Sleep: My Baby (and I) Need Some!

by Jennifer Ratner, M.D.

As a pediatrician, I answer parents' questions all day long. Questions about feeding, runny noses, teeth and teething, ear infections and vaccines. But some of the questions I am most frequently asked are about sleep. And they are usually posed by sleep-deprived parents of infant to school-age children.

Here is my Top Ten list of the most common sleep-related questions:

Question 1. In what position should I put my baby to sleep?

On his back. This is the only position in which healthy infants - through one year of age - should be put to sleep. Since this recommendation was made by the American Academy of Pediatrics over a decade ago, it has led to a dramatic decline in Sudden Infant Death Syndrome (SIDS). Not to say that we have entirely eliminated SIDS, but this simple teaching has made so much progress that the yearly SIDS rate has declined by more than 50 percent as a result. In addition, an infant's crib should have no stuffed animals or toys, and no pillows or blankets. And the crib mattress should not be soft.

Question 2. I know it's too early to train my one-month-old to sleep through the night, but are there some things I can do?

Well, you're right. It is too early. I usually tell parents that most babies start to sleep through the night - for approximately seven hours - by about two to four months of age (most often three to four months). Often this is related to the baby's weight or developmental stage.

But, yes, there are some things you can do, even at one month.

If your baby awakens during the night, you can teach him that it is the middle of the night - and that it is time for sleep. Keep feedings short and quiet. Don't turn on all of your lights at 3 a.m., and don't start playing with toys or reading books at that hour. Also, keep middle-of-the-night diaper changes quiet and calm.

Question 3. I have been exclusively breastfeeding my four-month-old. My mother-in-law says that she will sleep better if I give her a formula bottle at bedtime. Is that true? And is it the only way to get her to sleep better?

Some believe that babies who are bottle-fed formula may sleep through the night earlier, but this is definitely not a reason to give up breastfeeding if that is what you prefer. Rather, you might try nursing longer at bedtime. But now that your baby has reached four months, you should be able to establish a good, consistent bedtime routine, which is key to a good night's sleep - for you and your baby.

Most babies love a bath before bedtime, soft lullaby music, a feeding. But make sure to put your baby in the crib awake. If you whisper goodnight and leave the room and she cries, go back and try again. If the crying is persistent, you can ultimately let her cry for five minutes. (Don't forget to check a clock. Five minutes of your baby's crying always seems longer than it actually is.) After five to 10 minutes, go in and comfort your child, but try not to pick her up.

It can be very difficult to resist immediately responding to your baby when she cries, but you will be rewarded. With persistence, you will have a bedtime ritual. When that routine is established, your baby will likely sleep better. It follows that you, too, will sleep better. And a rested parent can be a better parent.

Question 4. My nine-month-old was such a good sleeper. She has slept through the night since she was two months old. But she's been waking up at 3 a.m. for the past four days. What happened? Do you think she has an ear infection?

After examining the baby and finding perfect ears and nothing else wrong, I then ask, "What have you been doing when she wakes up?" Usually the answer is, "Feeding her."

What many parents do not realize is that almost all "good sleepers" go through a phase (usually between eight to 12 months of age) during which they wake up in the middle of the night. This phase might be related to one of a number of factors - a developmental stage (such as separation anxiety); teething; or a growth spurt that's made the baby hungrier. It is important that you do not "reward" your baby for this new middle-of-the-night awakening. If your baby is again nursing for 10 minutes in the middle of the night, watch a clock and decrease the duration of nursing by two minutes every night until you have weaned her of this middle-of-the-night feeding. Likewise, if a baby is bottle-fed and has started again to take a full eight-ounce bottle in the middle of the night, I always recommend very slowly decreasing the quantity of formula over the next week. For example, if your baby is back to a full eight-ounce bottle, feed her seven ounces for two nights, five ounces for the next two nights, and so on until - with luck - the nighttime feeding has been eliminated. (And, perhaps, the developmental stage is over.) Your baby - and you - will be back on your way to sleeping through the night again.

Question 5. My 18-month-old wants to be held in the middle of the night. What should I do? My husband and I are too tired.

My immediate question is always, "How do you put your toddler to sleep at night?"

This lands us in a controversial area: sleep associations. Of the myriad advice books out there, this is probably one of the most controversial topics. In sleep jargon, sleep associations really just refer to the nurturing rituals associated with a bedtime routine: rocking, cuddling, back patting. As you probably already knew or have discovered, newborns usually need continuous gentle stimulation such as caressing or rocking to fall asleep.

