Healthy Sleep Habits, Happy Child

by Marc Weissbluth, M. D.

  I mentioned my “grieving” theory to Dr. Weissbluth, who politely discounted it. He said that when babies wake up in the middle of the night, they are in a twilight state between sleep and waking. They aren't likely to be grieving or doing much else. Obviously, if a baby has an ear infection, she might be in pain, but this wasn't the case here. He suggested putting her to bed fifteen minutes earlier—at 6:45 P.M. instead of 7:00 P.M. Even with all our good efforts, Carina might still be overtired. Well, no one ever said that it was easy being a parent.

  Carina has been with us now for nearly four months. She takes good naps in the morning and in the afternoon, and she sleeps about twelve hours at night. She is very happy to get into her crib and snuggle into her special corner. Occasionally she will wake up in the middle of the night, but we have learned to leave her alone. We have also learned to recognize the noises she makes when she's settling back to sleep, and these are very different from cries of pain or hunger.

  Have these healthy sleep habits produced a happy child? You bet. Carina is a joy to be around. As we've all gotten to know each other better, she has become much more affectionate. She is clearly crazy about Charlie, and he is very proud to be a big brother. As for me, I fell in love. And despite all my trepidation, it really didn't take that long.

  Injuries

  Injuries occur to children of all ages. Some can—or should—be prevented, but some cannot. Examples of preventable injuries include leaving a four-month-old infant alone on a changing table from which she falls, poisonings occurring when safety seals are not used or medicines are left lying around, or electrical shocks from uncovered wall sockets. A nonpreventable injury is truly an accident—for example, those resulting from an earthquake or a lightning bolt.

  The truth is, though—and I realize this sounds harsh to many parents’ ears—that most so-called childhood accidents are really preventable injuries that occur because of parental neglect or the lack of parental forethought. These injuries can be one consequence of home routines that create tired children—and tired families.

  But is there such a thing as an accident-prone child? To determine if traits within a child can cause him to suffer frequent injuries, various studies have examined babies before injuries start to occur. (After a child has had several injuries, a “halo” effect develops and adults are more likely to perceive traits in the child—clumsiness, lack of self-control, and so on—that “explain” why he has had so many injuries.)

  One study included two hundred babies who were evaluated between four and eight months of age. Some of the infants were difficult to manage. As we saw earlier, these infants were called “difficult” because they were irregular, low in adaptability, initially withdrawing, and negative in mood. During the next two years, difficult babies were much more likely to have cuts requiring suture than were babies with the opposite or easy to manage temperaments. This study showed that during the first two years of life, about one third of the difficult children had cuts deep or severe enough to require stitches, while only 5 percent of easy babies had similar cuts.

  Remember also my data: At four to eight months of age, difficult babies slept about three hours less than easy babies, and at age three, the difference was about one and a half hours. By age three, the briefer the sleep, the more active, excitable, impulsive, inattentive, and easily distracted the child appeared—the perfect description of an accident-prone child. Little wonder, then, that these tired children fell more often, sustaining deep cuts.

  Obviously, for both the “difficult” kids and all other children, chronic fatigue can lead to more injuries, such as cuts and falls. More sleep is the remedy.

  Another study that supports this fatigue-injury connection included more than 7,000 children who were one to two years old. Researchers compared children who frequently woke up at night with those who slept through the night. Among the night wakers, 40 percent had injuries requiring medical attention, compared to only 17 percent of the good sleepers. The parents of the children who were night wakers reported that they immediately went to their child when they heard a cry in order to prevent further crying. There was a tendency for the mothers of night wakers to feel more irritable in general and “out of control.” One sign of family tension was that these mothers felt unable to confide in their husbands; the association of marital difficulties with disturbed sleep has been mentioned in many studies.

  Maybe the parents who don't supervise sleep patterns so that the child can have his sleep needs met are the same ones who don't supervise children at play in order to protect their physical safety. The message is clear: If your child is often injured, it's not necessarily because he is careless or clumsy—he may be exhausted instead.

  I have seen many children who were so overtired that they fell down only a stair or two or fell from a very low height. But because they hit their head and were later noted to be sleepy or wobbly, the parents worried about a head injury or concussion. What these children needed was more sleep, not a CT scan!

  Falls from bunk beds can be serious, but most can be prevented by always using side rails in the upper bed and removal of the bed ladder when not in use.

  Overweight, Exercise, and Diet

  Difficult to manage children fuss and cry a lot. One way to respond to their demands is to put food in their mouths. This certainly quiets them. Coincidentally, their fussiness might also have some evolutionary value, ensuring their survival in times when food is scarce. This was shown to be the case among the Masai of East Africa during drought conditions in 1974. But in a study conducted in a white, middle-class Pennsylvania pediatric practice, the more difficult babies tended to be fatter babies. Perhaps this connection between fussiness and being fed sets the stage for obesity in later years.

