At Long Last: Sleep Training Tools For the Exhausted Parent

5 months, 30 days ago

Are you tired? Not sure how to help your kid sleep through the night? Here is my comprehensive guide to sleep training tools and methods to help tired parents and kids sleep better. These sleep training methods will work for infants, toddlers, and through school age. 

Free Bonus: I created a guide comparing my favorite sleep training techniques to help you figure out the best method for you and your child. It’s a quick two page PDF you can save and reference later as you try this yourself. Click Here to get the guide, free.

So, we’ve covered why fixing your child’s sleep problem is not selfish because it is good for you and for them. I imagine that lots of parents fix their kid’s sleep issues without a lot of difficulty. Then there are the parents who have made it to see me in Sleep Clinic. Generally, these parents have tried and failed to address their child’s sleep problem, for various reasons. Since there is a lot of information to cover, I’m going to break this out into a question and answer format, as I review all of the different effective sleep training methods .

 

What do you mean by sleep training?

When I refer to sleep training, I’m talking about behavioral (non-medication based treatment) of two common problems, sleep onset association disorder and limit setting disorder. Some kids have a mixture of both.

When should I consider sleep training?

I would wait until a child is at least 6 months of age, although some people have recommended trying it as early as two month of age (note that I don’t endorse this). I actually think that it is a bad idea to start before four months of age,  preferably once he is no longer feeding during the night. However, if your child is still feeding multiple times during the night and is over six months of age, that could be part of the problem. If your child has issues such as autism or developmental delay, these techniques will still work but must be applied more slowly.

When should I not start sleep training?

If you are worried that your child may have a medical problem which is disrupting sleep, please talk to your pediatrician.
If you want to pursue co-sleeping as a lifestyle, you may find it more difficult to adopt these recommendations, although they can be put into play if you are room or even bedsharing– it is just harder. I believe that cosleeping is associated with worse sleep long term for parent and child. If you are cosleeping and want to stop, here is my guide on how to stop the cosleeping habit.
If you have a major life event coming up– a move, a visit from the in-laws, a big project do at work.
If you have  major stresses in your that would make embarking on about a week of disruption.
For more on this, here is a comprehensive guide on when not to sleep train.

My child feeds at night. Is that part of the problem?

It certainly can be. Most formula fed infants are capable of sleeping through the night without feeding by six months of age; this milestone happens later for breast fed infants, probably between 9-12 months of age. Here’s my article on how and when to wean night feeds.

 

Ok, we’re ready. Whats the first step?
Free Bonus: I created a guide comparing my favorite sleep training techniques to help you figure out the best method for you and your child. It’s a quick two page PDF you can save and reference later as you try this yourself. Click Here to get the guide, free.

I think the most important thing is taking a hard look at your child’s bedtime ritual. I saw the great Jodi Mindell speak at the 2012 Sleep Meeting here in Boston. (Here’s a question and answer she did on some of these issues at Parents.com). She emphasized that bedtime need to be consistent, positive, and have a clear trajectory. High quality consistent bedtimes are associated with better sleep quality throughout childhood. Here’s a post explaining why this is. Let’s break this out a bit:

Consistency means bedtime happens about the same time on typical days, and has the same events in the same sequence. A good bedtime for babies and preschoolers through early elementary school age is between 7:30-8:30 PM.
Bedtime should included enjoyable, positive activities like stories and songs, with the last part occurring where the child sleeps. 
Bedtime should be short and sweet (<45 minutes), with a forward momentum. Meaning that you go to the bathroom, then the bedroom, then lights out. Keep things simple and moving. Don’t move your child towards bed, then away, then towards it again.
If your child has an aversion to being in their crib or room, it’s important to spend some pleasant, fun time playing there during the day to emphasize that it is a positive place.

In our house, we mark the start of bedtime by going upstairs with the boys between 7-7:15 PM. They brush teeth and bathe every other night. When one or the other attempts a digression (Wrestling! Running around naked! Peeing on the floor!) we firmly redirect them to the task at hand. They get in their pajamas, read stories, sing songs, and go to sleep on their own. If one parent is doing both bedtimes, the older one helps put the younger one to bed. Lights out is by 8:30 PM for the older boy. 

Recently, I’ve been reading The Power of Habit (affiliate link), which has some terrific insights into the importance of bedtime. Remember, the most powerful reinforcer of behavior by your child is positive reinforcement (kind words, contact, affection). This is WAY more effective than, say, sticker charts.

Habit cue reward.001

If you are reading this post, you and your child have likely fallen into some bad habits around bedtime (fighting, lying with them until falling asleep, eating a chicken dinner in bed, etc). By establishing a consistent time and pattern of bedtime, you are going to essentially revise these habits so that, with time, your child will actually crave their lovely and predictable bedtime.

If you are working on starting a good bedtime, here’s a video on how to start a good bedtime routine.

We already do all that stuff. Our child still can’t go to sleep without us and wakes up at night!

