How can I get my son to fall asleep without nursing?
Q. My son is eight months old, and I’m about to wean him off of the breast (need to, before I go back to work). Like probably all breast-fed babies, that’s how he’s accustomed to going to sleep. Any suggestions on how to get him to sleep once he’s weaned? Is there an easier way other than just laying him down and listening to him cry himself to sleep? I’ve heard that laying him down with a bottle works, but I’ve read that it will rot his teeth out. I’ve had the same nighttime routine for a while - a walk after dinner, then a bath and then - well, you know. I’d love to hear any suggestions. Thanks.

A. As you describe, many infants learn to associate nursing or drinking a bottle with falling asleep. While this is fine when infants are young, as they get older it interferes with them learning to fall asleep on their own. Also, sugar on teeth from milk (bottles) in bed can lead to dental caries (tooth decay or cavities) and should be avoided.

Acquiring the skill of falling asleep truly independently is key to a child sleeping through the night and is a skill that all children need to learn at some point. However children under 3 months of age should not be left to cry for more than 5 minutes and even less depending on the intensity of their cry. At your son’s age, I would definitely consider giving him the opportunity to learn how to fall asleep by himself. There are several advantages of encouraging self-soothing at this young age. In addition to improved sleep for everyone, bad habits are less ingrained and learning typically occurs quickly. If an appropriate sleep schedule and solid plan are developed, and carried out consistently, an older infant should be falling asleep on his own without much fussing or crying in less than a week.

There is much empirical support for the safety and efficacy of sleep training (also known as graduated extinction). In this approach, infants are placed in their crib (awake) to fall asleep. Parents are encouraged to check on their child, as they wish. These checks should be brief (2-3 seconds) and things that can lead to more crying should be avoided such as picking up the child or patting him. It is best to start a plan like this after speaking with your child’s physician to rule out medical causes of sleep problems (such as reflux and pain from teething and ear infections) and when you feel confident that you can be consistent. Speaking with a health care professional with training in this area to develop a treatment plan and to address your questions and concerns can also be helpful.

Introducing a transitional object can help with separation at night (and can make travelling much easier!). “Blankies� are often a good choice, because if your child rolls onto it at night, it will not disturb him. At this age, blankies should be no bigger than 8� by 8� and should be breathable (with holes). Giving him several may be helpful to ensure that he is always able to find one during the night.

My daughter has started waking at night, what can I do?
Q. After initially mixing up her nights and days, my breast-fed daughter began sleeping through the night by 2 months of age. However, suddenly, at approximately 6 months of age, she began waking several times during the night (anywhere from 2 to 6 times nightly). The only thing that settles her seems to be breastfeeding, but I can’t imagine that she is hungry, especially on nights when she is waking almost every hour. Due to her continuous waking, she has been co-sleeping with us. I want to stop (or significantly reduce) the night wakings and feedings and get her into her crib.

A. It is common for previously good sleepers to develop sleep problems between 3-6 months of age. This can be due to, at first, greater cognitive awareness, and then due to reaching new developmental milestones. As you described that these problems represent a change in her sleep, I would discuss them with her physician. If she is well, a sleep training approach as outlined in Question 1 would be helpful. In addition to ensuring that she falls asleep independently (if she isn’t already), this approach would also focus on her returning to sleep on her own following night wakings.

Most paediatricians will agree that the majority of healthy full-term babies who are gaining weight as expected do not need to be fed during the night after 6 months of age. 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 to eat. 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.

If your goal is to have your daughter sleep in her own sleep space, in her own room, it is suggested that you do not bring her to sleep in the parental bed. Doing so, even on an intermittent basis, will likely perpetuate her waking at night and her resistance to returning to sleep on her own. Also, there is ample evidence to suggest that a bed is not the safest place for a baby to sleep. For more information on safe sleep practices for infants, see the Canadian Paediatric Society handout “Safe sleep for babies�.

-URL for “Safe sleep for babies�
http://www.caringforkids.cps.ca/pregnancy&babies/SafeSleepForBaby.htm

What can I do about bedtime problems?
Q. How do I manage sleep routines when a new baby enters the scene? Our 3 1/2 year old sometimes is difficult to put down (delay tactics and calling out to us, sometimes louder than that by flat out refusing) and I am concerned with keeping the baby asleep if it happens to be sleeping. Also, is there anything I should be saying or doing to help our son understand that the baby sleeps in our room in its cradle for now and he should continue to sleep in his big boy bed?

