Sleep: A Developmental Approach

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A lot of the recent books on sleep out there are meant to do one thing – sell copies! I like the idea of an approach, a strategy, or a general outlook, but it needs to be practical and obtainable, and not promise 12 hours at 12 weeks. I like to break it all down and put a large dose of reality to our approach to sleep. I insist that we follow your child’s developmental stages, and not just a chapter in a book. And I think we all need to accept that when it comes to child-rearing in general, and especially when it comes to sleep, our feelings as parents count. That pain of hearing your baby cry and the thought of not tending to him – it can trigger significant emotions in a parent, and for some is just not an option. So let’s explore this very important issue of sleep, and hope to achieve the dream – a full night of sleep for everyone!

Why All The Fuss?

It’s tougher to be a parent nowadays. In the old days parents just did what they thought was right – there was less judgment, fewer methods and philosophies, less pressure to do this parenting thing to perfection. There is such a thing as information overload, and yet many parents keep searching for ways to get their little ones to sleep better. The truth is that you can read a thousand pages on sleep from seven different books or websites and still not feel like you are doing things “the right way.”

I think it’s nice to get some support and guidance, and there is nothing wrong with trying to make sure you are approaching a difficult pediatric issue armed with as much knowledge as possible. But don’t always trust the latest book on sleep, particularly ones that paint an unrealistic picture and give false hope. Most children will never give us 12 hours of straight sleep, let alone at 12 weeks old, and most 2 week olds shouldn’t be put down “drowsy but awake.” Furthermore, kids are not Pavlovian dogs and sometimes don’t respond willingly to the strict behavioral methods that Ferber preaches.

Sleep is one of the most intriguing, most discussed, and sometimes most stressful topics of child-rearing. There is no doubt that sleep is important to the child’s body; during sleep is when the body heals itself. A baby’s brain and even his individual cells all need sleep. And yes, parents need sleep, too, particularly if they are trying to stay sane!

I have read many of the new books on sleep and combed through the pediatric literature on the subject. Parents discuss sleep with me every day – what works, what doesn’t, and how painful it is when it seems that nothing will ever work. I prefer not to start with how much sleep a baby should get. I think that charts detailing how much sleep a child should get at each age will only stress you out. I have never met a parent who doesn’t want their child to sleep. So let’s not start with the total amount of hours of sleep to shoot for, although that will come up later. Let’s start with a developmental approach, and the concept of what that newborn baby is going through. 

Newborn Needs

Newborn babies are in a unique period of life. They go through growth spurts, cluster feed, and really don’t have a schedule or show much predictability. They may actually be hungry just an hour after a feed, and I strongly believe we should meet all of those needs immediately and not think too much about it. They are all over the place. I always tell newborn parents that next Tuesday will be different from this Tuesday. They change, day by day.

In the first month of life, babies simply need to be loved, 100 percent of the time, and fed as much as possible. There is no digging yourself into a hole here. Newborns don’t need to be toughened up, and they shouldn’t be crying it out. You should feed them on demand, period. Don’t look at the clock or watch, and don’t try to figure them out or crack their code. Get your sleep when you can, and forget about being a normal person with a normal schedule. Don’t return emails or entertain! No hummus for eager visitors, no dressing to impress, and no late-night movies! Just accept it: You are a parent of a newborn!

The newborn cry always indicates a real need. Aim to meet all of those needs. If you do misinterpret his cry, and he wasn’t hungry but you fed him anyway, no harm done. Babies don’t form bad habits for the first 3 months of life, at this stage of development.

As newborns move into the next stage, they express their demands in a different way. Seeing them emerge and blossom, really interact and communicate, is perhaps the most rewarding moment for new parents. They are real people! They have personalities! For about 100 nights, you have tended to them, loved them, and fed them without fail. Babies are getting a lot more than just nutrition during their nighttime feeding sessions. They are bonding, feeling love and warmth, and they won’t want to let go of this when the time comes. 

The Best Place To Sleep

If you ask the baby where the best place to sleep is, he would probably say back inside mom! But since that’s no longer an option, the next best place is anywhere that is safe. I don’t mind the occasional stroller nap, bouncy chair or car seat. Be careful about putting a baby to sleep on your shoulder or chest, as you may also fall asleep and could drop him. And every newborn needs to sleep on his back, as babies who sleep on their chests have an increased risk of SIDS. Even if you are watching him sleep on his chest, there could still be a risk for SIDS, especially if you fall asleep, too.

