Clinical Reference Systems: Pediatric Advisor 10.0

DEFINITION

• Your child is over 4 months old and wakes up and cries one or more times at night to be fed.
• Your child wakes up to be fed most nights.
• Your child is bottle-fed or breast-fed until asleep.
• Your child has awakened to be fed at night since birth.
• The child's parents are tired, but the child is not.

Note: From birth to the age of 2 months, most babies awaken twice each night for feedings. Between the ages of 2 and 3 months, most babies need one feeding in the middle of the night. By 4 months of age, most bottle-fed babies sleep more than 7 hours without feeding. Most breast-fed babies can sleep through the night by 5 months of age. Normal children of this age do not need calories during the night to stay healthy.

CAUSES

1. Nursing or bottle-feeding the baby until asleep. If the last memory before sleep is sucking the breast or bottle, the bottle or breast becomes the baby's security object. The child does not learn to comfort himself and fall asleep without the breast or bottle. Therefore, when the child normally wakes up at night, the child has the habit of not being able to go back to sleep without feeding. Being brought to the parents' bed for a feeding makes the problem far worse.

2. Leaving a bottle in the bed. Periodically during the night the child sucks on a bottle. When it becomes empty, the child awakens fully and cries for a refill. Bottles in bed, unless they contain only water, also can lead to severe tooth decay.

3. Feeding often during the day. Some mothers misinterpret "demand feedings" to mean that they should feed the baby every time he cries. This misunderstanding can lead to feeding the baby every 30 to 60 minutes. The baby becomes used to being fed small amounts often instead of waiting at least 2 hours between feedings at birth and at least 4 hours between feedings at the age of 4 months. A pattern of feeding every hour or so is called grazing. This problem occurs more often in breast-fed babies if nursing is used as a pacifier. Bottle dependency leads to the bad habit of carrying a bottle around during the day. Also, giving a child a lot of liquid at night means your child will wake up more often because his diapers are soaked.

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 FEEDER

1. Gradually lengthen the time between daytime feedings to 3 or 4 hours. You can't lengthen the time between nighttime feedings if the time between daytime feedings is short. If a baby is used to frequent feedings during the day, he will get hungry during the night. Grazing often happens to mothers who don't separate holding from nursing. For every time you nurse your baby, there should be four or five times that you snuggle your baby without nursing. Gradually postpone daytime feeding times until they are more normal for your baby's age. If you currently feed your baby hourly, increase the time between feedings to 1 and 1/2 hours. When your baby accepts the new schedule, go to 2 hours between feedings. When your baby cries, cuddle him or give him a pacifier. Your goal for a formula-fed baby is to give him 4 bottles a day by 4 months of age. Breast-fed babies often need five feedings each day until they are 6 months old, when solid foods are added to their diet. If your child is over 6 months old, also introduce cup feedings.

2. At naps and bedtime, place your baby in the crib drowsy but awake. When your baby starts to act sleepy, place her in the crib. If your baby is very fussy, rock her until she settles down or is almost asleep, but stop before she's fully asleep. If your baby falls asleep at the breast or bottle, it is best to wake her up. To help your baby not think of feeding at bedtime, consider feeding her 1 hour before bedtime or before a nap. Your baby's last waking memory needs to be of the crib and mattress, not of the breast or bottle. She needs to learn to put herself to sleep. Your baby needs to develop this skill so she can put herself to sleep when she wakes up at night.

3. If your baby is crying at bedtime or naptime, visit your baby briefly every 5 to 15 minutes. Visit your baby before he becomes too upset. You may need to check babies younger than 1 year or more sensitive babies every 5 minutes. Gradually lengthen the time between your visits. Make your visits brief and boring but supportive. Don't stay in the room longer than 1 minute. Don't turn on the lights. Act sleepy. Whisper, "Shhh, everyone's sleeping." Do not remove your child from the crib. Do not feed, rock, or play with your baby, or bring him to your bed. This brief contact will not reward your baby enough for him to want to continue the behavior.

4. For crying during the middle of the night, temporarily hold your baby until asleep. Until your child learns how to put herself to sleep at naps and bedtime, make the middle-of-the-night awakenings as easy as possible. If she 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 her until asleep. However, don't turn on the lights or take her out of the room. Try not to talk to her very much. Often this goes better if Dad goes in.

   After the last feeding of the day at 9 to 10 PM, feed your baby only once during the night. Provide this nighttime feeding only if 4 or more hours have passed since the last feeding. Make this nighttime feeding boring and brief (no longer than 20 minutes). Stop it before your child falls asleep, and replace it with holding only.

5. Stop giving your baby any bottle in bed. If you feed your child at bedtime, don't let him hold the bottle. Also feed your child in a different room than the bedroom. Try to separate mealtime and bedtime. If your baby needs to suck on something to help him go to sleep, offer a pacifier or help him find his thumb.

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 feeding. Phase out the nighttime feeding only after the time between daytime feedings is more than 3 hours AND your child can put herself to sleep without feeding or rocking. Gradually reduce the amount you feed your baby at night. Decrease the amount of formula you give a bottle-fed baby by 1 ounce every two to three nights. Nurse a breast-fed baby on just one side and reduce the time by 2 minutes every two to three nights. After 1 to 2 weeks, your baby will no longer crave food at night and should be able to go back to sleep without holding or rocking.

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 the 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 soon becomes a game.

9. Keep a sleep diary. Write down the times when your baby is awake and asleep. Bring this record with you to your office follow-up visit.

CALL YOUR CHILD'S PHYSICIAN DURING REGULAR HOURS IF:

• Your child is not gaining enough weight.
• 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.