take an age-appropriate nap. These windows of “sleep propensity” open and close, and they represent times during which it is easiest to fall asleep and stay asleep. Morning wakeful time will last about two hours for four-to five-month-olds or about three hours for eight-month-olds. Some easy babies or babies born early may be able to stay up for only one hour at four months of age. Then, plan a wind-down or nap time ritual of up to thirty minutes. You decide what you want to do: bath, bottle, breast-feeding, lullaby, massage—but limit it, because hours of holding your baby produce only a light or twilight sleep state, which is poor-quality sleep. Begin this ritual about half an hour before the end of your baby's wakeful period, not after it's over. At the end of your predetermined nap time ritual, whether your baby is asleep or awake, lie down with her or put her in her crib. As one mother commented to me, “I cannot tell you what a liberating experience it was to be able to put my baby down in her crib before she fell asleep in my arms.” She may now cry a little, a lot, or not at all. The temperamentally easy child cries very little, and the routine is repeated for an early afternoon nap. The temperamentally more difficult child, who may have also been an extremely fussy/colicky infant, might now cry a lot. The preemie also may cry a lot, and the following approach might be de-laved until four months after the exnected date of delivery.
Nap #1: Midmorning
This nap develops first, usually between twelve and sixteen weeks of age or twelve to sixteen weeks after the due date for premature babies. It occurs about 9:00 A.M. and may last an hour or two. Sometimes you can stretch the child's morning wakeful period by a few minutes each day to get to this time, or you might wake him up at 7:00 A.M. in order for him to be able to take this nap. This violation of the rule “Never wake a sleeping baby” is to help maintain an age-appropriate sleep schedule for the benefit of the baby. The rule mainly applies to waking babies for our social convenience, to their detriment. Try to anticipate your child's best nap time. If he takes this nap too early or too late, then it will be difficult for him to take the second nap on time.
We consider a sleep period to be a restorative nap if it is about an hour or longer. Forty to forty-five minutes is sometimes enough, but most babies in this age range sleep at least a solid hour. Certainly sleep periods shorter than thirty minutes should not count as naps.
If you are using Method A for naps (see page 235) or have a temperamentally easy baby, after putting your baby down for this nap, leave him completely alone to allow him to (1) learn to fall asleep unassisted and (2) return to sleep unassisted until he has slept about an hour in an uninterrupted fashion. Easy babies may cry very little or not at all; the temperamentally more difficult child may cry a lot. Remember, you are responding sensitively to his need to sleep by not providing too much attention. You are decisive in establishing a routine because you are upholding his right to sleep. Be calm and firm and consistent, because consistency helps your baby learn rapidly.
He will pick up on your calm/firm attitude and will learn quickly not to expect the pleasure of your company at nap time. You are not abandoning your child in his moment of need; you are giving him all the attention he needs when he is awake. Now he needs to be alone to sleep.
Q: How long do I let my baby cry?
A: No more than one hour.
Q: What do I do if the nap is short? When I put my child down to sleep, she cries a long time, but for less than an hour, and then falls asleep, but she doesn't sleep very long. Do I let her cry again”? Sometimes, she doesn't cry when I put her down for a nap, but she still doesn't sleep very long. Do I let her cry after the brief nap to see if she will sleep longer?
A: If the nap is substantially less than thirty minutes, you might try to leave her alone for an additional thirty to sixty minutes, even if she cries, to see whether she will return to sleep unassisted. If the nap is substantially more than thirty minutes, it is less likely that she will return to sleep unassisted so you might want to leave her alone for an additional thirty minutes or go to her immediately and not let her cry anymore. In general, the shorter the nap and the less restorative it appears, the longer you should leave her alone. Alternatively, you might want to try to lengthen the nap by rushing to your child at the first sound of awakening from a brief nap (less than an hour) and attempting to soothe your child back to sleep for a continuation of the nap. For some babies, this might be counterproductive and simply stimulate them to fight sleep more for the pleasure of the parent's company.
Q: After one hour of crying, what do I do?
A: Go to your baby and soothe her. Now you have two choices. Your baby might be wakeful, and you might decide that this was so stressful for you or her that you want to go outside for a walk, relax, and try again the next day to get a morning nap. Or your baby might be falling asleep in your arms after all this crying; if you feel that she will now be able to fall asleep, put her back down to see if she will nap. But do not let her cry for another full hour.
Q: What's wrong if I quickly check my baby when she first cries and I give her a pacifier or roll her back over”? She always immediately stops crying and returns to sleep.
A: Checking on your baby like this when she should be napping may not interfere with naps or night sleep in some infants between four and six months. But please be careful, because eventually all babies learn to turn these brief visits into prolonged playtimes. This learning process may develop slower if it is the father who does the checking and provides minimal intervention.
Q: My child had extreme fussinesslcolic and she is now about five months old, how do I get her on a 9:00 A.M. and 1:00 P.M. nap schedule?
A: Make sure she is sleeping well at night.
Control the wake-up time; try to start the day around 6:00 to 7:00 A.M. by not going to her before 6:00 A.M. or waking her up at 7:00 A.M.
Try intense, but brief, stimulation outdoors. Expose her to wind, rustling leaves, moving clouds, street noises, voices, barking dogs, sand in the playground, motion in the jogger or soft sling on your chest, swings, “swimming” pool splashing, and so forth.
Try to stretch her wakeful period to about 9:00 A.M. but be mindful not to allow her to become so frantically overtired that she will not be able to subsequently sleep well. She will get a little geared up and might get close to but not make it to 9:00 A.M.
Tone it down a little as you get close to 9:00 A.M.
Plan for a much longer and relaxing soothing-to-sleep routine before her morning nap because she will be a little overtired. Consider including a bath for relaxation, not for hygiene. Bathing might be stimulating but more often it is calm fun for babies.
Around 9:00 A.M., lie down to sleep with her or put her down to sleep. Review the sleep training strategies on page 211.
If she has a decent nap of close to one hour, repeat the same steps for her 1:00 P.M. nap.
If she does not nap in the morning, get out of the house and try to not let her sleep until about 11:00 A.M. Try the same soothing-to-sleep routine around 11:00 A.M. This means no car rides at 10:00 A.M.
Parents of postcolic babies or babies with a more difficult temperament (babies who are not self-soothing or who are irregular) might want to begin to practice Method A at this time. Many of these parents have been using Method B (your baby always begins naps with your help), as discussed in the previous chapter. Ideally, you have been very consistent with Method B up until now; the better rested your baby is when you make the transition from Method B to Method A, the easier it will be.
WARNING
It may be very difficult to establish regular naps at four to five months of age in some babies because their biological nap rhythms are maturing very slowly. Some babies don't evolve into a schedule of regular long naps until five or six months of age, especially if they had extreme fussiness/ colic when younger or if their parents were inconsistent or irregular about naps during the first four months.
For the difficult-temperament or postcolic baby, establishing the morning nap may be the toughest parenting maneuver that you have attempted so far. By focusing on the morning nap we try to help a postcolic baby learn self-soothing skills. It's best to begin establishing an age-appropriate nap schedule with the morning nap because it is the first one to develop; it is the nap that should be the easiest to obtain, because your baby is most rested from die night sleep, and parents usually can be more consistent in the morning, when scheduling conflicts are less likely to develop, than in the afternoon.
After your child's day starts, look at the clock. Within one hour of wakefiilness, clean, feed, and soothe using Method A. This ultra-short period of wakefiilness is designed to prevent the overtired state from developing.
Another reason why it is important to establish the morning nap by keeping the interval of wakefiilness very short is that the morning nap might represent a continuation of night sleep. The morning nap contains more REM sleep than the afternoon nap, and large amounts of REM sleep are a characteristic feature of a baby's night sleep.
“HE DID BEST WITH
HIS FIRST MORNING NAP”
The hours between 5:00 P.M. and 3:00 A.M. were the most difficult. When Eric was awake, he fussed or cried. The only way he would sleep was in our arms. My husband would cut up my food so I could eat with one hand while holding Eric with the other. I would nap from 8:00 to 10:00 P.M. to recharge for the next five hours. While I slept, my husband would alternately rock, walk, and bounce Eric. The routine was nearly unbearable. Eventually we made a chart to show Eric's schedule to Dr. W We determined that we were holding Eric eighteen or nineteen hours a day. No wonder we were exhausted.
I'll never forget the night and early morning at about three months of age when Eric was so sleep-deprived he could not go to sleep. I tried everything—nursing, rocking, walking, bouncing, singing. Eventually he did fall asleep while I pushed him around the house in the stroller listening to his favorite CD, only to wake up the second I tried to move him into his crib. The hours stretched on and Eric became more and more tired, overstimulated, and agitated. He began trying to pick the flowers off my pajamas. Though he seemed to want to go to sleep, he appeared unable to get there. I felt I didn't have any choice but to put him in his crib—awake and crying. After about twenty minutes of crying, he fell asleep.
He did best with his first morning nap, crying only one or two minutes, if at all, before going to sleep. The evenings remained the most difficult. The longest crying episode was twenty-one minutes. My husband and I would sit in the den holding hands, listening to the baby monitor, and engaging in self-doubt. Does he need us? Are we bad parents for letting him cry? We kept reminding ourselves that Eric was learning a valuable skill that would serve him (and us!) well for life. After about three days, we felt he had achieved success. He has been a terrific sleeper ever since. Now, at age eleven months, he sleeps from 7:00 P.M. to 7:00 A.M. and naps twice for an hour or two. Everyone who meets him says he is happy, joyful, and alert.
If there is bright morning light during this hour, open up all your shades, because exposure to morning light might help establish sleep rhythms. If there is no bright natural light, make the room as bright as you can with room lights. Darken the room as you begin your soothing to sleep. After several minutes of soothing, which may include breast-or bottle-feeding, put your baby down. If there is crying, ignore the crying for between five and twenty minutes. You be the judge of how much crying you think is appropriate, but watch the clock, because three minutes of hard crying might feel to you like three hours. The reason we do not let difficult temperament or postcolic babies cry for an hour, as we can with easier babies, is that they have increased difficulty falling asleep unassisted. Their parents are usually extra stressed as well. I would, however, like to point out that some babies scream their brains out for two minutes, moan and whimper for three minutes, and then go to sleep for a great nap! You might lose the chance for a long nap if you do not let your child blow off steam for a minute or two. As before, when you feel there has been enough crying, rescue your child and try it again the next day—or maybe put him back down if you think he will now go to sleep. For the remainder of the day, try to keep each interval of wake-fulness to no more than two hours, do whatever works to maximize sleeping and minimize crying.
An alternative to putting children in their crib for naps is to sleep with them in your bed. This may work well for first-time mothers who do not have other children to care for. However, as your child becomes older, she becomes more aware of her environment while awake, drowsy, and asleep. So you might have to use a sidecar arrangement with her crib next to your bed so she is not stimulated by your body movements, coughing, or snoring.
As you read the following story, please try to notice features such as controlling the wake-up time, the ultra-short interval of wakefulness before the morning nap, making the bedtime earlier, and transitioning from Method B to Method A.
