Posted December 8, 2014
Recently I had a call from a mother who began by saying "I'm not a fan of CIO. But I think we are going crazy here."
She had tried other strategies. She mentioned Weissbluth, Ferber, Baby Whispering ,"shhh", "pick-up-put-down, etc. She was hoping there was something else to try that would be gentle, compared to leaving her baby to "cry it out."
My feeling is that whatever version of sleep training a parent chooses, it needs to be done gently. I mean gently in the sense that the parent isn't angry, gently in the sense that the parent sets the stage well for the changes that need to be made and gently in that the parent gives the baby a clear message and offers optimism about the baby's ability to be successful.
I think she meant she didn't want her baby to cry in order to become a good sleeper - which is an impossible goal, really. Babies who have been nursed to sleep, rocked to sleep or had someone else lie down with them until they sleep - aren't going to give up those habits without a fight. Crying is the form their protest takes. Advice to "Never let your baby cry" is supremely unrealistic and not even fair to say to a parent. Babies cry when they are born, they cry sometimes when we give them to someone else to hold and some cry during a doctor's exam. Since we are changing sleep habits they've gotten used to why shouldn't they be allowed to protest?
CIO should be renamed. It should be called something like ATP. As in: "We are all too tired in this family; we need to figure out the best plan that will help our baby learn to put him/herself to sleep for bedtime and naps and back to sleep during the night. We'll need to Allow The Protest." ATP.
Both of my sleep programs, Sleep from the Start and Sleep from Now On are rooted in Attachment Theory. Nurturance and responsiveness are among the prime sources of attachment. Parents initiate a secure attachment with the unspoken promises we make when a child is born: "I will keep you safe; I will make sure good food is available and I will be sure you get the sleep and rest you need." And finally, "I will take good care of myself so I can keep these promises."
Children need to know they can rely on us to be gentle and consistant and know what we are doing. If we waffle on something as important as sleep, giving one message tonight and a different message tomorrow night, the messages are mixed and confusing for an infant, toddler or older child. If we take a toddler back to their room for the 25th time (following one sleep theory) and it's obvious we are getting angry by now, or if we choose a sleep training method which takes weeks instead of three nights, to accomplish, we can't claim it's "gentle" any longer.
So whether you're a "fan" of CIO or not, you realize that your child does need to be allowed to cry as he/she protests being put into bed awake for the first time or won't any longer receive milk in the night as a way to get back to sleep. Similarly, you know that your baby may cry when the doctor checks his ears or because mom has handed her over to dad when the baby prefers mom. Crying happens. Allow The Protest. You can say to friends that you aren't a fan of CIO either. You've chosen ATP instead.
When our children need to cry because of something they don't like but is not harmful, they gain strength from seeing that we, the parents, do not fall apart. We don't get mad and we don't rescue them from needing to learn their own self-calming skills and we don't make the doctor stop his examination. We know crying is normal in these situations and we know recovery will begin soon, with our gentle help. We need to trust a baby's capabilities to learn to sleep and we need to give the baby reason to trust us as parents. We'll feel confident that we are parents who will keep those promises even in the face of protest.
Posted September 6, 2014
I'm often asked "How much sleep does my baby need?" (or toddler or preschooler). I respond with the guidelines I use in my sleep counseling with parents: Aim for an 11-hour night from birth to six months (including night feeds); thereafter, move toward a 12-hour night. While children may not actually sleep for 12 full hours every night, this allows them to, at times when they need it. If theydon't need that much sleep on some nights, this gives them time to talk or play on the way to sleep or in the morning before 7 am.
Also, I sugges parents aim for an appropriate number of 2- hour (approx) naps through the day, depending on age.
Like parents I speak with, I wish there were universally agreed upon guidelines, based on firm research. The following abstract from a yet-unpublished article in the Sleep Medicine Journal tells why this definitive research on children's sleep needs - is hard to come by.