By 2 to 4 weeks, your baby should start to sleep in a co-sleeper, bassinette, or crib. He may not like this, but it will only get tougher later if he never learns to accept that feeling of lying on his back alone. If he doesn’t learn to accept the crib, he will likely not be a great sleeper at 6 months. So try to get him into a crib, and, if possible, his own room, by 4 months.

If you don’t have another room for the baby, try to create some kind of partition. If the baby sees and smells mom, it will be that much harder to sleep train. It can still be done in the same room, but you’ll have to be a robot – when the baby cries, check to see that he is ok, then just tell him to go back to sleep in a monotone voice, all the while being as strong as you can, aiming to get that stretch of sleep to extend. You can teach a baby to sleep through the first waking even if you are in the same bed or room, but it will certainly be harder.

Baby Monitors

If you want to get a baby monitor, by all means get a baby monitor, particularly if you live in a home with different floors. But parents with baby monitors end up watching their baby needlessly and going in to soothe him more quickly and more often, even when the baby is just moving around and doesn’t really need them. When babies are just fussing or whining quietly, that is not the time to go and get them. You should only go to them when they are truly hungry – and that cry will usually wake up the neighbors.

It is very unlikely that the monitor will catch anything worrisome that you would not have heard anyway. Just remember that when babies are sick, they should be observed intensely, but healthy babies can sleep safely on their own. If they truly need you, they will let you know. You should be catching up on your own sleep, anyway. Remember: When baby is sleeping, you should be sleeping! 

Sleeping Position and Safety

You absolutely do need to worry about SIDS and keeping the sleep environment safe. Although it’s a very rare occurrence, it is the scariest thing in the world. A relatively healthy baby goes to bed, and just doesn’t wake up? What is the cause of SIDS (Sudden Infant Death Syndrome)? There has been so much research on this topic, yet it’s still not fully understood.

It’s not as simple as the baby suffocating on a blanket, although that can be a contributing factor. We do know that sleeping on the stomach doubles the risk of SIDS – so what might be a 1/1,000 chance becomes 1/500. That is still a very low chance, so we should not think about SIDS every night. But we should take every precaution to prevent it. That means no cigarettes near the baby, always putting them to sleep on their back (even if they don’t like it), and not having anything at all in the crib that can get twisted around the baby’s head.

Once a baby is 6 months old, their risk of SIDS goes down dramatically. And if the baby learns to fully roll over on his own, it is safe to leave him on his belly. He has proven that he has a degree of body and head control, so it is safe for him to sleep on his stomach. Once the child is older, a “lovey” such as a doll or small blanket becomes safer, but you really have to always be on the safe side. Bumpers pose a slight risk, especially if they are loose, so I advise against using any bumpers. A baby can’t cause damage to his head by bumping it into the crib wall. Many parents decide to use thin, breathable bumpers – just check them each night to make sure they are tightly secured.

Swaddling

Swaddling is a very safe option, and most babies will sleep better and longer if properly swaddled. Although in the past there have been concerns about swaddling having a harmful effect on the hips, there has actually never been any proof of this. If babies are properly and tightly swaddled, they can’t roll over to their stomachs, so don’t worry about that. If they do break out of the swaddle and roll by themselves, it is not necessary to roll them back for safety – they have proven that they are strong enough to roll, so it is now safe for them to be on their bellies.

When babies roll over and find themselves in an uncomfortable position, it’s your call whether you want to help them or have them learn to accept the position they’ve put themselves in. If you always help to re-position them or to pop that pacifier back in, you may find eventually that you’re digging yourself into a hole.

As your baby gets older, use an occasional nap to see if he doesn’t need to be swaddled anymore – does he wake himself up? But there’s no need to break them of the swaddle; they will do that on their own. Indeed, many adults still like to be tucked in tight!

The Dream Feed 

You may have heard of the dream feed. The idea is to feed the baby one last big meal before you yourself go to sleep. So if you put your baby down for a 7 p.m. bedtime, but your own bedtime is 10 p.m., you would wake your baby before you go to sleep and feed him – a lot! – and then hope that he sleeps longer and better through the night.

It is a nice idea, for sure. And for some it works for a while. But I don’t think it’s a great permanent solution. Since you are trying to train your baby to sleep the entire night, the extra feeding is just an extra step that you will need to cut out later, in a separate battle. I like the idea of getting the baby to learn how to achieve a longer stretch of sleep, instead of getting them used to feeding so soon after bed time. 