“HIS SLEEP SCHEDULE
WAS OFF KILTER”
Even when Patrick was only a few weeks old we noticed that he was becoming a night owl. He had what we called the “late-night fussies” in which Patrick would fuss and cry until he fell asleep. This would begin between 7:30 and 9:00 P.M. and last until around midnight. He was going to sleep at night much too late and would not fall asleep unless one of us was holding him.
Our main concern was his crankiness at night and his inability to fall asleep at a normal hour. Dr. Weissbluth asked me to keep a record of Patrick's schedule for ten days. I created a bar graph for each twenty-four-hour period and color-coded it to show when Patrick was awake, asleep, or crying.
Dr. Weissbluth's conclusion was that we needed to alter Patrick's sleep schedule. The goal was to get him to sleep earlier at night and to wake him up by 7:00 A.M. We began this by not letting him sleep past 7:00. If he awoke on his own between 6:00 and 7:00, great. If not, I had to get him up. I would then have one hour to change, feed, and play with him. During this hour I was to keep him in bright sunlight or well-lit rooms to establish morning wake time. After he had been up for fifty minutes I was to begin “quiet time” for ten minutes. This meant any soothing techniques I wanted to use to get him ready for his nap. I then had to put him in his crib awake and leave the room. If Patrick cried, my instructions were to leave him alone for five to twenty minutes to see if he would fall asleep on his own.
The first day I woke him at 7:00 on the dot. He was in a great mood as he ate, and we played in the light. At 7:50 I turned down the lights, read him a book in the rocking chair, and walked him around the room singing lullabies. At 8:00 I put him in the crib and closed his bedroom door. He began to cry lightly as soon as I left. Knowing that it would be hard for me to listen to the crying and not go in to pick him up, I took my shower. This was the only way to force myself to stay out of his room. After exactly fourteen minutes he stopped crying and fell asleep for an hour! I couldn't believe how easy it was.
The next step was to put him down for a nap after he had been awake for two hours. We again did the same soothing techniques for ten minutes and I put Patrick in his crib awake. Unfortunately, things didn't go as well this time. Patrick cried for fifteen minutes and kept crying after I picked him up. His crying in my arms became louder, which was unusual, and eventually I was crying with him. I finally got him calmed down but had to wait until he fell asleep in my arms before I could put him back in his crib. I decided that we had to conquer the morning sleep before we could continue with the other naps.
I made my graphs of Patrick's sleeping habits and gave them to Dr. Weissbluth. After reviewing them, he said that the progress was good, but now we needed to concentrate on getting him to sleep earlier at night. His ideal pattern should be to wake up at 7:00 A.M., with naps at 9:00 A.M., 1:00 P.M., and possibly 5:00 P.M., with bedtime around 7:30 P.M.
That night we began quiet time at 8:30. Although Patrick had been happily playing with us, he began to yawn. He eventually fell asleep in my arms without a fight and slept in his crib through the night. What a relief!
It was now time to start putting him down awake for his second nap. I began this by using the same soothing techniques for his second nap as I used for the first, only I did not have a time limit. I would walk while singing quietly until Patrick began to close his eyes. I then put him in his crib awake but tired. Patrick would fuss for a few minutes and then fall asleep.
As the days went by and we felt comfortable with his ability to fall asleep for the first two naps, we tried the same technique on his occasional third nap and his evening bedtime. The end result is that we have a happy baby who takes great naps, falls asleep on his own at night, and is an absolute joy. We still have some challenges. There are days when Patrick wants to take his nap after he has been up less than two hours and others when he wants to stay awake longer. If he fusses in his crib for more than fifteen minutes we pick him up and try again later. Bedtime at night is absolute. We put him in his crib for good around 7:30 P.M. Sometimes he fusses for a few minutes, but most nights we don't hear a peep until the next morning. It took a long time to get to this point and it was not easy, but it was definitely worth it.
Midday Wakeful Time
Expect your baby to be ready for another nap after two to three hours of wakefulness. In general, avoid long excursions, which might lead to mini-snoozes in the car or park. Although I've been emphasizing sleep rhythms, remember that there are also wake rhythms—times when the body clock automatically switches to a wakeful mode, just as it switches to sleep mode at night and at nap times. Wakefulness turns on as sleep turns off.
If your child did not take a morning nap, do not allow him to take a snooze in the car or stroller at a time when he should be awake. If your baby naps when he should be awake, it throws the remaining sleep/wake schedule off kilter.
The development of wakefulness is an active process; it is not just the turning off of sleep. During a wakeful mode, it is hard to fall asleep or stay asleep. If you do fall asleep during a wakeful mode, the ability of this sleep to restore alertness and a sense of well-being is less compared to the same amount of sleep occurring during a sleep mode.
For adults, there is a dramatic wakeful mode associated with a period of physical relaxation between about 6:00 and 9:00 P.M. Even if you are drowsy or sleep-deprived, it is hard to fall asleep during this time. This distinct zone of decreased sleepiness or increased arousal during the early evening hours has been called the “forbidden zone” for sleep. This wakeful period has been recognized by television people, who have labeled it “prime time.” This is the time when most adults do not and cannot sleep. Recent research also shows that there is a “forbidden zone” for sleep in infants.
MAJOR POINT
It is as important not to let children sleep when they are in biological wake mode as it is to help them sleep when they are in biological sleep mode.
Usually if a nap doesn't occur, it is best to keep your baby awake and go to the next sleep period, whether it is another nap or nighttime sleep. Probably this next sleep period will take place a little earlier because of the missed nap. Try to strike a balance between not letting your child become extremely overtired and preserving or protecting’ the age-appropriate sleep pattern.
Nap #2: Early Afternoon
The second nap usually occurs between noon and 2:00 P.M., most commonly around 1:00 P.M., but in any case it should usually begin before 3:00 P.M. The nap should last about an hour or two. Then go out afterward and enjoy this longer period of wakefulness.
Please remember, this is an outline of a reasonable, healthy sleep pattern, not a set of rigid rules. In order to describe sleep patterns, we have to use clock time and the number of hours of sleep, but it is more important to watch your baby than to watch the clock. There is nothing absolute about napping at 1:00 P.M. or any other time in this sleep schedule. You'll have to make some adjustments to fit your own lifestyle and family arrangements. There will be special occasions when your child does not get the sleep he needs. He will recover from these exceptions faster if you have a regular pattern on most days. The problem with some families is that they never have a regular day, so the child is always somewhat overtired.
The most common problem with this second nap is that the interval of wakefulness following the first nap is too long. This causes your baby to become overtired, and he has difficulty either falling asleep or staying asleep. If you are using Method A, please leave your baby completely alone for one hour after soothing to see if he will fall asleep. If the duration of crying and sleeping associated with the early afternoon nap puts you way past 2:00 or 3:00 P.M., forget this nap and try to get your child to sleep in the late afternoon or early evening. If it is early, say around 4:00 P.M., limit this nap to about one and a half hours to protect a reasonably early bedtime. If it is later, say around 5:00 P.M., let your child sleep, because this “nap” may simply continue into the night and it's important to maintain an early bedtime hour.
IMPORTANT POINT
This afternoon nap commonly continues until the third birthday, but after age three, it begins to drop out.
Nap #3: Late Afternoon: 16 Percent of Babies Have Three Naps
The third nap may or may not occur. If it does occur, the time when it starts may vary between 3:00 and 5:00 P.M. Also, the duration of this nap may vary, but it is usually very brief. This nap disappears by about nine months of age. A problem with allowing this third nap to continue much past this age is that the child is unable to fall asleep in the early evening, and bedtime battles may emerge around nine to twelve months of age because the bedtime is too late. In order to go to an earlier bedtime, eliminate the third nap. The earlier bedtime then abolishes the tiredness that had made the third nap necessary. Early bedtimes are especially difficult in families where both parents work outside the home, but, as will be discussed later, the entire family benefits.
PRACTICAL
POINT
Never wake a sleeping baby except when you are trying to protect a sleep schedule.
Afternoon Wakeful Time
If there is no third nap, this is the time to go on longer excursions, errands, or shopping trips. Exercise classes and outings to the park may be fun during this wakeful period. Many parents will give their baby solid foods in the late afternoon.
Nap Duration
Q: How long should my child nap?
A: Ask yourself this question: Does your child appear tired?
If your baby is tired in the late afternoon or early in the evening, this might indicate insufficient naps. A possible solution is simply to put your child to bed earlier at night. Keeping a baby up too late produces fatigue and sleep deprivation, and will ultimately lead the child to resist falling asleep or to wake at night. This may be a problem, especially when a working parent or parents arrive home late, feeling guilty about being away from the family so long. As I mentioned above, after about six to nine months of age it is not a good idea to encourage a third, brief nap in the early evening just so the child can stay up later. This leads to an abnormal sleep schedule, and the result is the equivalent of sleep deprivation.
Bedtime
Remember, you are establishing an orderly home routine and enforcing a bedtime hour. You are not forcing your child to sleep. When your child seems tired and needs to sleep, you will establish his bedtime routine, whether he likes it or not. The bedtime routine should be regular in terms of what you do: bathing, massage, story, lullaby, rocking, or other soothing efforts. Approximately the same sequence each night helps signal to the child that it is the time for night sleep at approximately the same time. But don't be rigidly regular in terms of when you do it; there is enough normal irregularity in napping to produce some variability in bedtime. In much older children, extreme variability in bedtimes has been shown to be unhealthy.
PRACTICAL POINT
A parent who keeps a baby up past his natural time to sleep may be using this play time with the child to avoid unpleasant private time with the other parent.
Some parents make the mistake of always putting their baby down to sleep at exactly 7:00 P.M. For a few months this may work well, but when naps are irregular or the child stops taking the third nap, parents should learn to be more flexible in the timing of soothing to sleep at night, especially in the direction of an earlier bedtime!
Method A and Method B apply only to naps. At night, adopt whatever style seems comfortable to you. For example, at nap time, you may wish to put your baby down awake after soothing, and at night you may prefer to sleep with your baby. No problem. It appears that different parts of the brain are responsible for day and night sleep, so simply be consistent both in how you soothe to sleep for daytime naps and how you soothe to sleep at night, even if the two routines are different. You are “training” different parts of the brain at different times.
If it is your desire to put your baby down for the night after soothing and he is overtired, then there will be some crying. During the day, limiting the amount of crying to one hour in the hope of getting a nap at a time that will not mess up the rest of the schedule is reasonable, but at night, the crying that occurs as you put your child down should not be time-limited. Otherwise you train him to cry to your predetermined time limit. If you do not check on your baby, he will eventually fall asleep. He may cry more the second night, but each subsequent night he will cry less. This assumes that the bedtime is early, naps are in place, and night sleep is not fragmented.
This may be the first time you will ignore your child's protests, but it certainly will not be the last time. At some future point you will teach other health habits such as hand washing or tooth brushing. As he becomes mobile you will protect his physical safety by not allowing unreasonable risks involving playground equipment. Later still, you're not going to risk brain damage by letting him ride his bike without a helmet. In each of these cases, you won't let protest crying discourage you from implementing healthy practices and safety rules. Starting early and being consistent are the keys to establishing good habits.