The complexities of defining optimal sleep: Empirical and theoretical considerations with a special emphasis on children
"The main aim of this paper is to consider relevant theoretical and empirical factors defining optimal sleep, and assess the relative importance of each in developing a working definition for, or guidelines about, optimal sleep, particularly in children. We consider whether optimal sleep is an issue of sleep quantity or of sleep quality. Sleep quantity is discussed in terms of duration, timing, variability and dose–response relationships. Sleep quality is explored in relation to continuity, sleepiness, sleep architecture and daytime behaviour. Potential limitations of sleep research in children are discussed, specifically the loss of research precision inherent in sleep deprivation protocols involving children. We discuss which outcomes are the most important to measure. We consider the notion that insufficient sleep may be a totally subjective finding, is impacted by the age of the reporter, driven by socio-cultural patterns and sleep-wake habits, and that, in some individuals, the driver for insufficient sleep can be viewed in terms of a cost–benefit relationship, curtailing sleep in order to perform better while awake. We conclude that defining optimal sleep is complex. The only method of capturing this elusive concept may be by somnotypology, taking into account duration, quality, age, gender, race, culture, the task at hand, and an individual's position in both sleep–alert and morningness–eveningness continuums. At the experimental level, a unified approach by researchers to establish standardized protocols to evaluate optimal sleep across paediatric age groups is required."
Filed under: Sleep and sleep training
Posted July 15, 2014
(Published in Huffington Post Living, July 15, 2014)
"My oldest son wasn't a natural sleeper. I had been taught in my pediatric residency that newborns should sleep 18-22 hours a day. As I had planned on studying for my pediatric board exams throughout my brief maternity leave, I was counting on this dedicated sleep time while I could focus on my studying. He turned out to be a pitiful sleeper, requiring my constant rocking and feeding to get him to sleep, only to wake right back up when I lay him down. Thus began the constant cycle of feeding him in a carrier and pacing around my apartment with a stack of cue cards to keep him asleep while I tried desperately to study. So much for a relaxing and fruitful maternity leave.
When he turned four months old I was at my wit's end. I was exhausted and stressed that I wasn't accomplishing much on the studying front. I read five different parenting books to ascertain the best method of sleep training and dove in. One week I tried the classic Ferber method -- soothing him every five minutes in increasing duration. This failed pitifully, as every time I left the room he lost his mind. Next, the Pick Up-Put Down method -- even harder, as it seemed to be a huge tease for him. I tried the Shush-Pat method, where I stood over him and pat him back to sooth him to sleep. He thought I must have been kidding and wailed for hours.
On the verge of having a mental breakdown (truly), at my husband's suggestion I tried the dreaded Cry-It-Out Method. This was truly a last resort for me. It didn't make me comfortable. To this day I cannot stand hearing my kids cry and usually rush in to "save them" within moments of crying unless my husband holds me back. But he insisted and the sleep training needed to be done. I was going back to work in one short month and was exhausted. I started resenting my son and I wasn't enjoying our one-on-one time together as I had dreamed.
And so began our new bedtime routine with bath and stories, feeding and putting him down with soft white noise in his room. For three nights we put him down, on his own in his crib by 7 p.m. and left him in his crib till 7 a.m. save for a brief dream feed, preempting crying by sneaking into his room and feeding without waiting for him to cry.
The first night he cried three hours. Three hours! I thought my heart would stop. I left the house, literally. I went to stay at a friend's house and pumped there. My husband offered a dream feed of pumped milk. The second night was a huge improvement, at a mere one hour and 45 min of crying. The third night -- 2 minutes of crying! It was a huge success and has lasted till this day with only a few bumps in the road with illnesses and teething. It was horrible, the hardest part of parenting I've endured so far in my four years as a mom, but it was a means to an end.
Since this time we have sleep trained my younger son in exactly the same way -- with cry-it-out. The longest he cried was almost three hours. Lessening to an hour the second night and no crying the third night. I plan to train my next son the same way once he is four months old next April. I have suggested the same training method to over 1,000 parents so far in my practice, with the same results in 100 per cent of cases -- 12 hours of uninterrupted sleep for babies and parents. Two babies failed to train successfully in the first month, and after one week we resigned to trying again the following month. One month later these babies trained in two nights. Perhaps they weren't ready yet the first time, but it worked magically the second time around.
