Clinical Reference Systems: Pediatric Advisor 10.0
Prevention of Sleep Problems
Parents want their children to go to bed without resistance
and to sleep through the night. They look forward to a time
when they can again have 7 or 8 hours of uninterrupted
sleep. Newborns, however, have a limit to how many hours
they can go without a feeding, usually 4 or 5. By 2 months
of age, some 50 percent of bottle-fed infants can sleep
through the night. By 4 months, most bottle-fed infants
have acquired this capacity. Most breast-fed babies can
sleep through the night by 5 months of age. Good sleep
habits may not develop, however, unless you have a plan.
Consider the following guidelines if you want to teach your
baby that nighttime is a special time for sleeping, that her
crib is where she stays at night, and that she can put
herself back to sleep. It is far easier to prevent sleep
problems before 6 months of age than it is to treat them
- Place your baby in the crib when he is drowsy but awake.
This step is very important. Without it, the other
preventive measures will fail. Your baby's last waking
memory should be of the crib, not of you or of being
fed. He must learn to put himself to sleep without you.
Don't expect him to go to sleep as soon as you lay him
down. It often takes 20 minutes of restlessness for a
baby to go to sleep. If he is crying, rock him and
cuddle him. But when he settles down, try to place him
in the crib before he falls asleep. Handle naps in the
same way. This is how your child will learn to put
himself back to sleep after normal awakenings. Don't
help your infant when he doesn't need any help. (Note:
The sleep position recommended by the American Academy
of Pediatrics for healthy infants is on the back or
- Hold your baby for all fussy crying during the first
All new babies cry some during the day and night. If
your baby cries excessively, the cause is probably
colic. Always respond to a crying baby. Gentle rocking
and cuddling seem to help the most. Babies can't be
spoiled during the first 3 or 4 months of life. But
even colicky babies have a few times each day when they
are drowsy and not crying. On these occasions, place
your child in the crib and let him learn to comfort
himself and put himself to sleep.
- Carry your baby for at least 3 hours a day when he isn't
This practice will reduce fussy crying.
- Do not let your baby sleep for more than three
consecutive hours during the day.
Try to awaken him gently and entertain him. In this
way, the time when your infant sleeps the longest will
occur during the night. (Note: Many newborns can sleep
five consecutive hours and you can teach him to take
this longer period of sleep at night.)
- Keep daytime feeding intervals to at least 2 hours for
More frequent daytime feedings (such as hourly) lead to
frequent awakenings for small feedings at night.
Crying is the only form of communication newborns have.
Crying does not always mean your baby is hungry. He may
be tired, bored, lonely, or too hot. Hold your baby at
these times or put him to bed. Don't let feeding become
a pacifier. For every time you nurse your baby, there
should be four or five times that you snuggle your baby
without nursing. Don't let him get into the bad habit
of eating every time you hold him. That's called
- Make middle-of-the-night feedings brief and boring.
You want your baby to think of nighttime as a special
time for sleeping. When he awakens at night for
feedings, don't turn on the lights, talk to him, or rock
him. Feed him quickly and quietly. Provide extra
rocking and playtime during the day. This approach will
lead to longer periods of sleep at night.
- Don't awaken your infant to change diapers during the
The exceptions to this rule are diapers soiled with
bowel movements or times when you are treating a bad
diaper rash. If you must change your child, use as
little light as possible (for example, a flashlight), do
it quietly, and don't provide any entertainment.
- Don't let your baby sleep in your bed.
Once your baby is used to sleeping with you, a move to
his own bed will be extremely difficult. While it's not
harmful for your child to sleep with you, you probably
won't get a restful night's sleep. So why not teach
your child to prefer his own bed? For the first 2 or
3 months, you can keep your baby in a crib or box next
to your bed.
- Give the last feeding at your bedtime (10 or 11 PM).
Try to keep your baby awake for the 2 hours before this
last feeding. Going to bed at the same time every night
helps your baby develop good sleeping habits.
- Move your baby's crib to a separate room.
By 3 months of age, your baby should be sleeping in a
separate room. This will help parents who are light
sleepers sleep better. Also, your baby may forget that
her parents are available if she can't see them when she
awakens. If separate rooms are impractical, at least
put up a screen or cover the crib railing with a blanket
so that your baby cannot see your bed.