Here’s where it gets a little bit more complicated, and this is the place where many parents struggle– the realm of traditional sleep training methods. Children who can’t fall asleep on their own and who wake up frequently at night likely have inappropriate sleep onset associations and will require a little bit more intervention. The goal of all of these interventions is the development of the ability to self soothe– specifically, falling asleep solo at night.

 

There are a couple of evidence-based tools you can use if you put your child in bed and he cries or fusses until you come back into his room:

Bedtime fading: This strategy involves temporarily moving your child’s bedtime later while teaching him to fall asleep on his own. This can help use your child’s natural sleep drive to make falling asleep easier. Usually I recommend moving the bedtime later by 30-60 minutes depending on prior experience. For example, if the family has previously tried to put their son down and he cried for 45 minutes before they gave up, I will move the bedtime 45 minutes later or more. There is evidence that removing the child from bed if they do not fall asleep after 15-20 minutes then putting them to bed again a few minutes later (a “response cost”) is effective but I think that it is generally too complicated. Once your child can fall asleep within 15 minutes, you can move the bedtime earlier by 15 minutes every two days until you reach the desired bedtime (usually between 7:30-8:30 PM is best). It’s important to avoid letting your child sleep in in the morning or falling asleep in the late afternoon in the stroller or the car, as they will be less tired at bedtime. This is one “gentle” sleep training method. 

Avoiding “sneaky sleep” in the later afternoon.
Not allowing your child to sleep much later in the mornings, unless they are getting up at an uncomfortably early hour.

The “cry it out” approach:  The behavioral term for ignoring an undesirable behavior is “extinction”; obviously most parents don’t love the term. There are two ways to do this. Unmodified extinction involves putting your child down at the appointed hour, closing the door, and letting things play out. Many people struggle with this quite a bit. Graduated extinction (also known as the Ferber method), is where you check on your child at set intervals (e.g. 1 minute, 2 minutes, 3 minutes, then every five minutes until they fall asleep). When you check, the interaction should be very brief and without physical contact. Dr. Mindell recommends the script, “It’s night night time. I love you. I’ll see you in the morning”. This method is very effective but can be challenging to carry out. Some children may vomit. If this occurs, I recommend going in, cleaning up the child and bed, and leaving. It feels horrible, but you don’t want to reinforce vomiting as a tool to get what you want. Trust me. With time and experience, I’ve come to believe that this is pretty difficult to implement in children who have moved from a crib to a bed.
“Camping out” is another evidence based gentle sleep training method consisting of gradually withdrawing your presence from your child’s room at sleep time. It may result in less crying and be a better fit for some families, but takes longer than “cry it out.” This is another way that people use when they performing “gentle” sleep training.

Remember, when camping out, when your child looks to your for guidance, you have to provide, brief, minimal interactions. It helps to have a script. Look at your child and say, “I love you. It’s time to go to sleep. Good night.” Do this EVERY time.
Here’s a step by step guide for how close to be to your child, along with a video on how to do this. Each step should be between 1-3 nights. This starts if you are currently rubbing your child’s back to help her fall asleep. You move up the pyramid over time. Sleep_webinar_Ruth_FINAL__1__pptx

The “excuse me” drill is another gentle sleep training technique where you provide very frequent reassurance at first and withdraw it over time.

This gentle sleep training method is really for kids who are old enough to talk and have some abstract thinking– imagine age 3 and up. During the excuse me drill, the parent who usually stays with the child until he falls asleep (let’s say Mom in this case), will say, “excuse me, I need to step out and ___________ for a second. I’ll be right back!”. The excuse doesn’t really matter. Here are some suggestions:I need to…

check the soufflé
buy a lottery ticket
practice my breakdancing
bang out ten pull ups
(In all seriousness, boring excuses (“I need to check on your brother, take out the trash, etc”) work best

At first you will come back in very frequently– every few seconds on the first night. When you come back, you praise your child for staying in his bed, looking cozy, acting brave, etc. It is OK to touch him. Then you leave after making an excuse and come back a few minutes later. Over several nights, you reduce the frequency of checks. What makes this gentle is that you are not allowing your child to stress or be alone for more than a few seconds at first. The point is that nothing is more reinforcing for a child than parental attention and reassurance. Hopefully, your child will start falling asleep with you out of the room. Coupling this with bedtime fading is a great combination for an older, anxious child, and this has been studied in children with developmental issues (specifically Angelman syndrome) as well. Like all sleep training methods, it should be part of a detailed plan.
Nursing moms should try to avoid having nursing be the final activity prior to sleep onset. Ideally, the other parent should put the child to bed.
The binky can be challenging. The American Academy of Pediatrics recommends pacifier use up until 6 months as part of a number of interventions to reduce the risk of sudden infant death syndrome (SIDS). In older babies and toddlers you may find yourself replacing it frequently at night. If you are not ready to get rid of it, Dr. Mindell recommends keeping some pacifiers in the corner of the crib. When you put your child to bed, guide their hand to the binky and have her put it in her own mouth. That may help her find it on her own in the middle of the night.

