Excerpts From: "Guide To Your Child’s Sleep"

Birth Through Adolescence

Surviving the first few months

Getting your baby to sleep through the night

Making sense of common myths, theories, and controversies

Solving everyday problems and bedtime battles so the whole family can rest easy

George J. Cohen, M.D., FAAP, Editor-In-Chief

American Academy of Pediatrics

Avoiding Bedtime Battles So the Whole Family Sleeps Well

Sooner or later, almost every parent must deal with a child's sleep time problems. In early infancy, the first task is to help you baby learn to sleep longer at night and stay awake for increasingly longer periods during the daytime. A few months on, separation anxiety makes its first appearance. During this phase, which may come and go for at least a year and possibly much longer, parents have to persuade their child over and over again that they're around to protect him, that it's safe to go to sleep, that "Good night" doesn't mean "Good-bye forever!"

Other issues crop up throughout childhood. Each one is different, just as each child is unique. And yet the problems fall into predictable patterns, such as bedtime resistance, nighttime fears that keep a child sleepless, the midnight rambler who roams the house, the child who insists she can only sleep in her parents' bed. As each new problem arises, parents not only implore, "How can we get our child to sleep?" but also wonder, "When will we ever get a night's sleep?"

While sleep disturbances are common in childhood, they shouldn't be ignored. One study of 3-year-olds receiving treatment for sleep problems found that 84 percent of the children had had their problems since infancy. Another study showed that college students with sleep troubles had had similar difficulties since early childhood.

Unlike some minor behavioral issues, sleep problems usually don't just go away if you ignore them. Troubles with sleep can dog youngsters throughout the school years, causing difficulties with learning and behavior. The good news is that no matter what your family’s specific problem may be, it’s never too late to take steps to correct it.

When To Draw The Line

Our 3-year-old son refuses to sleep alone and instead goes to bed with my husband and me between 9:30 and 10:00 most nights. Our 6 year-old daughter has no problem going to her own bed on time at 8:00 PM., but in the middle of the night she also squeezes in with the rest of us.

Sleeping on his own is not my son's only problem, or rather, my problem. He refuses to fall asleep; keeps telling me he wants to play; wants me to get up and watch a video or TV with him; and often yells--until our ears are ringing--that he does not want lights out. This is hard because I need to get up at 5:00 AM to be at work by 7:00. My son also refuses to take scheduled naps; he only naps when his eyes literally close. If his sitter tries to put him to bed during the day, he screams that he doesn't want to nap--he wants to play.

How can we help our children not be afraid of sleeping on their own?

Children are happiest when they know who's in charge and what their limits are. Your son, at 3, is far too young to know what's best for himself or the family; however, because he's unsure of how far he can go, he constantly tests the boundaries. It's time to lay down some rules and enforce them.

You and your husband must agree on a plan and keep to it. In doing so, you will not only help your children to sleep better, but you will also teach them to consider other people's needs and feelings. Unless you do this, your son may have a difficult time getting on with playmates, adjusting to school, and eventually, dealing with life in the wide world.

First, tell your children that from now on, everybody sleeps in his or her own bed. This will let all the family get the sleep you need to work and have fun in the daytime. When your children get up at night, stay calm and lead them back to their own beds. Remember, your son will welcome even negative attention as a reward, so don't get upset, silently count to 10 if it helps, and keep your interaction with him on a low and unemotional level.

Second, set up new rules for TV/video watching and computer games, allowing a maximum of 1 to 2 hours a day, and in the daytime only. Select the programs your children watch, filter out violent shows and games, and choose materials suitable for your children's age group. Move the set to an inconvenient location-the basement or garage if necessary to enforce the new policy.

Third, when your son wants to play at night, tell him it's not playtime, it's sleeptime. Let him have a book and one or two soft toys to play with quietly in his bed. Leave a night-light in his room and try the "in bed-door open, out of bed-door closed" method to keep him in his room. However, before you go to bed, shut the doors to all sleeping rooms. The American Academy of Pediatrics recommends that doors to sleeping rooms be kept shut at night as a fire safety measure. Make sure that your child's room is "childproof"-free of breakable or hazardous objects.