Pacifiers

Pacifiers can help with sleep, although if you are a nursing mom trying to establish the perfect latch, I would advise waiting until 3 to 4 weeks to introduce a pacifier, as you want to avoid nipple confusion. Pacifiers can help with comfort overall, and between the ages of 1 month and 1 year, I am fine with them as a way to soothe a baby.

But for many, it becomes a necessary tool for sleep and something the baby just can’t do without. So do you go back each time to replace the pacifier when it falls out? I wouldn’t – I would give the pacifier to help with putting the baby to sleep initially, but after that they have to learn to sleep without it. So I wouldn’t replace it all night. And I would insist that they start to lose dependency on it at 1 year of age, as it can make the teeth curve up and out – but this, too, is a parenting decision. Just remember, the longer you wait, and the older your child gets, the harder it will be to have him sleep without the pacifier.

I feel comfortable with the safety of pacifiers, but make sure no part of it can come loose, or it becomes a choking hazard. You should also make sure that you’re ok with the material it’s made out of. Then there are some babies who just don’t like the pacifier, and that is fine – they will find other ways to self-soothe.

For information about teething and how it affects sleep, click here.

Transitioning from Baby to Big Kid

The no-cry sleep solution is a wonderful idea, but it isn’t very realistic. The idea of putting a baby to sleep, from birth, “drowsy but awake,” and not allowing him to associate feeding with sleeping, is just too much to ask of a new parent. A 2 week old isn’t capable of self-soothing and learning to sleep from an awake state!

So when the baby is a newborn, this is what you’re going to do. You are going to rock the baby to sleep, gingerly put him down in his crib while praying that he doesn’t wake up, and tiptoe out of the room. That is what we all do, and I wouldn’t fault you for it (especially with your first child), because you’re dealing with a newborn, and it isn’t worth it to make him suffer when he is so young.

But as babies approach 3 to 4 months, they are not really newborns anymore. They can hold onto their calories longer and are no longer waking from the feeling of hunger every 4 hours. Yet there is a natural sleep-wake cycle that exists, so every 3 to 4 hours, they get into a lighter stage of sleep and wake up, demanding to be fed. Most babies don’t naturally know how to go back to sleep on their own; they need to be taught, and they often don’t want to take that class.

Before I go on, I just want to acknowledge that every baby is different and every parent is different. There are babies that will sleep well on their own at 2 months old. But that isn’t the norm and therefore shouldn’t be your expectation. On the other hand, most kids can eventually give us a really nice stretch of 10 to 11 hours – we just need to work to get there. I like to refer to it as “sleep learning,” rather than tortuous and guilt-provoking “sleep training.”

The first step is to develop a bed-time routine. Start by figuring out your baby’s approximate bedtime – when your child does that first stretch – and begin the routine at that time. The routine should involve a book, a song, rocking, or some other form of bonding. It can also involve bathing and feeding. The routine shouldn’t be a time to play, and it isn’t special alone time with a parent. It is preparation for sleep, and a gradual walk down the lane toward the lovely world of dreams. When your baby is small, this routine may take up to an hour, but as he gets older, it should take less and less time to wind down. While you are establishing your bed-time routine, aim to give as much love and reassurance as you can, but don’t turn it into a lengthy extravaganza.

The goal is to get to the “promised land” at some point – a routine that consists of a book or two, then a big kiss and hug. Later on, it means your child getting into bed on his own, and with a smile on his face as he says goodnight! Admittedly, the promised land could be years off, and at the moment, it may sound completely impossible, but by establishing a good routine early on, you will

The First Waking

Parenting is about choosing your battles, and in my opinion the most important battle when it comes to sleep is the first waking, which usually comes 3 to 4 hours after you’ve put the baby down for the night. This first phase of sleep is the lightest, which is why he will wake up, but at this point he is very tired and probably not that hungry. Seize this moment! This is the time when you should decide to not feed your baby, because he isn’t truly hungry.

I don’t like to give advice about how long the baby should cry at this point. This shouldn’t be viewed as how much are you willing to torture your child. First you should decide whether or not you want to feed your baby. If you think he is truly hungry, you should feed him. But by the time he is 3 or 4 months old, he can go 6 to 8 hours without needing calories. You are not skipping a feeding by not feeding him at night; you are acknowledging that he is able to sleep longer and helping him learn how to go back to sleep on his own.