Often, sleep training may be more difficult for one parent than the other. When we did this, I sent my wife out for the first night so she wouldn’t have to listen to our older son crying. It may be a good idea to turn off the monitor if you can hear your child anyway.

What do we do if she wakes up at night once we start this?

If you fix bedtime, the nocturnal awakenings will go away over time. I usually recommend that parents just do what they have been doing in the past for nocturnal awakenings. The middle of the night is all above survival.
It’s not working. Help!

The most common reason why you have not been successful is being inconsistent. You need to be almost robotic in executing the same plan every night. Here’s my inventory of the top ten sleep training mistakes.

My child is an older and primarily has issues with bedtime. Any specific tips on working on this?

Bedtime fading as noted above can be really helpful in this context.
A bedtime chart showing what is expected of your child every night can be really helpful. Here’s a nice one you can purchase here. Sticker charts can be helpful as well. Dr. Wendy Sue Swanson has tips on implementing this here. Dr. Deborah Gilboa discusses the limitations of sticker charts here.
One strategy which I love is the bedtime pass. This works like a hall pass. Give it to your child and explain that she can use the pass to come out of the room one time for a curtain call e.g. a glass of water or another trip to the bathroom. After that one instance, she is expected to stay in her room and will be brought immediately back if she comes out. The research on this technique showed that kids tended to hoard the pass and not use it at all. Dr. Greene has a great summary of how to implement this. From Dr. Greene’s site:

So how do you use bedtime passes? Simple.

Give your child a special card good for one free trip out of their room each night or one visit from a parent – for a brief, acceptable purpose such as a drink and a hug. Many families decorate the cards, often with the child.
Require the child to get in bed at bedtime, but be sure the free pass is close at hand.
When the child uses the pass, the card is surrendered for the rest of the night.
If children leave the room again that night, they are walked back without a word and without eye contact.

You may need to carry out an extinction strategy which is more challenging to implement in a child in their bed who can easily get out of his bed, and out of his room. I strongly advise against locking children in their room. If your child comes out of his room, take him back to his room with the brief speech noted above (“It’s night night time. I love you. I’ll see you in the morning”.) If he comes out, put him back in his bed and close the door for one minute. If he is not in his bed when you reopen the door, close it for two minutes. Keep increasing the interval until he gets the message that you expect him to be in his bed. Another alternative can be putting a gate or two in the doorway of the room. (The second, higher gate is for kids that can climb).

 

What else do we need to know to succeed?
Free Bonus: I created a guide comparing my favorite sleep training techniques to help you figure out the best method for you and your child. It’s a quick two page PDF you can save and reference later as you try this yourself. Click Here to get the guide, free.

You can carry out these steps gradually. Let’s say your child falls asleep nursing in your lap in the rocking chair. You can stop nursing to sleep for a few nights (often useful to nurse earlier and have the non-nursing parent put the child to sleep), then stop rocking for a few nights, then put your child to sleep drowsy but awake.
Keep sleep diaries so you can monitor your progress. Here’s the log we use in clinic:PEDIATRIC SLEEP LOG
Be consistent. Intermittently giving in is a very strong way to reinforce undesirable behavior.

Will my child hate me? Does sleep training hurt my child?

There is no evidence to suggest that sleep training causes any damage to children, and lots of evidence that it helps– that children and adults are both happier and better adjusted after sleep training. This is touched on in the AASM article below. Dr. Mindell noted in her presentation that she is publishing a review of 35 studies which showed no significant evidence of harm. Over at Science Of Mom, there is a great review of this science as well.

There was a great summary published by the American Academy of Sleep Medicine in 2006 which reviews the evidence for all of these recommendations. You can download it here:  Practice Parameters for Behavioral Treatment of Bedtime Problems and Night Wakings in Infants and Young Children.

If you are consistent, your child should be sleeping better within a week. Remember, things get a bit worse (the “extinction burst” of worsening behavior) often on the second or third night. Don’t give up!

Parents: please share your experiences in the comment section below. What worked? What didn’t? Are you still struggling with these issues? If you are, let me know and I’ll try to help.

I hope that you have found this helpful. If so, you can support this site by shopping at in my store at Amazon.  Any purchases through that link (even it if is not in my store) will provide a small amount of support to the website at no cost to you. I have curated some of my favorite sleep hygiene products and bedtime stories.   Thanks!

The post At Long Last: Sleep Training Tools For the Exhausted Parent appeared first on Craig Canapari, MD.

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Facebook Live Chat: Weaning the breast, Weaning the swing, Sensory processing Disorders and other Topics

10 months, 28 days ago

This is a transcript of questions from my Facebook live session.You can watch the video here. I’ve also provided a lightly edited transcript below.

We’re gonna start with a question by Amanda.

What should you do, very specifically, about frequent toddler night wakings? Besides quick check-ins and no remove from the crib, how can you manage longer sleep stretches?