In making these changes, you may endure several nights of noise and disruption, but if you are calm and consistent, your children will accept the new rules and your whole family will enjoy better sleep and a more pleasant and restful atmosphere.

Finally, don't be afraid to set limits; your children are asking for them.

Your Baby Cries At Night

During the first several months, the best way to manage crying is to respond promptly whenever your infant cries. It's impossible to spoil a young baby by giving her attention; if you answer her cries for help, she'll cry less overall.

When attending to your crying baby, try to address her most urgent problem first. For example, if she's cold and hungry and has a wet diaper, wrap her to warm her up, change her diaper, then feed her. If her crying has a desperate quality, suggesting she's in pain, quickly check for an open diaper pin or a strand of hair wound around a finger or toe. When your baby is calm again but still awake, put her back in her crib, say your good nights, and leave the room.

If she cries again after you leave, give her a few minutes to settle on her own. Many babies go to sleep more quickly if left for a while. If the crying keeps up, repeat your visits at increasingly longer intervals, but no longer than 10 minutes at a time. Keep the room dim, speak quietly and no more than you have to, and avoid picking your baby up.

Swaddling Can Help An Infant Sleep

My 6-week-old infant thrashes about and cries out when he sleeps. He continually hits himself in the face and wakes up. Is this behavior normal? How do I help him to sleep better?

Many infants move about and whimper in their sleep. They sometimes wake themselves because they cannot yet control the movements of their hands and arms.

One way to help your baby, until he has better motor control, is by swaddling; that is, wrap him from the shoulders down in a sheet or a lightweight receiving blanket. Some babies sleep well if they are swaddled firmly; others seem to prefer a lighter wrap that lets them keep their arms partly free. An infant may also sleep better if, in addition to being swaddled, he is placed on his back with his head and body braced against the end and side of the crib and cushioned by the bumper.

The Solid Food Myth

My baby is almost 3 months old, and still wakes up hungry at least once or twice during the night. My mother insists that I could solve the problem by giving him some cereal in the evening. However, my pediatrician says wait another couple of months before starting solid foods. Who's right?

Follow your pediatrician's advice. Your mother's generation tended to introduce solid foods earlier than pediatricians now recommend. Even so, there's no relationship between starting solid foods and sleeping through the night. Many babies start sleeping through the night before starting solid foods, while others still want a nighttime feeding even though they are eating solid foods during the day.

Learning New Sleep Associations

My son, now 3 months, had reflux when he was born, so he had to be held upright for 10 to 15 minutes after feedings. He would always fall asleep during this time. Even though he no longer has reflux, he has gotten used to being held and now wakes up several times during the night just to be held. After I have held him for 10 minutes he falls back asleep, but wakes up every 1 to 2 hours to be held again. How do l break him of this habit?

While you held your baby to prevent his stomach contents from flowing back into his esophagus, he enjoyed the sensation of being cuddled or rocked to sleep. Now your challenge is to help him learn new positive sleep associations. Cuddle and quietly play with your baby during your bedtime routine, then put him in his crib sleepy but still awake. Place a small, soft toy in his crib where he can see it as he falls asleep and wake up to it in the morning. Eventually he may adopt it as his "lovey" or transitional object-a further aid to relaxation and sleep. Leave the room and return at increasingly longer intervals to pat your baby gently and reassure him with your voice, but don't pick him up. Manage further wakings during the night in a similar way:

Go to your baby's room, leave the lights off (except a night-light), pat your baby and speak softly to him, but don't pick him up. Leave the room when he is drowsy but still awake.

How Long Should Babies Sleep On Their Backs

Now that my 5-month-old baby is rolling over by himself, is it safe to let him sleep on his tummy? If not, what is the best way to keep him on his back?

The American Academy of Pediatrics recommends that parents place healthy infants on their backs to sleep, to reduce the risk of sudden infant death syndrome (SIDS). The number of cases of SIDS has been cut in half since babies have been placed on their backs, instead of their stomachs, for sleeping.