  In my own pediatric practice, fat babies are almost always overtired babies. That's because their mothers have incorrectly attributed their babies’ crying to hunger instead of fatigue. These mothers are always feeding their babies, then telling me that their babies can't sleep because they're always hungry! The major point here? Overfeeding the crying child to keep him quiet could cause unhealthy obesity.

  This overfeeding habit may actually begin innocently enough in some children at three to four months of age, when nutritional feedings in the middle of the night give way to recreational feedings. Later, the bottle or breast is used as a pacifier and the frequent sipping and snacking causes excessive weight gain. Please try to become sensitive to the difference between nutritive and non-nutritive feeding. Overdoing milk or juice bottles is a common way babies learn to not “like” eating solids. After all, they are getting calories, so they have no appetite to motivate them to eat solid foods when they are older. For children between five and seven years, we now have direct evidence that the more tired the child is, the more likely it is that he will be overweight or obese.

  Q: If I give my child a bottle at naps or at bedtime, will I make him fat? When should I not include a bottle in the bedtime ritual?

  A: Sucking or sipping a bottle before falling asleep comforts most babies and even older children. There is no harm in doing this and there is no particular age when you should stop as long as (a) you prop the baby, not the bottle, so he drinks in your arms, (b) the rate of weight gain is not too fast, and (c) frequent or prolonged feedings are not part of a sleep problem.

  The effects of exercise on sleep are hard to prove, even though most people assume that muscular fatigue induced by exercise will produce better sleep. Another possibility is that exercise reduces anxiety. However, strenuous exercise, especially common among teenagers, might mask an underlying problem of chronically insufficient sleep. The chronically or severely overtired adolescent is sometimes described as living in a “twilight zone”: frequent episodes of drowsiness, “micro-sleeps,” lethargy, depression, apathy, cognitive impairment, and proneness to accidents. Counteracting measures that fight the fatigued state are internal stimulation (heightened emotionality such as anger or elation) or external stimu
lation such as exercise. So, exercise may be helpful, but it will not solve an underlying sleep problem.

  Diet should influence sleep, because food provides the chemical building blocks for the brain's neurotransmitters. But studies in infants and adults do not show support for any strong link between sleep and diet.

  Child Abuse

  Let's get one ugly fact out in the open: When we are very, very tired of hearing our baby cry to fight sleep at night, we would like to shut her up. We don't act on our feelings; we don't harm our baby. But at nighttime, the thought might have occurred to us: “What if I weren't in so much control, might I… ?”

  The tired, difficult to manage infant whose howling at night will not stop can become a target for abuse or infanticide. Crying is the behavior that seems to trigger child abuse in some parents, and crying at night instead of sleeping is the historical setup for infanticide.

  So when your baby gets all cranked up late at night, with desperate, angry, or relentless screaming when she should be asleep, and you feel like a tightly wound spring, don't be surprised if you feel you want to “get even” or “shut her up for good.” If you and your child don't get the sleep you need, you may have experienced these intense feelings of anger, resentment, or ill will toward your child.

  Contact the following organizations, social workers at local hospitals, or your pediatrician if you feel the need for help.

  National Committee to Prevent Child Abuse

  1-800-244-5373

  Parents Without Partners

  1-800-637-7974

  It's difficult to see how we can help solve sleep problems when we ourselves are extremely sleep-deprived. This is the time to call for help.

  Atopic Dermatitis and Eczema

  Atopic dermatitis is a chronic skin condition that causes severe itching. Itching of the skin can cause restlessness during sleep because a lot of the scratching goes on during light and REM sleep. As a result, children wake frequently throughout the night. Some studies have shown that these children have difficulty waking up for school, difficulty staying awake in the afternoon, and major discipline problems. However, one study that used sleep lab recordings and videotapes during sleep of atopic children showed that the sleep abnormalities of frequent arousals actually did not occur with the act of scratching. This study was performed when the skin condition was in remission, so it is possible that, during flare-ups, there might be more intense itching that interfered with sleep consolidation. If your child is often scratching his skin, the best idea is talk to your pediatrician or ask for a referral to a dermatologist.

  Competent Parents, Competent Child

  KAREN PIERCE, M.D.

  The role of parent is the most rewarding job and also the most challenging one. A complex relationship develops when parents devote themselves to meeting a child's needs. Maturation does not proceed as effortlessly as one thinks. The hard work of rearing children gradually improves parents’ competence, which, in turn teaches that same competence to their child.

  Why is a child psychiatrist writing a chapter in a book about sleep? When my first child was about five months old, I was in a specialty toy store. A distraught mother came to me, frantically asking, “Do you know a child psychiatrist? My pediatrician just told me to let my five-month-old cry to train him to sleep through the night. Will I damage his self-esteem if I let him cry?” We both had a good laugh when she found out that I was a child psychiatrist. I took the opportunity to commiserate but pointed out that my training was not needed for this task. Setting limits and teaching a child self-soothing are part of every parent's job. Doing this job does not cause psychological harm. Instead, setting limits promotes growth.

