Posted tagged ‘sleep training’

Safe swaddling for babies

September 16, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Swaddle ‘em right, and it can help babies sleep and relax. Swaddle ‘em wrong, and you can mess up their little hips and get you arrested. Yikes!

As usual, too much of a good thing ends up being…. less of a good thing. I like swaddling, and I like to demonstrate a good swaddle for new parents, especially they’re a little anxious about knowing how to soothe their new baby. A nice swaddle can help  everyone relax.

But something you shouldn’t do is wrap up 7 – 12 month old babies so tight they can’t move, use knots to hold them in place, and throw blankets on their heads. That didn’t work out well for these two sisters, who used to run a daycare in California before they were arrested for child abuse.

What you can do is a simple, easy swaddle as demonstrated in videos on this page, from Children’s Healthcare of Atlanta. Safe swaddling involves holding the upper body still and in place, while allowing the legs and hips to move. Though they’re stylish, you don’t need a special blanket to do it right. Once babies start to wiggle out of swaddles (typically by four months), it’s probably a good time to stop swaddling altogether.

Some states have banned any kind of swaddling in day care centers, for fear that it can increase the risk of SIDS. One study did show that, but it didn’t look at the position babies had been left in—and we know that back-sleeping protects against SIDS. That study also found the strongest predictors of SIDS were parental use of alcohol or drugs,  cosleeping, or smoking during pregnancy. Other studies have refuted the SIDS-swaddling link, include ones that show that swaddled babies are less likely to sleep in unsafe positions, and one that showed better arousal in swaddled babies despite overall improved sleep patterns.

The best ways to avoid SIDS are outlined here, and current evidence certainly isn’t strong enough to convict swaddling as a cause. I’d also guess that since swaddling helps parents get better sleep themselves, that may end up actually being protective against SIDS and post-partum depression as well.

Apart from the (unsubstantiated) fear of increasing SIDS, the other concern with swaddling is that it can contribute to hip problems, specifically developmental dysplasia of the hips. But this really has only been seen in cultures that bundle up legs to hold them fixed and extended—that’s rarely done in the US. The current swaddling fad has not led to an increase in hip problems here. Still, review the video above, and make sure that if you do swaddle, Junior’s legs and hips are free to move around.

Swaddling is a safe and effective way to soothe a young baby, and parents can safely do it with a brief lesson and a little common sense. That’s one fewer thing to worry about!

Will cry-it-out hurt your baby?

May 16, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Jess, like many parents, has been hearing conflicting information about what crying can do to your baby. She wrote: “So, my husband and I accidentally let our kiddo (5.5 months) cry it out. So of course, I’m spending all sorts of time on Google finding out that I’ve caused long-term damage to my son and he’ll be more likely to get ADHD and be dumber now that I’ve let him cry. I know the studies on cortisol show that some longer-term stress may be evident (at least for a few days), but are there any other real, scientific studies that show long-term damage due to cry it out? I’m pretty sure the other studies cited in the article above are irrelevant to this–am I right? I know you’ve written about cry it out before, but with all the hype, can you clarify?”

A friend of mine is working on a project called “Guilt Free Childbirth”, meant to dispel the guilt and hand-wringing that so many families seem to experience during and after childbirth. What if I need a c-section? What if I can’t do it “naturally”? What if I can’t “bond” instantly with my baby?

This cry-it-out worry—I think I could make an entirely new blog, “Guilt Free Parenting,” just to try to dispel this nonsense. Parents are so saturated with messages telling you that everything—I mean everything—we do is wrong, it’s a wonder we don’t all just curl up in a ball in the closet sucking our thumbs.

Wait, thumbsucking. That’s bad, too.

Anyway: the sky isn’t falling. We are not raising warped, worthless, sick, incompetent kids. There are always things parents could do better (including me!), but that doesn’t mean that if we don’t do everything “right”, our kids will suffer.

Back to cry-it-out: babies don’t always learn to sleep straight through the night on their own, and there are several competing “methods” to help nudge them towards independence. Some parents are very eager to help train, others take a more “easy-going” approach. How you tackle this depends on how parents feel about the importance of a good night’s sleep, and also on the temperament of the baby. I am not going to declare that any one method is perfect for everyone.

