July 2011
Accompanied by some of my personal views!
It is easy to spend ages trying to figure out 'why your baby is waking up' when in fact there is no actual reason, but you might want to rule out the following.
Young babies have a moro reflex that can startle them and wake them up if unswaddled. Make sure you don't let the baby overheat however.
There are lots of products on the market to help swaddle babies e.g.
Slightly older babies sometimes like being 'tucked in' - in sleeping bag with sheet over their arms, tucked in each side.
Again, don't expect some product to provide a magic solution here.
Classic ways to settle babies are:
The book 'The Happiest Baby on the Block' by Harvey Karp has a lot of detail on settling babies using these - we didn't find it particularly useful but I know that plenty of people do.
Many of these are temporary solutions - and either become too demanding as the baby gets older or stop working. Babies seem to get used to whatever method you use, so it is probably better to be consistent than to keep trying different things. Methods based on white noise and rhythm are usually the least demanding and easiest to wean as you can gradually reduce them.
When a baby is young you may be able to move them to their cot asleep, but this can often stop working effectively when they get older, so if you can, settle them in their cot rather than move them when they are asleep.
Get blackout blinds. You may need dark curtains too. There are different opinions here on whether to go for pitch black or not - although babies may sleep better in pitch black, you may then end up with a baby who will only sleep in pitch black.
Have a bedtime routine. Have a nap ritual. Lots of the sleep books go into detail as to what you might want to do for these. I suspect that the key is consistency rather than exactly what you do. Standard bedtime routine seems to be bath, milk, book and it is usually recommended having something between milk and sleep to make sure that your baby does not feed to sleep.
Develop cue words or music for when the baby falls asleep. I suggest keeping these reasonably short as you'll have to repeat them a lot! We used counting softly which is also rhythmic and ended up having an almost hypnotic effect on our baby.
Sleep begets sleep. Gradually move bedtime earlier each night until it is about 7pm at the latest. This won't make your baby wake up earlier, don't worry! Don't be tempted to keep baby up for working parents coming home late - if you want to spend time with them, see them in the morning before work instead when they will probably be in a better mood.
Young babies cannot manage more than about two hours awake tops during day. As soon as baby shows tired signs such as yawning, rubbing eyes, or a decreased attention span, or gets grumpy, get them to bed. Babies have a 90 minute alert cycle and so are more likely to go to sleep at multiples of 90 minutes after they last woke up (you need to start trying to get them to sleep a little bit before the 90 minutes or 3 hours however).
I don't think it is worth obsessing over naps. If your baby has a major nighttime sleep problem an extra hour napping during the day won't make much difference I found. However, if the sleep problem is more mild, then being strict about naps for a week or so can help. I think it is more useful to think of it as giving your baby the opportunity to sleep rather than thinking that it is your job to get them to sleep.
Make sure that baby is in the dark during the night (7pm-7am) with no playing and as little interaction as possible. Also avoid unnecessary nappy changes during this time - you should only really have to change dirty nappies at night. Especially before they have figured out night from day, make sure they get outside in some sunlight during the day if possible.
Babies benefit from having the same sleep times each day. In particular, have the same bedtime and wake up time each day (usually 7pm, 7am).
For nap times, Gina Ford is the queen, and Health Sleep Habits, Healthy Child also has useful information on nap timing. It is difficult to follow a routine until your baby self-settles however so you will need to work on that at the same time as trying to get them into a routine and I think it can be difficult to establish a routine if you don't start in the first few months. Don't assume that a routine is the answer to sleep problems. You will also need to balance the restrictions of a routine with your own individul needs.
Babies get more stressed when things are unpredictable or not in their control. Make things as predictable as possible for them (this is where routines are useful, but you can also e.g. always do nappy changes the same way). Avoid overstimulation and give the baby a chance to play independently.
When babies are fed during the night, they get into the habit of waking up each night at the time that they are fed. After the first month or two, most wakings are not due to hunger, assuming they are receiving sufficient milk/solids during the day, and you can gradually reduce night feeds. It is useful to have a late evening feed at the same time each evening, and ideally a bottle of expressed milk or formula so you can be confident they have had a good feed. This is usually done at either 10pm or 11pm (I have seen recommendations not to do it after midnight) and some people manage to do it as a 'dream feed' with the baby still asleep.
There are basically two ways to reduce feeds:
1. Gradually reduce the amount of milk. This is easier for bottle fed babies (and you can also replace by cooled boiled water). For breastfed babies you can try reducing the time the feed takes or feed for a short while and replace your breast by a dummy.
2. Gradually lengthen the time between the late evening feed and the first night feed. This is the 'core night method'. Attempt to settle the baby some other way until the time for their feed if they wake up earlier.
For both of these you clearly need to be confident that your baby isn't hungry and need to reduces night feeds gradually rather than all of a sudden. There are different views about when a baby is ready for total weaning, however most babies over six months should be capable of going through the night without a feed.