This can be difficult. Older baby will make demands just as newborns do, but the difference is that now bad habits are being created. They are learning that every time they fuss they get fed, and as they grow older it is much harder to remove that crutch. Learn your baby’s cues over the first few months, and see when he is truly hungry versus when he just wants to be held and loved. You can really decipher these different cues, and my strong advice is to not feed your baby unless he is truly hungry.

That’s where it all starts actually. The first step is to not feed the baby who is just being fussy and isn’t really hungry. The next step is to not pick him up or rock him, then to not go to him at all. This is the real essence of sleep training – learning your baby’s cues. It’s not about asking “how long is it safe to let him cry?”

Again, sleep training is for the older baby, at 3 or 4 months. Don’t worry one ounce about spoiling a newborn, and please don’t try to sleep train a brand new baby. I don’t like that some pediatricians or books insist on starting sleep training at such a young age. It just creates stress, guilt and havoc as you misread your baby’s cues and fail to meet his needs. 

Sleep Training/Learning

We have all heard of the Ferber method, and none of us really love that idea, but it does work. The idea is that the baby needs to learn that he is not going to be fed, and mommy may not come at all, so he just needs to go back to sleep.

When a child wants something, even at 4 months old, he can get really upset if he doesn’t get his way. He is expressing his desires: “I want mommy to come now, and I want to feed.” Later in life, this same baby will cry for toys at the store and eventually yell at you until you let him borrow your car! (Click here to read more about shaping your child's behavior.) Of course, whether or not you sleep train is an individual decision, and there are many factors: Do both parents work? Are there older siblings that will get woken up? There are so many reasons that make us decide to just go in there and stop the crying. Regardless of what any pediatrician, book, or friend advises, it is always your choice whether you should go to your baby. There is no right or wrong.

The goal of sleep training is to get the whole family a full night of sleep. For most babies, this period of learning will last 4 to 7 days. And during that difficult time, there will be tears (likely for both baby and parents). The 15 minutes of crying will seem like an eternity. I can tell you from both the studies and my experience, however, that your baby will not be scarred at 4 months old because you didn’t go and hold him.

You can go in after 20 minutes and kind of reset the clock, but if you don’t go at all, your baby will be ok. He can’t harm himself by crying. He may completely lose it and cry in a way that you haven’t yet experienced, but he will wake the next day and still love you dearly. If it feels better to go in and console or feed you baby, you are not doing anything wrong. But for many, this is only prolonging the learning of that magical lesson of how to go back to sleep without being fed or comforted. Babies need to learn how to self-soothe, and they will learn it, at some point. Once they get that full night’s sleep, or at least a longer stretch, they’ll be better rested – and so will you!

But let’s be realistic about how much of this golden stretch we can hope to achieve. The average 4 month old can definitely learn to sleep for 6 to 8 hours. The average 6 month old can sleep for 8 to 10 hours, and by 9 months every single baby can go the entire night, which is realistically 10.5 to 12 hours in a row. No 1 year old requires nighttime feedings for calories or hunger – even thin ones! And these are actually generous estimates – many 4 month olds can go 9 hours without feeding.
So your goal should be to stretch out the length of sleep over time. Month by month, you should up your expectations. So when your baby is 4 months old, he may only give you 6 hours of sleep before that first waking, but by 9 months he should really be sleeping through the entire night. As your child grows, observe, analyze, and sometimes push. Don’t reinforce a waking that isn’t accompanied by true hunger.

Opting Out

Can you opt out of all this training? Yes! You can follow your heart and tend to your child whenever you feel it’s necessary. It isn’t wrong. Seriously, you can create a family bed (with a safe co-sleeper for the first months) and nurse all night, even with an older baby – and not do any sleep training at all. There is really nothing wrong with that. It’s just that there is a critical period for teaching your child to be a good sleeper, and it will absolutely be much tougher to convince him at 1 year, rather than 4 months, that he should sleep all night long without you and nursing. But for those moms who aren’t bothered by the wakings to feed and aren’t feeling sleep deprived, it is very healthy to nurse the baby as much as you want.

Unfortunately, I do often see the 18 month old who was fed on demand all his life and never slept through the night, and now the parents want to get some sleep or wean or both. We can help achieve the dream there as well – it will just be an all-out battle. It is simply not easy to undo a dynamic that has been created over hundreds of days. I have seen it happen so many times. Your family deserves a full night of uninterrupted sleep, and the best way to achieve that is by teaching your baby how to sleep early on in his life. 