We don't know exactly how long babies should sleep on their backs; however, once a baby can roll over (this generally happens between 4 and 7 months), he's usually past the highest-risk time for SIDS. There's probably no need to roll him onto his back or prevent him from changing position.

Night Waking In A Good Sleeper

My 6-month-old baby used to sleep all night but suddenly, without any reason, is waking in the middle of the night. He is not teething, hasn't been sick, and is growing and developing well. What could be the cause?

Waking phases come and go, often without any explanation, in the first few years. As long as your baby is healthy, well fed, and comfortable (bedroom not too warm or cold, diaper not soaked and clammy), this may be just a stage in his development.

It is also likely that your baby is experiencing the onset of separation anxiety, a normal developmental stage in which the child fears the loss of his primary caregiver and becomes wary of unfamiliar faces. During this period, infants and toddlers often wake once or many times in the night and may even call for one parent in preference to the other.

When your baby cries, give him a few minutes to settle down on his own. If the crying continues, keep the lights dim as you check to make sure everything is all right, pat your baby and reassure him but avoid picking him up, and leave his room again as soon as he is calm but still awake. During the daytime, play lots of variations on "peek a boo" to help your baby develop confidence and anticipate your return.

Give Sleep A Chance

My daughter, who is 7 months, seems to have a problem with falling asleep by herself or staying in her crib at night. She doesn't have a problem with naps during the day. I have tried various ways except for "letting her cry"; I don't feel comfortable with that idea. She falls asleep in less than a minute when her head touches our mattress, so she sleeps in the family bed at night. Now, after 7 months of sharing, I'm not getting enough sleep, my back hurts, and my husband has moved to the couch. How do I get her to sleep in her crib?

The answer is not to let her cry, but rather, to let her fall asleep. Your baby falls asleep without difficulty when you leave her in her crib for daytime naps. However, she can't do so at night because she is always moved to the family bed before she's asleep. Thus, she's learned that the family bed is where she sleeps at night and has become used to going to sleep on your mattress.

Help your baby learn some new sleep associations. Put her in her crib sleepy but still awake. Leave a night-light on or leave the door ajar so light shines in from the hallway; she may feel uneasy when her room is totally dark. After saying your good nights, leave the room and give your baby time to settle. If she continues to cry, return at increasingly longer intervals (between 5 and 10 minutes) to pat or rub her and quietly soothe her with your voice, but don't pick her up.

Be consistent, to make the learning process easier on your baby. If you pick her up, she will expect to be carried to the family bed. When her rhythm is disturbed in this way she is likely to become wide awake, and then have to start falling asleep all over again.

Night-Time Waking

Our 15-month-old is having terrible sleeping problems. He goes to bed around 9:00 PM, wakes up at 1:00 AM, and is wide awake until 4:00 AM. Then he sleeps until 8:00 and stays up until his 1-hour afternoon nap. How do we break this pattern?

As long as you provide entertainment at night, your child will wake up for it. If the TV/VCR is in his room, move it out. Keep the bedroom dark, with only a night-light to orient your child. When he wakes up, comfort him but don't turn on the light, and speak no more than you have to. Tell him it's time to sleep and all the Sesame Street people are asleep, too. Make sure he has a cuddly toy-perhaps a Sesame Street character-or another transitional object to comfort himself with as he falls asleep.

It may take some time for your toddler to learn a new sleep habit, but if you are consistent, he will sleep through the night and perhaps nap longer during the daytime in order to get the necessary sleep that children require at his age.

The American Academy of Pediatrics recommends that youngsters watch TV and videos (and when older, play computer games) for no more than 1 to 2 hours a day. The Academy recommends no TV or video watching at all for children under age 2.

For children who do watch TV and videos, there should be no viewing in the hour or so before bed, to help them sleep. It's not only scary programs that promote wakefulness; the lights, images, and sounds also stimulate the nervous system and can keep youngsters awake.

