Back to sleep
It is common for parents to come to see the paediatrician because they are worried about the sleep pattern of their baby.
- “My baby cries as soon as he is in his cot. He might sleep well in my arms just before, but his sleep is so light that when he touches the cot, he opens his eyes and cries. I think he does not have enough to eat, so I feed him more and he falls asleep very quickly and in the end, I have to keep him with me all the way. It is exhausting. I heard a friend saying that my milk is not rich enough and another friend saying that it is not good for baby to sleep in my arm and that she should be in her cot. I wanted to add a bottle of formula (actually I tried the other day, but she threw it up immediately.) I do not know what to do because, another day, I gave him formula as his grand-mother recommended and he slept well in his cot.”
- “Our 12-mo old daughter still wakes up at night to drink; I was told that she should not do that anymore. But she wants to breastfeed and anyway, if I don’t feed her, she would cry so much that everybody wakes up at home and I am afraid to disturb the neighbours. So I feed her. She drinks only a little and then goes back to sleep. Is it true that she should not be fed at night? I am surprised that she is still hungry so many times at night.”
- “Our son is two years old and wakes up four times per night because he wants to drink water but, though it is warm these days, I do not think he can be so thirsty. Actually, the weird thing is that before he fell sick a month ago, I think it was just a cold, he would sleep through the night. This makes us very tired and he is also easily in a bad mood during the day.”
The stories pictured here show babies of different ages with a common problem: sleeping. It is likely though, that none of them shown here suffer any serious medical or psychological problem. That is what we are going to explain here.
The problem explained
Sleep patterns
Babies, like adults, have different types of sleeps and, in particular, there are times when they are in deep sleep and others when their sleep is very light. Actually, at the top of the light sleep, they sometimes wake up. This is the time when we, adults, would typically turn in our bed. Most of the time, we don’t recall these change in our sleep, even if we wake up, because we plunge again back to another trip of deep sleep. When children wake up, they may also go back to deep sleep without other intervention. But this is not always the case.
The incentive
It is very natural that we would interfere sometimes where most of the time we just do nothing: children change and their need evolve. Some things are very natural too, like a baby falling asleep on the breast, and so in the arms. It can also happen during the colic period from birth to three month. It is very comfortable for the baby too and probably, overall, good for his development to be close to his parents. Babies often sleep with their parents and so get used to their presence throughout the sleep (it is convenient to feed the baby in the bed in the middle of the night.)
As babies grow it is a fact that many of us go on with this idea that odd needs can happen anytime and that we should fulfil it as good parents would do. So the incentive is there, from the beginning.
The ritual on tracks
Once the baby has requested something once, he might just ask another time: it is very natural to need milk every time it is time to sleep, and it is normal to drink water in the middle of the night. We do not see reason why it should change if the primary reason / problem is still there. Or perhaps is it that raising a kid is an ongoing experience.
The habit
In any case, what was once maybe a real need most likely becomes a habit: the physiological need has become psychological dependence. It happens then that children need always the same environment to fall asleep or to get back to sleep, they need a tool to get asleep again. Some children may be more sensitive, more prone to that, but most children would probably experience this situation under a proper incentive: it is not something abnormal and does not (necessarily) reflect a special need and a special treatment.
The questions
Is there a problem?
The three examples that we have relayed here are very frequent in paediatric practice. They can be described straight away to the doctor or found incidentally during the consultation: it may become such a long-lasting habit that it has become part of the normal family life. The question comes then: is it a real problem? This is up to the parents to answer.
In my experience, it depends on parents sensitivities and might be more perceived as a problem if the child’s habit becomes very demanding to the point that it challenges the family relationship balance.
What is the problem?
In the example, we see that the parents are often not clear about what is going on: bad dreams, abdominal pain, normal development stage, lack of calcium or iron, abnormal appetite, or that they have a child with a particular need or character.
This is made even more confusing and sometimes pressing by the flow of information coming from friends and family who all have their own experience and opinion on the topic.
Obviously, there is no one single answer to that important question. That is because, even though there is a clear pattern in the acquisition (and des-acquisition) of the habit / problem, there is always a certain degree of uncertainty proper to medicine.
Often, though, it can be safely assumed that nothing else serious is going on: the child or baby eats well, has normal stool, has a good colour, a good activity and smiles at other time of the day: the child does not look sick. If the child does not look otherwise sick it is likely that he is actually not sick. An important reassuring feature is also the stable nature of the child situation.
Do we want to solve it?
Once we believe that there is a problem connected with sleep, what do we think about it? What are the parents and perhaps the rest of the family thinking about it? Do we think that there needs to be some change? A clue on the answer may be that this becomes so disruptive for the family life that it requires action. We could also look at it by thinking on how much life could be simpler by not having to deal with those nightly session.
Do we need to solve it?
Some family function in such a way for years and the child can grow well without any other trouble. It is likely however that changing the situation is good for the following reasons:
- Sleep: for parents and child, which might have consequences on work and school performances;
- Couple life of the parents;
- Setting limits: in letting the child and parents understand what are reasonable demands to allow everyone to function harmoniously. Setting limits is about saying no in some circumstances. Saying no is not something that should be regarded as bad, but on the contrary and opportunity to give a structure towards a balanced relationship. It is something that the child will encounter throughout his life and will have to face with creativity. The child does not suffer when he faces a refusal, he suffers when the refusal is inconsistent and unclear to him.
