It is “unnatural” to have urban stimulation (noises, voices, shopping trips, errands), day care (naps not occurring when sleepy, too late a bedtime at night), mother working outside the home (returning late causing a late bedtime), or social isolation (mother is alone and becomes exhausted with too many things to do). It is “unnatural” to deliberately wake your baby and remove your breast before putting him down to sleep “awake.” It is “unnatural” to try to force-feed your baby at night to try to make him sleep better. Is all this brand new? Probably not. We know that during the Egyptian and Roman empires, wealthy women did not breast-feed their babies but instead hired wet nurses.
Can you change your lifestyle so that your child will receive the soothing to sleep at those times when she needs to sleep? Can you avoid too much social stimulation from interfering with sleep even if it means ignoring your child's crying only at those precise times when she needs to sleep? These are difficult questions that many families never have to confront. Many popular books on children's sleep give simple answers or easy solutions that often fail for this group of 9 percent of infants.
Recent research on an initial group of 1,019 families supports my idea that at four months of age there are two subgroups of overtired children who appear to have a difficult temperament. Many mothers dropped out of the study, but the 560 mothers who stayed were more likely to be married, have completed more formal education, have higher household incomes, be nonsmokers, breast-feed, and have “higher levels of social support.” They noted that at three months of age there were thirty-five children who were crying enough to be called colicky. Of these, eighteen (51 percent) had been this way at six weeks of age (typical colic) but seventeen (49 percent) had not (“latent colic”). They felt that these represented two subgroups of colicky infants and went on to describe a third subgroup (14 percent of colicky infants) that continued to cry substantially past three months of age. The authors considered this to represent a “persistent mother-infant distress syndrome.” Comparing this study to my analysis, I would say that at four months of age there are about 9 percent of overtired children with difficult temperaments representing two groups of whom five out of nine, 56 percent, were formerly extremely fussy/ colicky babies (similar to the “typical colic”) and four out of nine, 44 percent, had common fussiness/crying (similar to the “latent colic”). I believe that those families with limited resources for soothing their babies are at greater risk for the overtired/ fussy/crying state to persist. However, I do object to the term “mother-infant distress syndrome” because of the blame it directs to the mother. Obviously, fathers, grandparents, financial factors, and so forth can stress a family independent of the mother's capabilities to nurture her child.
Postcolic: Preventing Sleep Problems
After Four Months of Age
After extreme fussiness/colic winds down around four months of age or sooner, a child may be overtired, not sleeping well, and difficult to manage. But not all difficult to manage four-month-olds had colic. I suspect there are two groups of children at four months of age, both of whom have difficult temperaments.
The first group with a difficult temperament comes from the large group (80 percent) of infants with common fussiness/ crying. Only about 4.5 percent of these children, or four infants out of a hundred, fall into this category. I think they are less overtired than the second group. When parents put forth great effort to help them sleep better, there is relatively fast improvement. They are more adaptable and it is easier to change their sleep routines. “No cry” sleep strategies are likely to work well.
The second group with a difficult temperament comes from a small group (20 percent) of infants with extreme fussiness/ colic. About 27 percent of these children, or five infants out of a hundred, fall into this category. I think they are more overtired than the first group. When parents put forth great effort to help them to sleep better, there is relatively slow improvement. They are less adaptable and it is more difficult to change their sleep routines. “No cry” sleep strategies are not likely to work and parents have to consider “let cry” sleep strategies.
Here is a practical example of how different these babies are. Read the following advice on how to move your baby out of your bed. If you had decided that you wanted a family bed before your child was born, you might decide to continue the family bed for a long time, and when you move your baby out, the transition might be very easy if your baby had common fussiness/crying and now has an easy temperament. On the other hand, if your decision for a family bed was in reaction to extreme fussiness/colic and your child now has a difficult temperament, the transition might be very stressful for the entire family.
Transition from Family Bed to Crib
Q: I am breast-feeding and my child sleeps with us, but I want to move him out of our bed. How do I do this?
A: There is no one right way to do this, but however you do it, do it gradually and slowly over several weeks or a few months. Make the move when both parents agree that it is the right time. Always be mindful for your baby's safety. Initially, respond promptly when your baby calls for you. Later, you might delay your response. A baby might be placed in a crib secured to the side of your bed with the railing down. Later the railing is placed up and the crib is moved a few inches from your bed. Gradually, the crib is moved farther away until it is in baby's room. An older child might sleep on a mattress on the floor in your room, with or without the parent. Later, the mattress is moved to the child's room, with or without the parent. Sometimes you might just want your child to be in her crib or bed but in your room. If you are going to use a separate room and your child is older, announce the planned move in advance, make the room very attractive, or let her help decorate her room. Alternatively, move your baby into the room or bed where the siblings are sleeping. Some parents will begin the night together in the parents’ bed and then move the child to a crib after she has fallen asleep.
Q: Do I have to wean my baby from breast-feeding before I move him out of our bed?
A: I think the answer depends on your resources for soothing other than breast-feeding, especially the assistance of the father, plus your desire to continue or discontinue breast-feeding. I see no reason why weaning from breastfeeding has to precede or accompany your moving the baby.
The observation that brief and interrupted sleep often follows extreme fussiness/colic might suggest that some congenital, biological factors lead initially to extreme fussiness/colic, and that they are still present in the baby after the colicky period has passed. This is supported by the observation (mentioned earlier) that despite successful drug therapy that eliminated or reduced colicky crying, brief sleep periods were still the norm at four months of age. In addition, some, but not all, postcolic infants continue to behave as if they had heightened activity levels and excessive sensitivity to environmental stimuli.
Here is another example of sensitivity to environmental stimuli from my own experience. When my first son had colic, I had to keep the crib railing up and locked in place, because the clunk of the spring lock would always awaken him. This makes it awkward for me to place him in his crib, but fortunately I was limber from college gymnastics. For my wife, it was an impossible situation until we got a sturdy stool for her to stand on—but it still hurt our backs!
Interestingly, these two temperament characteristics (high activity and high sensitivity) are not part of the diagnostic criteria for babies who fall into the difficult temperament category. But some of these postcolic infants were exquisitely sensitive to irregularities in their nap or night sleep schedule. Disruptions of regular routines due to painful ear infections or holidays and trips subsequently caused extreme resistance to falling asleep and frequent night waking, lasting up to several days after the disruptive event. These prolonged recovery periods might reflect easily disorganized internal biological rhythms caused by enduring congenital imbalances in arousal/ inhibition or wake/sleep control mechanisms. Alternatively, parents who put their baby to sleep
slightly too late, or who often cause their children to skip naps after four months of age, keep their postcolic infant close to the edge of overtiredness. What happens when some natural disruptive event occurs is that the child falls into the abyss of severe agitated wakefulness and irritability and the child is unable to easily get back into a regular sleep pattern.
Some postcolic kids have boundless energy. “She crawls like lightning” was how one mother described her baby. These babies are constantly on the move. They would rather crawl up mom's chest to perch on her shoulder than sit quietly in her lap. But once having reached the shoulder, they immediately want to get down and check out that dust ball or some equally exciting object off in the corner. They appear easily bored; they also seem very stimulus-sensitive, especially to mechanical noises such as those of a vacuum cleaner, hair dryer, or coffee grinder (which may have seemed to calm them down during colicky spells when they were younger). It's as if they have a heightened level of arousal, activity, and curiosity. When overtired, they are always crabby and socially demanding, needing mommy's presence and wanting to be held all the time. They also are quick to fuss when mom leaves the room for only a minute. But when they are well rested, it's a different story.
When they've had enough sleep, these same babies appear to have boundless curiosity, actively seeking opportunities to learn. Maybe these are very intelligent children who are so alert, curious, and bright that they have difficulty controlling their impulses to explore or investigate the world. No data support the conclusion that postcolic kids in general are more intelligent, but there may be a small number who are so exceptionally bright that they gave birth to this myth. One study of infants published in 1964 connected increased crying (induced by snapping a rubber band on the sole of the foot at age four to ten days) to increased intelligence at three years of age. Whether this artificially induced crying and its link with intelligence can be generalized to colicky crying is an open question.
When you become your child's timekeeper and program her sleep schedules, she will be able to sleep day and night on a regular schedule. For most parents, this is a relatively easy adjustment to make. But for postcolic infants, expect to put forth a greater effort to be regular and consistent. Your effort to keep the child well rested will be rewarded by a calmer, happier, more even-tempered child. One family that was finally able to permanently decrab their baby explained, “The ‘other’ baby is back!”
Here is a story of a child who probably had extreme fussiness/colic, even though the parents wanted to call him sleep-deprived. There was no quick sleep solution, but improvement did come slowly. Patience is always rewarded if you are reasonably consistent.