A. Preschoolers are notorious for making repeated requests at bedtime, fondly referred to as “curtain calls�. At this age it is even more important to set limits on bedtime behaviours such as no additional snacks after a bedtime routine has been started, no t.v. as part of a bedtime routine, and not coming out of his room. Discussing the bedtime routine as you go along (e.g., how many books you will read) and being clear about what is allowed and what is not allowed can be helpful. Some parents report that using an egg timer that is set to go off at the child’s bedtime to signal that the routine is over is helpful. Giving in to additional requests (extra books, another snack or drink etc.) can maintain the stalling behaviour.

Continuing to have a predictable, calming bedtime routine (that is done in the child’s room), adhering to a regular sleep schedule, and ensuring that a child this age falls asleep, and back to sleep, independently on a consistent basis is important. You can explain that when babies are born they need to sleep in their parents’ room. In your words you can describe that you have some “rules� and one of them is keeping the baby in your room at night. You can remind your son, that you also did this (if you did) when he was born. The use of white noise where your baby sleeps and in the hallway outside the bedrooms can be helpful to block noise.

Lastly if your son is still napping, you want to be sure that too much day sleep or napping too late in the day is not interfering with him falling asleep at night.

Dr. Nicky Cohen is a Registered Psychologist in private practice in Toronto. She received her Ph.D. in Clinical Psychology from York University and developed an interest in parenting issues related to children’s sleep disturbances after having her first child 5 years ago. She is active in the community disseminating information on healthy sleep practices and increasing awareness of the importance of making sufficient sleep a family priority. Dr. Cohen has held various research and clinical positions at the Centre for Addiction and Mental Health, the Hospital for Sick Children, and the University Health Network (Toronto General Hospital). More information about Dr. Cohen’s work can be found at: www.kidsleep.ca.

©Dr. Nicky Cohen 2009

Night wakings in young children (and even adults) are very common and often the result of ‘poor’ or negative learned sleep associations (also known as “bad habits�). Children who do not yet have the skill of falling asleep independently are usually unable to return to sleep following periods of normal partial arousal that we all have during the night.

Most children will need the same conditions that were present at sleep onset (bedtime) to be re-established when they wake at night in order to return to sleep. In these circumstances a child may wake up visibly upset at night because she has fallen asleep under one condition (such as while feeding or with a parent in the room) and woken up in a different condition (e.g., alone in a crib or bed). This is akin to us (an adult) falling asleep in the comfort of our bed and waking up on the couch. We would not be happy!

These “behavioural� wakings can be ruled out (or in) as the cause of night wakings by reviewing the way in which your child is falling asleep at night and how he is being responded to when he wakes. Also reviewing the presentation and symptoms of other causes of night wakings such as sleep terrors and nightmares can be helpful.

If poor learned sleep associations are determined to be the cause of your child’s sleep disturbances, sleep training is often helpful (see below for recommended readings). However, note that sleep training methods are not recommended until a child is 3 months of age (full-term) and healthy.

Discussing your concerns with your child’s physician or another health professional with training in the area of parenting issues regarding children’s sleep, may also be helpful in developing an appropriate treatment plan to address these problems.  

Recommended Readings for sleep training:

The Sleepeasy Solution: The Exhausted Parent’s Guide to Getting Your Child to Sleep – from Birth to Age 5. (Jennifer Waldburger & Jill Spivak, 2007)

Sleeping Through the Night: How Infants, Toddlers, and Their Parents Can Get a Good Night’s Sleep (Revised Edition) (Jodi A. Mindell, 2005)

Dr. Nicky Cohen is a Registered Psychologist in private practice in Toronto. She received her Ph.D. in Clinical Psychology from York University and developed an interest in parenting issues related to children’s sleep disturbances after having her first child 5 years ago. She is active in the community disseminating information on healthy sleep practices and increasing awareness of the importance of making sufficient sleep a family priority. Dr. Cohen has held various research and clinical positions at the Centre for Addiction and Mental Health, the Hospital for Sick Children, and the University Health Network (Toronto General Hospital). More information about Dr. Cohen’s work can be found at: www.kidsleep.ca.

©Dr. Nicky Cohen 2009

Q. When will my son drop his final nap?
My son is almost 3 years old and has recently stopped napping. He is very tired in the late afternoon and sometimes falls asleep on the couch. When this happens, getting him to bed before 9:30pm is very difficult! Is there anything I can do to get him napping again? 

Dr. Cohen:
Many children drop their single (afternoon) nap between 3-5 years of age. However many 3 year olds still need to nap and have trouble making it to bed time without their nap. A nap may be dropped prematurely due to social activities or because a child starts resisting the afternoon nap at the usual time. I am an advocate of not dropping a child’s nap because of social activities but parents make this decision considering a variety of factors. Sometimes if a child starts resisting their nap it is helpful to move it later by 30-60 minutes to increase his drive to sleep. A 3-5 year old, for example, may not be ready to nap before 2:00-3:00pm.