There is also the 'wake to sleep' method, where if a baby is always waking at the same time each night, you disturb them slightly just before the time.
If your baby is a bad sleeper, you will have probably already realised that virtually all the things the SIDS guidelines advise you not to do are things that help your baby sleep better.
Cosleeping - The jury seems to be out on whether cosleeping increases or reduces the risk of SIDS although the official guidelines recommend against it, so you need to make your own decision and also need to be very careful about risks of suffocation and rolling out of bed. I suspect that cosleeping can either make babies sleep better or worse, increasing or reducing the risk correspondingly - physical proximity helps them sleep better whilst being disturbed makes them sleep worse. We coslept for the first three months so I am sympathetic to cosleeping, but also realise that it doesn't always work. In our case, we kept waking eachother up with neither of us getting much sleep.
Sleep positioners - Some babies sleep better with sleep positioners to make them feel snug or between two rolled up towels. The SIDS guidelines do recommend not putting objects in the cot. When we were in hospital they used the rolled up towel trick though, so we figured that it couldn't be that risky!
Transitional objects - Some babies find it helpful to have a 'lovey'.
Sheepskin - some babies apparently sleep better on sleep skin.
Pillows - again some babies apparently sleep better with a pillow.
Move yourbaby to its own room before six months - Lots of people do this. Most babies sleep better in their rooms, and most parents sleep better with their baby in a different room!
Ultimately, until your baby 'self-settles' i.e. falls asleep without any help, you will almost certainly always have sleep problems. This is because babies partially wake during the night and if conditions are different from when they originally fell asleep, they will wake up fully. The advice that you often here is 'put your baby in its cot drowsy but awake'. However this advice is clearly of limited use if your baby is never actually drowsy or will only fall asleep in certain ways i.e. has certain 'sleep associations'.
If none of the suggestions so far solve your baby's sleep problems, then your only remaining options are either sleep training or gradual withdrawal. These will both involve crying and it is up to you what you want to do while that crying happens and whether you want to have a small amount of crying each day spread over a long time period or a large amount over a much shorter time period. Since tears are a way to excrete stress hormones, and a baby with chronically high stress levels will have problems sleeping, then I doubt there is any way to avoid this crying. I suspect babies that learn to self-settle by themselves have effectively gone through gradual withdrawal over an extended period of time.
Sleep training basically consists of being strict about not letting your baby fall asleep anywhere other than in their cot. Different forms of sleep training recommend different forms of comforting during this process - the more gentle methods recommend lots of comforting while the less gentle methods recommend very little if any. Sleep training gets a bad rap, however I think most of the people who criticise it are just lucky enough not to have experienced that bad sleep deprivation. Everybody has limits which will depend on you as an individual and your circumstances such as how much help you have, whether you need to return to work and whether you have other children as well as your physical capabilities, and you will probably know when you have reached yours!
Different types of sleep training, from least gentle to most gentle:
Different books will give you different information on exactly how to comfort your baby. I suspect it doesn't make a huge difference and in the end it is up to you as to what you feel happiest with. Similarly you need to decide what level of crying to respond to. If you want your baby to sleep in its own room, then at some point you will need to make sure that they are falling asleep without you in the room, or when they partially wake, they will awaken fully.
You need to start sleep training at the start of the night and continue it until the morning (6.30am-7am) even if this means your baby does not go back to sleep. There are different views on how to do nap training which generally takes longer than sleep training. It is worth doing nighttime sleep training before nap training as it will make nap training easier. If you have some way to nap your baby e.g. sling or pushchair, you may want to start with just the morning nap and then use your usual method for the afternoon nap. Options are:
Babies cry more in the presence of people they are most comfortable with, especially when they have eye contact. So babies will often cry more with their mother present than with their father present (assuming that the mother is the primary carer) for example, and more with somebody present than nobody present. This means that you can't 'delegate' sleep training and that methods with the least amount of your presence will work quicker, although they can be less effective longer term.
When to do it?
The things that are hard about sleep training are not giving up, not getting dispirited when things are two steps forwards and one step back or it takes a while, and coping with the extra sleep deprivation while you are doing it. There are sleep consultants out there and we found it useful to use one to help with this.
Gradual withdrawal aka gradual retreat is essentially sleep training where you start with a large amount of comforting and gradually withdraw that amount as the baby cries less and does not need it any longer. So you might start with Attended Cry It Out and then when your baby sleep reasonably well with that (or after say a week), start leaving the room when they are not crying or only fussing, and comforting them slightly less when they are only crying slightly. You might then move to the other side of the room, or pop in and out depending on how much they are crying. Similiarly, if you rock your baby to sleep, you could gradually reduce the length and amount of rocking you do.
In terms of choosing between these options, this is going to depend on: