Healthy Sleep Habits, Happy Child

by Marc Weissbluth, M. D.

  Here is an account of one mother's first eight weeks.

  “MY FIRST BATH IN EIGHT WEEKS”

  Today my baby girl, Allyson, is eight weeks old. I celebrated by taking my first uninterrupted bath since her birth. Of course, she woke up just as I was toweling off, but I have learned to be grateful for small pleasures.

  Allyson doesn't sleep much, and when she's awake she's usually either crying or nursing. It's been a little better the past week, but she still sleeps very little: six to eight hours at night and two to four hours during the day. And since I can't bear to hear her cry, that means she spends most of her time on my breast, where, mercifully, she can always be soothed. I feel as if I've merged with the brown corduroy chair where I nurse her.

  Lately she's good for a couple often-to twenty-minute play periods (on the floor on her back, me leaning over her, or on the changing table while I change her diaper). I can't hold her and play with her; she's always squirming to get at my breast. So, anyway, she's on my breast ten to twelve hours a day.

  Given Allyson's behavior (constant crying or fussiness, and a constant desire to nurse or at least hang out at my breast), I naturally concluded that my baby was starving, that I did not have enough milk for her. If I did have enough, surely she would fall asleep and stay asleep. Obviously, I thought, she was waking after a few minutes or half an hour because she was hungry. A weighing at the doctor's, where I learned that she was in the seventy-fifth percentile for growth (at three weeks) did not reassure me.

  When I talked with the doctor, he said it did seem my baby was colicky, and I took his book home to read. Finally, I found descriptions by other mothers of babies like mine! I was not alone. I came to understand how sleeping problems, like those of my baby, appear to be hunger, but really aren't. I also learned that there's nothing I can do for my baby that I'm not already doing, and so I might as well turn some of my energy around and start taking care of myself. Truly, I believe that in the case of a colicky baby, who in most cases cannot be treated for her condition, it is the mother who needs “treatment” or help, and to this end I suggest:

  Get out of the house an hour or two a day, minimum

  When out of the house, try to get some physical exercise to burn off the tension

  Don't feel guilty about doing anything that makes you feel good

  Socialize as much as possible outside the home

  Keep a diary or log of your baby's sleeping/feeding habits

  When the baby is asleep, get some sleep yourself, unless you're doing something for your own peace of mind

  And things are getting better. Last night Allyson woke up from a three-hour nap, nursed calmly, and wasn't fussy for several hours afterward. She didn't go back to sleep, but she didn't cry either. Later that evening she slipped back into her old ways, but I got to hold her and play with her for over an hour; then she stayed calm in the swing for a while.

  And I got my bath this morning.

  If you are lucky to have an easy baby, at five to six weeks you may have already noticed her sleep patterns becoming somewhat regular. You can try to help your baby become more regular by putting her down or lying down with her to sleep when she first appears tired, but, in any case, after no more than two hours of wakefulness. She may or may not drift into sleep easily. You do not need to let her cry at all, but some babies will fuss or cry in a mild fashion before falling asleep. If she cries for five, ten, or twenty minutes, it will do her no harm, and she may drift off to sleep. If not, console her and try again at other times. Try to become sensitive to her need to sleep. The novelty of external noises, voices, lights, and vibrations will disrupt her sleep more and more, so try to have her in her crib or your bed when she needs to sleep. Go slowly and be flexible.

  Remember, sleep training means starting to respect your baby's need to sleep when he is a newborn by anticipating when he will need to sleep (within one to two hours of wakefulness), learning to recognize drowsy signs, and developing a bedtime routine. Then your baby will not become overtired.

  Now you might want to try to help your baby sleep better at night. The ease with which you can accomplish this is related to whether your child is currently well rested or overtired. And this depends on whether he had common fussiness/crying or extreme fussiness/colic and whether you were able or unable to successfully soothe him during the first six weeks.

  Alternatively, you might have no need or desire to try any of these three sleep training strategies. Your baby might be sleeping well at night, and there is no reason to rock the boat. Or, you are enjoying the family bed and do not wish to change or allow your baby to cry. This is fine for now, but after four months of age, you probably will want to consider some changes in sleep routines to accommodate your baby's need for an earlier bedtime. These changes do not necessarily mean that your baby will cry.

  Always consider both your child's ability to self-soothe and your resources for prolonged daytime and nighttime soothing. Do what works best for you and your baby.

  FOUR SLEEP-TRAINING STRATEGIES: WHEN TO TRY

  At six to eight weeks of age if you have to return to work and/or you are totally exhausted and unable to function. May work well for common fussiness/ crying babies, especially if they appear to have an easy temperament.

  At eight to sixteen weeks of age to help your baby sleep better at night for babies with common fussiness/ crying. Success may be quick and easy.

  After sixteen weeks of age to help your baby sleep better at night for babies who had extreme fussiness/ crying. Success may be slow and difficult.

  1. “Let Cry,” Ignoring, Extinction

  Not responding to your child at night is most difficult for parents. It is also not always clear if your baby is or is not hungry. Between six to eight weeks and four months, babies might be hungry and need to be bottle-fed two or three times a night, but after four months, only once or twice, and after nine months, not at all. The idea is to respond if you think your child is hungry but not at other times. This determination may be harder for a mother who is breast-feeding because of uncertainty regarding her breast milk supply. Fathers should give a bottle of expressed breast milk or formula to help clarify whether the baby is hungry or not.

  In addition, there is almost always a temporary increase in crying at night when parents do this. While appearing harsh, it is my impression that the total amount of crying with “Extinction” is less than with “Graduated Extinction” because success occurs faster. Research comparing these two methods showed that parents using “Extinction” reported less stress in parenting. This supports my observation that parents are more willing to employ “Extinction” again following changes of sleep routines such as holiday trips, special events such as birthdays, or illnesses. In contrast, because “Graduated Extinction” often takes longer, parents are less willing to repeat the procedure when changes of sleep routines cause the child to become overtired. Another observation is that for older babies or children where there is less uncertainty regarding hunger at night, “Extinction” is simpler to execute and parents can therefore be more consistent. In contrast, “Graduated Extinction” requires a detailed plan of action to be modified gradually but consistently over several days or longer.

  Here is one mother's account.

  ARES

  We brought Ares home from the hospital with only a ballpark notion of what it would it be like to care for a baby. As far as I knew, Ares would sleep when he needed to sleep. As the months progressed, I went to him whenever he cried and changed him and nursed him on demand. At night he woke often and slept in bed with me most of the time. Whenever Ares cried I would sort of panic. I seriously would have done anything to soothe him. All my adrenaline turned on and my heart raced. People would ask me if I had him on a sleeping or nursing schedule, and I didn't know what to say. He nursed on what seemed like a constant basis, and he hardly slept. I snuck two-minute showers listening to him cry, feeling guilty the whole time. When I asked people about babies and their sleepin
g habits, they would say vague things like “Babies sleep when they need to sleep, no less and no more” and “Every baby is different, like a snowflake. Some just need less sleep than others.” I found this less than helpful. I kept waiting for Ares to “sleep through the night,” but it never happened. At night he was up seven or eight times. During the day he didn't sleep much, just little short naps. Sometimes, when I nursed him to sleep and put him down for a nap, he would wake up and cry right when I put him down. I started holding him while he slept.

  I read that you should always take your baby everywhere and “wear” your baby like the Native Americans did. I carried him around in a Bjorn baby carrier on walks and to do errands. By the time he was ten months old, his nighttime routine was established. I would nurse him to sleep at 8:00 P.M., put him in his crib, and he would wake up at 10:00 P.M. and cry. I would change him and nurse him back to sleep, and carefully, oh so carefully, put him back in his crib, and repeat this process all night every two or so hours. Sometimes he would wake up when I put him back in bed and I would have to start all over again. As the night progressed, and he became more and more exhausted, he was more likely to wake up when I put him down, and it took longer to soothe him back to sleep. By 6:00 A.M. he was up for the day, napping occasionally and only briefly. Sometimes I couldn't even put him down long enough to eat dinner. I held him while I ate. One night I went to him when he cried and nursing did not soothe him. He could not stop crying no matter what I did. I realized at that moment that he didn't need me so much as he needed to sleep. We were all exhausted.

  We had heard about “crying it out” before, and I thought it sounded cruel. But my husband wanted to do it, and it was clear that we had to change our methods, because although I was perfectly willing to deprive myself of sleep on his behalf, Ares was clearly suffering from sleep deprivation. Ares had all the symptoms of an overtired child. He was easily startled, and cried uncontrollably at sudden or loud noises. He was unable to go to sleep on his own, and unable to stay asleep once he did. The book explained that in going to Ares every time he cried at night, I was stimulating him and keeping him awake, not soothing him and reassuring him as I had thought. All that stuff I had read about “nighttime parenting” and “attachment parenting” was not only not helping, it was hurting Ares. We decided to try Dr. Weissbluth's “Extinction” method.

  The first night I put Ares to bed at 8:00 P.M. as usual, but when ten o'clock came and he cried, I didn't go to him. It was one of the hardest things I have ever done, but I wanted to give it a try for his sake. He cried for forty-five minutes. I thought I would die. My nervous system went haywire. I cried, my whole body got hot, I was shaking and sweating and my heart pounded. He's going to think I abandoned him, I thought. He will never trust me again. But once he stopped crying he slept all night long. Ares had never slept for more than four hours in a row. I thought for sure he had died. But he woke up the next morning happy and rested and then fell back to sleep a couple of hours later on his play rug, another first. Ares had never in his life fallen asleep without nursing. From then on we were convinced that Dr. Weissbluth knew what he was talking about. We worked to make sure Ares got the sleep he needed. At night we developed a sleep ritual of bathtime, reading to him and nursing him at 6:00 P.M., and putting him down sleepy but awake. He took two naps a day, following a slightly abbreviated sleep ritual, and slept for two hours in the morning and one hour in the early afternoon. For some reason he didn't cry at nap time, he just went quietly to sleep. At night, however, for several weeks he still cried for forty-five minutes when I put him down. This was extremely difficult, even painful. But once he fell asleep he stayed asleep for twelve hours, which was incredible to me, and he was so much happier during the day that we stuck with it. In the daytime, he was so much calmer; he even seemed sleepier for the first few weeks. He almost never cried anymore, and his attention span was longer. Eventually, Ares went to sleep without crying, and he still sleeps every night all night long, for at least twelve hours a night.