How Much Sleep Does My Child Need

I don’t love charts, and I don’t think they’re the best place to start. If a chart tells you that your 5 month old should sleep 14 hours, and he sleeps 13, what should you do? Benadryl and whiskey cocktails will work – but aren’t really a safe option! It’s best to remember that each child – like each adult – is different. Each 6 month old will take in a different amount of calories per day and need a different amount of sleep at night. The average amount of sleep is a good guide, but the aim really should be to get that stretch at night longer and longer. The naps will fall into place.

There are guidelines for each age, but many kids will fail to achieve these numbers each and every night. Most newborns sleep up to 16 hours a day, but in no predictable manner. Most 1 year olds sleep 13 hours, and most 3 year olds sleep 11 to 12 hours – but again, these are just averages. For that newborn period it is simply impossible to add up all the time, as there are cat naps and their schedule is all over the place. For the older baby, you can fine tune here and there to ensure that your child is getting the most sleep – perhaps adjusting nap times or improving the sleep environment by using black-out shades or providing a night light. Changing the pictures on the wall can reassure an older child, and a blanket or special doll sometimes helps.

You should continuously examine your child’s sleeping environment and bedtime routine; these kinds of measures are sometimes an experiment – seeing what works best for your child. We all love when our children sleep well, and for as long as possible. So when you really think about it, those charts and guidelines add little value and a lot of stress to the equation. Your goal should simply be to get as much quality sleep as possible for your child. 

The Stubborn Sleeper

Just as every adult has a different personality, so does every child. There’s the easygoing kid and the easy sleeper. And then there is the high-maintenance child and the really tough sleeper. Trust me, I know! My first child was a really tough sleeper, and there were times when we needed to throw out all of the advice and just go to her to do whatever it took to get her back to bed! At 8 p.m. we set our goals and make our game plan. Then at 2 a.m. it all gets thrown out the window. That is understandable and normal – we can only do our best.

Nonetheless, tough sleepers require even more consistency. The toughest sleepers try to convince us to delay all of this sleep training. They scream like they are in pain to convince us to come. We feed two or three times a night, or go to them and rock them back to sleep, or bring them in our bed. And this family bed notion can be a lovely thing – if that is what you want. If you actually don’t want the child to be in your bed, I suggest that you don’t open that up as an option or it will take forever to break the habit.

Let’s take a look at the difference between first-time parents and seasoned parents. How does a parent put down their third baby at 5 months old? They just put him down! It’s usually the first-time parent that creates the one-hour routine, nursing or rocking their baby to sleep, or staying with him until he falls asleep. It is certainly no one’s fault, as first-time parents are new to all of this, but these dynamics don’t get created all of a sudden at 2 years old. Rather, they are developed over time, and it should be your goal to shoot for healthy sleep habits from the very beginning.

There is a critical development period at 4 to 6 months, during which you need to attempt to achieve that stretch of sleep. You need to push a bit, which may entail implementing the hardcore “cry it out” Ferber method, or some modified version. Your baby will continue to wake after 3 to 4 hours, but he needs to learn how to self-soothe and go back to sleep. When you are able to achieve that stretch of 6, then 7, and eventually 10 to 12 hours in a row that most babies can get to, you’ve pretty much hit the jackpot.

The opposite is also true. When you fail to achieve any stretch, and the child is still waking every 3 to 4 hours and is now 9 months or older, you have dug yourself into a hole. I find that the vast majority of children who are poor sleepers at 2 years old were really never great sleepers. They never learned how to go back to bed on their own, and they never really achieved that stretch.

That is why I keep emphasizing getting your baby to sleep longer starting at 4 months. At 2 a.m. you may just want to do whatever it takes to get your baby – and the rest of the family – back to sleep. But you are only setting yourself up for future sleep problems. I think tough sleepers can still learn to sleep well, but they should learn this lesson at 4 months, not 18 months.

Again, I must place an asterisk here. If you don’t mind feeding the baby all night, and/or bringing the baby into your bed, then I don’t mind either. I work with plenty of moms who are just fine with feeding their baby two or there times at night. There is absolutely nothing wrong with that. My only concern is that you may decide to change the dynamic when your child is 2 years old, for example when you decide to move him into his new big-kid bed. This is when you’ll find out who the real boss of the family is! After such a long time of having it one way, your child isn’t going to want to change a thing. So that’s why you should keep in mind that at 4 months you are not making the decision to sleep train for one night or one week – you are making a long-term plan that will still be effective at 12 months and even 24 months. 

