Psychobabbling

My little dude has a new habit: waking up at 4:30am.  After weeks, nay months, of gloriously silent nights, he is up after last call and ready to party.  He has also concurrently developed separation anxiety, and for the first time gets markedly upset when his loved ones leave his sight.  I can’t help but think that these two things are related.  This is cool because it means that he is developing a sense of himself as separate from us, and is beginning to understand object permanency, that objects continue to exist even when they are not in sight.  He doesn’t understand yet that we’ll be coming back after we leave, so he freaks out.  But while his new found joy in peek-a-boo is hilarious, his early morning attempts to engage us, and his upset when we are not in his room with him indefinitely, is getting to be a real drag.  And it’s a fine line between reassuring him that we’re not abandoning him and joining the party at his crib.  Some suggestions I’ve found include giving him a security or transitional object for comfort (done - he’s not that into it), and putting him to bed earlier because he may be overtired (so far he’s not down with this, but we’ll keep trying).  I must say, I’ve never been so excited for daylight savings time to begin - 4 days and counting.

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As someone who was formerly obsessed (see exhibits one, two, and three) with everything baby sleep, I thought it might be useful to write a bit about what I found to be helpful and the most useful resources I came across in my (somewhat limited) research. 

When the little dude first came home, we found that having him sleep with us was really helpful and best for those frequent late-night feedings (which I wrote about here and here).  For naps, we would have him sleep in a bassinet in our room, then eventually his room so he got used to it.  After a few months, we started having a bedtime ritual with him, at the suggestion of his pediatrician and Healthy Sleep Habits, Happy Child; read a story, turn out the lights, rocking until drowsy, maybe feeding, then putting him to bed drowsy but not asleep.  This whole thing of putting him down drowsy but not asleep took some time and was not easy.  The point of it is that he is learning to sooth himself to sleep so that he is not dependent on us to get him to sleep.  We also swaddled him for the first few months, which really helped a lot to reduce that startle reflex from waking himself up, but around 3 months he was not having it anymore and so we stopped.  It was around this time that he found his thumb, and started sucking on it to sooth himself to sleep.  Babies and adults wake up many times during the night, and the goal is to help him learn how to put himself back to sleep himself.  The thumb did the trick.

At about 4 months, the dude’s pediatrician suggested that we try to have him sleep in his crib at night.  At that time he was sleeping sometimes in bed with us, sometimes in a bassinet next to the bed.  Her thought was that we were actually waking him up during the night when we toss and turn, and he might sleep better if he were in another room.  This was tough to swallow, he was only waking up 2 or 3 times a night at this point, but we gave it a shot.  And in fact, he did sleep for longer periods in his crib.  When he would wake up, I would go and feed him, but eventually, again at the pediatrician’s suggestion, the dude’s psychopapa would go to sooth him to sleep again, to break the association of nighttime with feeding.  This was when he was around 5 months.  The dude is 6 months now, and he sleeps 10-12 hours a night, usually without waking.  I’m not philosophically opposed to Cry-It-Out methods, but I’m really glad we haven’t had to use them so far.  I know we’re really lucky and got a kid who’s a good sleeper, but I think some of these interventions probably helped to some degree as well. 

Interestingly, the dude is much more inconsistent in terms of daytime sleep.  We found it really helpful at times to, as the book suggested, put him to sleep within 1 1/2 to 2 hours of being awake during the first few months, as to not let him become over tired.  But this doesn’t always happen, he doesn’t always go to sleep during the day when we want tim to, even with the rocking, soft music, dim lights, etc.  Some days he sleeps like a champ, some days he only takes a few 20 minute naps.  But contrary to expert opinion, this fortunately hasn’t affected his nighttime sleep.  At this point, according to the book, the goal is to get him to consolidate his naps into 2 to 3 a day, and this does happen, sometimes.    This variability also may be related to who is with him during the day, as he is sometimes cared for by me, his papa, or his babysitter, and we each have our own styles.  It hasn’t been too much of an issue so far, except when we’re trying to get stuff done around the house on a day that he doesn’t nap much.  I’ve heard of families having the opposite issue, with kids who are great daytime nappers but don’t sleep well at night, and since I have to go out into the big mean world to work 4 days a week, I appreciate that the former is the dilemna we have. 

Every kid and family is different, but I liked the balanced and relative approach of HSHHC.  There’s a lot of research in the book, which can be useful or burdensome depending on your interests and level of sleep deprivation, but I really appreciated that the only agenda the author seems to have it to get everyone in the family to have more sleep.  Also a good read was Sleep Solutions for Your Baby, Toddler and Preschooler.  And the journey isn’t over yet, so I’m sure we’ll be referring back to these gems as the dude grows and there are more bumps in the road with his sleep.  So far, so good, though.