If, however, your 15-month-old falls asleep at night being cuddled and gently rocked in a rocking chair like a newborn, he may wake up at 3 a.m. expecting a re-run of the bedtime routine. If this is disrupting your household or making your life difficult, then you may want to start to gently cut back on the bedtime "sleep association" or routine. Or you may want to change the association altogether. For example, start to put your child to bed by patting her in the crib rather than rocking her in a chair. If there is still nighttime awakening, you may be able to pat her in bed rather than take her out. Eventually your bedtime routine might involve simply reading a book to her while she sits in the crib, or patting her - then leaving on lullabies while you walk out of the room. These measures may involve some crying at first, but eventually they should pay off.

Of course, if your child goes to sleep every night with gentle rocking in a chair and sleeps the whole night through and both of you love this bedtime ritual … there is nothing to change!

Question 6. How much sleep does my four-year-old need? She wants to stay up as late as her ten-year-old brother.

Three- to five-year-olds still need 10 to 12 hours of sleep, but it is very common for those with older siblings to want to stay up late. My recommendations are "classics": a special bedtime story with lots of attention for the younger sibling. Then say goodnight, and do your best to resist your child's stalling. Good luck!

Question 7. My six-year-old son still wets his bed. What should I do?

With a child this age, pediatricians first like to rule out medical problems with a physical exam and a urine analysis. In the vast majority of instances, there is no medical cause. If all is normal and the child has never really had consistently dry nights, the problem is often a familial one. (Dad may have wet his bed as a child, too.)

While you may have seen advertisements for bed-wetting alarms, usually we reserve these until children are seven or eight years old. Until your child's bladder matures fully, however, simple measures work best. Cut out drinking liquids within about an hour before bedtime. Make sure your child goes to the bathroom just before he goes to bed. Most importantly, however, do not tease or speak negatively about your child's bedwetting. This will not help. And don't forget to buy a plastic sheet for your child's mattress.

Question 8. My child had a night terror last night - or was it a nightmare? How can I tell the difference, and what can I do?

Usually nightmares occur infrequently - and usually in the second half of the night or very early in the morning. The child will wake up anxious and crying. He is entirely awake and is able to describe the "dream." Reassurance by you - "it was only a dream" - is the key. If nightmares are recurrent or frequent, talk to your pediatrician.

Night terrors are very different and usually occur within a few hours after falling asleep. The preschool or early school-age child will sit up abruptly with open eyes and loud cries for help followed by moaning, thrashing and agitation. The agitation can last for up to an hour. Then the child returns to normal sleep and remembers nothing about it the next day. Though these are not common - but very scary - they are normal. Again, reassurance is key. Hold your child until he falls back to sleep. Night terrors can occur once or several times, and your child will outgrow them. If they are frequent or recurrent, call your pediatrician. He may recommend an earlier bedtime, as night terrors are sometimes related to being overtired.

Question 9. I can't get my six-year-old to sleep at night. What's the problem?

These problems can be very individualized, ranging from the actual bedtime - yes, sometimes a bedtime can be too early - to behavioral. Some children have prolonged separation anxiety or have bad "going-to-sleep" habits from toddler years that have persisted until school age. You should speak with your pediatrician about your child's particular situation and ask his or her advice.

Question 10. What books do you recommend?

It goes without saying that I have only touched on a few of many sleep-related issues. Go to your local bookstore and you will likely find rows of books about children and sleep. Pick up any of this month's magazines aimed at parents of young children and you will almost certainly find an article about sleep.

Two books that I think have a lot to offer parents are published by the American Academy of Pediatrics: Caring For Your Baby And Young Child: Birth to Age 5, Steven P. Shelov, Editor-In-Chief; and Caring For Your School-Age Child: Ages 5 to 12, Edward L. Schor, Editor-In-Chief. These books, based on the experiences of numerous pediatric specialists, are comprehensive guides to a broad range of issues - including sleep.

And, of course, there are several groundbreaking bestsellers on the issue of childhood sleep. One of the better-known authors is Dr. Richard Ferber; I share his view that a child should be put to bed in the crib while still awake. But Dr. William Sears and his family of pediatricians present a different approach in their works. The philosophies of both of these doctors, and countless others, are available in their books and online.

As with all parenting issues, use your common sense and instincts. Many books tout themselves as non-judgmental, then go on to instruct you on the "best" way to put your baby to sleep. This type of advice will only lead to unnecessary parental guilt. Just remember: sleep is a very personal issue. What works for the children in one family might not work for those in another.

And, as always, ask your child's pediatrician for advice.