Solve Your Child's Sleep Problems

Part I

Your Child's Sleep

Chapter 3

Helping Your Child Develop Good Sleep Practices

We all have our own ways of interacting with our children at sleep times and different means of shaping their sleep habits. These differences occur among families, ethnic groups, and cultures. The sleeping child may be swaddled, lightly clothed, or naked; he may sleep in his own room or share a room with brothers and sisters, or the entire family may sleep in a single room, even in the same bed. The child may sleep on his stomach, side, or back, in a room that is dark, dimly lit, or brightly illuminated. It may be quiet, or there may be noise: constant sounds from a humidifier or air conditioner; intermittent sounds from a radio, television, or traffic outside; or occasional noises from airplanes, sirens, and other children. He may fall asleep nursing at the breast, sucking on a bottle or pacifier, rocking in a chair, or lying alone in bed. He may say good night downstairs and go to bed by himself, or fall asleep only after having a story read to him, saying his prayers, playing a quiet game, or discussing the day’s events. A child may go to bed at different times every night with no set routine, or he may follow exactly the same routine each night.

Considerable variation among routines exists, but not all routines work equally well.

The Importance of Your
Child’s Bedtime Routines

Although I do believe some bedtime rituals are better than others, there are few absolute rules regarding sleep behavior. If your routine is working—if you and your child are happy with it, if he falls asleep easily and night wakings are infrequent, if he is getting enough sleep, and if his daytime behavior is appropriate—then whatever you are doing is probably fine.

However, it is important to keep in mind that some routines and approaches are more likely to help your child develop good sleep patterns now and avoid problems as he gets older. For example, if you are in the habit of rocking your child to sleep (or rubbing his back, or any similar custom) for twenty to thirty minutes each night, and you need to repeat the ritual once or twice in the middle of the night to get him back to sleep, you may actually be interfering with his sleep and delaying his ability to sleep through the night. Even if you “don’t mind” waking up, I suspect you would be happier if you could simply put him down easily at bedtime and have him sleep through the night as well. Whether or not you mind having your own sleep disrupted, you should still be aware that it is in your child’s best interests to sleep through the night without interruptions. The kinds of bedtime rituals and routines to consider include all the activities that take place as your child prepares for bed and while he falls asleep. If he is an infant, you probably change his diaper and then hold him until he falls asleep. Perhaps you rock him and nurse him until sleep comes, then move him to the cradle, crib, or bed. Or your infant may still be awake when you put him down, so that he falls asleep on his own. Generally any of these patterns are fine in the first few months, when you cannot expect your baby to sleep through the night anyway. But by about three months of age most full-term healthy infants are able to sleep through most of the night. If your baby still has more than one or two nightly wakings at that age, or if he still hasn’t “settled” (started sleeping through the entire night) by five or six months, then you should take a close look at his bedtime routines. If your child is always nursed or rocked to sleep, he may have difficulty going back to sleep alone after normal nighttime arousals. To help him sleep better at night, you may have to change some of his routines. For instance, it is very important for some children to be put down awake so that they can learn to settle themselves and fall asleep alone both at bedtime and after nighttime wakings (see Chapter 4).

As your child gets older, bedtime routines remain important. If bedtime is pleasant, your child will look forward to it instead of becoming fussy when the time approaches. Bedtime rituals differ, of course, and you should choose a routine that suits your family, but make sure you always allow enough time to spend with your child each night. Follow the routine as consistently as you can. Your child should know when he has to change into his pajamas, brush his teeth, and go to bed. He should know what bedtime activities are planned and how much time will be spent on them, or how many stories will be read.

Bedtime is often a time of separation that can be difficult for many children, especially young ones. Simply sending a toddler or young child off to bed alone is not fair to him, and he may even find it scary. It also means you will miss out on what could be one of the best times of the day. So set aside ten to thirty minutes to do something special with your child before bed. The final routine should take place in the room where your child sleeps so he will learn to look forward to going there. If it takes place elsewhere, then he’ll learn that he must leave that pleasant place to go to bed, and the bed or bedroom can take on negative associations, signaling the end of that happy interactive period and perhaps the start of a separation. If a child is to fall asleep alone, it should be the parents who leave: he should stay where he just had an enjoyable time. Avoid teasing, scary stories, and anything else that will excite your child at this time—save the wrestling and tussling for other times of the day. You might both enjoy a discussion, quiet play, or story reading.

But let your child know that your special time together will not extend beyond the time you have agreed on and then stick to those limits. It’s a good idea to tell your child when the time is almost up or when you have only two or three more pages to read. Don’t give in to demands for an extra story: your child will learn the rules only if you enforce them. If both you and he know exactly what is going to happen, you’ll avoid the arguments and tension that can arise when there is uncertainty (see Chapter 5).

Paul is a four-year-old boy. His father leaves for work early in the morning and doesn’t see Paul until dinnertime. He likes to be the one to put his son to bed; if he weren’t, the two would not have any time together until the weekend. So the period from seven o’clock to eight o’clock each night is special for both of them.