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Yes, I’m a bit obsessed.  But I thought this site about research on infant sleep is pretty interesting.  I particularly appreciate their study about parents’ experiences with sleep interventions, the finding that advice from various books and theories about sleep are inconsistent and frustrating to parents, and that interventions themselves add stress and anxiety to their lives.

“Indeed parents expressed significant worry about how well they were managing sleep, indicating that perhaps infant sleep has become, not only a developmental milestone for infants, but a measure of parental competence as well. “

As to why we stress about baby sleep, the researchers write that we tend to associate prolonged sleep and the ability to self-sooth with the development of independence in our children, which is a trait of utmost importance in our culture.  They argue that this does not often jive with children’s biological and developmental needs around sleep. 

Speaking of conflicting messages, here’s a page that goes through and summarizes the different books out there about babies and sleep.  While I’m obsessing I’m reading about why I shouldn’t obsess.  I guess I’m trying to mitigate the effect of all of the advice, but it’s nice to read that I’m not the only one confused and going a tiny bit bonkers about this stuff.

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Baby sleep patterns and Infant sleep problems: A guide for the science-minded parent from Parenting Science

Interventions for Infant and Toddler Sleep Disturbance: A Review

Sleep Solutions blog

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Originally, like say up until a few weeks ago, I always thought that babies sort of find their own rhythm when it comes to sleep, and you just have to roll with it until they mature enough to get into a regular pattern and sleep through the night.  I though that my little dude would let me know when he’s tired, and I would put him to sleep then.  This was of course until our most recent appointment with the pediatrician, in which she encouraged us to try to get him to nap an hour or so after he wakes, regardless of whether he seems tired.  She said that we should try to coax him into sleep with swaddling, putting him in a quiet room, turning off the lights, and so on.  The thing is, it’s not that easy.  There are times when this works, mostly during the morning and afternoon, and other times when he is totally awake for 2 hours or more at a time, and he reacts to us putting him down in his bassinet as if we were dropping him in a tub of ice cubes.  He’s not sleeping in the family bed anymore because it was starting to interfere with the family sleep, and he actually sleeps for longer strecthes at night when he’s swaddled in his bassinet.  So now I’ve started to think more about this whole sleep issue, and, quite frankly, spending a lot of time doing so as I’m still on maternity leave and have a lot of time to (over)think about these types of things.

There has been some discussion on a neighborhood parents’ listserv I subscribe to about different books written to help babies sleep better.  There seem to be a lot of different opinions about the books mentioned, and there seem to be so many out there it is difficult to know which one is most useful.  I’ve read The Baby Whisperer and The Happiest Baby on the Block, both of which were given to me by loved ones who found them helpful, and have found some useful information and tips from both (more so from the latter), but I still have some unanswered questions.  

Many of these baby sleep books claim to be supported by research, but do not cite the studies their methods are based upon, so I’m left wondering what method to use, or whether we need a method at all.  And much of their advice contradicts that of other authors.  What’s normal in baby sleep?  When should he be sleeping through the night?  How much should we sooth versus let him self-sooth?  Do we need to get him on a schedule or let him make his own?  Clearly this is a problem for a lot of people; there are so many of these books so there must be a market for them.  These questions could drive a parent bonkers, which is why I was thrilled when I came across this article from the New York Times from several years ago that actually discusses some empirical findings on this stuff.  The take home message is that most of the techniques outlined are effective, as long as parents are consistent in their implementation.  So it seems that you just need to find one you like and go with it.

The findings by Mindell, Kuhn, Lewin, Meltzer, and Sadeh (2006) were published in the journal Sleep.  I found a pdf of the article through Google Scholar, and here’s the abstract:

“This paper reviews the evidence regarding the efficacy of behavioral treatments for bedtime problems and night wakings in young children. It is based on a review of 52 treatment studies by a task force appointed by the American Academy of Sleep Medicine to develop practice parameters on behavioral treatments for the clinical management of bedtime problems and night wakings in young children. The findings indicate that behavioral therapies produce reliable and durable changes. Across all studies, 94% report that behavioral interventions were efficacious, with over 80% of children treated demonstrating clinically significant improvement that was maintained for 3 to 6 months. In particular, empirical evidence from controlled group studies utilizing Sackett criteria for evidence-based treatment provides strong support for unmodified extinction and preventive parent education. In addition, support is provided for graduated extinction, bedtime fading/positive routines, and scheduled awakenings. Additional research is needed to examine delivery methods of treatment, longer-term efficacy, and the role of pharmacological agents. Furthermore, pediatric sleep researchers are strongly encouraged to develop standardized diagnostic criteria and more objective measures, and to come to a consensus on critical outcome variables.” 

Before going into the specifics of their findings, and a description of which methods were included in their review, I want to highlight that the authors state in their introduction that the development of sleep regulation is primarliy a result of neurobiological maturation which can be influenced by environmental factors.  In other words, babies do tend to find thier own sleep and wake rhythm, but it can be thrown off course and put back on course through behavioral modification.

The strongest support was found for unmodified extinction, which involves putting the child to bed and not responding to protest until a set time the next morning, and for preventive parent education, which involves establishing good sleep habits early on, including “bedtime routines, developing a consistent sleep schedule, parental handling during sleep initiation, and parental response to nighttime wakenings” (p. 1267).  They also found support for: graduated extinction, in which crying and tantrums are ignored for specific periods but not the entire night (eg. Ferberizing): for bedtime fading/positive routines, which involves taking the kid out of bed if s/he does not fall asleep for a certain amount of time and sticking to a set bedtime with quiet activities respectively; and for scheduled awakenings, which involves waking the child before a spontaneous waking would typically occur (this is grossly over simplified, see the article for more detail).

Bearing in mind that most of these techniques were tested with children who were having established sleep problems at an older age than my little dude, the most applicable to our situation is the preventive parent education category, as we would be in the prevention stage, so to speak.  So, establishing good sleep habits is the task at hand, and how does one do that exactly?  One aspect of this, according to the article, that most of the strategies that fall under this category involve putting the child to sleep drowsy but not asleep.  I went back to Google Scholar and found one of the studies cited in this article in this category, Pinilla and Birch (1993) from the journal Pediatrics.  Here’s the abstract:

“The study objective was to investigate whether exclusively breast-fed infants could be taught to sleep through the night (defined from 12:00 AM to 5:00 AM) during the first 8 weeks of life. The design was shortterm longitudinal, from the last trimester of pregnancy until the eighth week after birth. Twenty-six first-time parents and their newborn were randomly assigned to treatment and control groups (13 in each group). Treatment parents were instructed to offer a ‘focal feed’ (between 10 PM and 12 AM) to their infants every night, to gradually lengthen intervals between middle-of-the-night feeds by carrying out alternative caretaking behaviors (eg, reswaddling, diapering, walking), and to maximize environmental differences between day and nighttime. All parents kept 72-hour diaries of their infants’ feeding and sleeping patterns every week from birth to 8 weeks of age and rated their infants’ temperament at birth and at 8 weeks. By 3 weeks, treatment infants showed significantly longer sleep episodes at night. By 8 weeks 100% of treatment infants were sleeping through the night compared to 23% of control infants. Treatment infants were feeding less frequently at night but compensated for the relatively long nighttime interval without a feed by consuming more milk in the early morning. Milk intake for 24-hour periods did not differ between groups. Treatment infants were rated as more predictable on Bates’ Infant Characteristics Questionnaire. It is concluded that parents can have a powerful influence on the development of their infants’ sleep patterns. Frequent night waking in breast-fed infants often results in early termination of lactation. Parents can teach their breast-fed infants to lengthen their nighttime sleep bouts, making the continuation of breast-feeding easier for the new mother.”

These strategies sounded familiar to me, and I realized that they’re actually described in another book I recieved as a gift, What to Expect the First Year.  So maybe I will try some of these strategies and see what happens.  I think what will be most difficult is stretching the feedings out by keeping him amused in the middle of the night.  I don’t know about you, but the only thing that will keep me amused in the middle of the night is sleep.  And what about daytime napping?  We’ll just go with the pediatrician on this one, as best as possible.  Fingers and toes crossed.

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In pursuit of more information, I found this site by the Mother-Baby Behavioral Sleep Laboratory at the University of Notre Dame (by way of Wikipedia, I must admit).  Among other things, it states:

“While advocates of solitary infant sleeping arrangements have claimed any number of benefits of infant sleeping alone, the truth o the matter is, none of these supposed benefits have been shown to be true through scientific studies. The great irony is that, not only have benefits of solitary infant sleep NOT be demonstrated - simply assumed to be true, but recent studies are beginning to show the opposite that is, it is not, for example, solitary sleeping arrangements that produce strong independence, social competence, feeling of high self esteem,good comportment by children in school, ability to handle stress, strong gender or sex identities - but it is social or cosleeping patterns that might, indeed, contribute to the emergence of these characteristics.”

Ok, but what about safety?

“No infant sleep environment is risk free. As regards cosleeping (in the form of bed-sharing) what we know to be true scientifically is that for nocturnal infant breast feeding and nurturing throughout the night both mothers and babies were designed biologically and psychologically to sleep next to one another. And while beds per se did not evolve mother-infant cosleeping most assuredly did-and not maximize infant and maternal health and infant survival! Infant-parent cosleeping with nocturnal breast feeding takes many diverse forms, and it continues to be the preferred “normal” species-wide sleeping arrangement for human mother-baby pairs. In the worldwide ethnographic record, mothers accidentally suffocating their babies during the night is virtually unheard of, except among western industrialized nations, but here there are in the overwhelming number of cases, explanations of the deaths that require reference to dangerous circumstances and not to the act itself…

… While there is evidence that accidental suffocation can and does occur in bed-sharing situations, in the overwhelming number of cases (sometimes in 100% of them) in which a real overlay by an adult occurs, extremely unsafe sleeping condition or conditions can be identified including situations where adults are not aware that the infant was in the bed, or an adult sleeping partners who are drunk or desensitized by drugs, or indifferent to the presence of the baby. In these cases often the suffocation occurs while the parent and infant sleep on a sofa or couch together.”

So I feel a bit better now, and I don’t know about you, but to me, Notre Dame is nothing to shake a stick at, so I trust the source.  They also list some guidelines about co-sleeping:

“While mother-infant cosleeping evolved biologically, it is wise to recall that beds did not; whether sleeping in a crib or in the adult (parental) bed, the mattress should be firm and it should fit tightly against the headboard so that an infant cannot during the night fall into a ledge face down and smother. Since contact with other bodies increases the infant’s skin temperature, babies should be wrapped lightly in the cosleeping environment especially, and attention should be given to the room temperature. Obviously if the room temperature is already warm (say above 70 degrees F, the baby should not be covered with any heavy blankets, sheets or other materials A good test is to consider whether you are comfortable; if you are, then the baby probably is as well.”

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When I read this article in the New York Times last fall, I couldn’t imagine that I would ever let my child sleep in my bed with me.  Well, guess what?  That’s where he spends most of the night.  It didn’t start out that way, I think for the first week he was in his bassinet next to our bed, and I would get out of bed and go sit in the rocking chair to feed him every two to three hours.  Then somehow, and I can’t really pinpoint how, we started to put him in the bed when he had trouble settling down, and it was SO MUCH EASIER.  My sleep and his was greatly improved; he would wake up for 20 minutes to nurse and then fall quickly back to sleep, as would I.  So there he remains today.  Sometimes we’re able to start him off in the bassinet, but I’m searching for some sort of compelling reason to make the effort to get him to stay in the bassinet for the whole night that would be worth the grief that it would cause to get him there.  When he naps during the day, he’s sleeps in the bassinet, though usually after some parental soothing and falling asleep on an adult shoulder or chest.  One drawback I keep thinking about is that it’s going to get more difficult as he gets older to get him out of the bed, and I don’t want him to be 12 and still sleeping with us (I’m only half joking).  So I’m thinking that a goal of three months is reasonable to get him out of the bed.  But before I make a plan, I want to find out more about if it’s really so bad for him, or for us, and if this is something I should be concerned about at all, or just let evolve as it may.

According to the NYT article, the American Academy of Pedeatrics recommends that children do not sleep in their parents’ bed because of the risk of the parents smothering the child in their sleep, or the child getting caught up in the sheets, pillows, or in the space between the bed and the wall.   But the research on this has been ”inconclusive,” except for parents who drink too much, smoke, or don’t make the bed safe (for the record, we use foam positioners made to keep baby in place, and presumably to keep parents from rolling on baby).    

The article also cites a study which groups parents into three categories: intentional, reactive, and circumstantial co-sleepers.  The greatest concern is about the reactive group, because they don’t really want their kids to sleep with them but it’s the only thing that works for them.  Such an arrangement is most stressful for both parents and kids in this group.  Oh crap, that’s us.  Except that there is something I find to be enjoyable about it too.  I realized this in the middle of last night, when the little dude fell asleep after eating, and I probably could have put him in the bassinet, but it was nice to have him there, comforting for me as well as him.  When he was in the bassinet the whole night, I used to wake up periodically throughout the night to check if he was still breathing, and I don’t do that anymore.  And it just feels good to have him there, at least for now.  So that leads me back to my original question as to whether we should continue to do this, what the benefits and drawbacks are, and if we keep him there, how long should he be there.  I’m going to have to do a bit more research…

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