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:
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, 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
My 5 year old daughter has started to grind her teeth during sleep. Is this normal, genetic or some disorder?
Dr. Cohen:
Occasional teeth grinding is common in young children and, in most cases, is temporary and does not cause any harm. However, while the sound of the teeth grinding can be disturbing to others, children who engage in this behaviour are usually unaware of it. Teeth grinding can occur while a child is falling asleep and throughout the night. Things that can increase teeth grinding include allergies, certain medications, and stress.
Teeth grinding is usually self-limited, meaning that it often resolves on its own and treatment is not typically warranted. However, teeth grinding or clenching that is repetitive and persistent is, in clinical terms, referred to as “bruxism”, a sleep-related movement disorder. Bruxism can cause headaches, tooth, jaw, and/or face pain, and wearing down of teeth. Bruxism does tend to run in families with research showing that children with a parent who has bruxism (or a history of it) are almost twice as likely to grind their teeth.
Be sure to discuss any concerns you have with your child’s physician and dentist. If you suspect that stress is a contributing factor, sources of stress should be explored and dealt with.
Q. What should we do about our son who jumps in his crib before falling asleep?
My almost 14 month old will jump for up to an hour before napping from 12:30 - 2:30pm and up to 30 minutes at bedtime before crashing from 7:45pm – 6:30am. I tried putting him down later today for his nap (12 instead of 11:30) and he jumped until 12:40pm. He’s happy and not fussing when he’s doing it so is it ok to just leave him jumping in the dark? He’s always liked to jump but it’s lasting longer lately. It’s harder to read his sleepy signs for nap now but he will definitely eye rub before bed and we have routines for both we’ve been doing for a long time. Should we just let him jump or do I need to adjust the timing of when he goes to bed?
Dr. Cohen:
It depends on the reasons for his “jumping”. Three possible explanations come to mind 1) he is not tired enough (i.e., there is a “mismatch” between his readiness for sleep and the time that he is being put down), 2) he is overtired, which can cause some children to get a “second wind” and have more difficulty settling, and 3) the jumping has become a learned behaviour – a behaviour that he associates with going to sleep.
If you suspect his naptime or bedtime is off, consider making a change. A good naptime for young toddlers is usually around 12:00-12:30pm and a good bedtime is 7:00-7:15pm. You can also try putting him down at the time that he normally falls asleep and see if this later time is helpful in reducing or eliminating the jumping.
If you think the jumping behaviour is just a habit, be careful that you are not doing anything that may be inadvertently reinforcing it, such as giving it attention (good or bad). As long as you feel he will not hurt himself, I would try to ignore it as best you can, and in the meantime, be sure to regularly tighten crib screws and bolts, as the jumping can loosen them.
Q. Is screaming and talking during sleep normal?
My daughter sometimes screams and says no in her sleep, is this normal?
Dr. Cohen:
Sleeptalking is common, and in itself, is not indicative of a sleep disorder. Screaming or crying while sleeping, however, is one of the main characteristics of sleep terrors (also known as night terrors). Sleep terrors are in the same category of behaviours as sleepwalking, and confusional arousals (a mild version of sleep terrors) – collectively classified as partial arousal parasomnias.
Research has found the prevalence of sleep terrors ranges from 1-6%. Partial arousal parasomnias run in families, and aside from genetic vulnerability, they are commonly caused by sleep deprivation. Therefore, moving bedtime earlier and addressing any bedtime problems, night wakings, and daytime sleep difficulties can be helpful.
While many parents worry that sleep terrors are indicative of, or may cause, psychological problems, there is no scientific evidence to support this. In fact, following a sleep terror, parents are often more upset than their children, who are unaware of their own behaviour.
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
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
Parenting your Child to Sleep: Sleep problems in children - How common are they and what parents can do
Parental reports of sleep problems in young children are very common. Research shows that approximately 30% of infants, toddlers and preschoolers experience sleep problems. Other findings suggest that these problems are even more common. Several years ago, the National Sleep Foundation’s Sleep in America poll investigated sleep habits of children (infants to 10 year-olds) and their parents/caregivers living in the United States. They found that 46% and 36% of toddlers and preschoolers, respectively, still wake at night and that 43% of toddlers and preschoolers fall asleep with a parent (or other adult) in the room at least a few nights a week. It is not surprising that 76% of parents surveyed reported that they would like to change something about their child’s sleep.