Now is the time to let him learn to fall asleep at night by himself, to return to sleep at night by himself, and to learn that being alone at night in slumber is not scary, dangerous, or something to avoid. Keep everything calm and not too complicated as you go through a bedtime ritual. Fathers should be involved, especially if the child is breast-fed, because babies know dads cannot nurse them and so any protest crying is likely to be less intense or shorter.
Once your child is in bed, he is there to stay, no matter how long he cries, if you are using the Extinction method. Please do not return until your baby falls asleep. Little peaks or replacing pacifiers may be harmless when he is four months old, but they will eventually sabotage your efforts to help your child sleep well because intermittent positive reinforcement has enormous teaching power. Remember:
1. When the duration of protest crying at night is open-ended, not limited, learning to fall asleep unassisted takes place.
2. When you put a time limit on how much protest crying at night you can tolerate or accept before going to the baby, you teach the baby to cry to that time limit.
HELPFUL SUGGESTION
When your child is crying and she is not hungry, say to yourself: “My baby is crying because she loves me so much she wants my company, but she needs to sleep. I know the value of good sleep, and I love my baby so much that I am going to let her sleep.”
Night Wakings for Feeding
Your child may wake to be fed four to six hours after his last feeding. Some children do not get up then. Others are actually hungry at this time, and you should promptly respond by feeding.
You may say, “But when my baby was younger, he slept through the night.” Remember, in a child under four months, the bedtime was much later and the last feeding at night was much later. Now your baby is going to bed earlier, is fed earlier in the evening, and may need a night feeding; this is normal. This night feeding, and a second night feeding, may be needed until the baby is about nine months of age.
As you may recall, partial awakenings or light sleep stages, called arousals, occur every one to two hours when your child is asleep. Sometimes your child will call out or cry during these arousals. If your child is not sleeping with you in your bed, going in to him at the time of these partial awakenings will eventually lead to a night-waking or night-feeding habit. This is because picking up, holding, and feeding your baby will eventually cause him to force himself to a more alert state during these arousals for the pleasure of your company. He will learn to expect to be fed or played with at every arousal.
However, if you are sleeping with your baby and breastfeeding, you might promptly nurse at all of these arousals while you and the baby are still in a somewhat deeper sleep state, and then there is no real sleep fragmentation. No night-waking habit might develop.
Parents should not project their own emotions or misinterpret these naturally occurring arousals as signifying loneliness, fear of the dark, or fear of abandonment.
If your baby wakes at night and behaves as if she is hungry, feed her. If your baby appears to want to play at night, stop going to her. At night, the question is “Does my baby need me or want me?”
A second waking for feeding may occur around 4:00 or 5:00 A.M. Some children do not get up at this time, but those children who do awaken are wet, soiled, or hungry, and a prompt response is appropriate. While you attend to your baby's needs, maintain silence and darkness so your child will return to sleep. A common mistake is to quietly play with your child, preventing the return to sleep. The return to sleep is important so your child will be able to comfortably stay up in the morning until the time of the first nap. Although many children do not need to be fed twice at night, others simply get up at 2:00 or 3:00 A.M. or not at all. A common mistake is to feed around midnight, 2:00 A.M., and again around 4:00 or 5:00 A.M. Please do not respond at the 2:00 A.M. time; the baby is not hungry then.
Summary: Your Baby at Five to Eight Months
In this age range, many babies accept naps without protest and fall asleep at night without difficulty. These easy babies may still awaken once or twice in the middle of the night. I consider this behavior normal, natural, and not changeworthy—if it's for a brief feeding and not prolonged playtime.
Choose the one or two times when you'll go to feed your baby and change diapers, and don't go at any other time. Please review the earlier discussion on arousals (Chapter 2) if you are puzzled as to why babies sometimes get up or call out frequently throughout the night. If you have an intercom or baby monitor that allows you to hear all the quiet cries or sounds that occur during the arousals, turn it off. All you are accomplishing by listening to your child's awakenings is messing up your own sleep. A mother's sleeping brain is so sensitive to her baby's crying that any loud, urgent call will awaken her. You do not need an amplification system to ruin your sleep over every little quiet sound your baby makes!
Most mothers will partially synchronize feedings to sleep patterns so that the child is fed around the time he gets up in the morning, around the time of (before or after) the two naps, around bedtime, and one or twice at night. In other words, bottle-feedings or breast-feedings now occur four to five times per twenty-four hours. Frequent sips, snacks, or little feedings throughout the day are not necessary.
Gradually your child will begin to associate certain behaviors on your part, certain times of the day, his crib, and his sensation of tiredness with the process of falling asleep. This learning process, when started at about three or four months of age, usually takes only about three days in a fairly well-rested baby, or a little longer in an older or overtired baby.
Stranger wariness or stranger anxiety may be present in some babies by about six to nine months of age, and with this new behavior, some mothers note some separation anxiety—that is, the child shows distress when the mother leaves. I do not think this type of separation anxiety directly makes it more difficult for a child to fall asleep unassisted. I have observed that babies with separation anxiety learn to sleep well as rapidly as any other babies when their mothers leave them alone at sleep times. The problem is that some mothers also suffer from the thought of separation and will not leave their children alone enough at sleep times to allow healthy sleep habits to develop. (This will be discussed further in Chapter 12.)
REMEMBER
Watch your baby more than your watch.
A major problem in implementing an age-appropriate sleep schedule is that it is inconvenient. Many parents resent the fact that their babies are now less portable. It is inconvenient to change their lifestyle to be at home twice a day so that the baby can nap. But when parents initially suffer through the process of establishing a good sleep schedule and their child is well rested, occasional irregularities and special occasions that disrupt sleep usually produce only minor and transient disturbed sleep. The recovery time is brief and the child responds to a prompt reestablishment of the routine.
Bluntly put, when parents are unwilling to alter their lifestyle so that regular naps are never well maintained or the bedtime is a little too late, then the child always pays a price. The child's mood and learning suffer, and recovery time following outings or illness takes much longer. These parents often try many “helpful hints” to help their child sleep better. I'm not sure any or all of these hints can ever substitute for maintaining regular sleep schedules. Parents in my practice who have utilized regular sleep schedules have rarely, if ever, found these hints to be useful.
BUREAU OF “HELPFUL” HINTS OF DUBIOUS
VALUE TO SOOTHE BABY TO SLEEP
Lambskins
Heartbeat sounds
Womb sounds
Continuous background noises
Elevating head of crib
Maintaining motion sleep in swings
Changing formulas or eliminating iron supplement
Changing diet of nursing mother
Feeding solids only at bedtime
PRACTICAL POINT
You are harming your child when you allow unhealthy sleep patterns to evolve or persist—sleep deprivation is as unhealthy as feeding a nutritionally deficient diet.
Babies seem to respond quickly at this age to a somewhat scheduled, structured approach to sleep. If you can learn to detach yourself from your baby's protests and not respond reflexively by rushing in to her at the slightest whimper, she will learn to fall asleep by herself. As one mother said of her child, “She now goes down like warm butter on toast!”
Month Nine:
Late Afternoon Nap Disappears.
No More Bottle-feeding at Night
Strong-willed, willful, independent-minded, stubborn, headstrong, uncooperative. Sound familiar? These are the words parents often use to describe their toddlers. You may observe that your child is simply less cooperative. A psychologist might use the term noncomplianceto describe this lack of cooperation, but the psychologist would also point out that these behaviors go hand in hand with the normal, healthy evolution of the child's autonomy or sense of independence. All infants can now express what they do and do not want with greater energy than previously. It is harder for you to distract your child. This increased ability to express intentional behavior may be described as persistence, drive, or determination. A child's expressing her own likes and dislikes may be called “self-agency,” which becomes stronger over time.
Usually, the experts tell us, the times when you should expect the most difficulties, or “oppositional behaviors,” are at dressing, during mealtimes, in public places, and at bedtime. Since this is the beginning of the “stage” of autonomy (and noncompliance), some experts claim that it is natural for this independence/stubbornness to cause either resistance in going to sleep or night waking. I will explain later why I think this “stage” theory is an incorrect interpretation.
Children in this age range also often develop behaviors described as social hesitation, shyness, or fear of strangers. A child also might cry or appear distressed when his mother leaves him alone in one room while she goes to another room or when she leaves the child with a baby-sitter. Psychologists call this behavior stranger wariness, stranger anxiety, or separation anxiety. So if a child developed increased resistance in going to sleep at night at this stage, some experts might say that separation anxiety, or fear of being apart or away from the mother, was the cause. I think this is an incorrect interpretation also.
The major sleep change that occurs around nine months is the disappearance of the third nap. If the late-afternoon nap persists, it often causes the bedtime to become too late. Also, children who are bottle-fed after nine months of age are likely to develop a night-waking or night-feeding habit. If your baby goes right back to sleep after a feeding, then do not stop the feedings. But if he decides to play with you and does not easily and quickly return to sleep after the feeding, then stop going to him at night. Again, if you are breast-feeding in the family bed, no night-waking habit might develop.
Months Ten to Twelve: Morning Nap Starts
to Disappear but Mostly Two Naps
A small percent (17 percent) of babies are now taking only one afternoon nap. Often the bedtime now has to be twenty or thirty minutes earlier because they tend to get more tired near the end of the day. Sometimes it is the afternoon nap that starts to disappear because the morning nap is too long. In this case, move the bedtime much earlier and/or wake your child after an hour or an hour and a half into the morning nap in order to protect the afternoon nap.
Nap Deprivation
When parents have invested the effort to create an age-appropriate sleep schedule and their child is well-rested, occasional disruptions due to illness, trips, parties, or holiday visits cause only minor disruptions of sleep. Such a kid requires only a brief recovery period before getting back on track. But when parents allow poor-quality sleep patterns to emerge and persist, then there is a gradual accumulation of significant sleep deficits. Now, even minor disturbances create long-lasting havoc.
In this age range, nap deprivation seems to be a major culprit in ruining healthy sleep patterns. It's only natural that you want to get out more and do more things with your child, who is now full of new social charms, is cheerful, and crawling or maybe even walking … why not hang out together and enjoy the good weather at the park or beach?
Your child is likely to feel the same way. Self-agency might lead him to protest naps because he would rather play than sleep. If you allow him to skip his nap, then he will become fatigued. The natural adaptive response to fatigue is to fight it with stimulating hormones, which allow him to maintain more wakefulness. However, this heightened state of alertness or arousal creates an inability to easily fall asleep or stay asleep for subsequent naps and night sleep. Not only does a vicious circle of sleep problems begin, but your child may also develop emotional ups and downs or a reduced attention span as a by-product.
As naps slip and slide, a trend of increasing fatigue clearly develops. First, the child becomes a little more crabby, irritable, or fussy, maybe only in the late afternoon or early evening. You might think it's normal for children this age to be easily frustrated or sometimes bored. Then he starts to get up at night for the first time ever, “for no reason.” Later, maybe following a cold or a daylong visit with his grandparents, he starts fighting going to sleep at night, and you wonder why night sleep is a suddenly a problem.
When you reestablish healthy, regular nap routines, the night-sleep problem corrects itself (although noncompliant behaviors still exist and separation anxiety is unchanged). I have seen this over and over again. That's why I think nap deprivation and not a particular “stage” is the culprit behind disturbed night sleep.
PRACTICAL POINT
Boredom may be masked tiredness. If your child's motor is idling and she's not going anywhere, maybe she's tired.
