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Clinical Reference Systems: Pediatric Advisor 10.0
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Prevention of Sleep Problems

DESCRIPTION

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 later.

NEWBORNS

  1. 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 side.)

  2. Hold your baby for all fussy crying during the first 3 months.

    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.

  3. Carry your baby for at least 3 hours a day when he isn't crying.

    This practice will reduce fussy crying.

  4. 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.)

  5. Keep daytime feeding intervals to at least 2 hours for newborns.

    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 grazing.

  6. 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.

  7. Don't awaken your infant to change diapers during the night.

    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.

  8. 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.

  9. 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.

TWO-MONTH-OLD BABIES

  1. 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.

  2. 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 your bedtime.

FOUR-MONTH-OLD BABIES

  1. Try to discontinue the 2 AM feeding before it becomes a habit.

    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 older.

    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 feeding.

    Note: Some breast-fed babies will continue to need to be nursed once during the night.

  2. 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.

  3. 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.)

SIX-MONTH-OLD CHILDREN

  1. Provide a friendly soft toy for your child to hold in her crib.

    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 night.

  2. 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 nearby.

  3. 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.

  4. For middle-of-the-night fears, make contacts prompt and reassuring.

    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.

ONE-YEAR-OLD CHILDREN

  1. 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.

  2. 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 bedtime.

  3. If your child has nightmares or bedtime fears, reassure him.

    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.

  4. Don't worry about the amount of sleep your child is getting.

    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.


Written by B.D. Schmitt, M.D., author of "Your Child's Health," Bantam Books.
Copyright 1999 Clinical Reference Systems