The Older Child Who Won't Sleep

If you find yourself facing the predicament of a 2 year old who just won’t sleep, what should you do? Call a sleep consultant? Look for medical issues? See a psychiatrist? It can be completely overwhelming, and I see this quite often – the family that’s at their wit’s end because every night seems like a huge battle. Part of the problem is that the older child doesn’t just whimper like a baby will. If a 9 month old screams and stands up in the crib, crying until he gags or spits up, what does the 2 year old look like? Like you are torturing him! There is absolutely nothing worse. He'll look like he’s convulsing! If you try to get him to stay in his crib or big-kid bed, he will completely lose it. After all, you used to stay with him, rock him, or lie next to him until he was fully sleep, and now you are daring to do something different.

Are these kids truly scared? They may be. Two year olds can have fears. But it is not like our adult minds. It isn’t that they’re afraid something bad will hurt them. It has more to do with the fact that they just don’t want you to leave! You can try a nightlight, but don’t leave the whole room bright as day. You can try a blanket, a doll, a poster on the wall to make the room bright and safe. You can also start a sticker chart, give rewards, or just give lots of encouragement. But in most cases, none of these tactics will work 100 percent of the time. In almost every single case, there is going to be an all-out battle, and that will involve a lot of crying and a lot of guilt.

When your child is younger, he may yell his head off for you to come back, but at least he is safe in his crib. The moment your child can climb out of the crib, he has access to your room and won’t stop until he gets into your bed. (At this point, he needs to be in a big-kid bed, and you should safety-proof the entire room to the highest degree possible.) So again, the earlier you help your child achieve good sleeping habits, the better.

That older child who fights sleep just isn’t easy. Try as hard as you can to not reinforce the waking. Don’t feed them anything – they need to learn to eat during the day, not at night. The 2 month old is actually hungry, and the 4 month old may be hungry after 6 or 7 hours. The 1 year old and certainly the 2 year old is not, and that is true even if the child is thin or didn’t eat well that day. So don’t feed him, and don’t give him a bottle or sippy-cup filled with water. The pacifier is ok for the first year or so, but at some point your child needs to sleep without it.

When you do feel the absolute need to go and check on your child, be a stoic robot. Check to see if he got stuck in the crib, vomited, or has a fever. But be in and out, with no hugs or smiles. You are sending a message here, and the message should be “mommy loves you, but it is time for sleep.”

For the older child in a big-kid bed, this painful process may even require a gate, which feels really barbaric. Your child will scream his head off for an hour, holding onto his bars like a prisoner. This is certainly not what we envisioned when we signed up for parenting! But you need to remember that this is only a stage. It will not scar your child. He won’t have a bad childhood or blame you later. If he is exhausted the next day, that is ok. Perhaps that will allow him to fall asleep easier the next night.

While most kids take 4 to 7 days to adjust to this new arrangement, some may take 2 to 4 weeks. But I promise that as painful as the process might be, it will only be for a limited amount of time. You will get sleep at some point if you stick to the plan. The plan could be the most extreme – not going at all, not even once. Or it could be a slower, modified one, taking weeks or even months. Listen to your heart and follow its lead. If you know that you just can’t do it, you simply can’t hear your child cry, I totally respect that. You are a good parent, and you are not failing any test here.

The bottom line is that there is no easy answer. But if you ask me how you can get your 2 year old to sleep after 750 days of him not sleeping well, my answer is that you’ll need to go through some form of a battle. And as awful as it seems while you are in the middle of it, it will all be worth it once you and your family are getting a full night’s sleep again.

Medical Reasons For Poor Sleeping

While even the toughest sleeper will eventually learn to sleep, you don’t want to let a baby cry it out if there is truly something wrong with him. There are medical factors that may interfere with sleep. Most babies have reflux, but the majority of the time it’s not serious and doesn’t bother the baby, awake or asleep. Some babies have very significant symptomatic reflux, and this can make them squirm, grunt, or squeal. Severe reflux will definitely lead to early and frequent wakings. If left untreated, severe reflux can also lead to less enjoyable feeding or nursing; some babies even develop a feeding aversion, as they learn that feeding produces pain.