But if sleeping through the night is a priority, I have offered up one simple solution that works well for many families. Yes, there is crying. No, I don’t think there is any good evidence that shows any lasting ill effects from letting your baby cry some. There are certainly lots of web sites, pro and con, and lots of people with strong opinions—sometimes they’ll even comment in ALL CAPS for emphasis. But you are not damaging your child by letting tears fall without instant intervention.

Babies have been crying for many, many years. It is how they get our attention. If crying were so damaging, well, I don’t think any of us would have survived.

Jess included an example of reporting that stressed the damage done by cry-it-out sleep training, a list of 10 reasons it’s bad for babies. Most of the reasons were undocumented opinions from the author, who has clearly made up her mind on this issue. The references that were included are rife with methodologic issues—especially retrospective bias (of course parents with children who are thought of as problematic are going to report more sleep issues, in retrospect, when asked), or skim though the complex issue of cause-and-effect. That is, did the excessive crying cause the later problems, or are children who are temperamentally difficult more likely to resist sleep and more likely to later experience emotional problems? One thing may not cause the other, even if they are correlated.

Studies of levels of the cortisol rely on that hormone as a biomarker of stress, and cortisol does indeed increase with stress in humans and other animals. But is that bad? Didn’t human babies always have stress in their lives? Some studies point out that cortisol can change the way brains develop, or can perhaps contribute to the pruning of interconnections between neurons- but that is a normal process that occurs in the development of the human brain. Interfering with this process by avoiding undue “stress” may actually be harmful in the long run.

Or maybe not. I am not saying that babies need to cry to be healthy. Certainly I spent a lot of time holding and reassuring my babies (and even babies in my practice!) But these studies that some claim show cry-it-out = bad for babies, it’s a stretch. And it is not something that parents ought to be worrying about.

Though there aren’t a lot of great, long-term, clinical studies of the consequences of these different sleep approaches, one published last year was reassuring—a method that allowed more crying didn’t lead to scary consequences later.

Also: there are consequences to poor sleep, both for babies and for parents. Underslept babies are fussy and unhappy. Underslept parents are irritable and miserable, and may be more likely to get in car accidents, get divorced, or smack their child. It’s not unreasonable for parents to want to take an active role in pushing towards a good night’s sleep.

A great website with far more detail and insight into baby sleep issues is at www.troublesometots.com—including a detailed guide to one common-sense way to help babies learn to sleep better. Yes, there may be some crying. It’s OK.

Sleeping through the night in three easy steps

May 18, 2011

The Pediatric Insider

© 2011 Roy Benaroch, MD

Sleep….what every parent of a young baby needs. And ironically, if you’re not getting enough sleep, you probably don’t have the energy to slog through any of the “help your baby sleep” books. Fortunately, we’re here to help. You want to teach your baby how to sleep through the night? I’ll tell you the three necessary steps. Do this, and you and your baby will soon get a good night’s sleep, or at least get closer—sorry, no guarantees here. Babies have their own plans, and their own personalities, and there is never a one-size-fits-all solution for everyone. Still, these ideas should help any baby get closer to a full, solid night’s sleep.

You can start these sleep-training ideas at any time. If getting a solid night’s sleep is a priority, the younger you start training, the better.

Step 1: Ensure that Junior is getting enough calories during the daytime. Think of it this way: he knows how much he needs in a 24 hour cycle, but he doesn’t really care if he eats more in the day or night. “Oh, don’t worry, Mom,” baby might say. “Don’t rush to feed me this afternoon. I’ll just wake you up earlier tonight!” As babies get to 3-4 months of age, they will be able to go longer between day feedings. Do not allow this. Don’t let them stretch out the day feeds until the night is one solid block of sleep.

Nurse frequently. During the day, if Junior is awake and it’s been more than 2 hours since the start of the last feeding, it’s time to eat again (if baby is asleep, wake at 3 hours past the start of the last feeding.)  Start solid complementary foods at 4-6 months (earlier is not better).

Step 2: Don’t react to every little noise babies make as they sleep. You will stir a bit, baby will fuss a bit, and then you’re both wide awake. As soon as you feel comfortable, move your baby to his or her own room so you don’t keep waking each other up. If baby wakes and makes a little noise, don’t rush in immediately. Take your time. At least sometimes, Junior will put herself back to sleep without your going to see her. Give her a chance to soothe herself!  If you must share a room, try to lie quietly when you hear your baby start to make noise.

