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Ella's
Ask the Sleep Expert Column
Sleep (or lack of it!) is top of mind for every new
parent. New parents are almost always sleep deprived and desperate
to find a way to get more rest. Sleep continues to be a hot
topic for every parent as their baby grows.
Staying true to our promise to help you on your parenting
journey by providing expert advice and exchange, Ella Centre
is pleased to announce an ‘Ask the Sleep Expert’
column on our website. Dr. Nicky Cohen, a clinical psychologist
specializing in the area of pediatric sleep, will be answering
your top sleep questions on the Ella website.
To submit your question, email info@ellacentre.com.
While not all questions will be answered, Dr. Cohen will post
new answers to your most frequently asked sleep questions
in January, March and May 2007.
Read Dr. Cohen's most recent articles on normal sleep development
and establishing healthy sleep habits:
For babies 0-5 months
click here (pdf) >>
For
babies 6-11 months click here (pdf) >>
More about Dr. Nicky Cohen
Dr. Cohen is a clinical psychologist, working in the area
of pediatric sleep in Toronto. She earned her doctorate degree
in clinical psychology from York University. Dr. Cohen’s
clinical work focuses on the assessment and treatment of common
sleep problems in infants, toddlers, and preschoolers.
Dr. Cohen provides sleep consultations for bedtime problems,
night wakings, daytime sleep difficulties, early morning awakenings,
night terrors, and nightmares. She and her husband have two
young children – who, yes, sleep very well.
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March
FAQ’s
Question #1
My daughter is three months old and generally sleeps well
at night with one wake for a feed. I put her down around 10pm
and she is starting to wake around 6am for the feed. Then
I put her back down and she sleeps until around 9:30am. When
do I begin to make her bedtime earlier so that she is not
sleeping in so late? I am worried that if I put her down earlier
she will wake more than once in the night. Because of this
sleep in, our morning nap routine is all over the place. I
know she is only three months, but any "schedule"
help would be great. Also, she is very hard to put down for
a nap and when she does finally fall asleep she only sleeps
for 30-40 minutes. Is this normal?
Dr. Cohen:
Usually 3-4 months of age is a good time to move bedtime earlier.
Babies of this age often do well with an earlier bedtime (e.g.,
7:30pm) and for biological reasons may start to have a harder
time staying up later. Many babies in this age range sleep
for 11-12 hours at night (interrupted by feedings), so having
an earlier bedtime is likely to naturally move your daughter’s
wake time earlier.
Generally, most healthy full-term babies who are between 3-5
months of age need at least 1, if not 2, feedings a night.
Because your daughter is now only feeding 1 time in an 11-12
hour period, shifting her bedtime earlier is unlikely to change
her feeding frequency. Some babies, particularly those who
fall asleep with parental assistance (e.g., are fed or rocked
to sleep), require these same conditions to be re-established
following night wakings. So, for example, these babies (who
do not fall asleep independently) may need parental assistance
(including being fed) to return to sleep following night wakings.
I often recommend that parents start thinking about developing
a sleep schedule when their infants are 3-4 months old and
are therefore developmentally ready for a schedule. A sleep
schedule at this age may include a calming and predictable
bedtime routine, falling asleep independently (self-soothing)
closer to 4 months of age, and naps using the 2 hour rule
(i.e., being put down for a nap after about 2 hours of being
awake). While it often is frustrating for parents, many young
infants take “cat naps”. When infants who are
4 months of age and older continue to take “cat naps”,
parents can try increasing the periods of wakefulness (i.e.,
time between naps) slightly (by 15-30 minutes) to increase
their child’s drive to sleep. They also can try giving
the infant a chance to return to sleep if it seems that the
baby has woken too early from a nap.
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Question #2
I have a 6 month old girl who we are working with this
week to help her sleep independently through the night. We
used to rock her, used the pacifier etc. It has been 3 days
using the Ferber technique and we are seeing some results.
My question is when is it safe to let your baby sleep through
the night without a feed. I am breastfeeding her and feeding
her around 9pm before bed and then sometime between 5-6am.
She is approx. 16lbs, is there a weight or age threshold when
you know your baby is getting enough nourishment to sustain
the night?
Dr. Cohen:
I am glad that you are having some success with sleep training.
I often encourage parents to start implementing healthy sleep
habits earlier rather than later as it is easier to teach
a younger child how to sleep well than a toddler or older
child who is having problems sleeping.