You answer, this, he is still waking at night, but now in a bed, climbing from crib. He needs a bottle to lay with to go back to sleep, or it’s an hour plus of crying and I just don’t have the energy in the middle of the night. Well Amanda, I hear you. And this is a really common problem. Let me just show you guys a few quick pictures that are, explain what we’re talking about here. So essentially, this is what a normal night of sleep should look like.

So, from bedtime to wake time. Your child goes through different stages. Your child’s falling asleep on his or her own, she’ll so through a long stretch of sleep. You know, anywhere from one to three hours. In this early evening, a period of sleep, this is where if you put your child, if your child falls asleep in the car, you could pick your child up, carry them to their bedroom, and they fall asleep. Then about two to three hours in, they have their first REM period. REM sleep is a lot like wake sleep, it’s easy to wake up from REM sleep. And in fact, it’s really common. And this red bar is essentially just what a, a night of him waking up. Generally, if we know how to put ourselves to sleep, we can just roll over and go back to sleep, maybe adjust your pillows. You don’t remember it in the morning. However, if your child needs you to fall asleep, it’s very different. You hold your child, you give them a bottle. He falls asleep. You try to relax for a few hours, and then all of a sudden, you’re getting into bed two hours later, and he wakes up. Then, you need to repeat bedtime again. The next REM period, you’re gonna do it again. And again, and again, and eventually you’re awake for the day. So really, this is, this feels like a middle of the night problem because the middle of the night is really painful.

But what it is, is a bedtime problem. And really what you need to work on is getting your child to fall asleep independently. (Here’s more on toddler night wakings). In Amanda’s situation, if your child is in a bed, it’s a little bit different. And I really don’t think the cry it out approach is particularly feasible or advisable in a child who’s sleeping in a crib. Its difficult to institute, in older children, I just think it’s too painful. Doing something with a mixture of a later bedtime, and slowly withdrawing yourself from bedtime. You know, what is on my website is the camp it out approach. And I want to say I didn’t come up with the term. The term came from Harriet Hiscock in Australia. But I would really work on getting your child to fall asleep independently at night. And the nighttime awakenings should extinguish with time. Really, don’t beat yourself up, don’t feel like you have to solve problems in the middle of the night. Just do it what you’re doing to survive, and work on getting your child to fall asleep.

So, Lindsey has a question:

How should we manage different sleep needs for two siblings who share a room and like to keep each other up?

“I have a two and a half year old who naps about 90 minutes per day, and no matter what, we won’t sleep until between 8:30 and, he won’t sleep between 8:30 and 8:45. We wait until he’s down to put his older brother, a six and a half year old brother to bed, because if we don’t it’s a circus show of mutual shenanigans. The older kid is really tired in the morning from going to bed that late.”

Well, Lindsey, I feel you because I have two boys, and it can be kind of a disaster sometimes if they get going. And that geographical split can be critical to allowing you to succeed. Now, not everybody has the luxury of a room for each of their children. Or, or, alternatively, how you, you know, maybe your kids want to room together for whatever reason. I think there’s a couple of solutions. One is you can actually try to put the older child down earlier. Now that’s a tough sell, because it’s very unjust to a six and a half year old to go to bed before the brother or sister. Sometimes, a bribe, I’m not trying to say big, can be very helpful to get the child in and settled.

The other thing you could do is try to move the younger child’s nap a little bit earlier in the day.

The final thing you could do is you could take some measures to get them to sleep in a little bit later. It’s a tough sell, again, because little kids get up earlier. But making sure the room is dark, really, really dark, so light from the outside is not waking them up can be helpful. And also, depending on who your early riser is, if its the six year old especially, ask them to come and get you first.

Now, the question here from, from Jen from Food Allergy Buzz, which is a great site, you should really check out.

”How should I wake a teenage who’s a very heavy sleeper. She has a difficult time waking, even if he gets eight or nine hours of sleep.”

It’s telling to me that this is a teenager, cause I think there’s a couple of issues. One is, if your teenager’s getting eight or nine hours of sleep, on average, that’s one thing. But many teenagers aren’t able to do this. And not to get on my hobby horse, but, school really does start too early for teenagers. So I would say that if your child is consistently getting enough sleep at night and still can’t get out of bed in the morning.

If they snore, they certainly should be evaluated for something like, I’m sure if it’s sleep apnea, which can make their sleep not high enough quality. And the other thing is, it is, you know, biologically, it’s hard to get teenagers up in the morning. They want to sleep from midnight to nine. And if they do that, they’re usually pretty easy to get up. But if you’re trying to get them up earlier than that, you’re going against their body clock and it’s a struggle.

So I have another question from Lindsey actually, about sensory processing disorder. And there are a couple questions about this. Those of you not familiar with this, sensory processing disorder is an issue where children have difficulties managing sensory input. And it can be in any domain. But usually we think of sensory issues being around oral or feeding problems, like children that gag on soft mushy foods, such as myself, because I don’t like mushy vegetables. They make me gag. But in all seriousness, some kids with feeding issues have difficulty tolerating certain consistencies. There are also kids that have trouble with loud noises, or need loud noise, to you know. And most commonly in the sleep domain, with sensory issues. So Lindsey writes:

”Can you suggest sleep strategies for a kid with a sensory disorder beyond the usual weighted blanket, sensory diet during the day?”