Reports of children’s sleep problems are not new. Documentation from as far back as the 16th century by Thomas Phaire details sleep problems during childhood and their implications for the family. In the first English textbook of paediatrics (1545), Phaire describes 39 paediatric “maladies” (illnesses or disorders) that he believed to be particularly common in children (4 of which were problems related to sleeping).
Sleep problems in children are not only very common, they are also often the cause of significant distress to the child and parents. They can negatively affect family life and are a source of parental concern, stress and conflict. Consequences of inadequate quantity or quality of sleep are numerous – both for the child and parents. Poor sleep can cause a variety of mood, behaviour, cognitive, and physical changes. If sleep problems persist, these changes can intensify as sleep debt accumulates (increases) over time.
Since the scientific approach to children’s sleep problems began in the 1980’s, much information of practical value has emerged. Unfortunately, this knowledge is not sufficiently well known to the general public or by many health care professionals. The result is that many opportunities for helping parents with their child’s sleep problems are missed or inadequately addressed.
Many parents are also unaware that sleep problems in their children can often be prevented or effectively treated, even in cases where the problems seem serious or persistent. In addition to this lack of awareness, a common but incorrect assumption is that not much can be done to address sleep problems in children.
Behavioural interventions for bedtime stalling, problems falling asleep independently, night wakings, early morning wakings, and daytime sleep difficulties exist. These treatments have been shown to be very effective, sometimes with surprisingly quick results, even when the problems have been long-standing in nature.
Before a treatment plan is implemented, a detailed assessment of the problem should be done to identify the underlying cause(s) and contributing factors. Although medical causes of sleep problems are uncommon, it is suggested that parents speak with their child’s physician before implementing a sleep training program.
It is recommended that specific behavioural interventions be combined with principles of good sleep hygiene. In all cases this should include discussion of an age appropriate bedtime/naptime routine, self-soothing, nighttime feeds (if necessary or if weaning is required), safe sleep practices, recommended hours of sleep, and a well-timed sleep schedule (depending on the age of the child). As well, the rationale and specific guidelines for implementing a sleep training program should be outlined.
Sleep training programs differ from child-to-child and depend on the age of the child and the presenting problems. However, the focus of many treatment plans address bedtime routines, ways in which a child is falling asleep, and how they are being responded to at bedtime and during the night.
Sleep training methods are highly effective if both 1) an appropriate plan has been developed (e.g., the right choice of treatment is made, all factors that are contributing to the problem are addressed) and 2) the plan is carried out properly. The effectiveness of such methods should be evaluated only after such a plan is fully implemented. It is not uncommon for parents to feel that they have carried out a similar treatment plan, however with careful inquiry, the wrong choice of treatment was made, or the plan was not carried out properly.
While a common myth is that sleep problems are inevitable in the first few years of life, the fact is that good sleep habits can be encouraged from an early age and that most babies can learn to sleep well starting from a few months of age. Regardless of the age of your child, it is never too late to make positive changes!
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
Email: dr.nickycohen@kidsleep.ca
Dr. 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 7 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. More information about Dr. Cohen’s work can be found at: www.kidsleep.ca.
Q. Why does it take so long for my son to fall asleep? My 6 year old son is in and out of his room from 8 pm when we put him to bed until about 9 or 9:30 pm. He has lots of excuses. Is there something we can do to help him sleep or should we put him to bed later?
Dr. Cohen:
This is a bit of a tricky question to answer in this format. When I see parents for this problem, I do a detailed assessment to find out more about the child’s bedtime resistance (e.g., What is going on between the time that the child is put to bed and the time that he falls asleep? Is the environment and all of the “activity” at bedtime stimulating? Is he falling asleep truly independently? Does he seem overtired or not tired enough?). Having this information is helpful to determine what the cause(s) may be and then, in turn, what the parents should do.
