Straight Talk About Sleep in Infancy, (Updated Pedcast)

Introduction

Welcome, I am your host, Dr. Paul Smolen.  It has 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 you and your infant.  You remember that whole concept before you had kids– you lay down and are not disturbed for 8-12 hours.  You sleep. Bliss.  A day doesn’t go by without me talking to a family with a serious sleep problem regarding their children. Like the family I spoke with recently.  Lovely people with a gorgeous child who came in for their infant’s six-month checkup.   I asked the standard questions about Johnnies 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 her children so in today’s pedcast, I am going to give you some simple tools to teach your children how to become good sleepers.  Don’t miss this important episode of Portable Practical Pediatrics.

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.  With regards to sleep ritual for healthy infants older than 4 months.  Most have found it useful and easy to follow, but some missed the major point on their first listen. Here is the critical point– make sure you create a sleep ritual for your older infants, ideally between 4 to 6 months old, that does not involve you, their parent.  A good sleep ritual in my mind does not involve feeding, rocking, singing, or allowing your child to get drowsy in any place other than their crib or bassinette. Because of these experiences, I now recommend that you listen to this podcast twice 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!

Musical Introduction

Sleep Advice for Tired Parents

So what advice did I give them?  How can we make things better for a family with a 6 and 11 year old sleeping in their parent’s bed and a six-month-old infant who is up all night demanding attention?  This is the western world and the entire family sleeping in one bed or on the floor in the same room is not necessary, practical, and healthy in my view.  I knew I had my work cut out for me. I know, I know, you “attachment parenting” fans aren’t going to like my advice about sleep but I think the advice I am about to give you is sound advice. Let’s just agree to disagree.

 

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.  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. So let’s start there. 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–we don’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 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, Johnny needs to make the transition to the adult pattern of falling asleep–he 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 Johnnies family is having trouble doing.

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 properly to be an independent sleeper, the subsequent children learn good sleep habits very easily as they grow.

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 that all through their childhood. Keeping them awake very late into the evening so they are exhausted and feeding them late at night as they fall asleep will certainly 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 is a Doc Smo pearl for you to remember;  “Anytime your child can learn to do something for themselves, that’s a good thing!”  Training your child to be independent at night if they are able is a good thing for them as well as for the rest of the family.

How is Infant Sleep Different from Older Children?

So let’s get started.  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 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. 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 not breastfeeding, just not feeding to induce sleep.

 

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 feature 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.

 

I find that babies need to learn how to put themselves to sleep by about six months of age or rocky times are ahead.  The training sounds difficult and scary but actually is easy and good for both you and your child.

 

Remember that Doc Smo pearl I just taught you:  all through childhood….”Anytime you can get your child to do something for themselves that is a good thing.”  because The ultimate goal of childhood is to create a happy, confident, self-sufficient adult.

 

How Do I Train My Baby to Sleep all Night?

The idea is to get parents out of bedtime and have an infant who can put itself into their own comfort position to fall asleep. That way they can repeat that process at anytime in the night.  Feeding needs to be gradually removed from bedtime.  This is not what you did when your baby was under 3 months of age but you need to trust me, this works.

 

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 Johnny cries. Go back in as often as you wish. Every few minutes are fine.  Pick Johnny up until he quits crying but not until he gets sleepy. As soon as the crying stops, put him back down.

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.

 

QuestionSo what do we do when Johnny awakens in the middle of the night?

Good question. Assuming Johnny 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, Johnny 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.  Problem solved.

 

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.

For additional information about sleep, check out my Safe Sleep pedcast or video on my website. Until next time.

 

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 itself 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 also now 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 the graphic linked in my Smo Notes.

 

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.

 

Smo Notes:

  1. Charlotte Observer- pdf (application/pdf Object)

http://www.charlotteobserver.com/images/graphics/post/safeSleepPoster.pdf

  1. SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment

http://pediatrics.aappublications.org/content/early/2011/10/12/peds.2011-2284.full.pdf+html

 

 

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26 Comments

  1. Taylor Wise says:

    You (and my amazing video monitor) were a lifesaver when it came to getting my son to sleep throughout the night! I don’t think Starbucks is appreciating the sudden downturn in sales now that mommy’s sleeping too!

