Introduction

Welcome, I am your host, Dr. Paul Smolen.  At the time of this recording, it will have been my honor to practice general pediatrics for the past 35 years. Today we are going to talk about an extremely important topic for you and your child….how to get a good nights sleep for both you and your infant.  You remember that whole concept before you had kids– you lay down and are not disturbed for 8-12 hours and you sleep.  Ah, bliss.  A day doesn’t go by without me talking to a family with a significant sleep problem regarding their children. Like the family I spoke with recently.  Lovely people with a gorgeous child who I was seeing for his six-month checkup.  Let’s call him Johnny. I asked the standard questions about Johnny’s sleep and I got that look.  Mom is up with him at least 3 times a night breastfeeding and rocking.  She seemed exhausted and maybe starting to get resentful of her child’s constant demands at night.   She is a working mom and totally exhausted all the time.  This situation is not good for this mom or Johnny, so in today’s pedcast, I’m going to tell you what advise I gave Johnny’s family and I am going to give you some simple tools to teach your children how to become good independent sleepers.  Don’t miss this important episode of Portable Practical Pediatrics.

Musical Introduction

Straight Talk about sleep in Infancy 2.0

The 2.0 version of this post is actually a revision of my original pedcast called Straight Talk About Sleep in Infancy and I have a few years of experience with parents listening and implementing my original podcast.   Most parents have found it useful and easy to follow, but some missed the major point on their first listen. So, if you remember nothing else from this pedcast, remember this critical point– Successful sleep training is ideally done between 4 to 6 months and involves creating a situation where your baby can put themselves to sleep by getting into their own “comfortable position of sleep” after a brief sleep ritual.  And when I say brief I mean brief that does not involve feeding, rocking, singing, or allowing your child to get drowsy in any place other than their crib or bassinet. Once your baby finds their own unique “comfortable position” and can find it on their own, they will quickly know what to do when they need to sleep.  I recommend that you listen to this podcast twice just to make sure you have a clear understanding of the routine I suggest before you institute any changes. I want you to be successful the first go round!

 Sleep Physiology 101

Before we get into my advice for this particular family, lets digress and take a little detour down “Science lane” and review a little about sleep physiology.  You must understand how  your children sleep in order for you to know how to make it all work for your family.  Fact: We spend a third of our entire time on earth sleeping and many of us don’t have the foggiest idea of how it works. There are basically two types of sleep–REM or rapid eye movement sleep, also known as “active sleep” and NonREM sleep or deep, slow brainwave sleep.  With a good night’s sleep, we cycle all night between these two types of sleep states which means that no one sleeps all night long in deep sleep without waking up periodically, even babies.  Prolonged sleep is an active process of fluctuating between deep sleep and active dreamy sleep.  Most people have at least 3 sleep cycles a night.  So here is a major concept for you to understand–your baby doesn’t fall asleep just once at night but many times.  Older infants and children must, I repeat must, be able put themselves back into deep sleep repeatedly at night, without the help of their parents, in order to “sleep through the night” without the help of their parents.

Transitioning from the infant Sleep Pattern to the Child Sleep Pattern 

Babies come into the world wired for the infant pattern of sleep–by that I mean mom holds them, they suck and get drowsy, and fall asleep.  Without mom they can’t sleep!  Between four and six months of life however, I feel they need to make the transition to the adult pattern of falling asleep–your baby lays down awake, he gets in his own comfortable position of sleep, and he falls asleep.  No mom involved.  Making the change from the infant pattern of sleep to the adult pattern of sleep is exactly what many families have trouble doing because their parents fail to teach them.

Over the many years of my practice, I have found that bringing this topic up at the four-month checkup is crucial to achieving good sleep habits for the long term.   Parents who encourage their infants to learn to put themselves to sleep independently usually find the process very easy, only taking a few nights to accomplish.  I have also discovered if the first child is trained to be an independent sleeper, the subsequent children learn good sleep habits very easily as they grow.

Babies Change As They Grow

Babies change as they grow however. Just because your baby needed feeding and mom to go to sleep at one and two months, doesn’t mean that he or she will need them all through their childhood. Keeping them awake very late into the evening and feeding them late at night as they fall asleep may be what your parenting instincts tell you to do, but I’m afraid doing so usually trains your child to need you all night long, the opposite of what you want to teach them.   So here are some Doc Smo pearls for you to remember;  “Anytime your child can learn to do something for themselves, that’s a good thing!” and “The ultimate goal of childhood is to create a happy, confident, self-sufficient adult.”  Learning new things and promoting self-sufficiency begin with babies putting themselves to sleep. Training your child to be independent at night when they are old enough is a good thing for both them and the rest of the family.

Sleep Advice for My Patient’s Family 

Here is the advice I gave Johnny’s family. I explained to Johnny’s parents that no one really sleeps through the night. Most of us go through at least three awake and sleep cycles a night but we are usually unaware of our awakenings since they are so brief.  I explained that we think we slept all night but we actually don’t.  The key to our smooth nighttime sleep for your little Johnny is to teach him to go from being fully awake to completely asleep without the help of his parents in the early evening.  He needs to develop his own comfortable position that does not involve mom or dad to fall asleep.  Johnny needs to be able to put himself to sleep all night without help from Mom or Dad!  But before three months of age, most babies cannot do this.  They have almost very limited control of their bodies and are hungry all the time.  They can’t put themselves into a comfortable sleep inducing position. They also need constant reassurance and help so if they are that young, do not try and create independence. It’s too early. But for older normal infants, here is the major point; babies who are at least four months of age, who learn to separate feeding from going to sleep by finding their own comfortable position of falling asleep, usually make a smooth transition to nighttime independence without a struggle.  I think the ideal time for this transition to the adult pattern of sleep is between four and six months of age. This doesn’t mean you need to stop breastfeeding at four months, just move the feedings away from bedtime.

