Sleep
Hands down the most questions I get for the first 2 years of life in kiddos are sleep questions, and it is perfectly understandable why. Sleep is awesome. We all need it. Kids need it to grow and not be absolute monsters during the daytime. Parents need it to be awesome parents, especially when dealing with monsters during the daytime.
Then why do kids seem like they want to fight it so much?
Is it teething? Is it nightmares? Is it hunger? Is it one of a million bajillion other things? Sure! What all those sleep books and sleep consultants don’t tell you is that sleep is different for every kiddo and every family. Each kid thrives with different sleep environments, schedules, positions, etc. But what do all these books and specialists say as a running theme? Consistency. Now I don’t mean that all parents are required to set a rigid schedule around the sleep schedule of their kids, but there should be consistency in how sleep is introduced, maintained, and troubleshot at home.
So where do we start? Well, let’s start at the beginning of baby.
When baby was in their parent’s belly, it was all dark with no real cues for light and dark to note sleep and wake times, right? They were free to sleep when they felt like it in the same weightless, warm, and cozy environment for 9 months with no real change to the environment the whole time. So why do we expect babies to know when to sleep or how to sleep as soon as they come out into the outside world? They don’t. We need to teach babies everything about sleep. I mean, sometimes when babies come out, they don’t even know that they need to close their eyes when they sleep. How crazy is that?
So now that we know as parents that we need to teach our kids about sleep, how do we do this effectively? Consistency, consistency, consistency.
Are there some babies that come out into the world as excellent sleepers from Day 1? Yes, like 1% of babies are these miracle babies. So, if you are lucky enough to have one of these perfect sleeping babies, here are some words of advice: Just shut up about it. Please don’t say anything. Your other tired non-sleeping parent friends don’t want to hear it, and you don’t want to jinx it.
For the rest of us, babies usually come out sleeping whenever they feel like it, and most of the time they will have their days and nights messed up. Why? Our anthropology friends think it is an evolutionary thing. When were cavepeople parents around to hang out and feed baby? When they were not hunting and gathering, i.e., the nighttime. So baby might as well be active during that time. Others think that it was at night when mom was sleeping that there was less movement of baby’s surroundings in utero. This allowed the baby to do a bit more activity peacefully without worrying about mom doing cardio at spin class. But for whatever reason, most babies think nighttime is the right time; however, that does not mean we have to play along with this.
So for the first few weeks, let baby sleep and wake whenever, but if it is nighttime (i.e., pick an eventual bedtime for baby and use this as the start of nighttime) and baby is up, you just feed and soothe and that is it. No need to read to them or play chess; don’t make nighttime exciting. Also if it is nighttime and baby is sleeping (and they have hit the milestone of being past their birth weight), do not wake baby to feed. Let their gut get used to moving slower at nighttime. But if it is daytime and they are up and looking around, make it fun! Show them cool things, play peekaboo, and all that stuff. Let them know that their parents are way more fun in the daytime and thus as a baby, I should figure out how to be up more during the day and less at night. But even with doing this, don’t expect a lot of consistent nighttime sleep for the first 1 and a half-ish months when most babies reach a point that they figure out what day and night are, usually letting us know by having that nighttime stretch be the longest stretch of sleep in a 24-hour period.
For the first few months after that, we want to slowly get baby used to the idea of self-soothing/self-reliance when they wake up at night. Remember, everyone wakes up multiple times during the night, kids and adults alike. It’s just at some point our parents made us figure out that it is still nighttime, we are still tired, and that we can just get into a different comfy position and go back to sleep without fully getting out of unconscious sleep mode. So I always tell parents that a baby crying or whining in the middle of the night is NOT an immediate emergency that needs to be addressed right away. Give your baby a few seconds to minutes to see if they turn to the side, go back to sleep, or find their hand to suck on to soothe enough to go back to dreamland. Maybe if they pass that bit of gas on their own, that’s all they needed. Not every time a baby wakes at night is it due to hunger. In the same way that when you wake at night, it is not always because you are hungry. But if we always go to feeding as 1st choice for night time wake up intervention, even if baby just fed an hour ago, they will think/learn that feeding is humans only soothing option. So always try other forms of soothing if needed before feeding at night if it has not been at least 3-4 hours since the last good feed. Remember, you are teaching them everything about sleep.
The Line in the Sand
Okay, so here we are at 4 months. The critical sleep juncture in most pediatricians’ and parents’ minds. By this time, if your baby has caught the drift early with your chill behavior at night and is sleeping through the night, awesome! Keep it up! If not, like the majority of babies, then we need to do a bit more sleep teaching. Oftentimes, babies will start showing signs of a 4-month sleep regression as their sleep patterns get more mature and adult-like. Meaning, they have this lighter stage of sleep now that they will easily awaken from. Remember those early days when your baby was sleeping in and no matter what noises you made they stayed asleep, even when you dragged them to that cute and loud place for brunch? Yeah, kiss those times goodbye, thanks to this more mature sleep stage they have now.
This new 24-hours-of-nap schedule is tough on any family. So if I have a baby who is showing these regression signs, is gaining good weight (usually past 14 lbs), and is 4 months of age, I am going to recommend sleep training ASAP to get out of this phase and get everyone back on a great nighttime sleep routine for everyone’s health and wellness. I know if I mention sleep training at this age, I will lose a quarter of my parents right there, but hear me out. After years and years of guiding thousands of families and their sleep practices, introducing sleep training early for infants pays dividends. Not just anecdotally with patients in my clinic but in good scientific peer-reviewed studies. The earlier we can safely do sleep training, the better kids sleep their whole lives, and the less likely they are to have anxiety conditions and panic attacks when they are older. The self-soothing part of the brain that needs to develop to help a baby fall back asleep is the same as the self-soothing a teenager needs to do when their math teacher in 11th grade gives them a pop quiz. They need to be able to recognize Yes, this is not ideal, but I can do this. No need to freak out. There is no lion chasing me, no need to engage that fight-or-flight/panic attack part of the brain for this calculus quiz. I got this.
So, I don’t look at sleep training as punishing or being mean to an infant, but more that parents who do sleep training early are giving their kids the gift of a lifetime of better sleep and the ability to chill in stressful situations. And I promise, as the research reiterates, that babies who are sleep-trained have the same love and attachment for their parents as those kiddos whose families did not sleep train. Sometimes actually more so, as parents who are chronically waking up at night through toddler and childhood have a higher tendency for disengagement during the day due to sheer exhaustion. Isn’t raising a kiddo hard enough even with a good night of sleep?
Sleep Considerations at 8 Months
So let’s say that you did not do sleep training or were bestowed with a kiddo who is not sleeping through the night by 8 months. It’s okay. It just makes sleep training a bit harder if you want to start it now. The main reason is that kiddos by this time have object permanence, meaning that when you leave a room, they know that you just didn’t disappear and that you are probably hanging out watching TV in the living room. How parents usually notice this new brain realization is that if they drop something and it is out of direct eyesight of little kiddo, the child will start looking for it around where they think it is/could have gone. So once at this stage, it makes the rip-the-bandaid/cry-it-out method a lot harder to accomplish because they are just more pissed off that you are not coming to help them when they are screaming their heads off because they know you are watching Law & Order in the next room.
So, most pediatric sleep docs recommend a more gradual sleep training method such as the Ferber method at this stage; instead of cutting them off from parental help at night cold turkey, you gradually extend the time it takes for you to respond to their whining and crying at night. But when you go in to help, it is minimal and always the same no matter who comes in to address the situation. I call this the 2-minute rule. When you go in, there is no picking them up or removing them from their sleep area (which can signal to them that the more they cry, the more interaction from their parents they get). At most, a back rub and a song that can be done by anyone helping out overnight, and then when 2 minutes hits, boom! You are out of the room. Then when they cry again, wait double the amount of time you did previously, and go in the room with the same calm demeanor and do the same back rub and song, and when 2 minutes hits, boom! You are out the door…rinse and repeat. Now, where the cry-it-out method takes a few days to a week, this one usually takes double the time because it takes a bit for kids to realize Man, this is a lot of energy I am exerting for the same boring sleep intervention. There has to be a better way to go back to sleep.
The Other Sleep Regressions
The science behind sleep regression or what causes a sleep regression past the 4-month instance is a bit murky. But over the years taking care of lots of kiddos, pediatricians do see a trend toward sleep steps backward, if you will. Around 1 year of age, we commonly see kids who are learning to pull up to stand and walk have a sleep regression. Oftentimes, kids will be up standing in their cribs, ready and happy to show the cool new trick they are working on at 2 in the morning. Try to handle these with minimal excitement and bring that 2-minute drill back into play to nip this in the bud.
Another common time is around 18 months to 2 years of age when kids blend the terrible two temper tantrums with not wanting to go to sleep. Stay strong and stick with the same bedtime routine that you have been doing well for the past 2 years. And if they start screaming their heads off (often before they even go to sleep), trying your best to ignore this behavior will provide the signal that there are better ways to get their way, not just for sleep preferences, but also for everything else during the day that does not go their way and can result in a temper tantrum.
The next sleep regression we often see is between 2.5 and 3.5 years when we start having kids sleep in a big kid/toddler bed rather than a crib. This new-found freedom will often find its way into your bedroom with a wide-awake kiddo staring at you while you are sleeping until you wake up. If this is happening over and over again, I highly recommend the zombie method of toddler sleep training. Here, you start with having some sort of tangible signal that kids can rely on to let them know when it is still nighttime and they should stay in bed and when it is morning/wake-up time and they have permission to come and hang out with you for some breakfast and snuggles. This can be a color-changing light or something similar. So, if the color is on the do-not-get-out-of-bed designation and your kiddo gets out of bed and tiptoes to your room, then your job is to act like a zombie. You slowly get up, hold their hand, walk them back to their bed with your eyes straight forward and no interaction, and then you walk back to your bed. You do this over and over and over again. The first night is no fun. You will literally do this hundreds of times. But after that, your kiddo knows you mean business when you say nighttime is for sleeping, and there is no way they are getting any extra attention or extra hang-out time at 2 in the morning. Once it clicks with them, you will see a dramatic decrease in these events.
Fear-Based Sleep Regression
Thanks a lot, Uncle Joe, for showing my little kiddo that scary movie, and now they are waking up all the time, worried about monsters in their bed. These stressor-related sleep disturbances and wake-ups can happen at any age. Kids will wake up with these regressions scared and basically wanting reassurance that everything is OK and that you are where you said you would be just in case the monster from under the bed comes out. For these sleep regressions, we want to give kids the feeling that they have power over the situation, but this is learned over time. The way that I like best to teach this is the “15-minute pass” method. For this, you do a little art project with your child where you make a door knob hanging pass. Color it and label it however you want to get the kiddo engaged with the idea. Let them know that at night they can use this pass once for 15 minutes of reassurance/back rubs/singing songs from parents. But once it is used, that is it, and back to the zombie method if they wake up. At first, it is okay to let them try using it once a night. Then, over time, we drop it to once every 2 days, then 3 days, then once a week, etc. until the kiddo no longer needs it, feeling empowered and secure seeing that they can rest assured that their family is around to keep them safe when needed and that scary movie is a distant memory.
The Other Ones
There are too many other regressions to name as really anything that is not of the norm in terms of schedule or new discomfort is going to mess with sleep, from a cold to new teeth coming in, to jet lag from that late flight. If any of these other regressions occur, just get back to the regular routine as fast as you can and stick with it. The body will remember good solid sleep hygiene like riding a bike; it just takes a couple of nights to get back into the swing of things.