  2. Laura says:

    This makes perfect sense! I desperately want to try this training with my 5 1/2 month old son. Can you recommend a toy that is safe for me to leave in the crib with my son to help him put himself to sleep? I don’t understand what an activity play center for a crib is? Just want to make sure we do this training correctly from the beginning so we can be persistent once we start. Thanks!

    • DocSmo says:

      An activity center is a toy that is tied to the side of the crib that has no loose parts. It usually has things like mirrors, spinning parts, and squeaking toys. In other words, something similar to a mobile but that can be attached to the side of a crib. Best of luck, let me know if you have any other questions!

      • Laura says:

        DocSmo you are our hero today, and hopefully for many more happy days ahead!

        Last night after listening to your pedcast, my husband and I spent about an hour scheming how we would go about with this “sleep training”. What each of our roles would be and every what-if scenario so we wouldn’t cave in and so on. By then it was getting late and our son was getting tired so we decided maybe we’d try another night. But after the normal bedtime bath and routine, I said oh what the hell. With a makeshift (but safe) activity center and a plush rattle and low expectations I laid my son in his crib awake and happy. With alot of perserverance and very little crying he had put himself to sleep without being nursed or held within ~45 minutes. I probably went to his crib 20+ times, but he got tired before I did! And then to my surprise he SLEPT THRU THE NIGHT. Unheard of at our house! At 4 am I heard him wake up and put himself back to sleep. Ironically, I was so excited I couldn’t sleep! I hadn’t been giving my son enough credit. It’s so clear now. I’m the one that taught him to wake up and nurse every 2-3 hours. It was time to send him a different message. So simple.

        From now on we won’t be so sloppy with our bedtime routine and the timing of our last feeding. Hopefully this will continue to work because I have big expectations now. Should we expect him to regress once he’s learned to put himself to sleep and sleep through the night or is it like learning to ride a bicycle so to speak?

        Thank you Dr Smolen!!

        • DocSmo says:

          Great work. You are creating a new sleep habit and this takes a few nights to become solid. Remember, you have provided the crib, done the laundry, paid the electric bill, paid the mortgage, tunes up the heat system, paid the real estate taxes etc and all you are asking of your infant is to lay down and go to sleep without assistance. Once mastered, HE and YOU will be better off. Encourage some time in the crib so he can play there during the day as well so it will become fun for him. Good luck and good work.

  3. Tanya says:

    What about a baby who is sleeping great during the 4-6 month period that is best for sleep training . . . then starts waking up repeatedly during the night at 8-9 months? Do you follow the 10-10-10 approach at that point?

    • DocSmo says:

      I encourage you to re-listen to the Pedcast. Most babies between 7-9 months have a strong fear of separation which frequently leads to sleep problems. Babies need to master the self soothing, “putting themselves to sleep ritual” by 7 months or rough waters are often ahead. Usually the difficulty starts just after an illness or travel when the infant may of had their sleep disrupted. Make sure your child has mastered the initial going to sleep without rocking, feeding etc and then the 10-10-10 is the ticket to good nights. Without the child mastering the initial sleep process without your help, the 10-10-10 is destined to fail. Talk to your child’s pediatrician if you are still having trouble. They can be very helpful.

  4. Christie says:

    Dr. Smolen,

    Our 4 month old has been sleeping through the night for the past 2 months so we decided this week that we would transition her to her crib upstairs. She continues to sleep through the night up there but will not take naps up there. She is accustomed to napping in her swing (swinging or not) so I’m sure that this is the problem as she settles right down after being put in her swing.

    Do you have any suggestions? I have tried to be consistent with putting her in her crib at naptime, but give in usually after 45 minutes of checking in every 3-4 minutes.

    I just don’t want her to be dependent on her swing for naps when she outgrows it or we go out of town.

    Thanks!

    • DocSmo says:

      Dear Christie, thanks for writing in, and sorry I’m just now responding. I’m happy to hear that your child is sleeping through the night in her crib, but the goal should also be for her to be able to take her naps in the crib or other safe sleep surface. Perhaps the issue is that she wants to be near you during the day. Have you tried a pack-and-play or other safe sleep surface that might be closer to you? Let me know how it works out!