Can we solve it after all?
Yes, sleep problems can be solved most of the time and do not require a specific treatment or complicated management. It requires determination and a bit of patience. We are however, dynamic, ever changing beings: the victory of one day is to be followed on closely as one night everything could start again. Let us look at the solution.
The solution
Changing the habit
The point is then to change the habit: we should try to understand precisely what is it that the child or the baby wants and what do we want as parents. We would then probably discover that, for example, if the baby was sleeping in the arms very well after feeding and now wakes up as we have just put him in his bed, it is most likely not because he is hungry. But as we saw earlier, because he is used and happy to sleep in the arms. And the point is: he could be as happy sleeping in his bed. An older child, similarly, after careful assessment might not be thirsty or hungry four times in the middle of the night and wants something else: the tool to go back to sleep.
Changing the habit is about removing the tool that he needs, or replacing it by a tool that does not require as much sleep disruption for him and his parents.
Challenges
The challenge in changing a habit lies in the fact that most of us do not like changes, especially not children, and so we need a good reason and a bunch of energy to do that.
As we mentioned earlier, the point is to say no to our child for something we feel not reasonable: he will most likely start crying. And there we will have doubts on whether we are doing right.
“If the child cries, he must have a good reason” And indeed, the child has a good reason as he / she doesn’t see the problem as we do. In the child’s mind, it is a separation. In reality, not quite so: we do not leave the baby, instead we do not give what She/ he wants. Seeing through his / her eyes, you would feel that mum or dad does not love you. The child does not make the difference between “no” and “I do not love you” and reflect it in his / her cries. That is challenging enough for a parent, because even if we know the difference as adult, we feel that a child does not know that and is perhaps not able to learn it. On the contrary, the child is actually very able to understand a clear message from a very early time: the key is consistency.
We are built in a way that makes us very resilient in keeping our mind, and makes us able to hold a discussion and have the energy to convince. It means that something will convinces us quickly if it comes from a trusted source, but we will need more argument if we do not know the source as trustable. What is probably one of the most challenging part of parenting is to find the balance between a strictly consistent opinion on some matters and a more liberal discussion-based mutual understanding. That is because children do need firm opinion also for their structuration.
Technique
Crying
The classical technique to get the child to sleep is commonly called the “let cry” technique. It is largely true but not as simple because what that label implies and does not say.
We need to first put the child in an environment, in a condition that is compatible with a good comfortable sleeping. That means accompany him to the place that has been prepared for him and that has to be welcoming and quiet enough.
Soft Ritual
The time is an opportunity to entertain close relationships with the parent, tell stories or sing a song. In these busy days, it is often a unique opportunity to have some privileged encounter with our child.
It might be the time also to explain what we hope for the night and that from today it will be that way; that he / she will maybe be a bit sad, but that it is a way to become a big boy or big girl and that tomorrow everybody will have slept better and will be in better mood.
Younger babies may not talk, but would certainly sense the caring environment.
Children love these moments and expect them for the pleasure it gives them, and ….for the habit.
Presence & Reassurance
If the baby cries when we say good night, it is important that we do not leave immediately without further explanation. It is equally important that ultimately he deals himself with what he used to get from us: if he / she usually falls asleep on the breast, he / she would fall asleep in the bed; if he /she likes to hold mum’s hand half an hour to get asleep, then mum will not hold his / her hand that evening; if the desire is to be carried until the sleeps comes, then we would not carry him / her.
Other than that, we must show our love and care. We must also ensure that we do not replace one tricky habit with another one and so we need to make the getting-asleep process simple and straight.
Patience
As the child cries after what we decided to be the right falling asleep ritual, we can leave the room and let him cry in his bed. We might need to close the door and might use the threat as a “horrible” blackmail if he comes out of the bed. In any case we must ensure that the area is safe.
You would come back after five long minutes (a watch is useful, because five minutes of a good movie are much shorter than five minutes of cries) and reassure the baby, still without giving the baby what he wants and that you refused him. You would do well in spacing the time you go to see your child. He / she will fall asleep after a while because he / she understood that no matter how long, it is not worth the effort. And perhaps also because at that time he is confident that you are strong and loving.
Important Tips
- Start before a week-end
- Agree on the attitude within the family so that the whole plan is not destroyed during one of these hot evening just because one of the parents’ heart broke.
- Be consistent: once the decision has been taken, after the proper weighing of pros and cons, there should be not giving up. Giving up means that we have said something to the child that we made important in our words and advices, then by letting him cry, to only deny the whole thing thereafter: what kind of word do we have for the child, how can he / she believe us, and can he /she have the confidence that a promise is a promise that will be kept, even in other areas of the family life?
How long does it take?
In my professional and personal experience, it takes four nights. This is also what you can read in the medical literature.
The first day is an extension of Hell. The second day is a pretty good imitation of hell. The third day is a convalescence; the fourth day a celebration.
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