Q. What can I do about my daughter climbing out of bed at night?

We have co-slept with our 12-month old daughter since she was born. At first it worked well because she was waking frequently so it was easy to feed or pat her to get her back to sleep quickly. The problem is that she is still waking and sometimes she tries to get off the bed during the night. I am concerned she may do this while we are sleeping. What do you recommend?

Dr. Cohen:

At her age, the safest place for her to be sleeping is definitely a crib! All the soft materials that are on a bed are a risk for suffocation and strangulation and there have been numerous reports of accidental falls off a bed as well as children getting trapped between a mattress and headboard or wall.

Also, as you described, research shows that many parents and children who co-sleep do not sleep through the night. This is because noises and movements from one another can disturb sleep and because it is easier to respond to (and therefore reinforce) night wakings due to being near-by.

For all these reasons, I would suggest transitioning her to a crib in her own room. This can be done gradually, if you think it would be helpful. For example, you can start by sitting next to her crib and patting her until she falls asleep for 5-7 days. I would then move on to just doing very brief ‘checks’ and aiming for her to fall asleep on her own. This same gradual approach can also be done following night wakings and for her naps. At her age, things may get worse before they get better, but with a good plan and a lot of consistency things will improve.

Q. Can I put my baby on her side or tummy to sleep?

When I put my 5 month old to sleep in his crib, I put him on his side or tummy as I find he sleeps much better that way. Is that OK to do? He has started to roll a little bit during the day but is not yet rolling in his crib when he sleeps.

Dr. Cohen:

According to Health Canada and Canadian Paediatric Society guidelines, children should be placed on their back to sleep for all sleep periods until 12 months of age. This position, until a child can roll on his own, is associated with a decreased risk of sudden infant death syndrome. However, according to the guidelines, once a child is able to roll on his own to sleep on his side or stomach, it is not necessary to roll him back during the night or nap, unless his physician has told you of a medical reason to do so.

For more information on safe sleep practices for infants, see the following handouts for parents:

“Safe Sleep for Babies� (Canadian Paediatric Society)

“Safe Sleep for Your Baby� (Health Canada)

Q. How can I keep my son from climbing out of his crib?

My 2 year old son has started to climb out of his crib when I put him to bed at night. I know a lot of kids are in beds at this age but I am worried he will be up all night and all over the house! What should I do?

Dr. Cohen:

If he is close to 3 years and otherwise sleeping well, I would consider transitioning him to a toddler bed with guard-rails. If not, I would suggest keeping him in his crib. If the transition to a bed is made too soon, bedtime problems and night wakings often develop or worsen and then you have a child who is up and about all night. This could be a safety concern as well as difficult to manage because many young children are not yet “mature� enough to understand the rules associated with staying in bed. Barring no safety concerns, I like to keep a child in a crib until 3-3.5 years if possible.

If he only climbs out of his crib when a parent is in the room or if the lights are on, be sure to only put him in his crib in the dark as you are about to leave his room. If he is brave enough to continue climbing out, I would suggest putting up a safety gate at his bedroom door to try to deter the behaviour. Children quickly learn that if they stay in their crib the gate comes down. Some parents use crib tents to keep their little ones safe in their cribs.

©Dr. Nicky Cohen 2011

Sleep Problems in Toddlers and Preschoolers

Sleep problems in toddlers and preschoolers are very common, with bedtime difficulties and night wakings topping the list of parent concerns. Research shows that 25-30% of toddlers have bedtime problems and up to 50% still experience night wakings. These problems continue to be common (from 15-30%) in preschoolers. Often times, difficulties falling asleep and night wakings occur in the same child.

Population surveys of parents suggest that these problems may even be more prevalent. The National Sleep Foundation’s Sleep in America Poll (2004) found that 43% of toddlers and preschoolers fall asleep with a parent present at least a few times a week and 46% and 36% of toddlers and preschoolers, respectively, still wake at night and need “help and attention� to return to sleep.