How To Deal With A Different Point Of View

Friends encourage my partner and me to allow our baby to sleep with us in a family bed. They warn us that our failure to "nighttime parent" will cause our child to be insecure and that our approach-having our child sleep in a crib and letting him cry for a while as long as he's not uncomfortable-is inhumane. This method has worked for us; our child sleeps well. Of course, if he awakens during the night and cries persistently, we go in at once to see if anything's wrong. However, I now feel guilty about doing something that others consider to be child abuse. Could a method that works so well be wrong in the long run because, as our friends claim, it promotes psychological damage?

Time and again in this book, we emphasize that there are few cut-and-dried solutions to children's sleep problems. The best solution is the one that works for your family.

It sounds as if you have found such a solution: Your child sleeps well and receives as much nighttime parenting as he needs. There is no evidence that the approach you have adopted leads to psychological problems. Thank your friends for their suggestions, chalk them up to differences of opinion, and let it go at that.

Gagging And Throwing Up: Proven Scare Tactics

My son, age 2½, has always gone to sleep with either Mom or Dad lying beside him. Now we're trying to break the habit and get him to go to bed by himself. The problem is, he cries to the point of gagging and almost throws up. Help!

We don't recommend that you leave your toddler to cry until he's too worked up to sleep. However, gagging and throwing up are not harmful in themselves, and some toddlers deliberately gag and make vomiting sounds because they know it's a shortcut to parental attention. A few episodes of minor gagging and throwing up may be an inconvenience you have to put up with to help your child reach the important goal of settling by himself. To make clean-ups quick and easy, put two sheets on the mattress, so you can whisk the soiled one away without having to remake the bed.

Keep this necessary transition period less upsetting for your child by following a regular bedtime routine. Try the "odd job" method of gradual withdrawal or sit quietly either in your child's room or in a chair just outside the door, where he can still see you as he becomes sleepy. You may have to follow the same procedure several nights in a row, perhaps moving your chair farther from your child's bed and closer to the door until the new habit becomes an established one.

Parents With Opposite Points Of View: Which One Is Right?

My 2½ -year-old daughter often wakes and cries in the night. After we have calmed her, she stays quiet for a few minutes but then starts crying for us again. My wife wants to let her cry herself back to sleep, but l feel I must go back and calm our little girl by gently rubbing her back. When she cries, I can't sleep, but my wife says I am setting our daughter up for a lifetime of sleep problems. Should we let her cry or is it all right to go back for a few minutes?

What's important is that you and your wife agree on an approach and join forces to put it into practice. Even if you are not setting your daughter up for a lifetime of sleep troubles, you may unintentionally be giving her the message that "divide and conquer" is a sure path to power. In other words, if Mommy says, "No," go ask Daddy.

Once your toddler is calm and drowsy again, pat her a couple of times and leave the room. When you keep going back as soon as you hear a whimper, you reinforce her crying, instead of helping her comfort

herself and fall asleep.

Perhaps this is a point where the more objective parent needs to take charge. If you find the crying intolerable, invest in a pair of earplugs and let your wife attend to your daughter's subsequent wakings during the night.

If At First You Don't Succeed... Don’t Give Up

We have a 3-year-old son and not one night goes by without his waking up and coming into our room to sleep. I'll bring him back to his room three or four times before I finally give up and lose the battle. Is there any way we can all get a good night's sleep?

Your question suggests that you already know the answer. As you say, you "finally give up and lose the battle," and in doing so you teach your 3-year-old that persistence is the key to success. He knows that after three or four trial runs, he will eventually get what he wants.

To reprogram the behavior, you will have to demonstrate similar persistence, and return your son to his bed every time he gets out. This may mean a higher level of sleep disturbance for several nights, but your youngster will catch on. If you prefer to head him off before he reaches your bedroom, try hanging a small bell on his door to wake you when he leaves his room. And if he is unusually persistent, you may have to stay awake long enough to train him with the "in bed-door open, out of bed-door closed" approach (see below).

If you use this method, don't forget to shut his bedroom door after he's asleep, as a fire safety measure.