I would agree that 8:00pm is a reasonable bedtime for a 6-year old. If he genuinely seems not tired enough, you can try putting him to bed closer to 8:30pm. This may help increase his drive to sleep. It is important to ensure that he is not getting any day sleep. A “cat-nap”, however brief, can lead to problems falling asleep at a reasonable bedtime. Another strategy that can be helpful is temporarily moving bedtime closer to the latest time that he actually falls asleep (in your case 9:30pm). Once he is falling asleep quickly at this later time, you can slowly start to move bedtime earlier by 10 minutes every 3-5 nights.
Repeated requests at bedtime (fondly referred to as “curtain-calls”) are common behaviours in older toddlers and preschoolers. Setting limits on inappropriate bedtime behaviours is important. Removing reinforcement for “bad” behaviour (also known as negative attention) is helpful. Setting up a contingency for non-sleep compatible behaviour (e.g., coming out of bed, crying) is key. This can include closing the door (but not locking it) or putting up a safety gate if a child is not showing sleep compatible behaviour (e.g., lying in bed calmly). Having a well-timed bedtime is important. And, as always, consistency is key.
Q. How can I get my daughter comfortable with someone else putting her to bed? I am a mom and I have always been the one to put my 2-year-old daughter to bed. We sing and read stories for about 30 minutes before bed time. The problem is that she won’t let anyone else put her to bed now. Not my husband or my parents. It ends in hurt feelings for everyone else and makes it difficult for me to even think of going out at night. What should I do?
Dr. Cohen:
I think you have 2 options: the first is to go out after she has gone to bed and the second is to get her familiar and comfortable with someone else putting her to bed. If you prefer the latter option, I would gradually build someone else into the bedtime routine. This person, at first, can just come in for 5 minutes and be present. This time can be increased to longer periods and can become more inclusive over time (e.g., he/she can be part of the singing and reading). As she gets more comfortable, you can start having this person do part of the routine on his/her own while you are present in the room. With time, I would leave the room and have him/her do parts of the routine with her alone. As you have always been the one to put her to bed it will likely take time for her to get comfortable with someone else filling your shoes.
Q. When does bedtime get earlier and what about cat-napping? My daughter is 4 months old. She generally sleeps well at night with one wake for a feed. I put her down around 10pm and she is starting to wake around 6am for the feed. Then I put her back down and she sleeps until around 9:30am. When do I begin to make her bedtime earlier so that she is not sleeping in so late? I am worried that if I put her down earlier she will wake more than once in the night. Because of this sleep in, our morning nap routine is all over the place. I know she is only 4 months, but any “schedule” help would be great. Also, she is very hard to put down for a nap and when she does finally fall asleep she only sleeps for 30-40 minutes. Is there anything I can do to get longer naps?
Dr. Cohen:
Usually 3-4 months of age is a good time to move bedtime earlier. Babies of this age often do well with a bedtime of 7:00-7:30pm. Many babies in this age range sleep for 11-12 hours at night (interrupted by feedings), so having an earlier bedtime is likely to naturally move your daughter’s wake time earlier.
Generally, most healthy full-term babies who are between 4-5 months of age need at least 1, if not 2, feedings during the night. Because your daughter is now only feeding 1 time in an 11-12 hour period, shifting her bedtime earlier may not change her feeding frequency. Some babies, particularly those who fall asleep with parental assistance (e.g., who are fed or rocked to sleep), require these same or similar conditions following night wakings. So, for example, these babies (who do not fall asleep independently) often need parental assistance (including being fed) to return to sleep when they wake at night.
I often recommend that parents start thinking about developing a sleep schedule when their infants are 3-4 months old. A sleep schedule/routine at this age may include a calming and predictable bedtime routine, falling asleep independently (self-soothing), and naps using the 2-2½ hour rule by 4 months of age (i.e., being put down for a nap after about 2-2½ hours of being awake). While it is often frustrating for parents, many young infants take “cat-naps”. While some infants seem more ready to start taking longer naps by 5 months of age, many continue to cat-nap until daytime sleep training is done. Once a child is falling asleep independently for her naps, giving her a chance to return to sleep if she has woken too early from a nap (less than 1 hour) can be helpful.