I do think those daytime interventions are pretty important. And it sounds like you already have an occupational therapist. I prefer actually Lycra sheets to weighted blankets. Weighted blankets are really heavy, and they’re uncomfortable during the summer time. They’re also very expensive. A Lycra stocking for your bed works really well. And what you do is you actually, it’s like a sock that you slide over your kids bed. They slip down into it. You can actually pack stuffed animals around their body, if your child is that sensation seeking when they want to be wrapped up like a twinkie. There is, there is an Etsy storefront called Cohsy Comforts. It’s actually the mom of one of my patients, makes these. She’s had a lot of luck with her son. And on Amazon, there’s something called a SnugBug(affiliate link), you can purchase as well. So you can certainly try that.

Question from Jen on starting sleep training.

What should you do when you start sleep training and your child starts teething or gets sick?

“I delayed starting because those top teeth looked like they’re just about ready to pop through, but actually took three months. So in the end, I started a couple days later, the teething started becoming more painful, and baby got a cold.”

So there’s two questions. A sign when to start sleep training even though teething may be a factor. And what to do when you start sleep training and something comes up. So I’d say the first thing is if you’re starting sleep training, first of all, make sure there’s no major developmental issues on the, on the horizon. If your child’s about to start potty training, if your child’s about to start walking, put it off for a couple of weeks. I wouldn’t worry so much about teething, because those teeth buds, as you said, can linger.

Make sure you have a couple weeks of runway. And by that I mean, weeks where you’re not going anywhere, there’s no major disruptions in schedule, and you know, less helpful in laws aren’t coming to visit. So just kind of plan that out a little bit.

Question from Beth here:

My daughter’s 14 months and still waking once a night to nurse, and then for good between five and six in the morning.

“I don’t know how to wean her. She goes nuts if I try to calm her without nursing. I’m a single mom, so I can’t hand her off to anyone else for comfort. Any advice? I’m dying for a full night’s sleep.”

Beth, I feel your pain. And I think especially single parents struggle with this because, even if you’re not single, some of the parents out there struggle with this as well because, only one of you can nurse typically. I think that I have a couple of thoughts.

One is, you have to think about when you’re ready to wean all together. If you are a parent that works outside of the home, nursing at night may be the only time that you’re nursing. So if you wean those night feedings, it may be the end of your nursing. And that’s totally fine. But it’s really up to you when you’re ready to do that. I think because Beth is kind of alluding to the fact that there’s two parents in the house, will often have the non nursing parent be the one who takes over these feedings. I mean the five or 6:00 A.M. awakening you’re kind of stuck with, but I think you want to think about when you’re ready to stop nursing, and maybe, it may be time to do that. And there’s no magic way to do it. You just kind of have to stop. (For more on weaning feedings, read here).

How do you handle night wakings when they happen? My 19 month old and three year old fall asleep independently but both wake up at night and won’t go back to sleep until I come in and check on them.

Interesting. I wonder if they wake up at the same time, and if they’re in the same room. If that’s the case, there may be one child that’s driving both of these wakings. If kids are really falling asleep independently at night, and they are waking up. My first thought is well, is there a medical issue that could be waking them up at night? The most common in my world is obstructive sleep apnea, so your child snores, you might have them get checked out by their doctor.

If they’re complaining about leg pain, they could have a disorder called restless leg syndrome, which is a problem where you have a lot of kicking, leg restless, and leg discomfort. It occurs in about 1% of kids. And 1% doesn’t sound like a lot but, most kids don’t any medical problems, so that’s fairly common. So I think that I’d sort of look into, you know, make sure you’re not missing any medical cause.

You probably aren’t. Most kids are healthy. And then just sort of see about how you could peel back those, those interventions. And really what you want to do is, do the minimum intervention you can. They’re sharing a room, think about separating the, so one child is not waking up the other. And a check at night should be, I love you, go to sleep, good night, put them back to bed. So let’s keep going.

Katy writes:

My 17 month old falls asleep while being rocked to sleep, but will only stay to sleep two to three hours tops before crying for mom and daddy.

“She refused to go back to sleep in her own crib the second time around. So she ends up in the bed with us, help.”

Katy, many of us have been there, and I feel you. Again, this is a sleep onset association. If you work on the independent sleep, and peeling yourself out at bedtime, that’s going to get rid of those nights of awakenings. Save your energy for bedtime. (On my website, I have a whole bunch of stuff on different ways to use sleep training, whatever your parenting philosophy is.) And then the night time awakenings should drop off.

So Sharon’s writing:

My 18 month old daughter, was sleeping through the night but for a month has been month now waking up a couple times a night. Is it a regression, is it a leap?

“Do we wait out as we have before, try sleep training now? We’ve been weak trying it previously. She was sleeping through.“

The heartbreak when your child is sleeping well at night, and all of a sudden, they’re not anymore. It’s a huge bummer, Sharron, and I’ve got you. I have a couple of thoughts. I’m not crazy about the term sleep regression because I feel like it implies that kids are going back, and it feels that way as a parent. But really, if it’s a change in the sleep pattern associated with a major developmental milestone, I think of it as a step forward. I think that again, if, I’m sorry, let me just look through your question. I’d work on trying to falling asleep independently. I would look to see, you know, if it’s been going on, going on recently. Could she have an ear infection or something like that?

I think the first stop should be your pediatrician. If she’s not falling asleep independently, then I would work on that. I think you should certainly wait a couple of days and see where that gets you. And maybe you don’t have to make any changes.

So Brittany writes asking:

How should I wean a seven month old from multiple sleep associations. At once or in stages?

“Our son needs a bottle before bed, including naps. A pacifier to fall asleep and stay asleep, all while rocking him. Without all of this, he will not go to sleep. He’s unable to self-sooth, which we know is a main part of the problem, but how do we wean him from all these sleep associations at once without all hell breaking loose?”

And it does feel like hell when you’re trying to deal with these issues. Sorry if I’m offending anyone. I would leave the binky as is for right now because it’s pretty common for kids to have that pacifier. The falling asleep with a bottle, I might see if you can move that earlier in the bedtime sequence. So your bedtime sequence is story, song, bottle and rocking. I’d move the bottle earlier. Even if you can do it in a separate room, and then just try rocking him to sleep. And once you’ve broken out that association, then work on getting rid of the rocking and putting him down while he’s still awake.

There may be some crying associated with that. With seven month’s age, it’s difficult to avoid, but typically, it shouldn’t take more than a couple of days to get better. Then you can continue, again, with your middle of the night interventions to survive, but hopefully they’re gonna drop off over time.

So Becky asks:

Can we start sleep training for naps first?

“After six months of sleep deprivation, I broke down and started co-sleeping and nursing all night long with our eight month old. So many bad habits to break. We have a critically ill mother in law. Not a good time to sleep train.”

I agree with you, and I think that self care is an important part of any of these conversations, As parents, we need to decide, do we deal with mom, who’s in the hospital? Do we deal with baby? I haven’t gotten a ton of mileage with sleep training during the day, and a reason is, kids really aren’t that sleepy at nap times, when you think about compared with bedtime. At bedtime, they’ve been awake for most of the day, except for some short sleep periods. Whereas with naps, they’re less tired.

I can tell you Becky, when you child gets a little bit older the naps will get better, say once your he is walking. That was my experience. My older son struggled with naps until he could walk, and then it fell into place. I think that, I would think about what are the small incremental changes you can do.

Where would I start? I think you have to start with where you’re comfortable. I think that, obviously your child is less than a year. I wouldn’t start weaning the breast. I would just again, work on getting your bedtime perfect. Work on removing the, your involvement in your child’s bedtime, and do what you need to in the middle of the night. Your bedtime is your maximum point of energy and strength to deal with these things. So again, if you can kind of step back a little bit from your nursing the child, if your partner could do bedtime, and you could step out. You can go for a walk for an hour or something. Just work on the bedtime. Give yourself a break the rest of the time.

Michelle writes:

How do you wean the baby swing?

“I have a 13 month old who loves her swing. Every night we start in the crib, and she wakes up wanting her swing. If I keep her in the crib, she’s up for hours. If I put the swing in, she’s back to sleep within minutes and sleeps through the night. When you swing wean you?”

First of all Michelle, my oldest son loved the swing. I’m guessing this is your first child, because if your have a second child, there’s no way your leaving them in the swing for periods of time, because now the older child’s going to come and knock him out of it. (Let’s be real here. I have two boys.) I think that, it’s going to happen sooner or later no matter what, because your kid is just gonna get way too big for the swing.

I would again, peel away the swing at bedtime. Do what you need to survive in the middle of the night. Just make sure your kid is safe in the swing, because a 13 month old is probably getting close to exceeding the tolerances for this device.

Kay writes:

For a child with autism, the preschool age, delayed sleep onset and early morning awakenings, what is the best first step in addressing the sleep concerns?

Kay, I think a couple of things. First of all, Beth Malow, wrote a terrific book for parents on dealing with sleep problems in autistic children. (affiliate link). Dr. Malow is a professor at Vanderbilt, School of Medicine, and child neurologist. But she also has two daughters with autism. So she walks the walk. And I would,check out that book.

Here’s step one: get your bedtime just down. Kids with autism will really work well with a visual schedule. So if you actually, just draw it with stick figures, or take pictures of your children doing the things that you want them to do every night at bedtime. Every kid loves this, and I find it works really well with kids with autism.

The other thing is, if you talk to your pediatrician or if your working with, with autism, there maybe a role for medication like melatonin. I’m not the person to tell you if it’s the right thing to do or not, but I’d talk about it with your pediatrician. But, there’s no reason a child with autism can’t sleep better than what you’re describing right now.

Though it is true that some of my autistic patients do seem to need a little bit less sleep than their peers, so also, accepting the early morning awakenings, five to six, and also a later bedtime. It may be meeting your child’s sleep needs. But good luck. It and be challenging,

Natasha, has a 12 month old puts herself to sleep, but wakes once a night for feed.

Will she ever sleep to herself, by herself or do I have to night wean?

Eventually, she’ll give up the night wean, the night feeding. I mean it’s going to happen. So you can either wait for that. I don’t suspect the next couple months, she’s going to raise her hand and say, okay, mom, I’m done with this. So if you want it to stop, you’re probably gonna need to stop it.

Here’s how to do it: if there’s another family member in the house to take care of that awakenings a couple of nights, that would be best. But again, just recognize if you’re not doing a lot of nursing sessions anymore, your risk of weaning all together. That may be desirable for you. Don’t let anyone make you feel bad about weaning. But it can happen.

Katy writes, good Lord, my two year old has decided to resist getting in bed for his nap, every day. Then he naps for two hours. Its just a fight. We did sleep training, he’s in a twin bed. We keep pushing forward, and insisting naps, even though it’s very frustrating.

What should I do when my two year old resists his nap?

There was a study a couple years ago that was looking at napping for, looking at napping in kids with sleep problems at night. And what they found was that a certain subset of kids after age two, napping messes up their sleep at night. And as painful as it is to imagine, giving up that nap, you might try not having the nap, for a week, and doing an early bedtime and seeing if that makes your life better.

The thing is about these nap transitions: they stink. You’re gonna have a period of time where your child is cranky and irritable during the day. It’s never a picnic when they give up the nap. It’s not like they just give it up when they’re ready. But I would try that and see.

Sharon’s writes,

My child takes an hour to fall asleep. Should I stick with the current bedtime or move it later?

Great question. If your child, if you put your bed to, your child to bed at 7:30 and they fall asleep at 8:30, then I would just move the bedtime to 8:30. I promise you it’s going to go more easily. The technical term for this is bedtime fading and it’s often the secret sauce in my sleep training recipes.

Kelly writes:

How do you handle bedtime for a kid who’s overtired after daycare?

Some kids just aren’t ready for bed at bedtime. And we all know melatonin cause it’s in the news and people take it, often fall asleep. Maybe you’ve tried it. Melatonin is made naturally in your brain. What it does is it signals your body to say hey, dude it’s time to go to sleep. The time when that signal starts is called the dim light melatonin onset.

Normally, your brain starts making melatonin about an hour before you go to bed. A sleep scientist named Monique LeBourgeois figured this out that some kids who have problems falling asleep, actually had bedtime too early relative to their dim light melatonin onset.

So in general, the later your child is awake, the more sleepy they’ll become.

But, you have a natural system the counteract this natural tendency to fall asleep as it gets later in the day. It’s called the wakefulness drive. And it peaks after dinner. So essentially, and this is your body clock sending wakefulness signals, so we didn’t, we don’t just all, fall asleep every 15 minutes between lunch and bedtime. The wakefulness signal has a little peak after dinner. This is the forbidden zone. But, there’s another thing that you need to consider. I’m just going to mention late naps in passing, which can reek havoc on these things. But there’s something called the forbidden zone. This term I believe was coined by Dr. Ferber. And it’s an interesting idea.

So if your child is, we’ve all seen this. If you’ve ever, had, kept your kids up a little bit late for a special occasion, they’re acting nuts, and won’t go to bed. You’re in the forbidden zone.

So I think if you find that consistently your child is overtired and acting crazy around bedtime, either try bedtime that’s a half an hour earlier, or half hour later. And then you should get a little bit more mileage from that.

Colleen writes,

Our 21 month old put himself to sleep for bedtime, and nap time but still won’t sleep through the night. We tried to let him cry back to sleep and it just won’t work.

“For example, he woke up at 12:30 and cried for over an hour. It’ll get quite for a few minutes, and start crying all over again. My husband ends up holding him in a recliner for him to stop crying. So he wakes up at least one, usually two times, and up again at six, always crying, but can’t go back to sleep. His bedtime is at eight. He falls asleep by 8:30 or nine. Any tips?”

Just looking at these numbers here, Colleen, if you, I would shorten your bedtime ritual. And I would shoot for lights out at nine, cause he’s falling asleep at nine.

I do wonder if there’s a little bit of a habit formation here, because there’s nothing more reinforcing for a kid than contact and attention from mom or dad. I would try to have dad kind of minimize the involvement he’s doing. At night, just say, “I love you, go to sleep, good night,” pat him on the back, and leave. If you have to go in the room a couple of times, that’s okay.

I’d try, the later bedtime first. And, and then again, if there’s issues like snoring, or anything else like that, I would have him checked out by his pediatrician and make sure there’s not a medical issue. There probably isn’t, but medical issues like sleep apnea are common if your child snores for example, it could be disrupting your child’s sleep. So I would check.

How should extended night wakings be handled by parents with three year olds?

I would say that your kid’s really having extended wake times every night, the one thing I’d look at is actually a later bedtime, cause it sounds like you may have two distinct chunks of sleep during the night, and you want to push them together. So try bedtime 30 or 45 minutes later and see if that gets you where you need to go.

Any recommendations for a preschooler who has nighttime wakings and can’t fall back asleep alone because she’s scared

That can be challenging. And I think that one of the things that’s really helpful with the nighttime fears is to, there’s things you can do called flashlight scavenger hunts. And what you do is, you have your child spend a little bit of time in the room by themselves, during the day when your right outside and set up a little scavenger hunt for them in the dark. You can give them a flashlight. Encourage them to do this, just for very short periods, and make a game of it during the day. That can help with the nighttime fears.

Natasha writes:

I tried night weaning several times, but my daughter is a real screamer. She cried loudly for three hours.

I think your child’s around 14 or 15 months. You know, as I said, I don’t think there’s any real quick fix here in your situation. I think that at a certain point, you either have to make your peace with nursing once or twice a night, or you’re just gonna have to stop. And after a couple of nights, it would go away. But I feel the pain that that will entail. I know it’s not something that can be undertaken trivially.

Jeanine writes:

Our eight and 10 year olds share the bedroom and keep each other awake. The 10 year old has ADHD.

For this age group especially, reward good behavior works the best. For example, making a deal that if your children are quiet and go to sleep on time, we’re gonna actually give you some small rewards for this.

There’s actually a great book by Alan Kazdin, He’s actually at Yale as well. It’s called Parenting a Difficult Child (affiliate link), but don’t be put off by the title. It’s all about how to use positive reinforcement and rewards, which are going to work very well for eight and 10 year olds.

Lauren asked:

How do you know when a breastfed baby is night weaning?

I mean honestly, I think the night weaning comes down more to when mom’s ready to wean, and not when the child’s ready to wean. Honestly, I think that breast is best. I don’t want to come across like I’m anti breastfeeding, but, if you’re ready to wean, it’s okay to wean.

What are some recommendations to deal with sleep regressions after ear infections or illnesses?

I would say, do what worked before. High quality bedtime, consistency. Things will get better pretty quickly.

So Steve-o writes:

How should we manage a 15 month old that wakes every half an hour crying, clings to the breast 24 seven.

Steve-o, I would say, in all seriousness, send your wife away for a couple of nights and this will get better. Get her a nice hotel room, send her with her friends, she can bring her pump and keep pumping so she doesn’t lose her milk supply. I won’t lie, this will entail some crying. the only way to kind of care this situation is to have a parent, besides the nursing mom, do more of that care. And I’m sure you’re super involved, cause you’re asking the question.

One of the people watching, Liz, writes, “ I have a 16 month old and her grandma just babysat for three days. I went away. It was a huge difference when I returned.”

Here’s a question from Maria:

How to remove the midnight milk bottles for a three year old?

Again, it’s not always just nursing. I look at the volume of milk that the child is taking in. Cause this is a calorie problem. If your child is consistently taking, you know, if you’re consistently eating an ice cream Sunday in the middle of the night at midnight, then I’m going, you know, then you’re going to wake up if I take it away. So you want to take the bottle, say it’s five ounces. The next night it’s four ounces. The next night it’s three ounces. Get down to two ounces, and then you substitute water, and that’s the end of it.

Our six year old daughter was adopted from a trauma background. She just started sleeping through the night in her own bed, which is wonderful.

“She has always gone to sleep in her own bed, but wake at all hours of the night. Would sneak into our bed to feel safe. In the summer, we started taking turns on a cot in her room.”

In this situation, the normal rules don’t really apply. If you have a child with a history of trauma, I’m sure you’re already hooked into some services. The most important thing is making sure your child feels secure. If that means you aresleeping for a temporary period of time in her room, or you having a safe place on your floor where your child could come in and sleep, that’s wonderful Either way is fine. You don’t have to rush this.

It sounds like, if you worked really hard to get her in her own bed, just have a comfortable place for her, for you to sleep.

Also, you need to be very clear. For example, if you put her to sleep in her room, and you’re like, I’ll be sleeping in my room, just follow through on what you’re saying. And sometimes what works well is saying well, if you wake up in the middle of the night, I’ve set up a bed in my room. You can just come in and go to sleep.

But in your situation, first of all, wonderful thing you’ve done adopting a child. And my friend Julian who was on earlier is an adoption specialist, who’s awesome if you’re in the Seattle area. But, you know, just make your child feel safe and everything’s going to get better.

So guys, this has been great. Thank you so much for your questions. They were totally awesome. And, you know, just to put this out there, I’m actually just signed a contract, working on a book, incorporating a lot of the stuff that I’ve learned from you guys, which will be coming out at the end of 2018. Sign up for my email list and I’ll keep you updated.

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