Question: But Doc Smo, why do this training when they are so young.  Wouldn’t it be easier later?

An emphatic, NO. Teaching them to find their own sleep ritual is easiest at four-six months.  Anyone who has spent time around infants knows that something dramatic happens to the psyche of infants around seven months… that’s when most infants develop an intense fear of separation from their parents, especially mom.  This is a good sign from a long-term psychological viewpoint because it means that your infant has created a strong emotional bond with you and trusts you.  However, this makes sleep training almost impossible at this age.  In my experience, seven to nine months is a particularly bad time to try and train an infant not to need their parents at bedtime.  It is also about the time that most infants start getting mobility and start having on average one sickness per month.  The combination of having intense separation anxiety with frequent disrupted sleep from sickness is a bad combo for easy sleep training.  Training after 6 months of age is possible, but more difficult than it is with younger infants. I know many parents are scared at the idea of sleep training and find the whole thing scary but actually is easy and good for both you and your child.

Question:  But Doc Smo, how exactly do I do this training?

Gradual and gentle is the word of the day. Move feeding away from bedtime by 15 minutes a night until you get the last feeding accomplished at least an hour before your child gets too tired.  Bath, play, and do active things until bedtime.  When your child shows that they are getting sleepy take them to their sleeping place.  Do not rock, feed, tell stories, stroke or in anyway inject yourself into the actual sleep process. You can do all those things at times, other than bedtime.  Just put them in bed!

Leave a little dim light on but darkness is important for sleep.   Leave for a few minutes even if your baby cries. Go back in as often as you wish. Every few minutes are fine.  Pick him up until he quits crying but not until he gets sleepy. As soon as they calm down, put him back down in the crib.

Repeat the process until he goes to sleep.  Don’t feel guilty– you are right there reassuring him every few minutes.  Learning new things can be hard, but a must.  The first night may be unpleasant but I promise that within 3-5 nights your child will play in the crib and put themselves to sleep without needing you.  They will also awaken and put themselves back to sleep… given a chance.

Many people try this training, starting in the middle of the night without first changing bedtime routine–this will not work!!!!  That just intensifies your child’s fear of separation. If he doesn’t know how to fall asleep at 7pm, he certainly won’t know what to do at 2am!  Let’s get real.

Question: So what do we do when baby awakens in the middle of the night?

Good question. Assuming your baby has mastered his comfortable position training, I recommend a 10-10-10 approach in the middle of the night.   10-10-10 works for veggies in the garden, and it will work for your child’s nighttime as well.

After crying for 10 minutes, your baby gets your brief attention; just long enough for him to stop crying and know you are there.  Put him back down to sleep.  If he cries another 10 minutes, repeat the just attention process.  If he cries a third 10 minutes… do whatever he wants.  I find that most babies, over time, won’t keep it going.  Easier to use their comfortable position and go back to sleep.

I have found that with this 10-10-10 approach, used sometime between four and six months of age, almost all children will be sleeping independent of their parents at nighttime, sleeping all night, and quickly learn to enjoy their own beds.

The training I have outlined sounds difficult and scary but actually is very easy and natural.

Having watched an entire generation of babies grow up I am certain that creating independence at bedtime is a very good thing for both children and parents.  Parents who can enforce a reasonable bedtime are off to a excellent start at setting the many other limits a child will need during their childhoods. A good night’s sleep is vital to normal growth and healthy parenting.  It’s up to you to teach them how to get a good nights sleep.

How do parents blending sleep training with current Safe Sleep Guidelines?

Currently, the AAP recommends that babies should sleep in their parent’s room until at least 6 months of age, maybe longer.   That doesn’t mean however, that a parent needs to be in the room as an infant falls asleep and it doesn’t mean that a baby can’t learn to put themselves to sleep without a parent’s help. I still recommend that you establish the same sleep onset ritual when your baby is old enough, even in your room.

It is now also recommended that babies not have any toys in the crib as these might provide a choking, strangulation, or suffocation risk.

The new guidelines also encourage parents to put their children down to sleep with a pacifier that I did not address in my original podcast.  Personally, I am not a big fan of pacifiers since a parent needs to be involved in keeping it in a child’s mouth, but the experts have found a slightly lower incidence of SIDS in babies who fall asleep with them so they encourage their use.  To look at the entire list of Safe Sleep Guidelines, I strongly recommend that you take a look at these graphic links 1,   graphic link 2

 Outro

As always, thanks for joining me today for this very important pedcast. I hope I was able to help you with a topic that many parents find challenging. If you enjoy learning about child health with pedcasts, by all means subscribe to Portable Practical Pediatrics at www.docsmo.com or on iTunes. By subscribing you are simply providing me a way of getting you notice of new shows, nothing more. And while you are there, don’t forget to take some time to explore the entire library of over 400 podcasts, all, free for the taking, at www.docsmo.com. This is Dr. Paul Smolen broadcasting from beautiful Charlotte, NC wishing you and your family pleasant days and quiet nights.  Until next time.

I want to thank Dr. Monica Miller for her contribution to the making of this pedcast. Thanks Monica.

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