When a baby has severe and symptomatic reflux, he may eat less and not gain enough weight, so your doctor may prescribe an antacid medicine. The antacid doesn’t stop the reflux, but it does take the edge off the sour taste and can make a real difference in both sleep and general personality. Don’t worry about spit up or reflux causing a baby to gag to death. It will just run down the side of his mouth. So don’t worry if your baby spits up in his sleep, and do make sure that he sleeps on his back until he can roll over by himself.

Obstructive sleep apnea rarely happens in the newborn stage, but a 9 month old can start to present with swollen adenoids, which interfere with sleep. If your baby snores a lot beyond the newborn months, you should discuss that with your pediatrician. A little snoring that has a rhythm to it is usually ok. But any sign of choking, struggling, or loud snorts need to be addressed. It may be necessary to have a pediatric ENT look at the adenoids or conduct a sleep study – a full, intensive look at oxygen levels and chest wall movement – in a sleep lab. Obstructive sleep apnea (OSA) can definitely interfere with sleep, but that doesn’t mean a tough sleeper necessarily has OSA.

Insomnia is a real condition, but not in a 6 month old. Some children get night terrors, which often frighten the parents as well. But these occur in the middle of the night and the children are inconsolable, which is different from the child who fights his sleep and can easily be consoled the moment you tend to him. Older children will get nightmares and have real fears, but this isn’t a problem with babies.

A premature baby or a child with neurological issues also may not sleep as well. But that’s it in terms of medical issues – the majority of kids who are really tough sleepers are just that: tough sleepers. They may also be the kids who aren’t easy for their grandma, nanny, or kindergarten teacher. They may even be tough teenagers! But that shouldn’t change your approach. Your goal should still be to establish a short and sweet nighttime routine and not veer from the plan. 

Napping

Ahh, naptime. Siesta. Good for the baby, and great for the parents! When babies nap they are rejuvenating their bodies and minds, and catching up on some well-deserved rest. And parents get to catch up on a few things, too. So let’s take a look at a developmental approach to napping.

The newborn’s schedule is all over the place, so don’t lose sleep over their nap schedule in the beginning. The newborn sleeps up to 14 to 16 hours a day, but there’s no schedule at all. They sometimes take cat naps, they feel hunger often, and they wake easily. Don’t overthink their sleep schedule at this stage! Keeping your baby awake during the day to sleep better at night is not going to work, at least not in the first few months. You have to just allow the schedule to emerge, and that won’t happen until around 6 weeks. You should start to establish a rough bedtime when your baby is 4 to 6 weeks old, but don’t even think about a nap schedule with a newborn. It just leads to more frustration. Newborns need to cluster feed and have growth spurts that make them unpredictable in the beginning.

When you start thinking about trying to get a longer stretch at night, around 4 months old, put all of your energy into that first. You won’t be able to get an accurate feel for your baby’s daytime schedule until you get that stretch at night. Once you are getting that stretch, the naps will usually fall into place. Most very young babies take three discrete naps during the day, although one or two may be short ones. Then they move toward two naps, and often around 15 months they consolidate those into one good, long nap.

Those are rough guides or averages. The actual schedule of your day is all up to you, and there really is no right or wrong. I don’t necessarily recommend crying it out during naptime, but there will definitely be times when your baby is fighting sleep and you can approach naptime the same way you do bedtime: “The baby is not hungry, so I am not going to feed or hold him.” It’s ok to let your baby whimper or cry a bit until he falls asleep for his nap. 

Scheduling It All

The schedule you make up is completely up to you and your baby. Your pediatrician may provide some support and advice, but your routine is ultimately your call. Sometimes you have to try out a schedule for a week – like cutting two naps to one – and seeing if it works for you and your baby. Some families are early risers while some like a later schedule. If you look at 10 different babies, they are probably on 10 different schedules, but all of them are 100 percent healthy and ok. Whatever schedule fits you and your family is the right schedule for the baby.

A child could – and perhaps even should – nap for as long as he wants, and I wouldn’t wake him from a nap. Just don’t let him nap within 4 hours of the established bedtime, or he’ll never get to sleep at night. At what age should he stop napping altogether? Never! But most kids between the ages of 2 and 3 will fight their naps, so if you cut them out, it will lead to a much better nighttime sleeper. So it is up to you how long you keep the nap. Just know that you’ll get almost the same total hours of sleep in a 24 hour period, whether there are naps or not.

Most naps should ideally be in the same place that the child sleeps at night, so for older babies that is the crib. But naps in strollers or other places still count – they are still restful moments. The baby who fights naps and only naps outside his crib is less likely to be a good sleeper later, so you should really aim to put him down for his nap in the same place where he gets his nighttime sleep.