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.
Sleep terrors, sometimes referred to as night terrors, are partial arousals during deep sleep. As they can occur during any sleep period, including naps, they are more appropriately classified as “sleep terrors”. Sleep terrors are in the same category of behaviours as confusional arousals (a mild form of sleep terrors), sleepwalking, and sleeptalking.
As deep sleep is predominant in the first-third of the night, these behaviours most commonly occur 1-3 hours after a child has gone to sleep. As they almost exclusively occur during deep sleep, they do not involve dreaming (which happens during rapid eye movement (REM) sleep). The frequency of sleep terrors is variable. They can occur from multiple times a night to every few weeks (or less) and can last anywhere from minutes to an hour.
The presentation of sleep terrors involves both features of being awake and being asleep. For example, children having a sleep terror will often be crying and screaming, seem frightened, and may have their eyes open. They are often confused, agitated and “thrash” around. However, during a sleep terror, children are actually sleeping and are not aware of, or responsive to, their parents.
Studies have found that the prevalence of sleep terrors range from 1-6% in children. The good news is that they markedly decrease with age as there is a rapid decline in the amount of deep sleep in young childhood through adolescence. By age 8, 50% of children with sleep terrors no longer experience them, and by puberty most cases naturally resolve. The main features that characterize sleep terrors are:
TIME OF NIGHT: The time of night that these behaviours occur can be helpful in determining if a child is having a sleep terror or not. Sleep terrors usually occur 1-3 hours after sleep onset. However, in some cases, they can occur later in the night.
LEVEL OF RESPONSIVENESS: During a sleep terror, children are not awake and are difficult to wake. As they are sleeping, they are not aware of, or comforted by, a parent who is present. Parents describe that usual methods of getting their child to return to sleep (e.g., giving them a pacifier, feeding them, picking them up) are not successful. Some children may briefly wake at the end of the episode, only to quickly return to sleep.
READINESS TO RETURN TO SLEEP: Once a sleep terror has run its course, the child returns to a calm, deep sleep on her own (unless woken).
RECOLLECTION: Children have no memory of sleep terrors the next day (unless they were woken).
AVOIDANCE OF COMFORT: During an episode, most children avoid comfort or soothing by their parent.
Partial arousal behaviours are not fully understood but we know that they often run in families. There is a strong genetic predisposition, with 80-90% of children who present with them, having a first-degree relative who had/or currently has them. Aside from a family history, sleep deprivation is often cited as the most common cause. When the body is deprived of sleep, it gets less deep sleep; when it does have a chance to sleep, there is a rebound of deep sleep. And in vulnerable individuals (those with a genetic predisposition), this extra amount of deep sleep increases the likelihood of having an episode.
Therefore, it is important to ensure that your child gets adequate day and night sleep. Establishing an appropriate and consistent sleep schedule can be helpful. In many cases, it is necessary to address sleep problems such as bedtime resistance, night wakings, or poor day sleep that may be causing sleep deprivation. For example, a bedtime that is too late for the child or dropping naps prematurely can sometimes result in the onset of terrors. Also, things that may cause a child to wake more (e.g., a full bladder, sleeping in a different environment, noise, illness, stress) can increase the likelihood of an episode in a child already ‘at-risk’.
While leaving the crib or bed is not common during a sleep terror, concerned parents may want to clear the floor (in case the child gets out of bed), hang a bell over the child’s door to be alerted if she leaves the room, install safety gates at doorway and/or stairwells, and safety lock accessible doors and windows. Using bedrails and protecting your child if she ‘thrashes’ around are important (e.g., moving bed away from wall). If your child is sleeping away from home, inform an adult in charge of your child about the potential for these behaviours.
As intervening in the course of a sleep terror can worsen or prolong it, parents are encouraged to sit by their child’s side (if they wish to be present) and to let the terror run its course. It is best to avoid talking to the child about the sleep terror the next day as this can result in fears around going to sleep.