Normal Naps
You may think your baby needs only one nap now, but most babies in this age range still need two naps. One clue some parents have noticed is that their baby-sitter can have the child take two good naps, but they can only get her to take one, if that. The child is obviously more rested after the sitter leaves, and the parents wonder how the sitter does it. Well, children are very discriminating at this age. They know that the sitter, following parents’ instructions, has a no-nonsense approach and will put them to sleep on a fairly regular schedule. But they figure that with mom or dad, enough protesting may gain them more playtime together. After all, sometimes it works. And so long as your child retains the expectation that you will come to her and take her out of her boring, quiet room, she will fight naps.
Here are three dramatic turning points in sleep maturation for young children:
1. At six weeks of age, night sleep becomes organized.
2. At four months of age, day sleep is developing and night sleep is adultlike in terms of sleep cycles.
3. At nine months of age, the third nap is eliminated, naps are longer (especially for postcolic babies), and there is no need to be fed at night.
These turning points are so highly predictable and independent of parenting practices that we know they reflect maturation of the brain. Anticipating these changes and allowing them to occur naturally will set the stage for preventing all common sleep disturbances.
Comforting Habits
Routines that comfort your baby include rocking, soft lullabies, stroking, patting, and cuddling. Maintain these routines so your child learns to associate certain behaviors occurring at certain times in a familiar place with the behavior called “falling asleep.”
HELPFUL HINTS FOR COMFORTING
Soft, silky, or furry-textured blankets, dolls, or stuffed animals in crib
A small soft blanket over the forehead, like a scarf
Dim night-light
Nursing to sleep
Nurse to Sleep?
There is nothing wrong with nursing your baby to sleep when there is no sleep problem. Most nursing mothers in my practice do this all the time. But if you have difficulty letting your child learn to fall asleep unassisted, your child always falls asleep at the breast, and your child has disturbed sleep, then nursing to sleep might be part of the sleep problem. It may reflect the kind of separation problems discussed in Chapter 12.
Most mothers nurse their babies for soothing and comfort, and their babies either fall asleep at the breast or they don't. In either case, they are put in their cribs when they need to sleep. I think that this intimacy between mother and infant is beautiful, and nursing to sleep, in itself, does not cause sleep problems.
Q: Do I roll my older child over to his favorite sleeping position when he wakes up during the night? Do I help him get down when he stands up and shakes the crib railings?
A: No. I doubt that you like playing these games with your child at night. Think, too, about what you teach him when you go to him at night to roll him over or help him down. If he rolls over only once at night or gets stuck in the railings of the crib, then help him go back to sleep.
Q: Won't he hurt himself if he falls down in his crib? He can't get down by himself.
A: No, he won't hurt himself. He may fall into an awkward heap … and sleep like a puppy.
Try to be reasonably regular by watching the intervals of wakefulness in babies four months of age or younger, and by watching your baby and the clock when he's over four months. However, try not to get locked into a fixed or traditional bedtime hour; vary the bedtime a little depending on duration of naps, when the second nap ended, and indoor versus outdoor activities. Often babies between nine and twelve months need to go to bed earlier because of increased physical activity in the afternoon and the absence of a third nap. Remember, too late a bedtime causes disturbed sleep just as nap deprivation does.
When you are somewhat organized regarding sleep schedules, sleep is accepted and expected. But don't feel you have to be this way for feeding or other infant care practices! When parents are creative, free-spirited, and permissive regarding wholesome foods, feeding goes well. So respect the biological basis for regular sleep, but accept or reject the social customs for feeding as you see fit.
Preventing and Solving Sleep Problems:
Months Five to Twelve
It cannot be emphasized enough: The major sleep problems in babies from five to twelve months old develop and persist because of the inability of parents to stop reinforcing bad sleep habits. Some parents don't see themselves as interfering with an important learning process in their child, namely, learning how to soothe themselves to sleep unassisted. The failure of children to fall asleep and stay asleep by themselves is the direct result of parents’ failure to give their child the opportunity to learn these self-soothing skills. In other words, some parents can't leave their kids alone long enough for them to fall asleep by themselves. Don't underestimate children's competence and ability to learn at these early months!
Helping Babies Sleep Also Helps Mothers
One recent study of 156 mothers of infants aged six to twelve months with severe sleep problems used controlled crying (Graduated Extinction) to help solve the problems. This intervention improved sleep problems in the children and reduced symptoms of depression in the mothers. Unfortunately, the benefits for the child and the mother lasted only about two months. Another study was comprised of 738 mothers of infants six to twelve months of whom 46 percent reported their infant's sleep as a problem. They described a strong association between the maternal report of infant sleep problems and depression symptoms in the mother. After looking at all the variables that might have contributed to maternal depression and the observation that the better the child slept, the less likely the mother was depressed, they concluded that teaching how infants sleep should decrease or help prevent maternal depression. A third study consisted of 114 mothers enrolled when their infants were eight to ten months old; the mothers were again studied when their children were three to four years old. They concluded that infant sleep problems tend to persist or recur in the preschool years and are associated with more child behavior problems and maternal depression. Analysis of their data led to the conclusion that the maternal depressive symptoms are a result, rather than the cause, of the children's sleep problems. It is uncommon for so many studies to be in agreement.
WARNING !
Sleep problems in children may cause maternal depression.
The Importance of Early
Experiences: Theory versus Facts
What does it mean to be a “good parent”? Parents feed and protect their young and provide comfort and guidance. When your baby cries, you go to him. On the surface, it certainly seems reasonable to say that the cry of your baby communicates messages: feed me, change me, pick me up, hold me, hug me, or rock me. The question is, Why is it that when a parent makes a complete response to these messages, some babies still cry? Alternatively, if crying is a form of necessary communication, why is it that many parents will deliver complete, loving, and sensitive care even when their babies do not cry? Perhaps crying as a signal system is not perfect: Some babies cry even when they don't need to cry because their needs are being cared for, and other babies don't cry but still receive the care they need. It may be an instinct: Birds fly, babies cry. In infants, it is possible that crying is no longer tightly linked to infant survival but still occurs as a behavioral remnant of some distant past. An important fact is that the meaning of crying changes with age.
The baby may cry because he is hungry and needs food to survive. The toddler may cry because he wants a second helping of dessert after dinner. The child may cry when afraid. The teenager may cry when feeling hopeless. The adult may cry from happiness at a wedding. Not all crying signifies pain. Unfortunately, when parents talk about crying, the assumption is that crying equals pain. This leads to the sometimes hidden thought: “If my baby cries, I am a bad parent.”
Thinking about how mothers relate to their babies during these early times and how they forge close relationships led to two popular concepts: infant bonding and attachment theory. Both focused almost exclusively on mothers and both claimed that future events would be strongly influenced by early experiences.
Infant bonding theories promoted the importance of early physical contact between baby and mother as a mechanism to a better adjustment later in life. The good news was that this concept caused the delivery of babies to become more comfortable even in a hotel-like environment. This was definitely an improvement for the family, compared to the cold, impersonal environment of a traditional delivery room. The bad news was that mothers who missed this experience because of complications around the delivery, and mothers who adopted older children, felt deprived and worried about their future relationship with their children. You see, infant bonding was thought to take place only during a critical period, very much like the imprinting of baby geese, who will follow any large, moving object they see at a specific time in their development. The fact is that there is no scientific evidence that a similar critical period exists for human babies, and there is no evidence that lack of “bonding” at a specific time right at birth effects subsequent behavior in either infant or mother.
Attachment theory not only considered the interaction between the mother and the child but claimed that if attachment doesn't develop well, the infant grows into an adult who has difficulty in peer relationships, romantic relationships, or parenthood. The good news was that mothers were encouraged to be affectionate, tactile, and warm without fear of spoiling their child. The bad news was that attention to children twenty-four hours a day was thought to be good.
The sad fact was that older theorists were unaware of the benefits of healthy sleep and how we are different in sleep and wake modes. Child psychologists, child psychiatrists, and pediatricians did not know the benefits of healthy sleep until recently.
The improvement in educating child health care professionals has been slow; a recent national survey of pediatric residency programs showed that only 4.8 hours of instruction on sleep and sleep disorders took place during their three years of training. This explains why pediatricians in practice so often incorrectly advise parents that their child is likely to “outgrow” the problem.
Popular distortions of attachment theory claimed that a twenty-four-hour parent—meaning one who attends to every cry day and night—would produce a more securely attached child than would a “selfish” parent who ignores a cry at night so she can get some sleep. Accumulated scientific data do not support these claims. In fact, published research on children between seven and twenty-seven months of age has shown that when parents are instructed not to attend to their children's protest crying (the technique called “extinction”), over time measurements of infant security significantly improved and all the mothers become less anxious. A similar study in sleep-disturbed infants also showed no evidence of detrimental effects on security. It's a simple but true statement that when the entire family gets more sleep, everyone feels better, even if the cries of one member of the family have to be ignored for a while to get there.
In discussing the myth of attachment theory, the famous child psychologist Michael Lewis emphasizes how the development of social skills and peer relation skills are encouraged and protected both by family members other than the mother and by people outside the family. Further, this development depends more on current, ongoing relationships than on past experiences.
Extremely violent or catastrophic events aside, for ordinary families the power of past events has been extremely exaggerated and the singular influence ascribed to the mother is unjustified. Strong proponents of the importance of early events have created in the minds of many mothers a false conclusion: “I am a bad mother if my child cries, because this may cause permanent emotional damage.”
Locus of Control
When your baby was younger, she slept when she needed to. She controlled your relationship with her, in the sense that you met her needs whether you wanted to or not. You didn't let her go hungry simply because you didn't feel like feeding her just then. You didn't let her stay wet because you didn't feel like changing her. Her needs determined your behavior.
But from now on, a shift should occur so that you are in charge. For example, when your child is older, you may decide not to give her junk food simply because she asks for it. You will not risk her physical safety by letting her climb too high on a tree simply because she wants to. And you will not let her stay up to play when she needs to sleep. What, then, are we to do when the child does not cooperate, crying because she does not want to go to sleep even though she needs to sleep?
“Let Them Cry”: A Division of Popular Opinions
There is disagreement among those who write for popular magazines about what happens when children cry after being left alone at night to sleep. In September 1984, McCall's said: “Letting a baby ‘cry it out’ will not teach him the basic trust of confidence he needs to feel secure in his new world.” While Parents magazine, in November 1983, said: “It may give him the feeling that there's nobody out there who cares. The child may become a passive, ineffective person, or he may become angry or hostile.”
On the other hand, the editor in chief of Parents wrote in the October 1985 issue, after the birth of her third child: “The trick was that after eight years of parenthood, my husband and I have discovered … [that] the first sound does not mean that the baby needs to be picked up immediately.”
Don't wait eight years to learn what experts discovered a long time ago!
“Let Them Cry”: An Agreement of Expert Opinions
While the popular press may give all types of conflicting advice from a variety of sources, expert opinion is solidly together. In fact, all evidence accumulated by a wide array of child health specialists concludes that “protest” crying at bedtime will not cause permanent emotional or psychological problems. In plain fact, the contrary is true. For example, Dr. D. W. Winnicott, a British pediatrician and child psychiatrist, emphasizes that the capacity to be alone is one of the most important signs of maturity in emotional development. In his view, parents can facilitate the development of the child's ability to soothe herself when left alone. Please don't confuse this with abandonment or, on the other hand, use this notion as an excuse for negligence.