When Jackson was four months old, he had never been on any kind of sleep schedule. He seemed to cry all the time and would only sleep about four hours at a time (if we were lucky!). My husband and I would spend hours on end, holding, rocking, bounding, singing, playing, doing anything we could think to do to get him to stop crying. Our pediatrician said that he had colic and there was nothing we could do about it but to wait it out. Looking back on it all now, I am convinced that he didn't have colic at all, but was just plain sleep-deprived. At first we were hesitant to allow Jackson to cry without holding him. Given that we are both psychologists, we were scared that leaving him alone to cry would be emotionally scarring and would affect his attachment and self esteem. But we were both sleep-deprived ourselves, stressed out, and desperate to try anything. Dr. Weissbluth's belief that to not allow him to learn to soothe himself to sleep was damaging in and of itself was what allowed us to finally take the plunge. The first time I put him to sleep in his crib for a nap, I left the room and he screamed bloody murder. I sat at the top of the stairs and just cried and cried. I was convinced I was the worst mother in the world. After twenty minutes (which felt like an eternity), he finally fell asleep and slept for two hours. Unfortunately, later naps did not prove to be so easy. There were times in which he screamed for the whole hour (and I cried for the whole hour) and we would get him and try again later. Jackson was a bit resistant to the whole idea, and even though we were very consistent, he always put up a good fight. Even now, at nine months old, Jackson will still cry before most naps and bedtime. Sometimes it's thirty seconds, sometimes it's thirty minutes. He sleeps so much better and longer than he ever did. We calculated that before he was averaging ten hours of sleep per day, and after just a few weeks he was sleeping around seventeen hours a day. The best part of all was that he learned how to sleep through the night. Now, he goes to bed most nights between 6:00 and 7:00 P.M. and he wakes up usually between 6:00 and 7:00 A.M. He takes two naps per day, one around 9:00 A.M. and the other in the early afternoon. My husband and I finally got the sleep we needed and the stress level went down dramatically. We have our evenings together back, which we desperately needed. And Jackson's temperament is dramatically improved. I would still say he is a highly active baby, but would no longer say he is fussy. Before, I was certain we would never have another child because it was just too much on us emotionally. But now we are planning to conceive again within the next year.
Without your effort to maintain sleep schedules, a child will have a tendency to sleep irregularly and become unmanageably wild, screaming out of control with the slightest frustration, and spending most of the day engaged in crazy, demanding, impatient behaviors. The majority of postcolic infants do not fit this extreme picture, but they do require more parental control to establish healthy sleep schedules, compared to noncolicky infants. Thus it appears that after about four months of age, poor sleep habits are learned, not congenital.
PRACTICAL POINT
For all postcolic infants over four months of age, my clinical observations are that frequent night wakings may be eliminated and sleep durations lengthened if, and only if, parents establish and maintain regular sleep schedules for their child.
It appears that most postcolic sleep problems are not caused primarily by a biological disturbance of sleep/wake regulation; rather, the problem is parents’ failure to establish regular sleep patterns when the colic dissipates at about four months of age. Both obvious and subtle reasons can be cited as to why parents have difficulty in enforcing sleep schedules when colic ends.
Three months of crying sometimes adversely and permanently shapes parenting cycles. An inconsolable infant triggers in some parents a perception that their baby's behavior is out of their control. They observe no obvious benefit to their extremely fussy/colicky child when they try to be regular according to clock times or to be consistent in bedtime routines. Naturally, they then assume that this handling will not help their postcolic child, either. Unfortunately, they do not observe the transition, at around four months, from colicky crying to fatigue-driven crying.
Alternatively, some parents may unintentionally and permanently become inconsistent and irregular in their responses to their infant simply because of their own fatigue. The constant, complex, and prolonged efforts they use to soothe or calm their extremely fussy/colicky baby are continued. But these ultimately lead to an overindulgent, oversolicitous approach to sleep scheduling when the colic has passed. Their nurturing at night, for example, becomes stimulating overattentiveness. In responding to their child's every cry, the parents inadvertently deprive her of the opportunity to learn how to fall asleep unassisted. The child then fails to learn the important skill of self-soothing, which she will need her entire life.
In addition, my studies have shown that when daytime sleep is interrupted, the same consequences occur. The nap-deprived infant develops a short attention span. Remember, other studies have shown that the difficult child is irregular. It is exactly these two temperament traits, short attention span and irregularity, that have been shown to interfere with a child's ability to learn—beginning with learning how to fall asleep without his parents’ help.
Effective behavioral therapy to establish healthy postcolic sleep patterns by teaching the child how to fall asleep and stay asleep may or may n
ot be acceptable to you, depending on your ability to perceive and respond to the sleep needs of your infant. (A variety of ways to achieve healthy sleep will be discussed in detail in the chapters that follow.)
Other parents, usually mothers, have extreme difficulty separating from their child, especially at night, as will be discussed in Chapter 12. They may have some difficulty themselves being alone at night because their husband's work requires frequent or prolonged absences, or because nights have always been lonely times for them. They perceive every cry as a need for nurturing. These women are wonderful mothers, but they may be too good. The infant's every need is anticipated and met before it is experienced; in doing so, the mother unintentionally thwarts the development of her child's capacity to be alone. For example, she may block her infant's attempts to provide himself with a substitute (such as thumb sucking or use of a pacifier) for her physical presence.
These parents perpetuate brief and fragmented sleep patterns in their children. Their infants become, according to Dr. Ogden, a child psychiatrist, “addicted to the actual physical presence of the mother and [can]not sleep unless they are being held. These infants are unable to provide themselves an internal environment for sleep.” Although the child has disturbed sleep, here the focus of the problem and the key to its solution lies with the parent.
WARNING
Persistent sleeping problems in children have been linked to psychiatric symptoms in adolescents, hyperactivity in children, and depression in their mothers.
Healthy Sleep Habits, Happy Child Page 20