At seven, they play together with Paul’s racing cars or Lego set for about twenty-five minutes; in warm weather they sometimes play outside. Paul’s father tells him when it is about 7:25, and then the bedtime routine begins. Paul has a bath and his father helps him put on his pajamas. Often they read a pleasant children’s novel, one chapter each night. Both Paul and his father look forward to the night’s reading, and Paul enjoys the bedtime routine rather than resisting it. Paul’s father warns him when only a few pages remain in the chapter. When the reading is over for the evening, the light goes off and the night-light is turned on. Paul kisses his father good night, curls up with his stuffed monkey, lets his father leave the room, and goes to sleep.

In later years, your child will still appreciate having some time with you before he goes to sleep. He needs close, warm, personal time, something that simply watching television together, for instance, will not provide: even if the shows are not exciting or scary—which is unlikely—and even if you are sitting next to him, the lack of direct personal interaction makes this bedtime routine a poor one. Instead, use the time to discuss school events, plans for the weekend, soccer, dance class, after-school programs, or music lessons. It might also be helpful to talk about any worries your child may have, so he will be less likely to brood over them in bed. (Use common sense, however: in some cases, it may be better to have that discussion during the day, to avoid giving him something new to worry about at bedtime.) As your child gets older, you can begin to vary the bedtime ritual from night to night. Some nights you may enjoy a walk outside, a trip for ice cream, a board game, Ping-Pong (if it isn’t too exciting), or helping with homework.

An eleven- or twelve-year-old may already want privacy as he readies himself for bed: he may want to read, listen to music, or spend time on a hobby before he turns out the light. But do stop in to say good night and chat for a while. A final routine before bed is still important, even though he can now handle everything himself. He should see that you still enjoy that time with him, that you remain available to help with problems or concerns, and that ultimately you are still the one in charge, preventing his routines from going too long or otherwise becoming inappropriate.

Emily, eleven, has a good bedtime routine. After dinner she finishes her homework, practices piano, and sometimes calls a friend on the telephone. She and her mother, a single parent, then spend some time together. They like to build things—a birdhouse or a picture frame—and they are currently working on a giant jigsaw puzzle. While they work, they get a chance to talk. At about nine o’clock, Emily changes for bed and begins to read while listening to music. Her mother stops in for a few minutes to discuss plans for the next day, and at 9:30 Emily turns off the light and the stereo and goes to sleep.

Of course, not all nights in Paul’s and Emily’s homes are quiet and pleasant, but most are, and major disruptions at bedtime are rare. If bedtimes in your home are usually unpleasant and full of struggle, the solution may be to establish more pleasant and consistent routines. At first that may not seem easy to do, and your child may resist for a while. But if you persist, both you and your child will grow to enjoy the bedtime routines, and the struggles will be over. It is certainly worth the effort.

“Back to Sleep”: Reducing the Risk of SIDS

Because of the relationship between sudden death in infants and features of sleep position and environment, this chapter’s discussion of good sleep practices must include a discussion of Sudden Infant Death Syndrome, or SIDS, and related conditions. SIDS is the most common cause of death in babies between one month and twelve months old. The term SIDS is defined as the sudden death of an infant younger than one year of age that remains unexplained despite thorough medical investigation. We presume that breathing stops (although we don’t know why), and eventually so does the heart. Nine out of ten cases occur in the first six months, with a peak between two and four months. Although no single cause has yet been determined, we do know of some practices and circumstances that can affect the level of risk. Among the factors known to increase the risk of SIDS are late or nonexistent prenatal care, prematurity and low birth weight, and maternal smoking during pregnancy. Some ethnic groups, such as African-Americans and Native Americans, are particularly vulnerable, and boys are affected more often than girls. Some studies suggest that breast-feeding offers some protection against SIDS, but the effect is slight if it is even present at all; not all studies confirm this finding—although most agree that breast-feeding is beneficial for other reasons—and the apparent effect, when present, may be due to other factors such as less smoking among women who breast-feed.

Sleeping in the prone (facedown) position, however, has been shown to increase risk significantly. So, unless your doctor specifically tells you to do otherwise, always place your baby on his back to sleep. Placing him on his side is better than facedown, but it is best for him to lie on his back. The American Academy of Pediatrics began recommending supine (faceup) sleep in 1992, and in 1994, along with other groups, it began the Back to Sleep campaign, aimed at making supine infant sleep the rule. Since then the proportion of U.S. infants sleeping facedown has decreased from more than 70 percent to about 20 percent, and the incidence of SIDS has decreased by more than 40 percent—a truly dramatic improvement for such a simple change.

At first, some parents and pediatricians feared that babies who slept on their back might choke if they vomited, but this has proved not to be a problem. A temporary flattening of the back of the head can occur, particularly if the child always sleeps with his head in the same position. To avoid it, place the baby’s head so that he sometimes faces a little one way and sometimes a little the other, and turn the baby or crib so that the door or light is not always in the same direction. In any case, SIDS is a much more serious risk, and this flattening is generally harmless and usually corrects itself over time.

Supine positioning is only important when the baby is asleep. During the daytime while awake, prone periods (“tummy time”) and periods held upright (“cuddle time,” as opposed to excessive time in car seats and “bouncers”) are important for upper-body motor development and to further avoid flattening of the back of the head.

By around five or six months of age, most babies can turn from their backs to their stomachs (they should have learned to turn from their stomachs to their backs a few weeks earlier). After this point, you can no longer assure supine sleep, but by this time the risk of SIDS is low anyway.

Other aspects of the infant’s sleep environment can also pose a risk to the baby. It’s dangerous to allow a baby to sleep on a surface not designed for infant sleep, especially extremely soft ones—a soft chair or sofa, a waterbed, a pillow, a comforter, a quilt, or a sheepskin. Such soft surfaces under a baby, or loosely tucked-in bedding over a baby, pose a risk of suffocation. Poorly chosen places for the infant to sleep can create a risk of entrapment, in which the baby’s face is caught between a mattress and a wall or bed frame, or between cushions. Sleeping together with a parent, particularly one who is overweight or whose own ability to wake is impaired by drugs or alcohol, not only increases the risk of entrapment against the parent but also adds the danger of “overlying,” where the sleeping parent rolls on top of the infant. The more people in bed with the infant, the less room there is for the baby and the greater the risk. Improper bed surfaces and bedding, bed placement, and adjacent walls and furniture, common in a parent’s bedroom, may increase the risk further.

Cigarette smoking in the home, especially in the same room as the baby, can double or triple the likelihood of death from SIDS. Overheating, another risk factor, can be avoided by clothing the infant properly for sleep, keeping the room temperature at a level comfortable for a lightly clothed adult, and avoiding inappropriate bedding. If a baby is clothed properly and the room kept at a comfortable temperature, blankets can often be avoided altogether. “Overbundling” in clothes and bedding, and subsequent overheating, may be one reason why SIDS is more common in the colder months. (Seasonal increases in respiratory infections may be another.)

Finally, based on a small number of studies reporting decreases in SIDS among infants who fall asleep with a pacifier, the American Academy of Pediatrics recommended in their 2005 guidelines*that parents consider offering their infants a pacifier at bedtime and nap times. The specific recommendations are:

·   During the first year, “the pacifier should be used when placing the infant down for sleep…. If the infant refuses the pacifier, he or she should not be forced to take it.” (No recommendation was made for or against its use while awake.)

·   The pacifier should “not be reinserted once the infant falls asleep,” since the studies did not find loss of protective effect if the pacifier falls out once the baby is sleeping.

·   “Pacifiers should be cleaned often and replaced regularly” and “should not be coated in any sweet solution.”

·   “For breastfed infants, delay pacifier introduction until one month of age to ensure that breastfeeding is firmly established.”

Additional studies should clarify the value of these recommendations (you can always check the Academy’s Web site, www.aap.org, for the complete and newest guidelines). The period from two to six months of age is the most important, since after that the risk from SIDS is quite low and the likelihood of pacifier-related middle-ear infections increases. It’s not clear how pacifiers protect against SIDS, if the effect is even real. It could be that pacifiers keep the mouth clear of soft bedding. Or the protective effect could be due to the increase in wakings known to occur among babies using pacifiers—in other words, the increase in safety may come at the expense of worsened sleep. Pacifier-caused sleep problems are described in Chapter 4.

Should Your Child Sleep in Your Bed?

The practice of “co-sleeping,” where the child sleeps in bed with his parents, is probably the single most controversial topic related to pediatric sleep. Some argue that it is always best for the child, while others argue that it is never appropriate. Each camp warns that the other’s position threatens psychological and even physical harm to the child.

Over the more than twenty-five years I’ve spent working with families and children with sleep problems, I’ve come to the conclusion that children can sleep quite well under a surprisingly wide range of conditions. As long as the children are sleeping well, there is little evidence that any of these ways is inherently better for them psychologically than the others. Children do not grow up insecure just because they sleep alone or with other siblings, away from their parents; and they are not prevented from learning to separate, or from developing their own sense of individuality, simply because they sleep with their parents. Whatever you want to do, whatever you feel comfortable doing, is the right thing to do, as long as it works. I do not presume to dictate parents’ child-rearing philosophies. As long as they don’t choose a path that I think will be harmful to their youngster, I will work with them according to their choice. The techniques may vary somewhat, but most problems can be solved regardless of the philosophical approach chosen. No choice is irreversible: parents are free to try one approach, and then change their minds if they find it did not work as well as they had hoped. If the path chosen is working well for everyone involved, it is probably fine; but if anyone is unhappy or not sleeping well, then the choice should probably be rethought.

Much importance has been attached by some to the fact that some form of co-sleeping predominated as our species evolved and persists in those cultures that remain socially and economically most “primitive.” Although this is perhaps an interesting fact, it tells us little about how children should sleep in modern cultures. Certainly we should not return to the circumstances of our early ancestors (where most infants died before their first birthday) and move our children out of heated homes into caves, have them sleep on the ground or on floors or mats instead of on mattresses, and eliminate medical care, sanitation, and most clothing. Clearly, pre-modern practices are not always the best ones.

Furthermore, in many co-sleeping communities, custom dictates that women and young children sleep together, older boys and men elsewhere. Privacy needs are different as well, since sexual encounters in these communities are usually not activities for the bedroom but, instead, routinely take place in the fields. Few Westerners, if any, would advocate either of these practices today.

We live in very different circumstances from those that existed when our species first evolved. That does not mean we should always do the opposite of what was done in the Stone Age, but it does mean that there are other factors to consider, including how we live now. Basically, as this applies to children’s sleep, it means you are free to choose the way that best suits you and your philosophy of parenting.

Children generally fall asleep quickly and sleep soundly at night, regardless of where they sleep. In the absence of any problems, most are asleep 98 percent to 99 percent of the time from lights out to final waking—that is, they are awake only a tiny fraction of that time, perhaps five to ten minutes during the night in all. Even during those five or ten minutes, they are drowsy, usually barely aware of anything other than the need to find a comfortable position and return to sleep. Thus, for most of the night children are not conscious of where they are or of who else is or is not with them.

But they are awake and aware most of the daytime: it is then that they need loving and nurturing adults constantly available. They need to know that their parents will be nearby, taking care of them, while they sleep, so they won’t get anxious at each waking. But when they are asleep, they are oblivious to their parents’ whereabouts, which is why many parents respond to their children’s wakeful crying at night but sneak away when the child is asleep again.

The majority of the families I work with have chosen to have their children sleep alone. Many parents who co-sleep would prefer not to but do so because of financial or space constraints, or because co-sleeping seems to be the only way they can get any sleep themselves. Still others choose the partial alternative to co-sleeping of keeping a bassinet or crib, designed for infant sleep and safety, in their rooms in the early months. But I have also had the pleasure of working with many families who chose co-sleeping for sound philosophical reasons, and most have been quite happy with their choice.

Before you make this decision, there are certain considerations you should take into account. The decision should be yours, made by the parent or parents, and based on your own personal philosophies, not on pressure from your child or from anyone else. Another family’s good or bad experience with co-sleeping or sleeping separately should not influence your decision: your child is not theirs, and your family is not the same. Finally, and very important, if you choose co-sleeping, you must plan when and how to stop. Far too many families start co-sleeping early, assuming it will stop on its own at some point, and then find themselves years later with a five-, seven-, ten- or twelve-year-old that they “can’t get out of” their bed. The parents are unhappy and the child is embarrassed, feeling “different” and unable to host or attend sleepovers. At that point most children want to leave their parents’ bed even more than the parents want them to go.

If one parent favors co-sleeping and the other is against it, either choice can lead to anger and frustration. If neither of you prefers to co-sleep but you do so because your child “demands” it, then you are probably making a poor choice for the long run. If your child sleeps with one of you and the other parent sleeps elsewhere, all of you may feel that the child has forced a separation and has replaced one parent as the other parent’s partner. Whether the decision was made out of compassion or out of desperation, it can lead to anger toward your spouse and toward your child. When you are angry and tired, it is difficult to nurture your child during the day and difficult to make rational decisions at night. I have worked with many such families who tell me that they will continue co-sleeping if that is the only “solution,” but that they will not consider having more children.

Specific Issues Related to Co-sleeping

Advantages and Disadvantages

Co-sleeping provides several potential benefits:

1.   Constant closeness whenever the child is awake. Children may like this, and many parents enjoy this feeling as well.

2.   Immediate support for any nighttime separation concerns or other anxieties or difficulties.

3.   The ability to nurse, and to respond to other nighttime wakings, quickly and without getting up.

4.   More time to spend with the child.

5.   Possibly better sleep for both the child and the parents, if the child was sleeping poorly to begin with.

Co-sleeping also has potential drawbacks:

1.   There may be a slight increase in the risk to the infant from SIDS and related causes.

2.   Parents may sleep poorly if their children are restless sleepers.

3.   Parents may end up sleeping in separate rooms, and they may become angry at their child or with each other.

4.   Children’s and adults’ sleep cycles do not coincide.

5.   Parents may have to go to bed at a very early hour, with their children, and be left with little time for their own evening activities and unable to use a babysitter for even the occasional night out.

6.   Certain sleep problems that arise (namely those based on patterns of parent-child interaction) may be more difficult to correct.

7.   Parents have little privacy.

Since it is the drawbacks of co-sleeping that can lead to problems, the potential difficulties bear discussing in more detail.

Co-sleeping with an infant in the kinds of bedding typically used in Western societies (soft mattresses, fluffy pillows, and plush comforters—as opposed to mats on the ground and thin pillows and blankets) does increase the risk of SIDS and suffocation slightly (available studies do not always make a clear distinction between the two). An overweight parent or one impaired by alcohol or other drugs or medications poses additional risks.

Some people claim that co-sleeping actually protects against SIDS, possibly because babies (and parents) experience more arousals during the night when they co-sleep than when they sleep alone. However, the scientific evidence regarding the safety of co-sleeping is mainly to the contrary, at least in the Western countries where most studies were done. But these studies are generally looking at the risk of unexpected sudden death from any cause (not specifically SIDS). Since this risk is increased when more people share the bed, and with inappropriate bedding, exposed places of entrapment (between bed and wall), and parental alcohol consumption and obesity, it seems that the increased risk may be mainly for suffocation. Furthermore, the SIDS rate in different countries where co-sleeping is the norm may be high or low, and where it is high it often at least partly reflects related environmental and socioeconomic factors, such as smoking and poor prenatal and postnatal care, more than it does co-sleeping itself.

If you choose to co-sleep, you can take steps to minimize or eliminate most of these risk factors. Most important is to take the precautions discussed in the section on SIDS and to be sure that the infant sleeps on his back and that smoking does not occur in the house, especially not in the bedroom. To reduce the risk even further, move the bed away from the wall and other furniture, be sure the sleeping surface is firm and flat, avoid loose, soft bedding and covers, limit the number of others in the bed to one or both parents, and avoid alcohol and other drugs that impair arousal. The safest way to assure that these precautions are always met while still keeping your infant close by, according to the American Academy of Pediatrics (www.aap.org) in their 2005 guidelines,* is to keep your infant in your room but in a separate crib, bassinet, or cradle with a firm mattress and proper bedding.

If your child is to share your bed after the early months, be aware that young children are frequently very restless sleepers. During normal nighttime arousals, they often kick, roll, moan, and thrash. Not uncommonly, they complete several full head-to-toe rotations before the night is done. They sleep well, but the parents may not. Or an H pattern may develop in the bed, with the child sleeping across the middle of the bed with the parents teetering on the very edges, the child’s head against one of them, his feet against the other. The size of a bed is a constraint that was not present for most of human evolution. In primitive or poor societies where people sleep on the floor or on the ground, and in societies that use futons, parents can give a restless toddler the sleeping space he needs without running out of space themselves. Some co-sleeping advocates suggest converting a single bedroom for sleep, with mattresses covering the entire floor, and setting up a separate room for intimate relations. This approach can work, but many families consider it impractical.

Because of a child’s restless sleep, some parents take turns sleeping in another room so that at least one of them will get some rest. This habit may not be good for the parents’ relationship. If this is happening in your home, examine your motivations for this choice of sleep patterns carefully. Do you and your spouse want to sleep together? If so, you should. Or do you really want to sleep separately? If so, you may be blaming your child for your nighttime separation instead of admitting your problems and exploring their significance.

A child’s sleep cycles never coincide perfectly with those of his parents—they cannot, since adult cycles are longer than a child’s. Each person’s normal, periodic arousals disrupt the sleep of the others in the bed; the more people, the more disruption. This generally affects the parents’ sleep more than the child’s, since adults sleep less deeply and often have more difficulty returning to sleep.

If your child not only sleeps in your bed but can fall asleep only when you are present, then you must be prepared to go to sleep when he does. If that means seven o’clock, so be it. You may or may not be able to sneak out later once he is asleep—but as will be discussed in Chapter 4, routinely sneaking away from a sleeping child is never a good idea anyway. You will not be able to leave him with a sitter unless he’s already asleep, and if he wakes before you return, he will not be able to go back to sleep. (Going out to the movies once in a while was not a consideration for our cave-dwelling ancestors.)

When parents and children share a bed, it is more difficult to set limits or change habitual sleep patterns. For instance, if you want your nine-month-old to stop nursing hourly all night long, or if you want to get your eighteen-month-old to stop twisting your hair, rubbing your face, or lying on top of you when he goes to sleep, you can make these changes more easily if you and your child are not in the same bed.

Keeping a separate room for sex is unworkable for most families. Waiting until your child seems to be asleep and then having sex “quietly” is not a good idea. He may wake to find you having intercourse—not the worst thing that can happen, but it may be misunderstood and confusing.

If the parents agree philosophically about co-sleeping, many of these potential problems can be addressed. Those caused by a child’s restless sleep may be unsolvable if he sleeps in your bed, but a solution would be to allow him to sleep in your room in a separate bed, on the floor, or in a crib. Also, a child can be taught to go to sleep alone in your bed, where you will join him later. Limits on inappropriate demands and behaviors can be set even if you sleep in the same bed. We will return to these points in later chapters.

Co-sleeping: The Endgame

Recommendations about when co-sleeping should stop are quite varied. Some people suggest ending it by the time the child is six months old, before separation anxiety becomes an issue; others suggest waiting until he is a year old. Some recommend stopping when he is weaned. Few child care specialists recommend co-sleeping much past the age of three. Again, the choice is yours, but when you begin co-sleeping, you should have a plan in mind of how and when you will stop. Unless housing and financial limitations dictate otherwise, in most cases I would agree that it makes sense to move a youngster out of the parental bed at least by age three. It is quite easy to do at six months. At one year a child with little previous experience being in a crib is unlikely to adapt to one very easily, if at all, and he may have to continue sleeping in a bed or on a mattress on the floor. But since he is already quite mobile, other boundaries such as gates will be necessary, for his protection if for no other reason. At age three, a child is able to be resistant and, now, verbally demanding for a longer time at bedtime since the ability to stay awake and protest increases with age. Finally, a child who still needs to sleep with his parents by the start of school faces embarrassment, sometimes even shame, because almost all of his peers will be sleeping in their own beds. The older a child gets, the harder it becomes to change his sleeping location against his will, because as he grows, enforcement becomes more difficult.

Some specialists recommend a transitional approach, getting your child used to sleeping in a crib or a separate bed in your room, even in a sleeping bag on your floor, before he makes the move to his own room. That approach is fine if it works smoothly, but it is difficult to enforce if the child resists (at least if he is out of a crib and continues to try to get into your bed). Even if you are successful getting him to sleep in another location in your room, you still have the job left of eventually moving him into his own room. A more consistently workable approach, I find, is to temporarily move into the child’s room with him as the first step, but to insist that he sleep in his own bed, with you sleeping in a separate bed or on a mattress on the floor. (This separation is easier to enforce in his room, using a gate or door as necessary, as described in Chapters 5 and 7.) Get him accustomed to sleeping in his room and in his bed before asking him to sleep in the room alone. It is not too difficult to enforce a plan of sleeping in separate beds in the same room; then, gradually (within days or weeks, depending upon the child’s needs and desires), the parent can begin leaving the room at bedtime, initially briefly, then longer, gradually helping the child to get used to being in the room and falling asleep alone. At first the parent would return and sleep there the rest of the night. Then, as another step, the child could be left to sleep alone the whole night. The techniques to do this are the same ones used to combat nighttime fears in an anxious child with difficulty sleeping alone and are discussed in detail in Chapter 7. The specifics depend upon the child’s age and personality, and they may include gradual desensitization, negotiation, limit setting, and positive reinforcement. It is too much to expect a child to move out voluntarily or to move out completely in one night if he has always slept with his parents.

The Sleep Challenges of Multiples:
Twins and Triplets

Multiple births are relatively common nowadays. Approximately 1 in every 300 births produces a set of identical twins. Nonidentical, or fraternal, twins are born about three times as often (this rate differs considerably from country to country and culture to culture). The incidence of fraternal twins has increased in recent years because of fertility treatments such as in vitro fertilization.

Parents of multiples often assume that their children’s sleep problems are different, or at least need to be treated differently, from those that occur in other children. In reality, the sleep and sleep problems of multiples are no different from those that affect other children, and the situations that arise are the same as those seen in any home, particularly in homes with two or more children close to the same age. Even though twins may do everything together all day, especially when they are young, the process of falling asleep is a task that each twin needs to learn for himself.

Even so, some specific considerations do need to be taken into account. Coming home from the hospital with a single child is hard enough; the challenges are even greater with multiples. If you have other children already, the work seems to increase exponentially, especially since two new children seem to require more than twice as much work as one. Children who are exactly the same age may have all the same needs at the same time: feeding, changing, toilet training, starting school. Even with help, the task for a parent may seem almost overwhelming. There is work to be done all day long. It’s not easy to work all night long as well.

Twins are almost always put in the same room, even if other rooms are available. Some families initially place twin newborns in the same crib. Regardless, twins are almost always expected to go to bed, wake up, nap, and eat on the same schedule. Parents do not usually have such expectations of siblings who are merely close to the same age. Most of the sleep problems that families perceive as specific to twins are actually due to these habits.

Putting infants into the same crib to sleep offers little benefit, especially after the first few weeks. Remember, although twins may often be together during the day, they are physically apart much of the time. They may share a carriage, but not the same seat. They ride in separate car seats, and they eat in separate high chairs. There is no reason why they should not also be physically apart at night. If they are sleeping properly, they will not even be conscious of whether they are in the same crib for most of the night and nap times, and the rest of their time in the crib they should be too sleepy to care. Sharing a crib can even be detrimental: neither child will learn to fall asleep without the other one there, and each child’s movements will wake the other one.

Although identical twins commonly have very similar sleep requirements and are often able to adapt to very similar schedules, they will not match perfectly every day, any more than a single child will sleep and wake at exactly the same times every day. The divergence between fraternal twins’ schedules may be much more striking. No parents should try to force a new baby to follow the exact schedule their first child was on at the same point in his life, but many families effectively do just that for their twins.

Every child, twin or not, has particular abilities and needs, and the parents need to learn to recognize them and respond properly. One child may sleep more hours; the other may give up middle-ofthe-night feedings sooner. One may play quietly when awake at night; the other may do everything he can to wake his twin (not to mention the rest of the house).

In short, twins or triplets, sleeping in separate cribs or beds in the same room, can have the same problems that any set of siblings sharing a room might have, and they should be handled in the same ways. For example, if one twin, who needs to sleep ten hours, is regularly awakened early by his sibling, who only requires nine hours, you have the same choices you would have for any two children. You can put the shorter-sleeping twin to bed an hour later than the other (the fact that they are twins does not mean they have to share a bedtime), or they can have the same bedtime, as long as you are prepared to get the early riser out of the room before he wakes the other. Or you may be able to shorten nap times a bit for the one who sleeps less at night (especially if he takes long naps), hoping that his nighttime sleep will lengthen to match that of his brother. You might get the nightly sleeping times to match, but possibly at the expense of differing nap times.

If one twin is sleeping well at night but the other needs frequent interventions, you may find it works best to separate them, at least temporarily. Then you can focus on normalizing the sleep of the wakeful twin (as described in later chapters) while allowing the other twin to sleep uninterrupted. Depending in part on the location of bedrooms, other sleep location options, and the severity of the problem to be addressed, sometimes it is best to move the twin who is having sleep problems, and sometimes it is better to move the other one. Even if both twins are having problems, it may be easier to work with them separately, in separate rooms, and then consider putting them back together once the problems have been addressed. You can always start to work on the problems with the twins in the same room, but be prepared to separate them if that isn’t working. Sometimes just being in sight of each other is enough to keep twins from quieting down and going to sleep; in that case, being in separate rooms may be the easiest way for them to start to sleep well. If only one twin gets excited, you may be able to keep them in the same room, but you might have to wait until the excitable one is asleep before you can put the other one to bed. The situation is no different here than when, for example, a three-year-old and a six-month-old share a room. It may be necessary to move the crib to another room, or to put the toddler in another bed temporarily, until matters are resolved. When the children are put back in the same room, they will very likely have different bedtimes.

The idea that multiples might have separate bedtimes or separate bedrooms, even temporarily, often seems wrong to parents. But failing to take the children’s individual needs into account does not do them justice. There is no reason the child with the shorter sleep requirement should stay in bed longer than he needs to, for example, just because his brother sleeps later. If one twin needs to go to bed before the other, he will quickly learn to fall asleep in a room by himself, just as he would if you had to take the other one out to deal with an illness.

Having multiples to care for is a difficult job. But don’t let the sleep needs of one dictate how you manage the others.

The Special Toy or Favorite Blanket

If your older infant or toddler needs to have something or someone in the bed with him to fall asleep, better that it be a “transitional object”—a stuffed animal, a doll, a toy, a special blanket—than that it be you (even if you share a bed). This item can help him to prepare for and accept his nighttime separation from you, and it can be a source of reassurance and comfort when he is alone. It will give him a sense of control over his world, because the toy or blanket can be with him whenever he wants, something he cannot expect from you. His toy won’t get up and leave when he falls asleep, and his special blanket will be there whenever he wakes. Even if he sleeps in your bed, his reliance on a special object will help give you the freedom to pick your own bedtime and the ability to leave him with a sitter.

A child will often choose such a special object early in the toddler years, typically at twelve to eighteen months, and he may continue to rely on it, or on other objects, for several more years. If your child does not have anything special that he likes to keep with him, it is reasonable to offer him things that you think might take on this role. However, he will always be the one to make the final choice, and you cannot make him attach to any particular toy that you think appropriate. More important is that you avoid playing this role yourself. If you always allow yourself to be used like a special toy—if you lie with him, nurse him or rock him, or let him cuddle you, caress you, or twirl your hair whenever he wants and for as long as he wants, particularly whenever he wants to fall asleep—he will never take on a transitional object, because he won’t need to.

If your child begins to favor a particular stuffed toy or doll, include it in his bedtime rituals. Have him tuck it in, or let it “listen to” the story. If he has a special blanket, make sure it is close at hand when he gets into bed. The comfort that these special objects provide will make the final good night that much easier.

Developing Good Schedules

As you may recall from Chapter 2, newborn infants do not have regular sleep patterns, and it usually takes between six and ten weeks for them to develop a consistent twenty-four-hour schedule with the longest period of sleep at night. Your baby’s sleep patterns during the first few days after birth are not an indication of things to come. Whether he sleeps well or fitfully in the hospital, and whether the nurses assure you that he is “extremely good” or warn you that they have never seen a baby who “sleeps so little,” things are likely to change considerably once you leave the hospital. If problems appear to develop after you get home, you might blame yourself and assume that your inexperience as a parent was to blame, but you would almost certainly be wrong. If you are too quick to believe a nurse’s warning about problems ahead, it can all too easily become a self-fulfilling prophecy.

In most babies, a sleep pattern emerges over the first two weeks, with many naps, some brief and some longer, distributed across the day and night. Some infants do sleep unusually well from the beginning, even having to be wakened for some feedings, but this is the exception rather than the rule. Try not to feel frustrated if your child takes a while to fall into a reasonable, easy-to-follow schedule.

Some babies seem to have their days and nights reversed, with the longest period of sleep falling during the day and the longest period of wakefulness occurring at night. This, too, will change. It is actually impressive that a child so young can show such a consistent (if inverted) pattern, since he has had little time to develop regular twenty-four-hour rhythms, and even less of a chance to learn day from night. This night-day reversal is not abnormal; it is, rather, an indication that the child has already developed a regular and predictable schedule. Most children correct this schedule reversal by themselves. But it will be easy to readjust their schedules if they don’t (as you will see below and in Chapters 10, 11, and 12).

Although most infants will develop a regular twenty-four-hour sleep schedule regardless of anything we do or don’t do, parents can assist the process considerably. You should use approaches that take into account your baby’s schedules, habits, learned associations, and nutritional and emotional needs, and avoid approaches that could interfere with the development of normal rhythms.

Feeding patterns are an important part of an infant’s daily schedule. Few pediatricians still urge parents to put their babies on a precise four-hour feeding schedule from the beginning. Instead, they generally recommend that you follow your infant’s cues. A newborn baby usually needs to be fed every two to six hours. Only if your baby was premature, or if he has medical problems, feeding difficulties, or poor weight gain, will you have to follow a more rigid feeding schedule.

There are two problems to watch for when feeding on demand. First, not all cries are hunger cries, and it will take you a little time to learn to recognize which sounds mean your child is hungry. Second, you should take care to impose reasonable limits. A newborn obviously needs to be fed more than twice a day, even if he seems to cry for feedings only every twelve hours. But it may be less apparent that a full-term, healthy infant does not need hourly feedings, even if he seems hungry at these times and nurses when you offer the breast or bottle. Hourly feeding is exhausting for the parent and painful for the mother if she is breast-feeding. It is unnecessary for the baby, and it interferes with the development of healthier sleep-wake and feeding patterns.

Of course, you want to show your baby that he has been born into a good and caring world, so you respond when he cries, and you try to do whatever it takes to soothe him. But helping him develop good sleep schedules is also an important part of his care, and to do that, you may have to tolerate some crying or find ways to calm him other than feeding him. Babies often stop crying if they are walked, rocked, or stroked for a while, and sometimes these are useful temporary measures to help you accustom your baby to falling asleep without an unnecessary feeding. (If these measures become troublesome habits of their own, they too can easily be eliminated later as discussed in Chapter 4.)

If your baby has been feeding every hour, begin to increase the time between feedings by an amount you feel comfortable with—perhaps fifteen minutes a day—until he is being fed every two hours, then every two and a half or three hours. He will adapt to the better schedule, the hourly crying will cease, and he will begin to develop the good sleeping and eating rhythms that should be forming over the first three months.

You can also start to make changes in your baby’s sleep schedule. For example, if he is sleeping six hours at a time during the day but is awake much of the night, and if this pattern persists past the early weeks, you can begin waking him earlier and earlier from the long sleep period, so that he will start to treat it as a nap and move the longer sleep segment into the nighttime hours. Although you are following your child’s cues up to a point, in this way you can still help to structure his sleep-wake schedule.

Over the first three months, most infants begin to respond on their own to the external cues of darkness, quiet, and inactivity at night and light, noise, and activity during the day. By three or four months of age they will be getting most of their sleep at night, usually including an unbroken stretch of five to nine hours. They will continue to nap at three or four fairly predictable times during the day, and the time during the day when they are awake the longest will become predictable as well. At this point you should begin working with your baby to improve his schedule further, to stabilize it, and to make changes in it as he grows. You will be doing both of you a favor, because as your baby settles into an appropriate schedule, you will be able to make better use of your own time and enjoy him more when he is awake.

As you begin to observe your baby’s periods of waking, activity, feeding, and sleep, you will learn to anticipate his needs and know when to play with him, feed him, or put him to sleep. Even if your baby is not crying for a feeding at the expected time, he may be ready to eat and will nurse eagerly. Similarly, he may be ready for his nap before he starts to yawn and become fussy. Although you can’t tie your child’s feedings, play, and sleep precisely to the clock, if you are aware of his emerging schedule you can encourage him to eat and sleep at reasonable and consistent times. That, in turn, will help him stabilize his developing twenty-four-hour cycles.

By the time your baby is three months old and has developed a fairly predictable twenty-four-hour pattern, it becomes more important for you to provide increasingly consistent structure. If you do your best to establish a reasonable and consistent daily routine and keep to it as much as possible, then it is likely that your child will continue to develop good patterns. If instead you allow the times of your child’s feedings, playtimes, baths, and other activities to change constantly, chances are his sleep will become irregular as well. Remember from Chapter 2 that when there is no schedule, people (including children) tend to run on a twenty-five-hour day. So if you don’t stick to a schedule for your child’s sleep, a pattern might emerge that would surprise you (although it wouldn’t surprise a sleep scientist).

I have worked with many families who had this problem. Typically, their child was functioning on a regular pattern, but one lasting twenty-five or twenty-six hours instead of twenty-four. As a result, the parents were following their child around the clock, letting him stay up later and later at night and getting up with him one or two hours later each morning. At times, most of the child’s sleep was occurring during the day. These children were normal, but since their biological clock was not being reset to a twenty-four-hour day by a regular schedule and, especially, by consistent exposure to light at appropriate times (see Chapter 9), their rhythms were allowed to drift.

It is equally important to help our children maintain consistent schedules through infancy, childhood, and adolescence. In fact, all of us, regardless of age, function best when we keep regular schedules. Studies on adults have shown that irregular sleep-wake patterns cause significant changes in our moods and sense of well-being and undermine our ability to sleep at desired times. The same is true of young children. So don’t let your two- or three-year-old decide what time he should go to bed—many would wait until they were so sleepy they could not stay awake any longer. Before long his schedule would be disrupted, becoming inconsistent and unpredictable. He might fall asleep early one night and late the next; he might nap some days and not others; and when he did nap it could be in the morning, afternoon, or early evening. With even more disruption, his mealtimes would also fluctuate. He might have breakfast anywhere from seven to ten o’clock in the morning; he would want lunch and dinner at odd hours and might skip meals altogether. Children on uncontrolled schedules like that can develop major sleep problems. Behavior problems may follow as well, though they can be subtle at first.

Instead, establish a reasonable daytime schedule in your baby’s first three months and maintain consistency as much as possible throughout his childhood. Your child cannot be expected to keep to a schedule on his own; you will have to set one for him and then be willing to enforce it. Of course, some flexibility is called for. Some children need more sleep than others, and some are better able to tolerate variations in their day-to-day routines. You will have to learn from experience with your child what schedule is best and how closely it needs to be followed.

Consistent schedules are especially important in treating sleep disorders. Regardless of a child’s age (at least after the early weeks of life) or the cause of his disorder, a regular and appropriate schedule will help the treatment succeed and may even be a cure in itself. So if you are beginning to address a sleep problem in your child, be sure to set up a firm schedule and stick to it rigorously for several weeks after your child has begun sleeping well again. At that point you will be able to relax the schedule somewhat without the problem recurring. You might skip an occasional nap for a special outing, or take your child out with you in the afternoon even though he may fall asleep in the car at an unaccustomed time.

Once a baby has settled into a good sleep-wake pattern, it is still subject to disruption. Teething, an illness, a trip, or an upset in the family can interfere with his sleep pattern. The disruption can continue for months unless you intervene. You may need to reestablish your child’s schedule, help him unlearn bad habits, address his anxieties, and be firmer in setting limits. We will discuss all of these approaches in detail throughout this book.

*“The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk,” Pediatrics 116, November 2005: 1245–55.

*“The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk,” Pediatrics 116, November 2005: 1245–55.