brain rule
Test before you invest
The video clip should have come with a disclaimer: “Warning: The video you are about to enjoy will intrude on your normally scheduled dose of decency.” Samuel L. Jackson—denizen of such violent fare as Pulp Fiction and Django Unchained—is shown reading from a script in a sound studio. This isn’t the dangerous Jackson you know and love, as the video soon reveals. His normally stern face is instead graced with a gentle smile, scholarly glasses perched atop his nose. He intones with the surprising tenderness of a loving father: “The windows are dark in the town, child. The whales huddle down in the deep.”
The script seems more in common with the children’s book I’ll See You in the Morning than the Jackson movie Snakes on a Plane—except that lulling a child to sleep is the text’s furthest goal. The next words hit you like a time-delayed ordnance, resonating with almost every newly minted parent I have ever met, and preserving Mr. Jackson’s foul-mouthed reputation. “I’ll read you one very last book if you swear / You’ll go the fuck to sleep!”
Jackson is reading from Go the F**k to Sleep, written by author Adam Mansbach. The book was wildly popular several years ago, topping Amazon’s charts 30 days before it was published.
The popularity of Mansbach’s salty text underscores just how challenging infant nighttime sleeping can be for rookie parents. After the fourth sleep-deprived night in a row, you may begin to crave sleep like an exhausted swimmer craves oxygen. You may become desperate for an answer to your child’s sleep issue. Any answer. You may even regret having signed on the biological dotted line, making baby your own. You will almost certainly mutter your own string of profanity. No wonder Mansbach’s first book has received so much attention.
Sleep consolidation, the formal term for a child’s process of sleeping through the night, is the subject of this chapter. Focusing mostly on the first year of life, we will explore some of the basic neuroscience of sleep, discuss insights from “sleep gurus,” and end with a few practical suggestions.
The science of infant sleep
So how do you get your child to sleep through the night? I can almost guarantee you won’t like my response: I can’t give you an answer for your baby.
The variables predicting successful sleep consolidation in pediatric populations are so numerous, we haven’t even finished cataloging them. We are even further from understanding how to shape the known factors into a slumber-inducing protocol providing every sleepless parent their well-deserved answer. We don’t even know the basics, like how many hours of sleep per day babies actually need. We can track how much sleep babies get, but that’s a different question from how much they need. We know sleep requirements vary by age; newborns undoubtedly need more sleep than 6-month-olds. Sleep varies by nation, too. Six-month-olds in Switzerland get about 14 hours a day. Six-month-olds in Japan get about 11. Infants in the United States get about 13. Undoubtedly both environment and genetics play a role, though we have no idea about the relative influences of each. We simply have the observations of an unpredictable system.
That’s why there are so many books on the subject: everybody is currently guessing. The situation isn’t hopeless, of course, but the disclaimer is necessary. I know, if you are a sleep-deprived parent, this is the last thing you want to hear. You are not alone in wanting an answer. Between 25 percent and 40 percent of babies born in the United States experience sleep problems in the first six months of life. And it’s not just an American problem. Depending on the country, between 10 percent and 75 percent of new parents all over the world report having problems getting their child to sleep through the night. Parents in Western cultures have three chief complaints: baby has difficulty falling asleep at bedtime; baby wakes up too many arousal times during the night; and baby awakens too early the next day.
What’s so difficult about going to sleep? Factors published by the scientific literature reveal the complexities in both baby and parent. Infant issues include biological temperament, the individual brain-wiring of their various “sleep centers,” the developmental changes that affect those centers over time, and even environmental factors (such as reactions to food, light, or being held). Adult factors include beliefs and expectations about sleep, the social context shaping those beliefs, individual adult temperaments, and memories of how the adults themselves were raised.
Getting a child to sleep through the night can be likened to a dance between two people who don’t know each other very well, and end up regularly stepping on each other’s toes. Both cry. A lot. Just how different are these dance partners? One of my son’s favorite rides at Disney World can help explain.
Tower of Terror
My sons have always loved elevators—their dad does, too—enjoying the feeling of near free fall you can sometimes get in the otherwise predictable experience of being in an office building. So you can probably imagine how we felt the day we climbed aboard the Twilight Zone Tower of Terror on a visit to Disney’s Hollywood Studios in central Florida.
The ride starts with a slow ascent to the top, similar to your standard office-building elevator. Suddenly you are pulled downward (as opposed to just letting gravity do its thing), creating the terrifying sensation of an uncontrolled free fall. The ride continues with a series of seemingly random drops and lifts, stops and starts, even sideways lurches. At least one fall traverses the entire vertical length of the tower. It’s a nauseating, exhilarating series of experiences.
These two elevator rides, the calm office building and the Tower of Terror, describe quite well what we know about adult vs. infant sleep.