Consequences of sleep deprivation are numerous and affect all main areas of functioning including social, emotional, cognitive, and behavioural. Sleep problems in children generally disrupt family life and are often the cause for significant parental distress, disruption to parents’ sleep, decreased level of effective parenting, and marital conflict. Signs of insufficient sleep in children include irritability, poor concentration, moodiness, unplanned naps, planned naps past an age when napping is appropriate, whininess, overactivity, and difficult to manage daytime behaviours (just to name a few).

Common causes of sleep problems in infancy also apply to toddlers and preschoolers. These include, but are not limited to, poor timing of sleep periods, not falling asleep independently, inappropriate and inconsistent responding during the night, co-sleeping, and an unsuitable sleep environment (e.g., too much light/noise/heat in the bedroom, toys in the crib/bed).

Parental presence at sleep-onset and following night wakings, including co-sleeping, is a common culprit in causing and maintaining sleep problems in toddler and preschool-aged children. However, with increasing age, other factors such as nighttime fears, moving a child to a bed (especially if the move is made prematurely), and limit-testing behaviours may also be relevant in causing or exacerbating sleep problems.

Many children are transitioned to a bed between 2-3 years of age. However, barring no safety concerns (e.g., a child climbing out of the crib in the dark when alone) waiting until age 3 to make the move is recommended. Children this age are usually more “mature� and better able to understand the “rules� associated with sleeping in a bed. Often times, moving a child to a bed is done with the hopes of resolving sleep problems. However, many parents report that making the move is not helpful and, often times, can make the problems worse as the child is now mobile. It is recommended that parents address sleep problems while their children are still in a crib. Use of a mesh crib tent can be helpful to maintain a child sleeping in a crib (in the face of safety concerns) until they are at a more suitable age to be sleeping in a bed. When a child is moved to a bed, parents are advised to use guard rails on their child’s bed.

Bedtime problems including bedtime resistance and bedtime stalling are common in older toddlers and preschoolers. While consistently setting limits on acceptable bedtime behaviours is often necessary, this is only effective if the timing of the bedtime is appropriate (i.e., parents put their child to bed only when tired). It is also important to ensure that too much day sleep and napping too late in the day are not contributing to bedtime problems.

Parents are often unaware that sleep problems in children can be effectively treated with behavioural strategies. Alone, or with the help of a health care professional, parents need to identify the factors which are contributing to the maintenance of the problems. Then, a detailed treatment plan that addresses such factors needs to be developed.

Treatment plans should include the development of an age-appropriate sleep schedule and an understanding of normative sleep patterns for the child’s age, the importance of bedtime/naptime routines, how a child is falling asleep and being responded to during the night, the benefits of introducing a sleep-compatible transitional (security) object, a suitable and safe sleep environment, and sleep training recommendations that are tailored to the child’s age and the presenting problems.

Often times older toddlers and preschoolers have a more favourable response to gradually reducing parental contact at bedtime and following night wakings. However, it is recommended to have a step-by-step plan in place to ensure that steady progress is being made. During this time, it is important to consistently work to eliminate parental behaviours which can maintain the problem such as co-sleeping, reinforcing unreasonable requests at bedtime and during the night including nighttime drinks/bottles, and other types of “responding� unless a child is sick. For children who are already in a bed, the use of a safety gate at their bedtime door, if necessary, is preferable to locking a door or holding it closed. A reward chart/system can be helpful to reinforce positive behaviour.

Sleep training methods are highly effective if an appropriate plan is developed (e.g., the right choice of treatment is made, all factors contributing to the problem are addressed) and if the plan is carried out properly. However, it is not uncommon for things to get worse before they get better, especially the older the child is. Parents are encouraged to evaluate the effectiveness of a treatment plan only after such a plan has been fully implemented. Before any sleep training is started, it is suggested that parents speak with their child’s physician to ensure that medical causes of sleep problems have been ruled out.

Pleasant dreams!

Dr. Nicky Cohen, C. Psych.
Practice in Clinical and Counselling Psychology
491 Lawrence Avenue West, Suite 203
Toronto, Ontario M5M 1C7
Tel/Fax: 416.783.3900
www.kidsleep.ca

©Dr. Nicky Cohen 2010