  5. Jennifer says:

    My 21-months old twin sons are your patients. They have been pacifier free for 2 weeks and during this time they have not been sleeping through the night. I’m guessing they are waking up because they no longer have their pacifiers to help them fall back to sleep. Should I be using the 10-10-10 approach to get them through the night again? Or is there something else I should try now that they are older?

    Thanks!

    • DocSmo says:

      Dear Jennifer,

      Thank you for following the blog. I think you should definitely use the 10-10-10 approach. Remember, we all wake at night and need to put ourselves back to sleep. Your boys are used to using the pacifier for this purpose. They will learn an alternative approach to falling back to sleep if you give them a chance. Be patient. Good luck. Doc Smo

  6. Jaclyn says:

    My LO is 7 months old and I guess I read this too late.
    Do you suggest another way to sleep train at 7 mths or just stick with this approach and know it will be harder since he is 7 months.

    • DocSmo says:

      Dear Jaclyn,

      All is not lost. It may be a little harder to sleep train a 7 month old than a 5 month old, but certainly not impossible. Be kind but persistent. Expect some struggle for a few nights but it should fade away quickly. Follow the steps that I laid out, concentrating on the early evening sleep ritual. Babies who are independent going to bed at 7pm, rarely present their parents with sleep problems at 2am unless they are ill. Make sure you and Dad are not part of the getting drowsy routine in the early evening. Once you have succeeded in your sleep training, both “YOU” and “LO” will be better off. Good sleep at night is essential for families to function well, especially as your child approaches the challenges of toddlerhood. Good luck.

      Doc Smo

      • Jaclyn says:

        Thank you for replying! Night one only took a half hour! Amazing! We did exactly what u said. One more question. He normally wakes up a few times a night and for that we will do ur 10 10 10 method. However at 3 am he is very hungry. He does not drink all the milk he should during the day for a 7 month old. He eats his solids great about 2 or 3 times a day but only drinks average of 15 oz a day. We normally feed him at 3 when he wakes up bc we know how hungry he is. So now that we are doing you sleep training do we not feed him at 3 am even if he is hungry? I’m having a hard time with knowing he is hungry and not feeding him. We tr as hard as we can to get him the min 25 oz he should have but he refuses. Thanks!

        • DocSmo says:

          Jaclyn,
          Make sure you get all the feeding, rocking, reading, singing, and waking the floors OUT of the bedtime routine. When your baby gets sleepy, put him in the crib. Check on him frequently and reassure him it’s time for sleep. He’s tired and he’s in the right place: what is he going to do other than go to sleep? Once he learns to go to sleep on his own at 7pm, 2am and other night wakenings usually takes care of themselves with the 10-10-10 method. Feeding is allowed in the 10-10-10 method but only on the third 10. By the way, most seven month old babies eat three solid meals a day during the day and consume 15-32 of milk as well. I think you need to make sure he gets these feedings during daylight hours. That will solve your hungry at 3am problem. Try offering him water instead of milk at 3am if you must.
          Sleep training usually takes three to five nights to work. Be patient and it will work. You and your baby will be better off once everyone is sleeping at night. Good luck and thanks for following my blog.
          Doc Smo

  7. Lisa says:

    My son just turned 6 months old and I started putting him in his crib in his own room. He eats around 7:00pm and is usually ready for bed around 9:00pm. He doesn’t have any trouble putting himself to sleep. He sleeps pretty solid until around 2-3am. I have tried your 10-10-10 method for a solid week now. He tries to go back to sleep but I think he is too hungry. After I feed him (usually an entire 8 oz. bottle) he goes back to sleep on his own. He is always a big eater and I feel like he just can’t skip that nightly feeding. His normal feedings consist of an entire jar of baby food along with an entire 8 oz. bottle 3 times a day. How do I get him to sleep all night without having to always feed him after my third 10-10-10 approach?