I have heard much controversy about the Cry-It-Out Method over the years. Mostly I hear that leaving your baby to cry leads to psychological damage for life. While I understand this argument and this makes theoretical sense to me, I have not noticed this to be the case. Once my kids (and countless others) are sleep trained, I find them happier and more relaxed. Parents uniformly tell me that their child changed dramatically for the better once they were sleeping through the night. Not to mention how much happier and more at ease parents are when they too can sleep. A well-rested parent is a more engaged parent, who is much better able to parent with love and patience. This is of obvious benefit to the child.
There is evidence that babies benefit greatly from predictable routines and long stretches of consolidated sleep. Emotional intelligence and cognition are enhanced (despite these first few hard nights). Babies are happier, more alert and more engaged if sleeping well. In addition, learning to sooth oneself is a life skill that will last a lifetime. I find that waiting till the baby is older leads to more difficulty with sleep training, as then the baby is more mobile and verbal. Hearing your baby call 'mama, dada', only makes this more difficult.
If you are a parent and in the uncomfortable situation of having a baby who is not interested in sleeping long periods at night, I suggest speaking to your physician about the options, including Cry-It-Out. I promise, you will not regret it!"
Filed under: Sleep and sleep training
Posted April 24, 2014
At last, research on sleep disorders in infants and children is gaining the attention it deserves. For the past 30 years problems with sleep for the youngest of the population, have been on the increase. Primarily the two sleep disorders which accurately describe pediatric sleep issues that are precursurs to insomnia are 1) night wakenings and 2) sleep onset problems.
Among the factors often associated with pediatric sleep issues (birth weight under 2500 grams, low Apgar score, long delivery, etc.) some parental characteristics are appearing to be a major influence in a child's ability to master good sleep. Following is a direct quote from the research of Dr. Evelyn Touchette. This article, titled "Factors Associated with Sleep Problems in Early Childhood", appeared in the most recent Encyclopedia on Early Childhood Development publication:
"Parent characteristics also influence the establishment of consolidated sleep insofar as they are associated with certain bedtime habits or practices. Anxious, over-protective or depressive mothers, or mothers who experienced insecurity in their attachment history, are more likely to have children with sleep problems compared to other mothers. For example, studies have shown that depression in mothers affects children's sleep consolidation. This relationahip may be attributable to a modification of maternal behaviors (over-protection) hindering the child's learning of independent sleep habits. Maternal age and education however, show little effect on sleep consolidation in children aged 0 to 4 years. Mothers who work outside the home reported that their children's sleep is more fragmented than that of children whose mothers are at home. However, family structure seems to have little effect on the development of a consolidated sleep-wake rhythm in young children."
In my monthly Sleep Class and in my work with parents by telephone, I sometimes find a definitive range of reactions when I've finished talking about the extinction method of sleep training (ranks highest in research for good outcome). Some women respond with words like "OK. I got it. Thanks." or "That's what I thought, I just needed to know it was OK." Many dads respond the same way. After asking a few questions about details, they are ready to go.
But some mothers begin to tear up at the thought of their baby going to bed awake and without help, to fall asleep. I can clearly see the pain on their faces and in their hearts and I understand how difficult sleep training will be for them. And of course (according to my observation) women do not tend to sleep as deeply or easily as men do (!!) so it's more likely to be the mom who has had the monitor on her side of the bed and wakes up often to check. I was one of those moms and if you'd asked me, I'd have answered "Well someone has to be on duty and it won't be my husband!"
And that is a major point. Its almost as if a baby can sense that both his parents are not feeling the same amount of confidence in his ability to do his normal protesting (crying) as he learns over the next three nights how to design and practice his self-calming skills. Maybe he isn't getting the unquestioned leadership he needs to see himself through this new learning. Or, he gets mixed messages about the new plan.
I want to talk to dads and moms who are already sure of themselves but just don't know the mechanics of sleep training and what to expect as they proceed. And I want to speak with parents who feel that their own anxiety or attachment issues or doubts of any kind might interfere with their baby or toddler's ability to learn good sleep skills. I can help identify post-partum depression, in case it exists, and together we can work through some of the issues that might be holding parents back from accomplishing this major parenting responsibility.
Filed under: Sleep and sleep training
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