Many parents worry that sleep terrors may cause or are indicative of an underlying psychological problem. While they can be triggered by stress, there is no scientific evidence to support these concerns. However, parents are encouraged to speak with their child’s physician or another health care professional with training in this area if they have concerns. In cases where sleep terrors are very frequent, cause significant family disruption, and/or involve high risk of injury to the child, other treatment options may be appropriate.
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.
Parents co-sleep with their children for different reasons. These may include choosing to do it as a lifestyle choice or, rather, in response to their child’s sleeping problems. Many parents co-sleep, not necessarily by choice, but rather in response to their child’s sleep problems or in an attempt to solve sleep problems (also known as ‘reactive’ co-sleeping). Often these parents report that co-sleeping is not helpful, especially in the long-term. Research has shown that most children who share the same sleep space as their parents do not sleep through the night. This may be due to the child being disturbed by the presence of the parent including their noises and movements, and the fact that parents are more likely to respond to and reinforce wakings due to close proximity.
Room-sharing (rather than bed-sharing) is recommended for the first few months of life due to research showing an association with reduced risk of sudden infant death syndrome (SIDS). However there are a number of risks associated with co-sleeping which has led the Canadian Paediatric Society and our American counterpart - the American Academy of Pediatrics - to caution against it.
The concerns with co-sleeping are primarily because most often it is not done safely. The main concerns include children accidentally rolling off the bed, falling between the mattress and wall, or mattress and headboard, overheating due to soft materials on the bed (which is a risk factor for SIDS), accidental smothering due to soft materials on the parental bed (e.g., such as pillows, bedding), and less commonly, accidental smothering by a parent.
If deciding to co-sleep, safety should be the top priority. Depending on the age of your child, using a co-sleeper, which provides a separate sleep space for the child attached to the side of the parental bed, can help provide a safe environment for co-sleeping. For toddlers or preschoolers, it is often helpful to use guard rails on the parental bed to prevent falls. Consideration also needs to be given to ensure that everyone is getting enough sleep. As adults often do not go to bed between 7:00-8:00pm, co-sleeping may mean making compromises and putting yourself on your child’s schedule (rather than putting your child on your schedule).
From a behavioural perspective, co-sleeping can interfere with a child learning to fall asleep on his own. The importance of this skill is that often times children need to be able to do it at bedtime in order for them to be able to apply it during the night, when they naturally have brief arousals. Therefore, learning to fall asleep independently is an important step that is often necessary for children to achieve “sleeping through the night”. It is also a skill that all children need to learn at some point. The earlier that parents give their child the opportunity to learn the skill (but not before a full-term child is at least 3 months of age and healthy) the easier it is for them to learn.
The other, often necessary, steps for sleeping through the night are consistent and appropriate responding on the part of the parent(s). Many children will keep waking if their wakings are reinforced (e.g., they are fed, rocked, or brought to the parental bed).
It is not uncommon for parents of young children to allow their child to come into the parental bed following an early morning awakening (e.g., after 5:00am or whatever their cut-off may be). However, often times, what started out as an early morning awakening and a transition to the parental bed, has slowly crept earlier and earlier in the night. This is because the child has learned to associate waking with making this transition and can’t tell time! That is, instead of falling back to sleep following a partial arousal – which we all have 3-8 times a night – many of these children have learned that when they awake and call out, that they will be brought to the parental bed (and some may simply walk over themselves).
Also some children who start off the night, and spend a good portion of the night, in their own crib or bed, may not sleep well in the parental bed. This is because they are used to sleeping alone and may be disturbed by others. Some parents describe that their children seem to “outgrow” sleeping in this potentially stimulating environment. As the drive to sleep decreases over the course of the night, and light sleep is predominant in the last third of the night, it is not uncommon for children to have a more difficult time falling back asleep during the early morning hours, especially if the change of scenery is exciting!
When deciding when to stop co-sleeping or if you want to co-sleep in the first place, it is important to keep in mind that the earlier you transition your child to their crib or bed the easier the process will be for her (and you). If you decide that you would like your child to sleep in his own crib in the long-run it is recommended that you transition her by 3-6 months of age. As children get older, habits become more ingrained and therefore more difficult to change. And while a 2-month old may be unaware of the transition to her crib, an 8-month old would certainly be aware.