Sleep Training With Siblings

Having older siblings around is what I call the reality factor. You know the general plan and approach for sleep training, and older sibling really shouldn’t change your goals for getting a full night’s sleep from your baby. But they do. You just don’t want to wake up the older one, who hopefully is now sleeping through the night.

Most parents will keep the new baby in their room until 4 months old, but after that point I recommend going for it: putting the baby with the older sibling if there is only one room for both kids. The older one will get upset and may even regress a bit, but he will usually work it out in time. And before long, the two will be sleeping through the whole night together – the dream!

Some parents prefer to fully sleep train the baby before bringing him to the older sibling – and that is just fine, as long as you have the space. In fact, a lot of this is just figuring out the personalities of the kids, as well as your own preferences. But from my experience, the older ones will usually do just fine, even if the baby wakes them up a few times.

Safety is a major concern. Having two young kids alone in a room can mean trouble. The older one could throw a loose blanket or a small object into the crib, or he could even climb into the crib. Well-meaning older siblings have inadvertently caused major harm to babies. So you’ll have to assess the safety of the room and always err on the side of caution. Some (but not all) 3 year olds will understand the risk to the little ones. But if you don’t think the situation is safe, keep your baby with you until your older one is ready. 

Sleep Consultants

As a pediatrician I work with a host of excellent specialists. Whether it is a pediatric cardiologist checking a murmur, or a speech therapist helping with speech, these specialists offer valuable input and experience. And I value sleep consultants as well – for those parents who truly need them.

First, sleep consultants will rule out any medical issues, specifically that there is no obstructive sleep apnea, acid reflux or other chronic conditions. Then they will charge you a lot of money, essentially to hold your hand. They will give you advice and call you often. For the first few nights, they will pull you back when you are tempted to tend to your crying child. I believe that they are indeed helpful, and most will get results. So use them when you feel you need them, and if your bank account allows for it. Sometimes a sleep consultant is exactly the person you need to reassure you that you are not doing anything mean or harmful to your child. 

Undoing Bad Sleeping Habits

I’ve already discussed the stubborn sleeper, but the topic is such a frustrating one that I wanted to re-emphasize some themes. Families sometimes come to my office just exhausted – both parents and children – and at their wit’s end. Sleep is just so important, and the last thing anyone wants is for each night to be a stressful battle.

When we look at the situation from the toddler’s point of view, we can understand where he is coming from. He is used to you staying with him and comforting and feeding him. If he had it his way, he would say, “Let’s do this until college!” You started this at birth, and it just feels right to him. You rocked him, you nursed him, and you reassured and loved him. You patted his back until he went to sleep. And now you want to take away these comfort measures? Don’t think it is going to be easy!

My advice for parents who ask me about how to approach older kids with poor sleeping habits is to keep saying to yourself, “It’s just not going to be easy!” In other words, if you are looking for a no-cry solution, it won’t be possible. At this age, children’s personalities are just too strong. Their mindset is “If I don’t get my way, I am going to completely lose it. There is no middle ground. If you try to break the routine, I am going to hyperventilate, throw myself on the floor, and maybe even vomit all over myself.” This is just what they do at this age. But keep in mind that they can’t cause any bodily harm to themselves (as long as the room is fully safety proofed), even if they cry for hours. They won’t be scarred for life, or suffer physically. It may seem like they are suffering emotionally, but really they are just making a case – a strong case – to get their way.

We all know the goal. The goal is to give the 2 year old a kiss good night, and then have him climb into his bed and just go to sleep for 11 hours straight! So just keep your eye on the prize and accept that things will be bad at first. How quickly your child gets there depends on many factors. Are you letting the bedtime routine go on for too long? Are you staying in the room until he falls asleep? Are you still giving in and bringing him to your bed on some nights? All of these habits can be undone. But it will take time and, in just about every case, a lot of tears – theirs and yours both.

Start by making realistic goals for you and your family, including how many minutes you’ll let your child cry before going in, or what you’ll do once you do go in, and try your best to stick to your guns and stay sane. Your pediatrician can provide you with advice and expertise, but there is no one there except you at 1 in the morning, with work looming the next day and a child you love more than anything acting hysterical. Only you can feel out what the right approach is. Just know that in 99 percent of cases, if you fight the good fight, you will win!

Good luck with achieving the dream!

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