    • DocSmo says:

      Lisa, Thanks for your question. You are on the right track. Be patient. He probably is hungry because he is used to eating at 2-3 am. His brain says hungry and he wakes. He has made the choice to fuss for 30 minutes (10-10-10) to get fed. He will get tired of that and eventually will wait till daybreak. Remember, he is about to start crawling and becoming physically active: that means getting more tired at night. He will get there. You just removed him into his own room, remember. Just be patient and I feel sure he will lengthen his sleep as long as his “going to sleep ritual” at 9pm doesn’t involve to much parent attention. It doesn’t sound like it does from your description. Most babies sleep through the night by the time they are 13-14 pounds. If he is that big, I feel sure he will be sleeping all night soon. Patience.

  8. Stephanie says:

    Doc Smo you are officially the baby whisperer at the Gardner house! Thank you for these easy to follow steps. After just 2 days Penelope is now falling asleep on her own in her crib and without crying! She slept 11 hours last night, amazing at 4 months! We just added the toy in the crib this afternoon and it seems to have really cut down on the tears. Excellent advice. Thank you!

  9. Anna says:

    Hi Dr Smolen, Im curious if it is at all possible to train our little one of 14 weeks with your method, but be able to use a variety of locations rather than just one, being her crib. Because of our work, we are daily in different locations and want very much to keep our little one with us, which we have been doing thus far. However; upon reading your post, I realize now, her nightly trouble is she cannot return herself to sleep on her own. Can we in fact incorporate different locations, or does that negate the true premise of the recommendations?

    • DocSmo says:

      Dear Anna, You can absolutely train your 14 week old to sleep in different locations. Your baby is getting to the age where he/she can learn to comfort themselves and return to sleep without your help. I think using different places to sleep, as long as they are safe sleep surfaces, is fine but remember, we don’t want to let your infant cry very long as they learn to put themselves to sleep. On the other hand, we need to give your child a chance to learn how to put themselves to sleep without you! At your infant’s age, learning to trust you and meeting their needs, trumps everything else going on. I don’t think you should let them cry/fuss more than 15 minutes at a time. Be patient, and ask your child to go back to sleep on their own, and they will learn to do so.

  10. Rayk says:

    Dr. Smolen,

    We are the grandparents working with the parents for this 6-month-old infant, and we care for him during weekdays. The parents are using your sleep training at night, but we are all unclear as to the best procedure for daytime naps. For the initial morning nap, he falls asleep fairly easily in his Pack-and-Play, but seems unable to nap in the afternoon, even though he becomes increasingly tired and irritable while crying fretfully. Should we be using the 10-10-10 procedure for daytime naps? What is your recommended procedure for daytime naps? Thank you for your helpful advice.

    Rayk

  11. Jen says:

    My LO just turned 1 years old and was sleep trained, however, she’s had several back to back illnesses that have made it hard to keep consistency. She also moved fully to cow’s milk so we’re now trying to transition her away from the bottle but she keeps waking up at night wanting to eat. She eat plenty of food during the day but we’re still working on getting her used to milk in a sippy cup. I think it’s more for comfort at this point.
    Is it too late to re-train her again? Do you suggest another way to sleep train at this age or just stick with this approach and know it will be harder since she is older? Also, what do you suggest we do if she wakes screaming for a bottle?

    • DocSmo says:

      Dear Jen,

      Thanks for your question. Remember, your daughter’s ability to put herself to sleep, without feeding, rocking, holding, is the skill she needs to acquire in order to be independent at night. It sounds like she is getting drowsy while feeding in the evening and this is now part of her expected sleep ritual. You need to create a ritual that doesn’t involve you and her being together. She is too old in my opinion to need feeding at bedtime. It is also not good for her dental health. I suggest you do her feeding at dinner time, play, and then put her to bed fully awake. She will resist for a few nights until she learns to put herself to sleep. Be patient.

  12. DocSmo says:

    Jessica says, “Just listened to your pedcast on sleep in infancy after our appointment on Tuesday. Isaac had a great day and his little cold seems about gone so I attempted his new sleep routine. After putting him down awake he has entertained himself to sleep! I didn’t think it could be done with this clingy little guy.. It appears I was enabling him to stay up late and play..
    What is your opinion of soft music or white noise machines? — feeling proud.”

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