Margaret S. Mahler, a prominent child psychoanalyst, has identified the beginning of the separation-individuation process whereby the infant begins to differentiate from the mother at four to five months of age. This is the age when children naturally begin to develop some independence.
Dr. Alexander Thomas and Dr. Stella Chess, two American child psychiatrists, followed over a hundred children from infancy through young adulthood. One item they examined was the regularity of irregular sleep and how parents responded. They wrote: “Removal of symptoms by a successful parent guidance procedure has had positive consequences for the child's functioning and has not resulted in the appearance of overt anxiety or new substitute symptoms. … The basic emphasis [of the] treatment technique is a change in the parents’ behavior.”
So please don't fear when your child cries in protest at night, because he is being allowed to “practice” falling asleep, that this crying will later cause emotional or psychological problems. By itself, it will not.
Let me be very clear about this. I am talking only about children over the age of four months and only during normal day and night sleep times. During these periods, emotional problems do not develop if parents ignore protest crying.
Drs. Thomas and Chess were sensitive to irregular sleep patterns in the infants in their study. Many of those infants also had frequent and prolonged bouts of loud crying. When I asked Dr. Thomas what advice he had given to the parents of those crying babies who did not sleep at night, he responded, “Close the door and walk away.” Did this create or produce any problems? He said, “No. None at all.”
Always going to your crying child at night interferes with this natural learning and growth. Such behavior produces sleep fragmentation, destroys sleep continuity, and creates insomnia in your child.
One study examined infant crying at one year of age. It compared children over six months of age whose parents indiscriminately responded to every cry, day or night, to those children whose parents were trained to respond promptly to every intense, stressed, or demanding cry but to delay their response to quiet vocalizations or weak cries. The children in the first group, whose parents indiscriminately responded, cried much more than children in the second group. This suggests that crying for attention can be learned or taught by at least six months.
Mothers who in general do not feel loving or empathetic toward their children, who are insensitive or emotionally unavailable to them, and who have a lack of warmth or affection later come to the attention of professionals. Consequently, some psychologists or psychiatrists take the attitude that parents should be encouraged never to let their child cry, for fear of encouraging a cold parent-child relationship. As a general-practice pediatrician, however, I don't share this view, because I see that the vast majority of parents are loving and sensitive to their child's needs. These parents should not fear letting their child cry at night to learn to sleep.
Q: How long do I let my baby cry ?
A: To establish regular naps, no more than one hour, but to establish consolidated sleep, there is no time limit at night if the child is not hungry or ill. If we place an arbitrary limit on the duration of crying at night, we train the child to cry to that predetermined time. When it is open-ended, the child learns to stop protesting and to fall asleep.
Q: Why is it good for my child to cry? Why not delay sleep training until he is older and more reasonable ?
A: Crying is not the real issue. We are leaving the child alone to learn to sleep. We are leaving him alone to forget the expectation to be picked up. We allow him to cry; we are not making him cry in the sense that we are hurting him. When he is older and still not sleeping, it will be harder for him to learn how to sleep well. Plus, losing sleep is physically unhealthy, just as is too little iron or too few vitamins in his diet.
Q: Isn't crying harmful?
A: Not necessarily. In fact, studies have proven that crying produces accelerated forgetting of a learned response. So when a child cries, she may more quickly unlearn to expect to be picked up. When trying to stop an unhealthy habit, crying may have some benefit, because crying acts as an amnesic agent.
Let's look at several of the most common unhealthy sleep habits at this age, and the proven, effective strategy to deal with each one.
Abnormal Sleep Schedule
When the bedtime hour and sleep periods are not in synchrony with other biological rhythms, we don't get the full restorative benefit of sleep. Please refer to Figures 5 and 6 (see pages 43 and 44) for age-appropriate times when children fall asleep or awaken.
At any age, abnormal sleep schedules often lead to night wakings and night terrors in older children. The schedule often gets shifted to a too-late bedtime hour because mom or dad (or both), returning late from work, wants to play with the baby, or because parents deliberately keep their baby up late to encourage a later awakening in the morning.
The strategy for bringing sleep schedules back to normal is based on developing an age-appropriate wake-up at 6:00 or 7:00 A.M.; a midmorning nap around 9:00 A.M.; an early afternoon nap, usually around 1:00 P.M., but always starting before 3:00 P.M.; an early bedtime, 6:00 to 8:00 P.M.; and unfragmented night sleep. This package of advice ensures good sleep quality, and it is quality, not always quantity, that really matters.
MAJOR POINT
The major fear that inhibits parents from establishing an earlier bedtime is that this will cause their child to get up earlier to start the day. In fact, the opposite will occur. An earlier bedtime will allow your child to sleep later, just as a too-late bedtime will eventually cause a too-early wake-up time. Remember, sleep begets sleep. This is not logical, but it is biological.
Q: Why do you recommend 6:00 to 8:00 P.M. as an appropriate bedtime ?
A: Survey data from my earlier research showed that the vast majority of children between the ages of four and twelve months went to sleep between 7:00 and 9:00 P.M., and so I used to recommend those hours. However, as I have helped families correct sleep problems over the past thirty years, it has become clearer that children who go to bed earlier tend not to develop sleep problems in the first place. In addition, children in this age range who did have sleep problems almost always benefited from an earlier bedtime. I think we have simply grown accustomed to having overtired children in the evening hours, and because it is so common, we have assumed that fussiness or irritability near the end of the day was normal. Imagine what was a “normal” bedtime before electric lights, radio, television, videos, commuting, or dual-income families traveling from work to day care to home.
When your nine-to twelve-month-old child does not promptly go to sleep at his nap times, you should leave him alone for one hour, maximum. If a nap develops and you are trying to establish a healthy sleep schedule, you would want to limit that nap to about one or one and a half hours in order to have the next nap or bedtime occur on time. If your child is overtired and you allow a two-or three-hour nap to occur, then it will be difficult, if not impossible, to establish a good twenty-four-hour schedule.
PRACTICAL POINT
You are enforcing an age-appropriate nap and bedtime schedule. Your child initially may not cooperate by falling asleep immediately. Don't give up.
Studies have shown that when sleep disturbances are associated with abnormal sleep schedules, control of the wake-up time may be sufficient to establish a healthy twenty-four-hour sleep rhythm. In other words, you set the clock in the morning!
Here's an account of one mother who left my office determined to set the clock that night and not wait until the morning.
“HE WAKES UP SMILING”
Our son did not like to sleep. In fact, if it can be said that babies are born with an aversion to any particular thing, for Ryan, sleep was it.
From the day we brought Ryan home from the hospital, he had shown himself to be a night owl. Through Letterman and 2:00 A.M. reruns of The Mary Tyler Moore Show, we would pace and nurse until sleep would overcome us sometime around Sunrise Semester. By the time he was four and a half months old, he was down to one nap a day. He didn't sleep through the night (and in my book, that's eight hours straight or better) until he was ten months old, and that lasted for only one night.
Not knowing any better, since Ryan was our first child, I thought this kind of behavior was perfectly normal for a majority of babies. When other moms would talk about their children sleeping through the night at three months of age and napping twice a day for two hours or better at a crack, I figured that it was either so much idle boasting or their children had some sort of neurological disorder. But when our pediatrician told me at Ryan's eight-month checkup that it was not normal for a child his age to go to bed at 1:00 A.M. and sleep until 10:00 A.M., I started to realize we had a problem. The thought of my husband and me looking like Dawn of the Dead rejects from years without sleep was not a pretty one.
We put Ryan to bed at 9:00 that evening and, as expected, he started to cry. We shut his door and went into the den, closing two more doors between the baby's room and the den in an attempt to muffle what were now becoming very loud screams. After a half hour had passed, the crying was more muffled but continued, so I headed for Ryan's room to “reassure him.” “Don't go in there now,” Tom suggested. “He'll just get worked up again if he sees you. Do something else for a while.” I could see the logic and agreed to hold off. A half hour later, I cracked the door open and again heard the crying. But now I could hear something else mixed in. Ryan was talking to himself. In a very hurt tone he was babbling and complaining between the sobs. My heart was breaking. “My God,” I said to Tom. “Now he's going to grow up hating us. I have to go to him.” For the second time that night, Tom talked me into leaving the baby alone.
The next fifteen minutes seemed like fifteen hours, but the next time I opened the door, there it was… silence. I could finally look in on Ryan without undoing all that we had just accomplished. So as not to awaken him with its squeaking, I turned the light on at its dimmest setting. In this low light and from across the room, I saw what appeared to be Ryan's blanket hanging over the side of his crib. As I moved closer to remove it, however, I discovered that it wasn't the quilt draped over the side—it was Ryan. Our son had fallen asleep standing up!
The next night we again put him to bed at 9:00 and again he fell asleep standing up. But this time he only cried for one hour. The third night, he cried for twenty-five minutes and fell asleep lying down.
These days, with few exceptions, he cries for only a few minutes before falling asleep. He also usually wakes up smiling, thus dispelling any fears I once might have had that he would grow up to hate us for letting him “cry it out.”
One mother solved the problem of her child waking up and always standing up in the crib immediately after being put down almost asleep by putting her drowsy child in the crib standing up. Now the child had only one way to go, down.
Nap Deprivation
Nap deprivation is a common occurrence between nine and twelve months of age. Children at this age are fearless, full of grace and self-confidence, and very explorative. Doing things with parents and siblings is simply a lot of fun. Unsure of when a child naturally shifts to needing only one nap, some parents try to get by with one nap before their child is ready. Afternoons full of activities help smooth over rocky moments of heightened emotionality or grumpiness. Anyway, mom or dad returns from work about then, so there is a loving play period early in the evening.
However, the fatigue from nap deprivation leads to increased levels of arousal and alertness, and this causes difficulties in falling asleep, staying asleep, or both. These changes in the direction of disturbed sleep and behavioral changes during the day may be very gradual, so initially it may appear that a single nap is all right. The effects of persistent sleep deficits are cumulative, though, and eventually the fatigued child starts to behave differently.
I was consulted about two children, five and six months of age, who had severe bobbing, turning, and jerking of the head and wincing or grimacing of the face. Both children had been hospitalized and evaluated for seizures or epilepsy, but all the test results were normal. Nap deprivation turned out to be the problem, and both children recovered completely when they were better rested, though the movements transiently returned to each child during a temporary period of overtiredness.
Here is one parent's account of how “the program”—that is, shortening the interval of wakefulness—helped her child sleep better.
“I WAS CERTAIN SHE WOULD
GROW OUT OF THIS BAD HABIT …
OUR OTHER TWO HAD”
On November 19, 1984, our third daughter, Rebecca, was born. Our other girls, Lauren, nine years old, and Karen, four years old, were busy with school activities, Hebrew lessons, and ballet. At that time I prided myself on how well I schlepped our new baby everywhere and how wonderfully she slept in and out of the car seat all day.
Our days were filled with errands and car pools, Rebecca nursing and napping on and off all day. What a cooperative baby, I used to think. But I was so exhausted by evening that I found the only way to survive was to sleep with the baby, waking up every hour or so to shift her so that she could nurse on the other side. I knew then that having her in bed with me wasn't such a terrific idea, but it was the only way for me to get any rest.
When Rebecca turned five months old, I placed her in her crib instead of going to sleep with her at my breast.
As I expected, every few hours she began to cry, expecting me to be by her side. I would quickly run into her room and rock and nurse her back to sleep … until the next time she woke up.
And so our next pattern began. She would wake up every few hours and I would faithfully run in and get her back to sleep. I was certain she would grow out of this bad habit … our other two had.
A few months passed. By now Rebecca was weaned to a bottle and I was sure things would change for the better. That didn't happen. In fact, things got worse. There were many nights when Rebecca would get up every hour on the hour. I tried letting her cry, fifteen minutes at a time, but it was much easier to just go in and give her a bottle.
When Rebecca was a year old, this pattern of frequent waking continued. It was difficult leaving her with a baby-sitter on the occasional evening we went out. I knew that within an hour or so of our leaving she would be up crying for me. I actually felt sick leaving her.
When Rebecca was almost thirteen months old we went to see Dr. Weissbluth. Rebecca was charming for him. Could this delightful child really be causing all this trouble? I wondered.
Our appointment went well. After our story was poured out, Dr. Weissbluth explained what steps we needed to take to change Rebecca's sleeping patterns. He cited studies, gave us graphs … this really was going to work! When we left his office I felt prepared for battle—armed with all the mental ammunition I needed to change Rebecca's nightly wakings. We started “the program” the next day.
In a week's time, the change in Rebecca was phenomenal! She was always a happy baby, but when she began to sleep better, she became even more relaxed, more affectionate, and more fun to be with.
The change in her sleeping pattern has had an effect on everyone in the family. I don't yell and lose my patience with my older children quite as much, for I am better rested. Ironically, for the first few nights of our “training program” I continued to get up every two hours, waiting for her to cry. I now also have learned how to sleep through the night once again, and I feel so much better physically and emotionally.
Throughout some of Rebecca's crying periods, especially in the beginning, there were moments when I was sorry that we started this whole thing. I just wanted to soothe my poor, crying baby! Both my husband and I kept reminding ourselves that we were trying to teach Rebecca how to sleep and that we had to stay with it without sabotaging the plan. (Maybe knowing that we would be checking in with Dr. Weissbluth every few days helped us to stick with it.)
This has been one of the most rewarding and positive experiences that we have shared as parents. We are so proud of Rebecca and also pat ourselves on the backs for a job well done.
Shhh! Rebecca's sleeping!
The treatment strategy involves (a) shortening the interval of wakefulness before the first nap and reestablishing the early afternoon nap by focusing on the midday interval and making sure this wakeful period is not too long, (b) making sure the afternoon nap does not start too late in the afternoon, in order to protect a reasonable evening bedtime, and (c) consistency in the nap time ritual.
If the afternoon nap is needed but that is when the child fights sleep the most, consider shortening the midday interval of wakefulness. Start the afternoon nap earlier. Perhaps you were allowing him to stay up too long and he became overtired and overaroused.
It's not uncommon for a child to sleep well at night but not nap well, especially in the afternoon. At night it is dark, everyone is more tired, and parents want to be regular with bedtimes because they themselves want to go to sleep. During the day, it is light, everyone is more alert, and parents are more irregular because they want to run errands or enjoy recreational activities.
So during a retraining period, it's easiest to establish good night sleep and easier to establish regular morning naps than afternoon naps. Don't expect improvement to occur equally at all times. Still, it's best to implement a twenty-four-hour sleep retraining program, because if you focus only on one feature, such as bedtime, and ignore naps, you will be less likely to succeed.
In general, I recommend a twenty-four-hour sleep package to help restore healthy sleep habits. Here is an example of an exception. The single mother has limited resources for soothing and is completely exhausted. The child does not sleep well day or night. The mother wants to continue breast-feeding but now wants to transition the baby from her bed to a crib. The first step might only be a temporarily ultra-early bedtime in the mother's bed to help the child get more sleep. Everything else stays the same. The advice is to do whatever is necessary to maximize sleep and minimize crying during the day. After the child is a little better rested, the second step might be to make the transition to the crib. This might involve crying, but because both child and mother are better rested, the crying may be very little and the mother is more able to cope. The third step is to work on naps. This will now be easier because everyone is better rested. If, instead, this mother had an enormous soothing support system to help her, she might try to do everything at the same time. Her child might become better rested faster and the greater stress in making all these changes abruptly would be shared by people other than the mother.
Some families have found it difficult to establish naps because their bedrooms are too bright or noisy during the day. One family I know was fortunate enough to have a large walk-in closet, which they furnished like a little bedroom and which was used only for naps. Other families have problems because they live in a one-bedroom apartment and it is difficult for anyone to sleep well when a child shares a bedroom with the parents. Such parents sometimes relocate to the living room and turn the bedroom over to the child so that the entire family can stay well rested. If you do not want to have a family bed, expect it to become difficult for your child to sleep well in your room. Plan ahead, before the family becomes overtired.
PRACTICAL POINT
As long as your child retains the expectation that she can convince you to play during nap time, she won't nap well. If she thinks she can outlast you, she won't give up her protesting.
Brief Sleep Durations
If your child is on an apparently normal sleep schedule and napping well, you might presume she is getting enough sleep. Overall, she doesn't look tired. But what if around ten, eleven, or twelve months she starts waking at night? What's happening? Many times, physical and mental activity increases around nine months. The child is now moving around more, exploring more, becoming more active and independent.
If the customary bedtime hour had been around 8:00 or 9:00 P.M. before the onset of night waking, the problem will often disappear when bedtime is shifted to an earlier hour. Most families find that if they gradually shift the bedtime earlier in twenty-minute increments, they reach a time when night wakings melt away. Usually this change is easy for the baby; sometimes it is hard for the parent who returns home late from work to accept. But small changes in sleep patterns often make big differences in sleep quality. Even a change as small as twenty minutes’ more sleep at the front end of the night can cause a big change in your child's behavior during the day.
Early Awakenings
Most children five to twelve months of age should go to bed between 6:00 and 8:00 P.M. and wake up between 6:00 and 7:00 A.M. Some also get up once around the midnight hour for a brief feeding. This pattern is very common, but many parents don't like the idea of starting the day so early! In this age range, though, it seems that the wake-up part of our brain is like a neurological alarm clock.
For well-rested children, this neurological alarm clock is fairly regular, and I don't think we can ignore crying around 6:00 A.M. simply because we don't want to get up so early. Because they are well rested, having slept overnight, it seems unreasonable to expect children to go back to sleep without any kind of response. Instead, I would suggest a prompt, brief, soothing response so that perhaps both child and parent can return to sleep. If responding before 6:00 A.M. turns out to be more stimulating than soothing, then I would suggest not going in until 6:00 A.M. The reason is that children who get too much attention too early in the morning fight sleep to get up earlier and earlier for the pleasure of their parents’ company. Increasingly, it makes it difficult to stay up to catch the first midmorning nap around 9:00 A.M., SO the whole day gets thrown off balance. Sometimes overtired children develop new patterns, such as waking up at 4:00 A.M. and not returning to sleep after a prompt, soothing parental response. These kids are really up and want to play, yet they are often not well rested. When the parents put these children to bed earlier, they get more sleep at the front end and they sleep later in the morning because they are more rested and are thus able to sleep better. Even though this is counterintuitive, it is true.
This means that when your child has disturbed sleep and an abnormally late wake-up time, you might decide to control his schedule by waking him up earlier so that the naps and bedtime hour all occur earlier. If your child has disturbed sleep and an abnormally early wake-up time, shorten the intervals of wakefulness before naps and make the bedtime hour earlier. When your child is well rested and has no disturbed sleep, an early wake-up hour may be inconvenient but not necessarily changeable.
METHODS THAT USUALLY FAIL TO PREVENT
EARLY AWAKENINGS
Keeping your child up later at bedtime
Waking him for a feeding when you go to sleep
Giving solid foods late at night
If your child is near his first birthday, you might consider some of the items discussed in the section on older children.
Different Sleep Patterns: No Problem—Temporarily
Sleep patterns are as varied as children themselves, family sizes, and parental lifestyles. One five-month-old always awoke briefly at 6:00 A.M. and then promptly returned to sleep until 10:00 A.M. A long midday nap occurred from noon to 3:00 P.M. and a brief nap from 5:00 to 5:45 P.M. Between 7:30 and 8:00 P.M. the child went to sleep for the night, until about 6:00 the following morning. This child was well rested, and the midday nap coincided with his older brother's single nap. For the time being, this pattern met both children's sleep needs. By six or seven months, this child developed the more common pattern of a midmorning nap and an early afternoon nap.
However, other children begin to accumulate a sleep deficit that grows, often slowly, over time. Eventually, daytime mood or behavior problems develop, as do sleep disturbances at night.
PRACTICAL POINT
A temporary disturbance or mild variation in sleep schedules, nap patterns, amount of sleep, or early awakenings may not be changeworthy. But if chronic or severe problems cause your child to become tired, then try to help your baby become more rested. Watch your child's behavior, not some inflexible schedule.
Night Wakings
In this age range, night wakings are typically the complete arousals from sleep associated with disturbed sleep in postcolic babies (see Chapter 4), partial airway obstruction during sleep (see Chapter 10), general disorganization of sleep with chronic fatigue (see Chapter 2), or parent reinforcement of such wakings.
Two separate groups of infants between four and eight months of age seem especially prone to night waking.
The first and larger group—about 20 percent of infants—includes those infants who had colic when they were younger. These infants not only awaken more often, their total sleep time is less. Although boys and girls in this group awaken the same number of times, parents are more likely to state that it is their sons who have a night-waking problem. In fact, boys are handled in a more irregular way than girls when they awaken at night. This was shown in studies using videotapes in dim light in the children's own bedrooms at home. Even when the colic has been successfully treated with a drug during the first few months, by four months of age the children still were reported frequently awakening at night.
My conclusion is that some biological disturbances in infants can cause an overaroused, too wakeful, hyperalert, irregular state full of crying, especially in the late afternoon or early evening. This is commonly called “colic.” In the past, the crying part of colic has been thought to be the major problem. But while this evening crying diminished at about three to four months, the wakeful, not sleeping, state may continue and thus be more serious and harmful in the long run.
This is because the parents have the correct impression that regular and consistent parenting does not much affect the colic, and, unfortunately, they give up the effort permanently. They do not know that after four months of age, regular and consistent attention to bedtimes and nap times really does help the older infant sleep better. The parents’ failure to develop and maintain healthy sleep patterns in these older postcolic babies then leads to prolonged fussiness driven by chronic fatigue. (This is discussed in more detail in Chapter 4.)
The second group of frequent night wakers in the four-to eight-month-old age group includes the 10 percent of infants who snore or breathe through their mouths during sleep. This difficulty in breathing during sleep might be due to allergies (see page 382). These infants awaken as frequently as do those with postcolic night waking, but their parents do not label this night waking as a problem. Probably the parents had not worried about night waking because the infants had not suffered from colic. Those infants who snored also had shorter sleep durations than other infants. As in many sleep disturbances, when one element of healthy sleep is disrupted, other elements are disturbed. (I will discuss why snoring is more than an acoustical annoyance in Chapter 10.)
A third frequent cause of night waking in this age group is sometimes associated with abnormal sleep schedules. Going to bed too late and getting up too late seems to set the stage for frequent night waking. Sleeping out of phase with biological rhythms produces an overtired and hyperaroused child. One child I cared for took two to two and a half hours of soothing, rocking, or holding before she would go to sleep, and then would usually awaken three to four times each night, sometimes as often as ten times. This prolonged period to put a child to sleep is called “increased latency.” It's also called a waste of parents’ time because the off/on twilight sleep for the child during the rocking, walking, and hugging represents lost good-quality sleep.
PRACTICAL POINT
Fatigue causes increased arousal. Therefore, the more tired your child the harder it is for him to fall asleep, stay asleep, or both.
One consequence of increased arousal is that disturbed sleep produces more wakeful, irritable, and active behaviors in children. Also, these children often have increased physical activity when asleep. Although all babies can have gross movements involving the entire body or localized movements or twitches involving only one limb, these are brief motions lasting only a second or less. But chronically fatigued babies who are overly aroused move around more in a restless, squirmy, crawly fashion when sleeping. It seems that their motor is always running at a higher speed, awake or asleep. I will explain how you can reduce your child's idle speed by making sure he gets the sleep he needs.
What is disturbed sleep?
Abnormal sleep schedules (going to bed too late, sleeping too late in the morning, napping at the wrong times)
Brief sleep durations (not enough sleep overall)
Sleep fragmentation (waking up too often)
Nap deprivation (no naps or brief naps)
Prolonged latency to sleep (taking a long time to fall asleep)
Too active sleep (lots of tossing and turning)
Difficulty breathing during sleep
Night waking is not caused by:
Too much sugar in diet
Hypoglycemia at night
Zinc deficiencies
Pinworms
Gastroesophageal reflux
Teething, contrary to popular belief, does not cause night waking. If you ask parents what happens when teething occurs, the answer is: everything! All illnesses, fevers, and ear infections that happen to occur around the time a tooth erupts are blamed on teething. Throughout medical history, doctors used the diagnosis “teething problems” as a smokescreen to hide their ignorance. In fact, at the turn of the twentieth century, 5 percent of deaths in children in England were attributed to teething.
A proper study of problems caused by eruption of teeth was performed in Finland. Based on daily visits and the testing of 233 children between the ages of four and thirty months, it concluded that teething does not cause fevers, elevated white blood cell counts, or inflammation. And most important, teething did not cause night waking.
Night waking between the ages of six and eighteen months is more likely due to nap deprivation, overstimulation, or abnormal sleep schedules—not teething.
PRACTICAL POINT
Putting your baby to bed, allowing die child to hold a bottle of milk or juice, or resting the bottle on a pillow, will cause “baby-bottle cavities.” Protect your child's teeth. Hold your baby in your arms when you give a bottle.
Growing pains also do not cause night waking. One study examined 2,178 children between six and nineteen years of age and found that 16 percent complained of severe pain localized deep in the arms or legs. Usually the pain was deep in the thighs, behind the knees, or in the calves. The pain usually occurred late in the afternoon or in the evenings.
But when the growth rates of these affected children were compared to children without pain, there was no difference. In other words, growing pains do not occur during periods of rapid growth! Blaming night waking on growing pains is a handy excuse. But the rubbing, massaging, hot-water bottles, or other forms of parent soothing at night are really serving the emotional needs of the parent or child and not reducing organic pain.
Night waking may be caused by:
Fever
Painful ear infections
Atopic dermatitis, eczema
PRACTICAL POINT
Do not attempt to correct unhealthy sleep habits unless you see a clear period ahead when you will be in control. Don't trust most relatives or baby-sitters to do as good a job as you can to correct unhealthy sleep habits. Also, if your child's sleep improves during a retraining period but suddenly he becomes worse, appears ill, or seems to be in pain, let your pediatrician examine him for the possibility of an ear or throat infection.
Let's consider the child who naps well, has a reasonably normal sleep schedule, does not appear overly tired, but simply gets up too often and/or stays up too long in the middle of the night. We want to help this child learn how to soothe herself to sleep unassisted when she wakes up. This skill also will help her fall asleep at bedtime, so the two strategies outlined here can be used when a child fights going to bed, too. The first technique, called “fading,” is a more gradual approach, while the second, called “extinction,” is an abrupt, cold-turkey solution. Let's look at how each works, and their pluses and minuses.
Fading
A gradual approach to reduce the number of night wakings until the baby can return to sleep independently is called “fading.” Over a period of time you gradually reduce your efforts at night, so that your child takes over for himself and falls asleep or returns to sleep by himself. This is like teaching an older child how to ride a bike. You first provide balance and support and then gradually withdraw as the child gains confidence and skill. Here is an example of a fade sequence to eliminate night wakings.
Respond promptly, spend as much time as needed
Father gives bottle or mother doesn't nurse
Change from milk to juice
Dilute juice to only water
No bottle
No picking up
No singing, talking, verbal communication
Minimal contact, patting, or hand-holding
No eye contact; sober, unresponsive face
No physical contact; sit next to child
Move chair away from crib toward door, slowly over several days
Reduce time with child
Delay response
This has been called the “chair method” when done with an older child in a bed because you are basically slowly moving the chair farther from your child until you are just outside the door.
The apparent advantage of gradually weaning the child from prolonged, complex contact is its seeming gentleness. A disadvantage is that it takes several days or weeks, during which many brief crying spells may occur. The major reasons why this approach usually only partially succeeds, or fails completely, are (a) unpredictable, real-life events interfere with parents’ best plans and schedules, (b) parents do not appreciate the enormous power of intermittent positive reinforcement to maintain a behavior (“I'll just nurse him this one time”), and (c) parents’ resolve weakens from their own fatigue and sometimes from impatience. Here is an account of one mother's attempt to use a gradual approach.
EXHAUSTION WINS OUT OVER PATIENCE
Lauren was eight months old when I finally sought help from the doctor; her sleep schedule could only be described as unbearable.
When we brought her home from the hospital after her birth, she would have a very long, wakeful period in the evenings from about 8:00 P.M. to 1:00 A.M. We can't say that she was colicky, as she was really quite pleasant most of the time. Only about once a week did she have an extended crying spell during which she would be inconsolable.
At around seven months or so, we decided to try nursing Lauren and putting her back in her own bed consistently. That's when the trouble really began! Lauren would wake up every few hours, and it would take one and a half to two hours to get her back to sleep. By now she had learned how to stand up, and I think that made it even more difficult for her to settle down.
The other thing Lauren did was to fall asleep easily at about 9:00 P.M. and wake up a half hour later, inconsolable. Eventually (after nursing, rocking, and so on), she would perk up and become very pleasant and often stay up and play happily for anywhere from two to four hours. At the same time, naps were totally irregular and unpredictable. She would usually sleep twenty minutes, but sometimes it was two hours.
When I saw the doctor, I explained that I was one of those people who didn't think I could let my baby cry herself to sleep. The doctor recommended a plan of action that involved a gradual withdrawal process that would stretch out over seven to ten days. The response to Lauren's waking was supposed to be consistently prompt, but there was to be less handling of the baby at each step of the plan.
I put Lauren in her crib, kissed her good night, walked out, and closed the door. She screamed for forty-five minutes and finally went to sleep. They were the longest forty-five minutes of my life—longer than labor! But it worked!
A few nights after our first success, we decided to leave her alone when she woke up at 9:30. Well, that crying session lasted for about thirty-five minutes. The next night Lauren went to bed about 9:00 P.M. and got up at 7:30 A.M.! I kept thinking that it must be horribly frightening for a baby, who is unable to communicate except through crying, to be left alone in a room to cry. What helped to convince me, however (in addition to utter and complete exhaustion), was the realization that as long as I stayed in Lauren's room she screamed anyway. Walking, rocking, singing—none of these quieted her anymore. The only thing that calmed her was endless, nonstop nursing! I finally came to the conclusion that as long as Lauren was going to be miserable crying anyway, she might as well be learning something positive from it—learning to go to sleep. Even now, if I stay in her room after I put her in bed, she stands up and cries, but as soon as I kiss her good night, walk out, and close the door, she lies down and goes to sleep.
Extinction (Going “Cold Turkey”)
When parents, however well intentioned, stop reinforcing a child's night waking, the habit can be eliminated quickly. In fact, psychologists have shown that the more continuous or regular you are in reinforcing the night waking during the first few months, the more likely it will rapidly be reduced simply by stopping the reinforcing behavior. The advantages of ending the habit of going to your baby at night are that the instructions are simple and easily remembered, and the whole process usually takes only a few days. But the seeming disadvantage is that a few nights of very prolonged crying are unbearable for many parents. This procedure strikes many people as too harsh, too abrupt, or cruel. Those are personal value judgments, but bear in mind that this procedure is effective. It works.
The sleep strategy that I have emphasized is called “extinction,” and the alternatives are “graduated extinction” and “check and console” (discussed on pages 214-215). An additional sleep strategy that might be tried at this age is “scheduled awakenings.” Parents note the approximate times when their child wakes up at night and then they awaken him before those times. The child is changed, if needed, and soothed back to sleep. Research has shown that extinction works much faster than scheduled awakenings but scheduled awakenings does work.
Here is an account of one mother who decided to stop going to her child cold turkey in order to eliminate her child's night wakings.
“ONE OF THE HARDEST
THINGS I'VE EVER HAD TO DO”
At six months of age, Stephen was strong, happy, and healthy in every respect but one—he didn't sleep well. He did all his daytime napping in the car, the stroller, or our arms. If we put him in his crib, he awoke immediately and cried until we picked him up. His nighttime pattern was different but equally exhausting. He went to sleep in his crib promptly at 8:00 P.M., but usually awoke within the first hour for a brief comforting, and two or three times between 11:00 P.M. and 5:00 A.M. for a feeding.
This routine was taking its toll. I was almost as tired as when Stephen was a newborn and I had no emotional reserve for handling everyday problems. I was sharp with the rest of the family and got angry if my husband was even ten minutes late getting home from work. We needed to make a change.
The doctor gave us explicit instructions for instituting morning and afternoon naps and unbroken nighttime sleeping. At the end of the appointment, I was full of resolve. We had the weekend ahead of us, when my husband would be around for support, so we decided to start that night.
We put the baby to bed at 8:00 P.M., and he awoke for the first time around 9:30. We didn't go in to him, and he cried for twenty minutes before going back to sleep. He awoke again around 2:00 and 4:00 A.M. and cried about twenty minutes each time. When he cried at 6:00 A.M., I rushed into his room, anxious to hold him and be sure he was the same healthy, happy baby I had put down the night before.
Over the next few days it was amazing to see how quickly he fell into the schedule we had set up for him. He cried ten to fifteen minutes several times, but never again for an hour. Now he naps regularly and sleeps all night, occasionally crying for one or two minutes during the night as he puts himself back to sleep.