Most paediatricians will agree that the majority of healthy
full-term babies do not need to be fed during the night after
they are 6 months of age. I am not aware of any literature
that suggests a particular weight that is related to sleeping
through the night. Rather, research suggests that sleeping
through the night is related to both developmental readiness
and behavioural factors (i.e., does the infant fall asleep
independently; is the infant responded to during the night
consistently and appropriately).
There is some research to suggest that infants who continue
to be fed at night – when they no longer require the
nutrition at night – will continue to wake during the
night. If there is no medical need to continue feedings after
the child is 6 months of age, I often work with parents to
develop a weaning schedule to eliminate the feed(s) over a
period of a few days to a week. This weaning process gives
infants a chance to transfer their hunger from the nighttime
to the day time. Also, it is often easier on parents to eliminate
the feeds more gradually than all at once.
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Question #3
Do you have any tips on how to get a 9-month old -- who
is now standing in his crib even when very tired -- down to
sleep?
Dr. Cohen:
It is quite common for previously good sleepers to start having
sleep problems when they reach a new developmental milestone.
Children often are excited with their new level of freedom
and would rather play than sleep! I often suggest to parents
who present with this problem to give their child extra floor
time during the day to practice their new skill.
For children who have recently started standing, this may
include teaching the child, and letting him practice, how
to stand and sit back down often during the day. When parents
are confident that their child can lie back down from a sitting
or standing position, they can start letting the child return
to sleep independently. While it is fine to “model”
the appropriate behaviour to the child once or twice (e.g.,
going in and lying them back down), returning to their room
to assist them over and over again can become a poor learned
association for the child (i.e., they will need to be laid
down or otherwise learn to need parent presence when they
wake during the night). Most often such disruptions to sleep
are short lived if principles of sleep training are applied
consistently.
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January FAQ’s
Question #1
I have a sleep question regarding my 2 1⁄2 year
old son. We recently moved him into a big bed and we are having
a great deal of difficulty getting him to stay in his bed.
When we first put him to bed he continues to get out for at
least 30 minutes to an hour. He then goes to sleep but he
is up in the night at least twice wandering into our bedroom.
Each time we bring him back to bed. We have now put a gate
in his doorway so he is up at night calling us. Do you have
any suggestions?
Dr. Cohen:
I would want to find out more about your son’s night
wakings to determine what the cause(s) may be. They may simply
have started since being moved to a bed and have now become
a habit. Also, sometimes parents move their children to a
bed in an attempt to solve sleep problems. However, in many
cases sleeping problems worsen as now you have a child who
is waking and who also is mobile. Night wakings in young children
also can be caused by nightmares.
So, depending on what is causing night wakings, the treatment
intervention would be different. Was there a reason that he
was moved to a bed? If a child was sleeping well in his crib
(and wasn’t in danger of climbing out) I often think
about putting him back in a crib. Usually 3 years of age is
a good time to be moved to a big bed. Children this age usually
are more mature and better able to understand the “rules”.
When parents decide to leave a child in a bed, have ruled
out nighttime fears as a cause of bedtime resistance, and
also have ruled out nightmares and medical illness as a cause
of night wakings, I often suggest considering the following:
1. Is the child resisting going to bed because he is not
tired when you try put him down to sleep? If so, I suggest
to parents to do one or both of the following: (i) move
bedtime closer to the time that the child actually falls
asleep. Once the child is falling asleep quickly at this
later time, you can slowly start to move bedtime earlier
by 5-10 minutes every few nights. (ii) wake the child from
his nap earlier if late napping or too much daytime sleep
is the culprit.
2. Be sure that the child is falling asleep independently
for all sleep periods with no parental presence. As described
in more detail in one of my other responses, children who
fall asleep under certain conditions (e.g., parental presence)
at bedtime, need these same conditions re-established upon
waking at night in order to return to sleep.
3. Develop a reward chart. Explain that when the child stays
in bed for the night and doesn’t call out to you,
behaviour he has control over, he gets a sticker in the
morning. After a certain number of stickers, he can get
something like a new book or favourite toy.
4. Use a night light attached to a timer to teach him when
he can get up and when he must return to sleep on his own.
Explain that when this light is off, everyone is sleeping
and that the child must not yell out but rather lie down
and go to sleep. Tell the child that when this light turns
on that he can now call out to be fetched. I started using
a light timer with my daughter who is 3, when she started
waking a little earlier than I thought her wake time should
be. It continues to work very well!