  Loving our children includes introducing and teaching them to live with frustration. Saying no to a child becomes just as important as loving her unconditionally. There is a popular misunderstanding that loving parenting means unconditional acceptance, without rules. This is not the case. We must start training children in infancy. This is not easy! But early training will help later on, when you try to teach your child in other areas, such as bike riding, homework, and social skills.

  Here is a story from a parent of one of Dr. Weissbluth's patients illustrating how difficult it is to set limits even though it is frustrating for both parents and children not to have them. As the mother writes, “We don't want to break her spirit.”

  “ONE MORE STORY”

  “One more story, Mama,” your two-year-old pleads. What parent doesn't feel conflicted when they hear those words? Books are good, you think; books are educational. And your child is on your lap, and she's warm from her bath and her hair smells sweet, and she's letting me hold her hand!

  Can you love your child too much? Never, and yes. If there ever was a question with two answers, that would be it.

  I think you can love your child so much that that love prevents you from setting clear limits and boundaries, from establishing effective structures and a sense of routine and order, which I believe children thrive on. The word discipline has harsh connotations for some parents, but in reality the word means “to teach.” And to teach is to love.

  My daughter Esme is two years old. The first years of her life have whizzed by and I've learned a lot as a first-time parent, especially about sleeping. Dr. Weissbluth helped me get Esme sleeping through the night by five months or so. Lately, though, our pleasant, orderly, structured bedtime routine seems to be deteriorating. Her bedtime is creeping later and later, and sometimes she's not asleep until nine or ten at night, and then, because she always gets her twelve hours, she'll sleep the next morning until 10:00. My husband jokes that it's like having a two-year-old teenager. I'm lucky to have a sympathetic husband. In fact, maybe he's a little like me—too sympathetic. Lately we find ourselves echoing each other, saying, “We don't want to break her spirit,” even though we intended to set limits and provide healthy discipline.

  Self-esteem

  How does one's sense of self develop? True self-esteem stems from the experience of competence and appropriate functioning. Self-esteem is a genuine sense of one's self as worthy of nurturing and protection. This allows us the capability of growth and development. As one's self-esteem is reinforced, a sense of competence leads to further increases in self-esteem. This positive spiral starts slowly and reinforces itself. This is a universal process occurring in both parents and baby.

  “When do I feed him?” “Is she getting enough milk?” “Do I pick her up?” “How do I stop this crying?” All of these questions are the beginning of creating a dance between parent and child. With the help of experience, innate abilities, and intuition, these questions become easier to answer and parents become more confident. Experience and knowledge often make parenting the second and third child easier. Therefore, as our children grow, our competence as parents increases.

  Infants are born with the capacity to organize experience, progressing to higher levels as they mature. Babies’ brains are programmed to work toward competency and efficiency. This ability expands as the child experiences more situations and develops the capacity to tolerate a wide range of stimuli. All exploration must be done in the context of a loving caregiver. Through the regulation of physiological functioning, emotional understanding, and interest in the world, infants grow. A baby who sleeps well and is well fed is more available to explore the world around her.

  Babies respond to cause and effect. As the mother or father coos and talks with their baby, he smiles and makes noises back. The parents’ continued responses to vocalization encourage more vocal production. Direct eye contact with your infant also encourages this dialogue.

  A child psychiatrist described how each infant needs a care-giver who can “attune” to the infant. Emotional attunement is a three-step process done by the baby's caregiver. First, the caregiver matches, labels, or identifies the infant's internal feeling state: The baby is hungry, tired, or sad. Then there is a recognition that the internal feeling state is different from the overt beha
vior, crying. Last, the caregiver responds to convey emotional resonance: “You are upset because you are hungry.” Attunement is not like looking in a mirror, imitating the behavior (“You're crying”); rather, it is reading the cues of the internal feeling state: Yes, the infant is crying and this is what it means. A mother of a six-week-old hears her son's cry knowing it is a hunger cry. When her baby smells her and feels that his mother is about to start breast-feeding, he quickly settles down, knowing that his dinner is coming. This rhythm was created by a repetition of a sequence that mom and baby learned. A wet-diaper cry can be differentiated from a hunger cry. As the caregiver responds to the baby's signal, babies become more organized, learn cause and effect, and feel more competent.

  Babies will respond differently to their fathers, mothers, siblings, and baby-sitters. Infants grow in the context of parents who try the best they can to be empathetic and to help develop their child's strengths and ideals. Early in life a child soaks up praise. “My child is the prettiest, smartest, cleverest, or strongest” can be choruses sung to our children. Tending to their needs with warm smiles is all part of this loving attitude.

  Your baby brings much to this equation, for she is born with her own innate level of tolerance and range for stimulation and arousal. Babies vary in endowment and maturation rates. This variability creates differences in how they experience initial and subsequent events. A mother or father each comes with his or her own endowments. How the baby-caregiver unit is formed varies greatly and creates the social environment of the child. This powerful unit brings changes to all parties.