Letting my baby cry was one of the hardest things I've ever had to do. Now that the experience is behind us, however, I have no doubt at all that it was right. It gave me more confidence in my abilities to handle tough issues as a parent.
PRACTICAL POINT
Small, soothing efforts such as kissing the forehead, rearranging the blankets, comforting, and patting appear trivial to parents, but they interfere enormously with learning to fall asleep unassisted.
A father told me that “it was painful for him and his wife to admit that what they had been doing was wrong and not good for their child.” What were they doing? At several months of age, they were going in about every two hours, every time the child cried a little. He said that it would have been much easier to blame or get angry with someone like me who said that too much attention at night was not good for their baby, and accuse me of giving bad advice, than it was to recognize that they were the ones responsible for her continued night wakings and irritability during the day. Another mother said that the reason some mothers and fathers have such strong emotional rejection of my advice is quite simple: parental guilt. Since they spend so little time with their child because they are both working, they feel bad and try to spend more time after work in the evening playing with their child. They cannot consider that the bedtime is too late for the child's health, so they conclude that my advice regarding early bedtimes must be incorrect.
HELPFUL HINT
Use thick layers of zinc oxide paste in the diaper region so that no rash will develop when you do not go to your baby at night to change diapers. Ordinary mineral oil will make removal of the paste easier in the morning.
Here are some typical questions and answers for this age group.
Q: I've heard that if I nurse my baby to sleep, I'll create a night-waking problem.
A: The issue is not whether nursing to sleep is good or not, but rather whether nursing too frequently or nighttime nursing is part of a night-waking problem. Please include nursing, if you wish, in nap time or bedtime rituals, but after you finish nursing, whether the child's asleep or awake, put her down, kiss her cheek, say good night, walk away, turn the lights off, and close the door.
Q: I heard that because she learns to associate my breast with falling asleep, she will be unable to return to sleep later in the night if my breast is not present.
A: Nonsense! Almost all the mothers in my practice nurse their babies to sleep, and at night, when they are hungry, either the mother nurses or the father bottle-feeds the baby. I believe it is perfectly natural to nurse a baby to sleep, and by itself this act does not cause sleep disturbances. Older children can be very discriminating; they can learn to expect dessert after dinner, if that is the family custom, but not after breakfast. I think babies can also become very discriminating; they can learn to expect to be fed when they are hungry but not to be fed when they are not hungry.
Q: Once I let my child cry a long time and she vomited. Won't I be trading one problem for another?
A: Consider other sleep strategies that involve less crying. However, if the vomiting always occurs, I think you will want to always go in to clean her promptly and then leave her again. If the vomiting is irregular and occasional, you should try waiting until after you think she is deeply asleep before checking, and then quickly clean her if needed.
Q: Won't my baby simply outgrow this habit?
A: Believe it or not, eighteen-year-old college freshmen who don't sleep well had difficulties sleeping as infants, according to their mothers, as reported in one study. It seems that if the child doesn't have the early opportunity to practice falling asleep by herself, she'll never learn to fall asleep easily.
Q: Even if she won't outgrow this habit, what's really wrong with my still going to her at night?
A: Consider your feelings. Good studies at Yale University show that all mothers eventually become anxious, develop angry feelings toward their child, and feel guilt about maintaining poor sleep habits. These feelings may persist for years. True, you will also feel guilty letting your baby cry in protest, but this will last only several days. Here's one mother's account.
“I FELT CRUEL,
INSENSITIVE, AND GUILTY”
The moment my daughter, Amanda, arrived home from the hospital, she exploded with a very bad case of colic. I took her to the pediatrician's office several times, only to be told there was “not a thing wrong, relax.” I also received several suggestions about nursing and a pat on the back. All of these suggestions irritated me, and I felt as though I was being perceived as an anxious, first-time mother.
After twelve weeks of crying and screaming, Amanda was evaluated by two child development specialists. I decided we should work with one until my daughter's crying and screaming settled down. We also saw a psychiatrist, who recommended medication and also suggested that we continue to be followed by the development specialists. In the meantime, our lives had become a nightmare. Amanda cried most of the day and always screamed in the evening. To our horror, this behavior had worked itself into the night hours, too.
By five months, we were referred to Dr. Weissbluth for what we hoped was a sleep disorder. I say “hoped,” because we were at the point of seeing a pediatric neurologist and having an EEG done. I was very frightened for my daughter, and my husband and I were exhausted. I was eager for the consultation. My daughter had definitely been cursed with colic. Could this now be wired exhaustion from a sleep disorder caused by the treatment for colic—rocking, swinging, motion all the time? It was.
Amanda was old enough now to try “crying it out.” It was the most difficult thing I've had to do as a new mother.
The first night Amanda screamed, choked, and sobbed for thirty-two minutes. I remember feeling sick to my stomach.
The first two days weren't too terrible. However, the third and fourth were almost intolerable. Amanda would cry through her entire nap time. Then I would get her up to keep Dr. Weissbluth's time frame going. Her temperament after these episodes is known only to mothers who have been through the same ordeal! When she would scream for over an hour during nap time and in the evening, I felt cruel, insensitive, and guilty.
Three things kept me going: my husband's support; Dr. Weissbluth's concern, encouragement, and compassion; and the fact that I knew it had to be done—Amanda had to learn to sleep.
It took Amanda about a week to catch on to the idea. The bags under her eyes faded, her sporadic screaming attacks stopped, and her personality was that of a predictable baby—a sweetheart when rested and a bear when she's past a nap time or her bedtime.
I would offer these suggestions to other mothers and fathers who have to take this measure in order to teach their babies to sleep:
You, as parents, have to understand and believe intellectually that it is the right thing to do. Otherwise feelings of guilt will overpower you, and you will give in. You must have the support of your spouse, as it will be too much of a strain to bear alone.
You are doing what is best for your baby. It seems cruel and unacceptable as a loving new mother to let your baby cry. But it is a fact of parenting—many, many things will bring tears and protests in the years to come.
Enlist the support of a sympathetic friend as much as you feel the need to. I found close telephone contact a tremendous help. Some parents may not need this close interaction, but many of us do.
In your role as parents, teaching your child to sleep may be the very first difficult task you have to undertake. Those parents who do should feel a special sense of accomplishment, for it is a very difficult task! Those of us who have been through a baby with a sleep disorder know what misery is. But so does the baby, who is crabby and exhausted all the time. Once patterns and the practice of sleep are established, everyone benefits and finally life can be somewhat predictable again.
It will get better!
A few more typical questions and answers:
Q: I don't believe in this kind of unnatural programming.
A: Consider the “unnatural” effects of chronic sleep fragmentation on your child.
Q: I don't think I can do nothing when my baby cries for me at night.
A: Letting your baby cry is not doing nothing. You are actively encouraging the development of independence, providing opportunities for her to learn how to sleep alone, and showing respect for her ability to change her behavior.
If, after reading the preceding sections, you want to try allowing your child to learn to soothe herself to sleep but still feel you wouldn't be able to listen to her cry, consider the following:
WHY CAN'T I LET MY BABY CRY?
1. Unpleasant childhood memories. These may surface and remind you of feelings of loneliness or being unwanted.
2. Working mother's guilt. You may feel guilty about being away from your child so much.
3. We already tried and it didn't work. Maybe the child was too young then; maybe you taught her, by your behavior, that if she cried for more than a certain amount of time, you would go to her; maybe you unknowingly provided partial reinforcement by going to her at some times but not at others.
4. I enjoy my baby's company too much at night. This may be because you're not a good sleeper yourself.
5. If I don't nurse my baby at night, she might lose weight. This is not true.
6. We're under a lot of stress. In My Child Won't Sleep, Jo Douglas and Naomi Richman write:
If you are feeling stressed, your child may respond by not sleeping so well. If the stress is related to difficulties between you as parents, you may think that your young child will not notice, but the chances are that he will. His way of waking at night and coming into your bed can be a way of preventing you from talking to each other and sorting out your problems, and his presence can act as a useful contraceptive.
Although this quote applies to older children, it's possible that maintaining the baby's night waking or having the baby sleep with you when he or she is younger also serves the purpose of avoiding marital problems.
7. I feel that I am a bad parent if my baby cries. You are not a bad parent if you are helping your baby learn healthy sleep habits.
8. I am afraid that letting my baby cry will cause her permanent emotional harm. There is no evidence that protest crying while your child is learning how to sleep better will cause any kind of emotional problems later in life.
PRACTICAL POINT
When your overtired child first starts to sleep better during a retraining period, he may appear, in the beginning, to be more tired than before! You are unmasking the underlying fatigue that had previously been present but was hidden by the turned-on, hyperalert state.
Summary
Infants’ sleep patterns begin to resemble that of adults at around four months of age. It may help to think of sleep as having two related components. The first is sleep/wake organization, which means how long the sleep period lasts and when the sleep periods are occurring. The second is sleep quality, which here means whether the sleep is consolidated or fragmented and the duration of the different sleep stages.
Let's Walk Around the Clock
Here is the package of advice to prevent or correct sleep problems for children four to twelve months.
1. Control the wake-up time
2. Short interval of wakefulness (ultra-short for postcolic kids) before first nap
3. Consistent soothe-to-sleep method (A or B) for mid-morning nap, around 9:00 A.M.
4. Limited nap duration to protect next nap
5. No snoozing during period of wakefulness if mid-morning nap is not taken
6. Consistent soothe-to-sleep method (A or B) for early afternoon nap, around 1:00 P.M.
7. Limited nap duration to protect bedtime
8. Variable third nap; you be the judge (but no third nap after nine months of age)
9. Early bedtime (time varies based on how your child appears, the quality of naps, and past performance) with regular soothing routine
10. No more than two feedings at night up to nine months of age (exception: unrestricted if breast-feeding in family bed)
Action Plan for Exhausted Parents
Months Five to Eight: 16 percent have three naps, 84 percent have two naps
· If your child is postcolic or has a difficult temperament put him to sleep, after soothing, within only one hour of wakefulness for the morning nap.
· During the one hour of wakefulness, if possible, expose your child to bright natural light.
· If he cries, leave him alone for at least ten to twenty minutes. If the child has an easy temperament, prepare to leave him alone for one hour.
· Try to establish naps around 9:00 A.M., 1:00 P.M.; and if needed, a late-afternoon nap. Try to avoid naps at other times.
Month Nine: 5 percent have three naps, 91 percent have two naps, 4 percent have one nap
· Eliminate late-afternoon nap to protect early bedtime.
Months Ten to Twelve: 1 percent have 3 naps, 82 percent have two naps, 17 percent have one nap
· Morning nap starts to disappear.
· When morning nap starts to disappear, move bedtime twenty to thirty minutes earlier.
· If afternoon nap starts to disappear because morning nap is too long, move bedtime much earlier to shorten the morning nap. Protect and preserve the afternoon nap.
· If there is resistance for the afternoon nap, start the nap earlier.
· Consider your resources for soothing (see page 73).
· If resources are limited, go slowly and tackle one problem at a time—for example, bedtime battles.
· If resources are unlimited, go quickly and fix the twenty-four-hour schedule at once: bedtime battles, night waking, and fighting naps.
· If your baby cries hard and vomits, consider changing sleep strategies to one that involves less crying.