"Odd Jobs:" A Way To Foster Independent Sleeping

My 3-year-old daughter won't go to sleep unless my husband or l stays in the room. She says she's afraid now, but will sleep alone when she gets bigger. When do children grow out of this fearful phase?

Your daughter has no incentive to go to sleep on her own as long as company is available. However, it may be too much to expect her to make a major change in one go. The "odd jobs" approach may be your answer. When you have completed your bedtime routine and settled your daughter in her bed, tell her that Mommy and Daddy have things to do in another room. (Be specific: tell her the kitchen, the laundry, or any room you choose). You will listen out for her and you'll be back in just 5 minutes. If she's upset at this plan, put a clock in her room and show her where the hands will be or what the numbers will say when it's time for you to come back. Leave the room and return in 5 minutes-no more, no less. If she cries or calls for you, answer from outside her room, but don't go back in until the 5 minutes are up.

When you go back, praise her for staying in bed, cuddle her if you like but don't let her get out of bed, then leave again on another errand, for perhaps a little longer. Make this your practice for the next several nights. Find increasingly time-consuming tasks to do in another room, but always go back briefly to your daughter's bedroom at the time you promised, even if you think she's asleep.

She may resist your leaving the first few times. But as she becomes confident that you will return, she will relax, get drowsy, and eventually fall asleep.

A Three-Year-Old Who Will Not Sleep In Her Room

My daughter, who just had her third birthday, will not sleep through the night in her room. She falls asleep in the living room and then we put her into bed. A short time later, she wakes up and wants to go back into the living room. How do we get her to fall asleep in her room?

Your daughter is comfortable in the living room because that is where she's used to falling asleep. She will enjoy sleeping in her bedroom if she learns to fall asleep there.

Establish a consistent bedtime routine (perhaps stories, hairbrushing, putting toys to bed) that takes place entirely in your daughter's room. If there are playthings that she regularly uses in the living room, perhaps they could be moved into the bedroom.

Tuck your daughter into bed when she's awake and relaxed, say your good nights, and leave the room. If she gets out of bed, try the "odd jobs" or "in bed-door open, out of bed-door closed" technique. If she wants to be in the living room to stay up with the adults, explain that it's bedtime, and her bedroom is for bedtime while the living room is for daytime.

In time, your daughter will form positive sleep associations in her bedroom and learn to fall asleep there in preference to taking over the living room for sleep.

A Three-Year-Old Waking To Nurse

My son just turned 3 years old and still is not sleeping through the night because he wakes up to breastfeed. How do I stop this?

The decision to stop breastfeeding is a highly personal one and varies considerably according to cultural customs and individual preferences. However, by age 3, your child no longer benefits from the maternal antibodies that protected him in infancy, and he should be getting all the nutrients he needs from a varied and balanced diet. By now, he is waking up out of habit and not because he is hungry and needs to nurse.

You may either explain to your child that the time for nursing is over and no longer offer him the breast at night, or you may shorten the time for nursing by about 2 minutes for several nights in a row, until you have reached a duration minutes, then stop offering the breast altogether.

In either case, your child will probably continue to wake up at night, since this is his habit. If he cannot settle back to sleep without a drink, as he is used to, let him have a small drink of water in a cup. Do not offer a bottle or suggest milk or juice. Your son does not need these fluids for nutrition at night, and the sugars they contain can remain in his mouth as he sleeps and foster tooth decay.

Help your child settle back in his own bed, and leave the room while he is drowsy but still awake. Both you and your son may need a little time to adjust to the new system.

A Four-Year-Old Night Owl

Our daughter, age 4½, is a night owl. We manage to get her into bed by 9:00 and turn the lights out by 10:00, but she often plays in bed until after midnight. Needless to say, it's difficult to rouse her for childcare at 8:00 the next morning, although she is fairly alert by the time she arrives at school. She naps on weekday afternoons but not on the weekends; however, even then she will not go to sleep earlier. Do night owl tendencies run in families?