When I meet with parents who present with the goal of wanting to stop co-sleeping, I work with them to develop a sleep training program which involves setting a consistent and appropriate sleep schedule, and most importantly giving their child the opportunity to learn to fall asleep on her own at the start of the night and following night wakings (if she is not due to be fed).
Eliminating co-sleeping can be done gradually or all at once. Toddlers and pre-schoolers can sometimes benefit from the more gradual approach. This may include co-sleeping in the child’s room for the first few nights – ideally in a separate sleep space – to get them used to sleeping in their room for the entire night. Once they have this level of comfort, you can gradually move out of the room in a step-by-step fashion (e.g., sitting on a chair, sitting by the door) over 1-2 weeks. Research suggests that some children may start sleeping through the night once they start falling asleep independently. However, the same procedure can be done following night wakings, if necessary. Consistency is key for success!
Deciding whether to co-sleep or not is a personal decision and may depend on different factors for different families. For those who would like more information on safe sleep practices, see the Canadian Paediatric Society handout for parents (www.caringforkids.cps.ca – see Pregnancy & Babies - “Safe sleep for babies”).
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.
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”.
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.
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.
Parents are in good company if their child is having early morning wakings – which I would define as waking before 6:00 or 6:30am. This is quite a common parental complaint and unfortunately one of the more difficult sleep problems to resolve. However there are certainly things parents can try before resigning to the fact that they will always be up before the sun.
A common cause of early morning wakings is what is sometimes referred to as a “negative” or “poor” learned sleep-onset association. This is when a child is not falling asleep independently at sleep-onset, but rather under a condition that she cannot re-establish on her own during the night. Examples include: being fed or rocked to sleep, falling asleep with a parent in the room or with a pacifier that she cannot find and re-insert on her own. The problem with falling asleep under such conditions is that when children have arousals during the night (which we all do), they may need the same condition(s) to be re-established in order to return to sleep. This can happen both during the night, including during the early morning hours.
Getting your child to return to sleep is probably more difficult in the last half to the last third of the night. This is because we (including children) get most of our light sleep in the early morning; therefore, it is more difficult to return to sleep following an awakening at this time. Contact at this time can serve to stimulate and arouse a child further. So be sure that you have addressed any negative sleep-onset associations that may be present and that you limit contact with your child during the night and in the early morning – unless of course she is sick. Ensuring that your child has the skill of falling asleep independently both at bedtime and following night wakings (unless she still needs nighttime feeds) is key to a child sleeping through the night.
Environmental factors such as noise or sunlight are common culprits of early wakings. Investing in room darkening shades and a white noise machine can be helpful. You also want to be sure that a heavy diaper is not disturbing your child. If this is the case, you can try extra absorbent nighttime diapers or a larger size diaper. Parents can also try reducing the amount of fluid their child has in the last few hours before bed time and offering her more during the day.
Putting a child to bed later can actually have the opposite effect and result in an early waking. This is because when some children get overtired they actually wake more at night and earlier than usual in the morning. For some children, being put to bed a little earlier can be helpful. However you want to be careful not to make bedtime too early which can result in an early wake time. A good bedtime for most young children is between 7:00-8:00pm, with some preschoolers needing to be put down closer to 8:00-8:30pm if they are still napping.
When children are used to waking in the early morning they may not be aware that it is still time to sleep. A night-light attached to a timer is a simple ‘morning signal’ that can be used to teach children (toddlers and older) when it is morning time. Explain that when this light is off, everyone is sleeping and that the child must return to sleep. Teach her that when this light turns on that she can call out to be fetched. A reward chart can be used to reinforce positive behaviour.
Finally, early morning waking can sometimes be the sign to drop a morning nap. However you would, of course, only drop the morning nap when a child was at the age where you would expect that a morning nap may be the culprit. In a child who is 13-16 months, this is often the case, and continuing to give her a morning nap may perpetuate the early morning wakings. This is because her body doesn’t need to both sleep-in AND have a morning nap so she is waking early in anticipation of being able to nap in a few hours.
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.
