Sleep Problems: from Holding Until Asleep

How do I know if my baby is a trained night crier?

A trained night crier is a baby who:

• Is over 4 months old and can’t sleep through the night (at least 7 hours)
• Wakes up and cries one or more times a night
• Can only return to sleep if you hold him or her
• Is held, rocked, or walked until asleep at bedtime or naps
• Doesn't need to be fed in the middle of the night
• Has awakened and cried at night since birth

When should my baby be able to sleep through the night?

From birth to the age of 2 months, most babies awaken twice each night for feedings. Between the ages of 2 and 4 months, most babies need one feeding in the middle of the night. By 4 months of age, most bottle-fed babies sleep more than 7 hours without feeding. Most breast-fed babies can sleep 7 hours straight at night by 5 months of age. Normal children of this age do not need calories during the night. They are capable of sleeping through the night without being rocked or held in the middle of the night.

Why does my baby wake up crying at night?

Some common reasons babies over 4 months old wake up crying at night include:

• Holding or rocking your baby until asleep.

  All children normally wake up 4 or 5 times each night after dreams. Because they usually do not wake up fully at these times, most children can get back to sleep by themselves. However, children who have not learned how to comfort and quiet themselves cry for a parent. If your custom at naps and bedtime is to hold, rock, or lie down with your baby until asleep, your child will not learn how to go back to sleep without your help. Babies who are not usually placed in their cribs while they are still awake expect their mothers to help them go back to sleep when they wake up at night. Because they usually fall asleep away from their cribs, they don't learn to associate the crib and mattress with sleep. This is called poor sleep-onset association.

• Providing entertainment during the night.

  Children may awaken and cry more frequently if they realize they gain from it; for example, if they are walked, rocked, or played with, or enjoy other lengthy contact with their parents. Being brought to the parents' bed makes the problem far worse. Crying at night can also begin after situations that required the parents to give more nighttime attention to their baby for a while. Examples of such problems are colds, discomfort during hot summer nights, or traveling. Many babies quickly settle back into their previous sleep patterns after such situations. However, some enjoy the nighttime contact so much that they begin to demand it.

• Believing any crying is harmful.

  All young children cry when confronted with a change in their schedule or environment (called normal protest crying). Crying is their only way to communicate before they are able to talk. Crying for brief periods is not physically or psychologically harmful. The thousands of hours of attention and affection you have given your child will easily offset any unhappiness that may result from changing a bad sleep pattern.

How long does it last?

If you try the following recommendations, your child's behavior will probably improve in 2 weeks. The older your child is, the harder it will be to change your child's habits. Children over 1 year old will fight sleep even when they are tired. They will vigorously protest any change and may cry for hours. However, if you don't take these steps, your child won't start sleeping through the night until 3 or 4 years of age, when busy daytime schedules finally exhaust your child.

How can I help my child sleep through the night?

Try the following suggestions if your baby is over 4 months old and wakes up crying one or more times in the night.

1. Place your baby in the crib drowsy but awake for naps and bedtime.

   It's good to hold babies and to provide pleasant bedtime rituals. However, when your baby starts to look drowsy, place him in the crib. Your child's last waking memory needs to be of the crib and mattress, not of you. If your baby is very fussy, rock him until he settles down or is almost asleep, but stop before he's fully asleep. He needs to learn to put himself to sleep. Your baby needs to develop this skill so he can put himself back to sleep when he normally wakes up at night.

2. If your baby is crying at bedtime or naptime, visit your baby briefly every 5 to 15 minutes.

   Visit your baby before she becomes too upset. You may need to check younger or more sensitive babies every 5 minutes. You be the judge. Gradually lengthen the time between your visits. Babies cannot learn how to comfort themselves without some crying. This crying is not harmful. If your child is fearful, hold him until he calms down. Then temporarily sit or lie down in his bedroom until he settles down. Try to leave before he falls asleep.

3. Make the visits brief and boring but supportive.

   Don't stay in your child's room longer than 1 minute. Don't turn on the lights. Keep the visit supportive and reassuring. Act sleepy. Whisper, "Shhh, everyone's sleeping." Add something positive, such as "You're a wonderful baby," or "You're almost asleep." Never show your anger or punish your baby during these visits. If you hug him, he probably won't let go. Touch your baby gently and help him find his security object, such as a doll, stuffed animal, or blanket.

4. Do not remove your child from the crib.

   Once you put your child in the crib, do not remove him. Do not rock or play with your baby or bring her to your bed. Brief contact will not reward your baby enough for her to want to continue the behavior. Most young babies cry 30 to 90 minutes and then fall asleep.

5. For crying during the middle of the night, temporarily hold your baby until he is asleep.

   Until your child learns how to put himself to sleep at naps and bedtime, make the middle-of-the-night awakenings as easy as possible for everyone. If he doesn't fuss for more than 5 or 10 minutes, respond as you do at bedtime. Otherwise, take your crying child out of the crib and hold him until he is asleep. Don't turn on the lights or take him out of the room. Try not to talk to him very much. Often this goes better if Dad goes in.

6. Help your child attach to a security object.

   After 6 months of age, a security object may be helpful. A security (transitional) object is something that helps a waking child go to sleep. It comforts your child and helps your child separate from you. A cuddly stuffed animal, doll, other soft toy, or blanket can be a good security object. (Caution: soft objects increase the risk of SIDS in young babies. Until your child is at least 6 months old and can easily roll over both ways, don’t place any soft objects in the crib). Sometimes covering a stuffed animal with one of the mother's T-shirts helps a child accept it. Include the security object whenever you cuddle or rock your child during the day. Also include it in your ritual before bedtime by weaving it into your storytelling. Tuck it into the crib next to your child. Eventually, your child will hold and cuddle the stuffed animal or doll at bedtime in place of you.

7. Later, phase out the nighttime holding.

   Phase out nighttime holding only after your child has learned to quiet herself and put herself to sleep for naps and at bedtime. Then you can expect her to put herself back to sleep during normal middle-of-the-night awakenings. Go to her every 15 minutes while she is crying, but make your visits brief and boring. After your child learns to put herself to sleep at bedtime, awakening with crying usually stops in a few nights.

8. Other helpful hints for sleep problems.
   • Move the crib to another room.

     If the crib is in your bedroom, move it to a separate room. If this is impossible, cover one of the side rails with a blanket so your baby can't see you when he wakes up.

   • Avoid long naps during the day.

     If your baby has napped for more than 2 hours, wake her up. If she has the habit of taking three naps during the day, try to change her habit to two naps each day.

   • Don't change wet diapers during the night.

     Change the diaper only if it is soiled or you are treating a bad diaper rash. If you must change your child's diaper, use as little light as possible (for example, a flashlight), do it quickly, and don't provide any entertainment.

   • Leave your child standing in the crib, if necessary.

     If your child is standing up in the crib at bedtime, try to get your child to settle down and lie down. If he refuses or pulls himself back up, leave him that way. He can lie down without your help. Repeatedly helping your child lie down can soon become a game.

9. Keep a sleep diary.

   Keep a record of when your baby is awake and asleep. Bring it with you to your office follow-up visit.

When should I call my child's healthcare provider?

Call during office hours if:

• You think the crying has a physical cause.
• Your child acts fearful.
• Someone in your family cannot tolerate the crying.
• The steps outlined here do not improve your child's sleeping habits within 2 weeks.
• You have other questions or concerns.