- Try to delay middle-of-the-night feedings.
By now, your baby should be down to one feeding during
the night (two for some breast-fed babies). Before
preparing a bottle, try holding your baby briefly to see
if that will satisfy her. If you must feed her, give 1
or 2 ounces less formula than you would during the day.
If you are breast-feeding, nurse for less time at night.
As your baby gets close to 4 months of age, try nursing
on just one side at night.
Never awaken your baby at night for a feeding except at
- Try to discontinue the 2 AM feeding before it becomes a
By 4 months of age, your bottle-fed baby does not need
to be fed more than four times a day. Breast-fed babies
do not need more than five nursing sessions a day. If
you do not eliminate the night feeding at this time, it
will become more difficult to stop as your child gets
Remember to give the last feeding at 10 or 11 PM. If
your child cries during the night, comfort him with a
back rub and some soothing words instead of with a
Note: Some breast-fed babies will continue to need to
be nursed once during the night.
- Don't allow your baby to hold his bottle or take it to
bed with him.
Babies should think that the bottle belongs to the
parents. A bottle in bed leads to middle-of-the-night
crying because your baby will inevitably reach for the
bottle and find it empty or on the floor.
- Make any middle-of-the-night contacts brief and boring.
All children have four or five partial awakenings each
night. They need to learn how to go back to sleep on
their own at these times.
If your baby cries for more than a few minutes, visit him
but don't turn on the light, play with him, or take him
out of his crib. Comfort him with a few soothing words
and stay for less than 1 minute. If your child is
standing in the crib, don't try to make him lie down.
He can do this himself. If the crying continues for
more than 10 minutes, calm him and stay in the room
until he goes to sleep. (Exceptions: You feel your
baby is sick, hungry, or afraid.)
- Provide a friendly soft toy for your child to hold in
At the age of 6 months, children start to be anxious
about separation from their parents. A stuffed animal,
doll, or blanket can be a security object that will give
comfort to your child when she wakes up during the
- Leave the door open to your child's room.
Children can become frightened when they are in a closed
space and are not sure that their parents are still
- During the day, respond to separation fears by holding
and reassuring your child.
This lessens nighttime fears and is especially important
for mothers who work outside the home.
- For middle-of-the-night fears, make contacts prompt and
For mild nighttime fears, check on your child promptly
and be reassuring, but keep the interaction as brief as
possible. If your child panics when you leave or vomits
with crying, stay in your child's room until she is
either calm or goes to sleep. Do not take her out of
the crib, but provide whatever else she needs for
comfort, keeping the light off and not talking too much.
At most, sit next to the crib with your hand on her.
These measures will calm even a severely upset infant.
- Establish a pleasant and predictable bedtime ritual.
Bedtime rituals, which can start in the early months,
become very important to a child by 1 year of age.
Children need a familiar routine. Both parents can be
involved at bedtime, taking turns with reading or making
up stories. Both parents should kiss and hug the child
"goodnight." Make sure that your child's security
objects are nearby. Finish the bedtime ritual before
your child falls asleep.
- Once put to bed, your child should stay there.
Some older infants have temper tantrums at bedtime.
They may protest about bedtime or even refuse to lie
down. You should ignore these protests and leave the
room. You can ignore any ongoing questions or demands
your child makes and enforce the rule that your child
can't leave the bedroom. If your child comes out,
return him quickly to the bedroom and avoid any
conversation. If you respond to his protests in this
way every time, he will learn not to try to prolong
- If your child has nightmares or bedtime fears, reassure
Never ignore your child's fears or punish him for having
fears. Everyone has four or five dreams a night. Some
of these are bad dreams. If nightmares become frequent,
try to determine what might be causing them, such as
something your child might have seen on TV.
- Don't worry about the amount of sleep your child is
Different people need different amounts of sleep at
different ages. The best way you can know that your
child is getting enough sleep is that he is not tired
during the day.
Naps are important to young children but keep them less
than 2 hours long. Children stop having morning naps
between 18 months and 2 years of age and give up their
afternoon naps between 3 and 6 years of age.