Tuesday, June 26, 2012

Sleep, Changing Patterns In The Family Bed | Jay Gordon, MD FAAP

Sleep, Changing Patterns In The Family Bed | Jay Gordon, MD FAAP

I can only imagine a mom and dad who are as tired as anyone can be, eager to see this article on sleep, and finding that we had made it unavailable for a little while!

We had to do that because I didn't write the article clearly enough and need to clarify some very important facts.

It would be hard to find as strong a proponent of the family bed as I am. Yet, I have received email commenting that there were sections of this "plan" which were easy to misinterpret as being just another angle on "sleep training" for young babies. It is not meant to be that. Not even close to an endorsement of the benefits of getting your baby to "soothe herself to sleep" during the first year.

Here's what I really want to do: I want to offer an alternative to Ferber and Weisbluth and the Whisperer. I never want to see my ideas applied to a four month old or even a seven month old baby. As a matter of fact, I am not too excited about pushing any baby around at night but I know that sometimes it will be done and I'd like to offer a gentle, supported plan for after the first year.

Before I go any further, let me express my overriding concern. Babies do better when we answer all their questions as best we can and meet their needs as best we can.

Most of the families I have taken care of in my pediatric practice sleep in a family bed.

Their babies tend to breastfeed for more than one year and they don't sleep through the night any better than most of us would if we napped and cuddled within inches of the best restaurant in town and knew it was open 24 hours a day.

This arrangement is not just adequate and tolerable, but actually feels easier to moms who can just roll over, nurse a while and fall back to sleep with their babies rather having to get out of bed to nurse or, alternatively, refuse to nurse and get their babies back to sleep some other way.

Lots of parents continue this pattern through the first year and well into the second and beyond, but some get tired of it — or just plain tired — after a while and are looking for a way to change things. Saddest of all, some moms and dads think that total weaning from breastfeeding is the best way to get more sleep. They choose not to look into nighttime weaning as a good option instead.

There are dozens of confusing books and magazine articles implying that there can be some quick and easy way to get your baby to sleep or to not nurse through the night. I have yet to read one which told parents the complete truth: It's not easy, it's rarely quick and it's usually a little loud and heartbreaking for a few nights . . . or more. I have seen too many families needing help and getting offered choices they didn't like at all.

I have a better alternative to completely weaning or to letting the baby cry it out. Babies wake up for the optimal interaction with their moms, breastfeeding back to sleep. If we offer them a little less than that for a few nights and then a little less and still less in the ensuing nights, gentle behavior modification will lead them to realize that it might not be "worth it" to knock on the door of a closed restaurant, so to speak.

I don't recommend any forced sleep changes during the first year of life. Probably the only exception to this would be an emergency involving a nursing mom's health. There are many suggestions in books and magazines for pushing "sleeping through the night" during a baby's early months or during the first year. I don't think this is the best thing to do and I am quite sure that the earlier a baby gets "non-response" from parents, the more likely he is to close down at least a little.

Don't get me wrong. I love the family bed, child-led weaning and cuddling all through the first, second, third year or more if it's working well and if the family is doing well. Don't let anyone convince you that this is a harmful choice or that there will be "no way" to get him out of your bed if you don't do it now. Don't believe anyone who says that babies who cuddle and nurse all night long "never" learn to self soothe or become independent. This is simply nottrue but it sells books and the myths stay in our culture.

Some moms just don't want to do this after some months or years and there should be a third choice to the dichotomy of crying it out or giving in to all-night nursing. Again, I support the family bed and frequent night nursing for a long time and even attempt to pull some parents along "just a little farther," but I often have to switch tacks and support and help families with difficult choices.

Here's what I recommend for older babies:

Choose the most valuable seven hours of sleep for yourselves. I personally prefer 11p.m. through 6 a.m. but you might have a slightly different idea.

Change the rules during those hours and be comfortable that a "well-built" family bed baby's personality can withstand this rule changing and the mild inconsistency of getting everything he wants all the time . . .oops, almost all the time. That's the word we want to show this baby. The word "almost." If only we could explain to him that "tired moms and dads take their children to the park a little less and that children of well-rested parents get to go the zoo and for hikes a lot more than children of exhausted parents." If that explanation only made sense to kids somewhere before the third birthday (and it doesn't!) they would simply roll over, say, "See you in the morning," and let us get the sleep we want.

