Clinical Reference Systems: Pediatric Advisor 10.0

DEFINITION

• Your child is over 4 months old and wakes up and cries one or more times a night.
• The crying occurs most nights.
• Your child is held, rocked, or walked until asleep.
• Your child doesn't need to be fed in the middle of the night. (Until the age of 2 or 3 months, most babies need to be fed during the night.)
• Your child has awakened and cried at night since birth.
• The child's parents are tired, but the child is not.

CAUSES

1. Holding or rocking your baby until asleep.

   All children normally wake up four or five times each night after dreams. Because they usually do not wake up fully at these times, most children can get back to sleep by themselves. However, children who have not learned how to comfort and quiet themselves cry for a parent. If your custom at naps and bedtime is to hold, rock, or lie down with your baby until asleep, your child will not learn how to go back to sleep without your help. Babies who are not usually placed in their cribs while they are still awake expect their mothers to help them go back to sleep when they wake up at night. Because they usually fall asleep away from their cribs, they don't learn to associate the crib and mattress with sleep. This is called poor sleep-onset association.

2. Providing entertainment during the night.

   Children may awaken and cry more frequently if they realize they gain from it; for example, if they are walked, rocked, or played with, or enjoy other lengthy contact with their parents. Being brought to the parents' bed makes the problem far worse. Trained night crying can also begin after situations that required the parents to give more nighttime attention to their baby for a while. Examples of such problems are colds, discomfort during hot summer nights, or traveling. Many babies quickly settle back into their previous sleep patterns after such situations. However, some enjoy the nighttime contact so much that they begin to demand it.

3. Believing any crying is harmful.

   All young children cry when confronted with a change in their schedule or environment (called normal protest crying). Crying is their only way to communicate before they are able to talk. Crying for brief periods is not physically or psychologically harmful. The thousands of hours of attention and affection you have given your child will easily offset any unhappiness that may result from changing a bad sleep pattern.

EXPECTED OUTCOME

If you try the following recommendations, your child's behavior will probably improve in 2 weeks. The older your child is, the harder it will be to change your child's habits. Children over 1 year old will fight sleep even when they are tired. They will vigorously protest any change and may cry for hours. However, if you don't take these steps, your child won't start sleeping through the night until 3 or 4 years of age, when busy daytime schedules finally exhaust your child.

HELPING A TRAINED NIGHT CRIER

1. Place your baby in the crib drowsy but awake for naps and bedtime.

   It's good to hold babies and to provide pleasant bedtime rituals. However, when your baby starts to look drowsy, place him in the crib. Your child's last waking memory needs to be of the crib and mattress, not of you. If your baby is very fussy, rock him until he settles down or is almost asleep, but stop before he's fully asleep. He needs to learn to put himself to sleep. Your baby needs to develop this skill so he can put himself back to sleep when he normally wakes up at night.

2. If your baby is crying at bedtime or naptime, visit your baby briefly every 5 to 15 minutes.

   Visit your baby before she becomes too upset. You may need to check younger or more sensitive babies every 5 minutes. You be the judge. Gradually lengthen the time between your visits. Babies cannot learn how to comfort themselves without some crying. This crying is not harmful.

3. Make the visits brief and boring but supportive.

   Don't stay in your child's room longer than 1 minute. Don't turn on the lights. Keep the visit supportive and reassuring. Act sleepy. Whisper, "Shhh, everyone's sleeping." Add something positive, such as "You're a wonderful baby," or "You're almost asleep." Never show your anger or punish your baby during these visits. If you hug him, he probably won't let go. Touch your baby gently and help him find his security object, such as a doll, stuffed animal, or blanket.

4. Do not remove your child from the crib.

   Do not rock or play with your baby or bring her to your bed. Brief contact will not reward your baby enough for her to want to continue the behavior. Most young babies cry 30 to 90 minutes and then fall asleep.

5. For crying during the middle of the night, temporarily hold your baby until he is asleep.

   Until your child learns how to put himself to sleep at naps and bedtime, make the middle-of-the-night awakenings as easy as possible for everyone. If he doesn't fuss for more than 5 or 10 minutes, respond as you do at bedtime. Otherwise, take your crying child out of the crib and hold him until he is asleep. Don't turn on the lights or take him out of the room. Try not to talk to him very much. Often this goes better if Dad goes in.

6. Help your child attach to a security object.

   A security (transitional) object is something that helps a waking child go to sleep. It comforts your child and helps your child separate from you. A cuddly stuffed animal, doll, other soft toy, or blanket can be a good security object. Sometimes covering a stuffed animal with one of the mother's T-shirts helps a child accept it. Include the security object whenever you cuddle or rock your child during the day. Also include it in your ritual before bedtime by weaving it into your storytelling. Tuck it into the crib next to your child. Eventually, your child will hold and cuddle the stuffed animal or doll at bedtime in place of you.

7. Later, phase out the nighttime holding.

   Phase out nighttime holding only after your child has learned to quiet herself and put herself to sleep for naps and at bedtime. Then you can expect her to put herself back to sleep during normal middle-of-the-night awakenings. Go to her every 15 minutes while she is crying, but make your visits brief and boring. After your child learns to put herself to sleep at bedtime, awakening with crying usually stops in a few nights.

8. Other helpful hints for sleep problems.
   • Move the crib to another room.

     If the crib is in your bedroom, move it to a separate room. If this is impossible, cover one of the side rails with a blanket so your baby can't see you when he wakes up.

   • Avoid long naps during the day.

     If your baby has napped for more than 2 hours, wake her up. If she has the habit of taking three naps during the day, try to change her habit to two naps each day.

   • Don't change wet diapers during the night.

     Change the diaper only if it is soiled or you are treating a bad diaper rash. If you must change your child's diaper, use as little light as possible (for example, a flashlight), do it quickly, and don't provide any entertainment. If your child is standing up in the crib at bedtime, you can leave him in that position. Try to get your child to settle down and lie down. If he refuses or pulls himself back up, leave him that way. He can lie down without your help. Encouraging your child to lie down can soon become a game.

9. Keep a sleep diary.

   Keep a record of when your baby is awake and asleep. Bring it with you to your office follow-up visit.

CALL YOUR CHILD'S PHYSICIAN DURING REGULAR HOURS IF:

• You think the crying has a physical cause.
• Your child acts fearful.
• Someone in your family cannot tolerate the crying.
• The steps outlined here do not improve your child's sleeping habits within 2 weeks.
• You have other questions or concerns.