5. If difficulties continue after trying the suggestions
above, I often suggest becoming more firm. At first I suggest
only going to the bedroom doorway briefly and telling the
child to return to sleep. Once this is working and the child
is climbing back into bed by himself, I suggest telling
him from the hallway or parents’ bedroom (depending
on proximity) to return to sleep. After a few nights, I
often suggest letting the child start returning to sleep
with no intervention – unless it is suspected that
the child is in danger or is sick.
I think putting up a safety gate in the doorway is a good
idea. It is not safe for young children to be wandering
around the house when their parents are asleep.
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Question #2
My son just turned four months and we are trying to get
him into a sleep routine. It appears as if he is resisting
sleep- crying as soon as we approach the crib if the lights
are dim. He is ok if we have the lights on but then he doesn't
want to sleep. We have never used the crib as a place to play.
I have tried with and without music. Any suggestions? Is it
ok if we let our baby cry until he sleeps? I don't want him
to think of bed and nap time as a negative experience.
Dr. Cohen:
Four months old is a good age to begin establishing positive
sleep habits including a sleep routine. A sleep routine or
sleep schedule includes having a predictable and calming bedtime
routine which will cue that sleep time is approaching, a set
reasonable bedtime, naps according to the clock (e.g., after
two hours or so of being awake for 4 month olds) or when showing
signs of tiredness, and learning to fall asleep independently.
Generally a healthy full-term 4-5 month old can start learning
to fall asleep independently. The advantage of encouraging
self-soothing at this young age (but not before 4 months at
the earliest) is that bad habits are less ingrained and that
the learning typically occurs quickly (over 3-5 nights).
At your son’s age, I usually recommend that anything
that doesn’t contribute to sleep be removed from the
crib (e.g., mobiles) as they may be stimulating and possibly
dangerous. I would reserve the crib for sleeping so that the
child begins to associate the crib with sleep. I wouldn’t
worry too much about negative associations with the crib.
Usually the process is harder on the parents than it is for
the child. Consistency is key.
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Question #3
How do I get my 5 month old to sleep through the night?
He used to sleep 8-9 hours until a month ago. But now he wakes
up at least 3 or 4 times whenever his soother falls out! All
I need to do is put it back in and sure enough he goes right
back to sleep. I don't know that I am prepared to let him
cry himself back to sleep alone.
Dr. Cohen:
It is common for previously good sleepers to develop sleeping
problems. Reasons for this include: greater cognitive awareness
(they are more aware of what is going on around them), reaching
a new developmental milestone (who wants to sleep when you
can explore!), teething, and illness. I would classify new
problems related to pacifier use in the cognitive awareness
category.
Infants who use the pacifier to fall asleep may not have been
bothered or aware when it fell out when they were younger.
However, once they are older, infants are increasingly aware
of the pacifier not being in their mouth when they wake (if
that is how they fell asleep) and will need it to return to
sleep. This is because they have become accustomed to using
the pacifier to fall asleep and may not have developed the
skill of self-soothing to sleep (falling asleep on their own).
Infants who have learned to fall asleep independently, without
parental intervention, usually do not “signal”
out (e.g., cry) during periods of partial arousal. These infants
will return to sleep, often without their parents being aware
that they were briefly awake. However, infants who, for example,
are fed, rocked, or who use a pacifier to fall asleep, will
need these same conditions to be reestablished following wakings.
This may happen several times a night, as we all have several
periods of brief arousal throughout the night.
When I see parents for this issue, I often outline the following
two choices for dealing with this problem. The first choice
is to tolerate this until the infant is closer to 8-10 months
of age. At this age, most infants are physically able to find
the pacifier and put it back in their mouth. Parents can facilitate
this by spending extra time on the floor teaching the child
to reach to get the pacifier, pick it up, and put it back
in their mouth. Keeping several in the corners of the crib
and guiding the child to find them may be helpful.
The other option, which most parents choose (especially if
their infant is young), is to get rid of the pacifier altogether
and to encourage the development of independent sleep onset
(i.e., without parental intervention). Sometimes introducing
a transitional object or “lovey” such as a small
breathable “blankie” (no bigger than 12”
by 12” with holes) can be helpful.
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The information contained in the "Ask the Sleep
Expert" column is not intended to be a substitute
for medical or other professional advice. It is recommended
that you consult with your child’s physician or
other qualified professional health care providers if
you have any concerns regarding your child’s sleeping
habits.
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