I try to do this in three- and four-night intervals.

I'm assuming that you have a wonderfully healthy 12-, 15-, 20- or 30-month old baby who still loves to wake up every 2 to 4 hours to cuddle, eat or . . . whatever. I'm assuming that you have thought this through, decided you want to make changes and alerted the neighbors that it might be a little noisy for a week or so.

I'm assuming that both parents agree — or almost agree — that this is the best thing to do. And, most important assumption of all, you are willing to go "in a straight line" to the goal of seven straight hours of sleep.

The reason for that last statement: If your baby learns that crying, squirming and fussing (euphemisms, let's just say "crying" . . . sorry) for an hour will get him fed you will set yourself back quite a bit. This is the best program I have seen but it's far from easy. And now, to say it again, I really like what you've been doing. Cuddling, nursing, hugging through the night. Don't change this with my program or any other if you're happy doing what you're doing. But . . .

The First Three Nights

At any time before 11 p.m. (including 10:58) nurse to sleep, cuddle and nurse when he wakes up and nurse him back to sleep, but stop offering nursing to sleep as the solution to waking after 11 p.m.. Instead…..

When your baby awakens at midnight or any other time after 11 p.m., hug him, nurse him for a short time but make sure he does not fall asleep on the breast and put him down awake. Rub and pat and cuddle a little until he falls asleep but don't put him back on the breast (or give him a bottle if that's what you've been doing). He must fall asleep with your comfort beside him, but not having to nurse to feel comforted enough to drift off.

Now, he will tell you that he is angry and intensely dislikes this new routine. I believe him. He will also try to tell you that he's scared. I believe he's angry, but a baby who's had hundreds of nights in a row of cuddling is not scared of falling asleep with your hand on his back and your voice in his ear. Angry, yes. Scared, no, not really.

During these first three nights, repeat this pattern only after he has slept. He might sleep for fifteen minutes or he might sleep for four hours, but he has to go to sleep and reawaken to get cuddled and fed again.

These will be hard nights.

You may have decided you're really not ready to do this. That's OK. Stop and start over again in a few months if you like. Choosing the right time is crucial and many people choose a time suggested or pushed by friends, doctors or in-laws. This doesn't work as well.

Is it better to do this in the family bed, a crib in the same room or using a crib in another room? I prefer to continue the family bed even though it might seem harder at first, but it has always seemed harder to me to be putting a baby in and out of a crib. However, a crib or toddler bed in your room may be what works best for you. Another option is to expand your bed's limits by placing another mattress against your mattress. A bit more space for each family member may help to solve some of the sleep issues. My least favorite choice is a crib or bed in a separate bedroom.

Again, during these first three nights, between 11 p.m. and 6 a.m., cuddle and feed short, put him down awake, rub, pat, talk until he falls asleep and repeat this cycle only after he's slept and reawakened. At 6:01 a.m., do whatever you have been doing as a morning routine ignoring the previous seven hours' patterns. Many babies will roll over, nurse and cuddle back to sleep and give you an extra hour or so. Some won't.

For me, one of the most reassuring parts of this "sleep plan" is seeing that babies wake up fine, happy and grudge-free about the change in the rules. You'll see what I mean, even if the first few minutes of the morning are not exactly as they've always been.

The Second Three Nights

Again, the nursing to sleep stops at 11 p.m. When he wakes up, hug him and cuddle him for a few minutes, but do not feed him, put him down awake. Putting him down awake is a crucial part of this whole endeavor because it really does teach him to fall asleep with a little less contact and then a little less. Not feeding is the big change during these three nights. One-year-old babies can easily go for those seven hours (or more) with no calories. Theylike to get fed a little through the night, but physiologically and nutritionally, this is not a long time to go without food.