While the world seems to be generally divided between early-rising larks and late-retiring owls, there is debate about the influence of nature versus nurture on the development of these characteristics. In any case, a natural tendency can be modified by scheduling that regulates the body's circadian rhythms. These rhythms, which play a key role in our readiness for sleep, naturally function according to the 24-hour solar cycle of daylight and darkness. But if not regulated by events that take place about the same time every day--exposure to light and darkness, eating, sleeping, and waking in the morning--the circadian rhythms tend to shift steadily later.

Your daughter's late sleep phase (the hours spent asleep and awake) and daily rhythms probably caused no problems when she was younger, but now her schedules for rest and activity are in conflict. Her cycles should be adjusted to help her fall asleep earlier and, consequently, wake up better rested to get more out of her school day.

The most important stimulus for the sleep/wake cycle is waking in the morning. Therefore, in resetting your child's schedule, keep strictly to the same wake-up time every day, weekends included, and make bedtime 15 minutes earlier every 2 or 3 days until you have settled at the target bedtime. While this adjustment is going on, limit afternoon naps to an hour. Avoid very stimulating play near bedtime. By age 4, many children are ready to give up naps. Once your daughter's sleep phase is reset, you may find that she goes without her afternoon nap in favor of an earlier time to fall asleep. It is often necessary to keep the same schedule 7 days a week to prevent relapses.

Waking Too Early

My 5-year-old gets up too early. His bedtime is 9:00 PM (changed from 8:00 in an effort to delay his waking) and he wakes up between 4:00 and 5:00 AM. 8y noon he's tired out. Unfortunately, he was assigned to a kindergarten class that begins at 12:30. He's irritable and sometimes behaves disruptively, and usually wants to take a nap in the middle of class. We've installed dark shades in his room (it's still dark when he wakes, anyway) and we don't know what else to do. Should we keep him up even later?

Buy an inexpensive clock-radio for your son's room and set it for 7:00 AM (or any time you choose). Tell your son that from now on, he must stay in his bed until the radio switches on and the numbers read 7:00. He may play with toys in bed or browse through a book if he wakes early, but he may not turn on any lights apart from the nightlight, or leave his bed except to use the bathroom. If there's a TV or VCR in his room, move it out. Go to his room, if you must, to make sure that the lights are off and he is in bed, according to the new rules.

Go back to an 8:00 PM bedtime, but allow for a regular winding-down routine, including listening to stories or quiet music but no TV or videos, before lights out at 8:45 or 9:00.

If you follow this schedule consistently for several weeks, your son's sleep phase (the hours spent asleep out of the 24) should shift until he is returning to sleep after his early waking. Eventually he may remain asleep until the alarm goes off. However, you must be prepared to accept the fact that your son may be a naturally early riser who also needs less sleep than the other members of the family.

"In-Bed-Door Open, Out Of Bed-Door Closed" Approach

It's never acceptable to keep a child' room door locked at night. In case of an emergency, such as a fire, the child cannot get out of a locked bedroom and the parents may be unable to unlock the door in time. Moreover, a child forcibly kept in her room behind a locked door will not develop the self-control to stay there willingly. And if a resentful child is forced to stay unsupervised in her room, she may injure herself or damage objects in the room.

However, when you are dealing with a persistent nighttime rambler, the door can be a useful aid. Many youngsters prefer to go to sleep with the bedroom door ajar. Tell your child that as long as she remains in bed, the door can stay partly open. The moment she gets out of bed, the door will be shut.

As with any approach to discipline, this one won't work unless you consistently follow up your words with actions. At the end of the bedtime routine, allow one last chance to go to the toilet or have a drink of water. After you leave the bedroom, stay near the door so that you can respond immediately. If your youngster gets out of bed, shut the door at once; when she gets back into bed, open it. The lesson will take only if you respond every time your child makes a move. As long as you do so, your child will probably need no more than two or three nights to learn to stay in bed.

When your child is asleep and before you go to bed, shut the doors to all sleeping rooms. The American Academy of Pediatrics recommends that doors to sleeping rooms be kept shut, but not locked at night as a fire safety measure.

"Guide to Your Child’s Sleep" is available from the American Academy of Pediatrics:

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