  2. Controlled Crying, Partial Ignoring,

  Graduated Extinction

  This is a variation of “Extinction.” One method is to leave your baby for about five minutes, then return and soothe him back to the sleepy state or put him down after soothing. If loud crying recurs, leave your baby for ten minutes and then repeat the soothing process. If loud crying again starts, leave your baby for fifteen minutes before repeating the soothing process. This sequence repeats with an additional five minutes of ignoring his crying until he falls asleep during one of the crying spells or does not cry after your soothing effort.

  Another method is to also increase the time of ignoring before checking on your baby, but increase the time by about five minutes every two days. Research has shown this method to work well over a period of four to nine nights. Again, your success depends on your child's tendency to fuss or cry, how well rested or overtired he is, and how consistent you are.

  This method appears less harsh than “Extinction” and works well for many children. It is my impression that for extremely fussy/colicky babies, by four months of age, parents are worn down from sleep deprivation and the child is way overtired. In this situation trying “Graduated Extinction” often fails because the child's crying outlasts the parents resolve to be consistent and “Extinction” produces results sooner.

  3. Check and Console

  Responding to your child at night is least difficult for parents. You quietly enter whenever your baby cries to see that she is all right and gently soothe her in darkness but you try to not pick her up. Instead, you rub her tummy, stroke her hair, or gently rock the crib. You do the least amount of rocking, singing, and if necessary, nursing to soothe her back to a calm, sleepy state. This method appeals to those who practice attachment parenting because they believe that it provides emotional security, that their cries will not go unanswered so they can learn to trust their mothers, and they will not feel abandoned. However, there is no evidence that babies are harmed when they are allowed to cry. Furthermore, this method could teach some babies to cry more frequently and longer in order to receive more soothing. In addition, it is very hard to only partially soothe a crying baby at night. On the other hand, if your baby is well rested and did not have extreme fussiness/colic, this method might work well.

  REMEMBER

  Different children require different approaches.

  4. Scheduled Awakenings

  See page 298 in Chapter 6 for a discussion of this method.

  Here is an account from one mother who needed to get her child's sleep on a firmer schedule before she went back to work. Trying her methods with a more irregular, extremely fussy/colicky child probably wouldn't have worked at this early age. But an easy, regular, common fussy baby often responds quickly to sleep-training strategies at around six weeks.

  In this story, the mother incorrectly equated sleep training with letting her baby cry.

  “MY MATERNITY LEAVE WOULD SOON BE OVER”

  When Ron and I interviewed and selected our pediatrician before David was born, we left his office comfortable with the care we felt our child would receive. Although we knew the doctor had a special interest in sleep disorders, we never dreamed we would be faced with a baby whose internal clock thought day was night and night was day.

  Oh, it didn't happen right away. In fact, the first few weeks were spent nursing and changing diapers in between David's naps. Looking back at those first weeks, Dr. Weissbluth must have really chuckled at some of the questions I asked him.

  At the same time, I was beginning to relax and feel, yes, everything is going along normally, David became more alert; Ron and I knew it was a great step in his development. We looked forward to his periods of wakefulness as a time to interact with him. But a pattern began to develop: David didn't want to go to bed at night.

  The doctor listened to what we were going through and assured us that, first of all, this was normal for some babies. David was really too young to g
o through sleep training at six weeks. So Ron and I resigned ourselves to some more of the same.

  When David was two months old I began to panic. My maternity leave would soon be over. I could barely stand up most of the time, I was so tired. I also wanted to continue to nurse David whenever I was home. I knew we had to do something before I went back to work. So we called Dr. Weissbluth and made an appointment to see him.

  First, the doctor checked David's physical condition. He was in perfect health. Then we talked. Dr. Weissbluth explained that we would have to make some changes in the way we handled David's sleep periods. David was to have a quiet, darkened room when sleeping. No more night-light, music, et cetera. Naps should last at least forty-five minutes to an hour. If David got up sooner, we were to leave him there until he got the rest he needed. Instead of letting David stay up late, we were to put him to bed between 7:00 and 9:00 P.M. NO rides in cars, strollers, or swings, where sleep occurred for a short time.

  We decided to start that next Monday, since Sunday was Mother's Day. I nursed David at 9:00 P.M., and by 9:30 he was asleep in my arms. I tiptoed him into bed and crept back to the living room and turned on the intercom. It was quiet until 9:45, when I heard David sucking his fingers. I thought, Okay, he'll get back to sleep soon, but by 10:00 the crying began. David cried until 12:30—two and a half hours. For every cry I heard I shared his frustration, anger, and seeming pain. And I was angry—at David, the doctor, Ron, and myself. Finally, David fell asleep, and he slept until 6:45 the next morning, when I woke him to nurse.