If I could wake my wife a few times each night, ask her to squeeze me a little fresh orange juice (my favorite drink) and rub my back while I drank it, I wouldn't choose to voluntarily give up this routine. My wife might have some different ideas and get tired of the pattern quickly. Babies rarely give up their favorite patterns and things — day or night– without balking and crying.

I really don't like listening to babies cry. I actually hate listening to babies cry. Unlike them, though, we adults can truly understand the implications of lack of sleep for a family of three, four or more people. Sleep patterns sometimes have to be changed. The incredible safety and reassurance the family bed has provided, and continues to provide, supplies the best context and location for these changes.

During these second three nights, some babies will cry and protest for ten minutes at a time and some will go for an hour or more. Your toddler is aware that you are right beside him, offering comfort and soothing. It just isn't the mode of comfort he wants at the moment. It is hard to listen to him fuss, but it will work. I believe that a well-loved baby, after a year or more in the family bed, will be the ultimate beneficiary of his parents getting more sleep. Not coincidentally, the parents benefit "big time," too.

"Yes, for the past many months we have enjoyed voting "1 to 2″ — non-democratically — in favor of . . . the baby. 'Anyone want to get up all night, feed and walk the baby and be really tired all day and the next day too?' Well, the vote is 1 to 2 in favor of the baby."

Now, what we're saying is, we will sometimes be voting two to one in favor of the baby's family. This "baby's family" concept may be abhorrent to he who considers himself the King of England, or Emperor of the Whole World, but our knowing he has that feeling of power allows us to confidently demote the dictator to a majority-respecting member of the family. His family.

By the end of the sixth night, your baby is going back to sleep without being nursed or fed. He's going back to sleep after a nice hug, a cuddle and with your hand on his back and your words in his ear.

If, at any point this is feeling "wrong" to you, stop, wait some months and start over. Don't go against your "gut instincts" which tell you that this is the wrong time to get longer sleep intervals from your baby. Your instincts are better than any sleep-modification program ever written.

The Next Four Nights

Nights seven, eight, nine and ten. Don't pick him up, don't hug him. When he awakens after 11 p.m., talk to him, touch him, talk some more, but don't pick him up. Rub and pat only. No feeding either, obviously. He will fall back to sleep. Repeat the rubbing and talking when he reawakens. By the end of the ninth night, he will be falling back to sleep, albeit reluctantly for some babies and toddlers, with only a rub and a soothing voice.


After these first ten nights, continue to cuddle and feed to sleep if you like and he wants to, but do nothing when he wakes up except to touch a little and talk to him briefly. This may continue for another three or four nights but occasionally keeps going for another week or more. Then . . . it stops. He has learned that he is just as well-loved, gets virtually everything he needs and wants all day, but must give seven hours per night back to his parents and family.

What happens if you travel, he gets sick or some other circumstance demands a return to more nighttime interaction? Nothing. You do what you need to do (cuddle, nurse, walk, in the middle of the night, as many times as you need to) and then spend a night or two or three getting back to the new pattern the family has established.

By the way, pay the baby. Make sure that he really does get a lot of the benefit of your getting a good night's sleep. Go to the park more often. Do all those things with him you said you'd do if he ever let you sleep longer. Explain it to him as you're doing it. He'll understand in an ever increasing way and will be OK with all this.

A. Reyna

Sunday, June 24, 2012

How to get one year old to sleep through the night?

How to get one year old to sleep through the night?

Dr. Markham
I'm desperate to get some sleep.  Our 12 month old son is still sleeping in our bed.  Is it possible to get him to sleep through the night – in his own bed?!

Dear Exhausted,
The challenge with babies is that their genetic makeup is essentially from the stone-age. 

Whether you believe humans started off in the Garden of Eden or a primeval forest doesn't much matter.  The point is that moms didn't have to go to work the next day, and babies couldn't sleep by themselves without getting eaten by predators. 

So babies are designed to sleep with their moms.  When they wake slightly between sleep cycles – which all of us do – they don't put themselves back to sleep naturally.  They first look around for mom and make sure everything's ok.

So the bad news is that many babies do not fall asleep without being held, and do not sleep all night in their own bed, unless they are "trained" to do so.  It simply isn't a "normal" thing for small humans to do, biologically speaking.  But of course that presents a problem for parents who expect to get a good night's sleep so they can function the next day.