If however, a later nap is interfering with falling asleep at night, limiting the nap (e.g., to an hour) and/or moving bedtime later (e.g., to 8:30pm) may be necessary. In some cases – when a later nap interferes with even a later bedtime or the child still resists napping at a later time – these may be signs that the child is ready to go without a nap. Eliminating the nap and moving bedtime earlier may be necessary.

Some children, during the transition in dropping their nap, may still need to nap periodically as their sleep debt builds. So continue to offer your child an opportunity to nap. On some days he may and on other days he may not. Replacing the nap with ‘quiet time’ can give everyone a bit of a break from an otherwise busy day!

Q. When do children transition from 2 naps to 1?
My daughter is 13 months old and has started to resist napping twice a day. Sometimes she does and on other days she will only nap once. Can you please discuss how and when the transition from 2 naps to 1 is expected to happen?

Dr. Cohen:
Usually the 2nd nap is dropped between 12-18 months of age, with an average age being 14-16 months. However, some toddlers still need 2 naps a day until as late as 20 months of age. A sign that it may be time to drop the 2nd nap is that a child is resisting the 1st or 2nd nap at appropriate times, which is usually after 3-4 hours of being awake. When this happens for more than 3-5 days in a row, the single nap can be scheduled around the mid-day mark and gradually moved later (e.g., 1 pm at 2 years of age). However during the first few weeks of this transition, there may be some days where she still needs 2 naps and other days when 1 is enough.

When the 2nd nap is dropped, bedtime may need to be temporarily moved earlier while the child gets used to having 1 longer nap and being awake for a longer period before bed. Usually the single nap is 1.5-3 hours in length. If your child has a fragment (i.e., an early waking) during his nap and/or still seems tired, give her 15 minutes or so to see if she will fall back asleep. It is important that toddlers are falling asleep independently for their nap(s) and at nighttime, and are being responded to appropriately and consistently. If children do not have the skill of falling asleep independently they will need assistance when they have an early waking both at night and during their nap.

An early morning wake time (in children over 1 year) can be another sign that a child is ready to drop her morning nap. In these children, maintaining the morning nap can result in early morning wakings because the body does not need to sleep to a regular hour and have a morning nap. Therefore the body starts to learn that because another sleep period is coming, it can wake early. Making changes to the daytime sleep schedule (i.e., dropping the morning nap) often resolves early morning wakings that are due to this cause.

Q. How can I get my infant to have longer naps?  
My son is 6 months old and his daytime sleep is very erratic. He has 4-5 “cat-naps� a day and usually only sleeps for 30-40 minutes at each nap. He often wakes up crying and still tired and will only sleep for longer periods in his stroller. He falls asleep on his own at night, but I am still rocking him to sleep for his naps. At his age, what can I do to encourage better napping?

Dr. Cohen:
Many 6 month olds nap 2-3 times a day. Usually the third nap is dropped between 6-9 months of age. At 3-4 months of age, most healthy full-term babies are capable of falling asleep independently for all of their sleep periods (both day and night). The skill of falling asleep independently is more easily learned at sleep onset for nighttime sleep as the drive to sleep is stronger than it is for daytime sleep. Once a child has mastered the skill at nighttime, he can be given the opportunity to learn it for his naps.

“Cat naps� can be due to several reasons including: (1) being put down too early (as the drive to sleep is not as strong as it should be), (2) not falling asleep independently, and (3) being given the opportunity to nap too many times throughout the day (as the body learns it does not have to sleep very long because it will be offered another sleep period soon). Many 6 month olds are ready to sleep after 2-2.5 hours after being awake if they are having 3 naps a day, and after 2.5-3 hours if they are napping twice a day.

Usually when sleep training for naps is initiated, and even following sleep training, some children continue to have fragments (i.e., early wakings) in their naps. However, if the timing of the naps is appropriate, many children will fall back asleep, if given the opportunity. If a child has slept for less than 1 hour for a nap (i.e., less than a full cycle of sleep), sometimes giving him 15-20 minutes to see if he will fall back asleep can be helpful. 
Pleasant dreams!

Dr. Nicky Cohen is a Registered Psychologist in private practice in Toronto. She received her Ph.D. in Clinical Psychology from York University and developed an interest in parenting issues related to children’s sleep disturbances after having her first child 5 years ago. She is active in the community disseminating information on healthy sleep practices and increasing awareness of the importance of making sufficient sleep a family priority. Dr. Cohen has held various research and clinical positions at the Centre for Addiction and Mental Health, the Hospital for Sick Children, and the University Health Network (Toronto General Hospital). More information about Dr. Cohen’s work can be found at: www.kidsleep.ca.