There’s a persistent half-myth that bottle fed babies sleep better. I call it a half-myth because it is in fact true, but not true for the reason people expect. Bottle fed babies do sleep through the night faster—but that is because it takes mom several minutes to go to the kitchen, warm a bottle, etc. By the time she makes it to baby, at least sometimes the baby will go back to sleep. For nursing moms, it can be quick and convenient to get a feeding started—and that’s a good thing, most of the time. But if you’re trying to sleep train, don’t be so quick to begin nursing the moment your baby starts to wake at night.

Step 3: I saved the most difficult for last. It’s time to allow your child to learn that he can fall asleep alone. Parents usually end up holding their little newborns as they fall asleep,  which isn’t at all a bad thing. Newborns may genuinely need a close warm loved one to help them make the transition to sleep. But many parents neglect to allow their own habits to change as their babies develop. They continue to hold their babies as they fall asleep, never even giving them a chance to begin to learn how to sleep on their own. If you’re holding, rocking, or feeding a baby while he falls asleep, the baby—guaranteed—will wake up again later that night after you sneak away. He will need you to come back and resume holding, rocking, or whatever to ease him back to sleep.

The concept here is “independent sleep associations,” referring to the kinds of things we’re used to having around as cues to help us fall asleep. It would be very hard for most of us to fall asleep without a pillow—because we’re used to having a pillow when we fall asleep. And if someone were to steal your pillow in the middle of the night, you can bet you’d wake up quick. If your baby depends on you as a sleep association, she will not stay asleep if you leave the room. You’ve got to camp out all night. Maybe that’s what you want to do. But if you’d like to have your own nighttime for yourself and your spouse, you cannot be a sleep association for your baby.

I’ll make it simple with some good rules of thumb: by two months of age, you should sometimes be putting your baby down when awake; by four months of age, you should usually be putting your baby down awake; by six months of age, always put your baby down while awake. If you never try, it will never work. It does not get easier to start working on these independent sleep associations as babies get older.

So what do you do when your baby isn’t falling asleep on her own? Follow the plan, and keep it simple. Put your baby down with confidence and no apologies. Say “Good night, honey, I will see you tomorrow.” Then leave. Do not go and check every few minutes—that teaches your baby that hysterics will bring mommy in running. The lesson here is: it is night, you are in your bed. It is time for sleep. This is the way it is. Now, you cannot make a child sleep—but you can control your own reactions. When Junior learns that this is the way it is, the crying stops, and the sleeping begins. Keep in mind that the older your baby is when you start this, the more stubborn she will be, and the longer she will cry.

Is it cruel to let babies “cry it out”? I do not think so. There will be hundreds of other occasions each day when your baby wants you to do something, and you’ll do it right away; there will be dozens of times each day when you’ll quickly respond to crying with hugs and reassurance. There are genuinely times when tough love is needed. When your 2 year old wants a candy bar at Target, she’ll throw a tantrum when you say no. Your teenaged daughter will scream “I hate you!” when you refuse to let her spend the weekend in Panama City with her boyfriend. Letting your baby cry at bedtime is not more cruel than other times when saying “no” is the right thing for a parent to do.

In fact, it may be more cruel to not let your baby learn to sleep through the night. For parents, lack of sleep contributes to marital discord, stress, and depression. You’ll be less patient and less engaged with your baby during the day when you’re exhausted. Furthermore, if you’re not getting a good solid night sleep, then your baby isn’t getting good sleep either—which compounds the cranky. In the long run, parents and babies need to get their solid sleep at night. Parents who delay sleep training are preventing their children from learning an important life skill while making family life miserable. Who’s being cruel?

Some babies will make this easy. Other babies will fight sleep and make this a more difficult transition. Exactly when to sleep train is a personal decision, depending on the parents’ plans and priorities. But if you want to get your young baby sleeping through the night, you don’t need a great big book to read. You just need to follow the three steps above, consistently, every night. It may seem rough at first, but soon you and your baby will all a better night’s sleep.

A shorter version of this was originally published on WebMD.