The good news is that if your baby is over a year old, you can teach him to put himself to sleep. I hasten to add that many families opt to continue to nurse babies at night well into the second year, and I was one of those moms. There is nothing wrong with that approach.  Sooner or later, your child will begin sleeping though the night.  Speaking from experience, as a teen your sleepless baby may well sleep a lot.

But I hear from many moms who have little ones over a year old and are so sleep-deprived they're considering sleep training.  Unfortunately, most sleep training methods are traumatic for the baby, and even for the parent. 

However, I'm happy to say that you can teach little ones to go to sleep in their own beds without leaving them to cry.  This is not an overnight process -- it can take weeks or even months -- but it definitely works.  It's just a matter or retraining their sleep associations.

Your goal  is to help your child sleep through the night.  For most babies and toddlers, that means helping him learn to fall asleep by himself, so he won't miss you when he goes through the stage of his sleep cycles when he wakes slightly.  This is a normal part of sleep for everyone, but we all know how to go right back into sleep so we don't even notice.  Your baby, unfortunately, moves into slight wakefulness and looks for Mom and Dad.

Often, however, when you teach your baby to put himself to sleep in the evening, he will then use that skill to put himself back to sleep during the night, and begin sleeping through the night.  The exception to this is kids who are still used to waking up to eat at night. Kids who sleep with their parents and nurse are more likely to insist on being fed at night for longer than other babies.  Is this because breast milk doesn't hold kids for as long as formula, or just because the snack bar is right next to them? 

We don't know, but it does mean that weaning your child from night feedings, once he's over a year old, is usually the first step toward getting him to sleep through the night. This is not a step to be taken lightly, and parents who opt for it should know that it will mean your little one will need to nurse (and eat) more during the day.

If you're ready for night weaning, the best way to do this is usually for Mom to sleep in another room for a week, so when Baby wakes up, Dad can rock him back to sleep.  (You don't have to rock him, but it will probably work faster than anything else.)  This isn't Ferberizing, because you never leave your child.  Dad is there comforting him the whole time, while he gets used to going without food at night.  It isn't really even sleep training, it's night-weaning. However, your child will certainly cry, and this is a very hard few nights. 

I personally do not think that kids need everything they want, even if they think they do, and I think night weaning is sometimes best for a family because it produces a well-rested mom. On the other hand, this is a lot to ask of your little one, and a big adjustment.  I would always advise you to hold out as long as you can before night-weaning.  I personally waited until my kids were old enough to at least understand what was happening.  

Kids in the family bed often seem to sleep better -- at least once they're night-weaned -- since they're reassured by their parents' presence, and since sleeping with the mother is certainly a natural state biologically for babies and toddlers. But clearly the Family Bed really isn't working for you, so you want your son to sleep by himself.  That means you need your son to learn to fall asleep by himself, so that then he can put himself back to sleep when he does wake up at night.

Start by teaching new sleep habits. 

1. Help your little one learn to fall asleep without sucking. If you've been helping your son fall asleep with feeding or rocking, he is likely to wake during the night unable to fall back to sleep until he is fed or rocked again and again.  Unless you want to rock or feed him to sleep over and over at night, your goal now is to help him fall asleep in his own crib or bed, comfortably.  That means putting him in his bed when he's awake, so that he can get used to falling asleep there himself.  Breaking his established habit can be challenging -- it's hard for him to understand why you can't nurse him or rock him now.  You can expect him to need your close physical proximity to settle down to sleep.

You can break the association with sleep completely by nursing or bottle-feeding your little one in the living room before beginning the bedtime routine.  Since sucking is a harder habit to break than rocking, you probably want to use a two step process.  First, get your child used to falling asleep without feeding, even if you have to rock him.  This is where having Dad put baby to sleep is great.  Mom can nurse the baby, or feed him, in the living room, and then Dad can take him in the bedroom and rock or walk him to sleep. Your baby may cry, but you know he has a full belly, and the comfort of Daddy. 

2. Help your little one learn to fall asleep lying still (in your arms).
Eventually, he will learn to fall asleep without nursing or a bottle. Once he's used to falling asleep being rocked or walked instead of eating, the next phase is to get him falling asleep without rocking.  So you begin with rocking, but then, before he is actually asleep, you stop rocking, and just sit holding him. If he protests, begin rocking again. Keep repeating this.  It may take 25 attempts, but eventually he will begin falling asleep even though you have stopped rocking. That's a real victory. Do this for a week or so until he's used to it as your new routine: getting sleepy while rocking and then falling asleep in your arms while not rocking. 

3. Help your little one learn to fall asleep in his bed.  The next step is to
 wait until Baby is almost asleep in the chair, then stand and hold him still in your arms in his sleeping position (on his back) until he is almost asleep and accepts the stillness. If he protests, rock him in your arms as he falls asleep while you're standing.  Again, do this for a week until he is used to this routine.

Next step is to begin lowering him into the crib or bed still awake although almost asleep.  When he protests, pick him up again in the rocking position and rock a little, then stop.  Keep repeating this.  It may take 25 attempts, but eventually he will let you put him in the bed without protest. Now you are almost home. 

Eventually, you will be able to put your baby in the crib and hold him there while he falls asleep, because he will not need rocking any more.  Then you move to touching, but not holding, your baby, while he falls asleep in the crib. Eventually, he will be able to fall asleep with you simply holding his hand, or putting your hand on his forehead. Keep doing this until he accepts it as your new routine -- getting sleepy rocking, but then being put into his bed lying on his back and falling asleep there, eventually without you even touching him.

Although this is a long process, the first few nights are the hardest.  If your little one is used to you rocking him to sleep, and now you won't do that, naturally he is likely to protest with vigor.  After all, he doesn't know how to go to sleep without rocking.  Your son is probably able to understand more than you think, and sometimes kids his age are helped by having you act out the new routine with stuffed animals.  He may still protest, but at least he understands more about what is going on.

What if he cries?  Your little one is learning new sleep habits, and that's hard for him.  He may well cry, especially at the beginning.  That's why I advise you to go very slowly.  If you feel your child is too upset, there is nothing wrong with trying again when he's older, or simply making your teaching more gradual. 

This is not "Ferberizing" which requires the parent to leave the room, even though you are actively "teaching" your child to put himself to sleep.  Throughout the process, while he learns this new skill, a parent is there offering comfort and sympathy.  Your child's deeper needs for connection and trust are always being met, he is never left alone to feel abandoned, wondering why Mom and Dad don't come to answer his cries.  And eventually -- within a few months, or even weeks -- your son will lie right down to sleep as soon as you put him in the crib, and will sleep through the night.  Sweet Dreams!

A. Reyna

Thursday, June 21, 2012

Sick baby.

Chilled most of the afternoon dozing in and off. She played after dinner and I just got her to sleep in our bed. figured shed be happier there up front. I can't take her to daycare without a doctors note tomorrow and since I can't get into see doctor until one, what's the point I'd she's doing mostly ok? Baby's had lots of kisses and hugs.


Wednesday, June 20, 2012

Olive at one year.

Starting to transition off bottles at school means no breastmilk during the day. Forced day weaning. I'm not comfortable with that but my hands are tied. She's healthy, so that's not an issue. I'm sad that we are close to ending this period of her life. At least she's not night weaning. Good grief, I need sleep. But we still have that. Guess I'll give her a bottle in the morning. Must research.

Wednesday, June 6, 2012

Anatomy of a somewhat bad day.

Awareness brought the realization that the power had gone out overnight. Fortunately, I had set my phone alarm and left it plugged in so I was able to have some peace of mind. Power did come back at some point prior to wake up.

Work. Dumb. I think being out for three weeks shielded me from the change happening because I've been walking around numb and frustrated with all the goings on.

Also frustrated and overwhelmed with the state of the house. Clutter everywhere and not enough energy to deal with it.

Self/Mom/Wife balance is currently precarious.

I miss cooking. And baking. Can't wait to teach Olive.

Olive giggles made the day so much better.