Adult sleep
Mature adult sleep might best be likened to your boring, standard-issue workplace elevator. You start at the top floor, fully awake. Then you get drowsy, signaling that your normal sleep cycle has commenced. You begin slowly descending through various sleep stages, losing consciousness, and arriving at the bottom floor where “real sleep” occurs. This happens about 90 to 100 minutes after the elevator began its journey. It is very hard to wake someone in this stage. We call this slow-wave sleep, or non-rapid eye movement sleep stage 4 (NREM4).
You don’t stay at the bottom long. In our evolutionary history, if we remained unconscious for a full eight hours, we’d probably wind up in some predator’s stomach. So after about 30 minutes in NREM4, the elevator begins to ascend again. Your eyes, still closed, start moving back and forth in a truly creepy, increasingly vigorous fashion, a stage called REM sleep (short for rapid eye movement, as you might suspect). At the top of this stage, you are restless and can be easily awakened.
If all is well, however, you may not fully awaken. After a period of time, you start the cycle again, your elevator executing another descent. It will move in the same deliberate, stately manner as before, returning eventually to the bottom. After another 30-minute sojourn in the land of NREM4, the elevator again rises, your eyes move back and forth, and you reenter an REM state. You will travel up and down in this smooth, calm manner on average five times a night.
There’s a bit of a surprise here. Even in the normal state, no one sleeps through the night in one continuous, uninterrupted chunk. Regretfully, that includes children.
Infant sleep
The central fact of newborn sleep is that it is nothing like adult sleep. Instead of gradual cycles of descent and ascent, newborns have only two speeds, christened by sleep researcher Richard Ferber as “active sleep” and “quiet sleep.” Both speeds are established in the womb, detectable by the middle of the third trimester.
The presence of just two tempos means infants are only beginning to learn how to sleep. They won’t exhibit a predictable sleep cycle for several months—or adult-like sleep behaviors for years. Sleep for them seems spasmodic, and parents get jerked along for the ride. On a good night, adults ride a smoothly moving elevator. On a good night, babies ride the Tower of Terror.
Why? Here’s what researchers know so far:
When babies are safely tucked inside their mother’s womb, they may respond to—even follow—mom’s natural biochemical rhythms. This is because they are plugged into the maternal central computer via the placenta and umbilical cord. It’s not just humans. All mammals get warmth, food, water, and hormones (including sleep-regulating melatonin) from mom on a regular basis. At birth, the comforting supply of warmth, food, water, and sleep cues become immediately and violently disconnected. (I literally cut the umbilical cord off both my sons with a pair of sharp scissors.)
In this one act, babies become completely out of sync with the cycles of adult existence. The newborn must solve these problems immediately after birth, the most important problem being food. Some researchers think the altered waking/sleeping patterns initially concentrate on getting a consistent food supply. Newborns’ task is Herculean. They need to eat about every two to three hours, some much more often. Consistent with this notion, infant sleep patterns have been shown initially to closely follow feeding patterns: the amount of time it takes babies to consume food, digest food, metabolize food, and then become hungry again. Baby may sleep, but only after the tank has been topped off.
Notice that I said “may.” Some babies are energized by food, in which case they are not ready to sleep after a midnight snack; they are ready to play, cry, or otherwise demand attention. So feeding doesn’t always ensure a round of sleep.
Active and quiet sleep
Babies’ two sleep tempos do have a rough equivalent to adult sleep. Active sleep is somewhat similar to adult REM sleep, which means baby is restless and more easily awakened in this stage. Breathing is shallower, more irregular. Babies move their eyeballs. Eyelids tremble. They might flex their little arms and legs. They may even vocalize. When babies first start nodding off, unlike adults, they immediately enter into active sleep. For most newborns, this active state lasts 20 or 30 minutes.
Then the quiet sleep mode, similar to adult NREM sleep, kicks in. Baby’s breathing becomes deeper and more rhythmic. Baby’s eyes stop moving. Limbs go limp. They are not very easily aroused. This means you can probably put them in the crib without fear of waking them. I have spent many hours gazing at both my little boys in this tranquil newborn state of theirs. How long does this heaven last? Usually an hour or less, which means I was too quickly jolted out of my reverie.
Quiet sleep represents the end of junior’s sleep cycle. The baby then does one of two things: either reenters active sleep for another go-round, or wakes up. I am convinced that some infants sleep through the night fairly early in life because they are born capable of reentering their active/quiet sleep cycle without much need to consult Mom and Dad. Some have problems for months because they can’t. At this point, we only have vague ideas about how to increase the probability of the former.
Do not disturb
I can offer one piece of advice for helping baby stay in active sleep in the first place. The instant an infant shows signs of sleepiness, exhausted parents often want to immediately put their kid in a crib. Frustratingly, the baby senses the disruption, begins to fuss, to wiggle, to arouse. That’s the opposite of what you want! Why did this occur? Remember, baby is still in active sleep mode, and easily aroused. Once you detect signs of sleep, don’t disrupt the process. If you are holding baby, continue to hold baby. Pay attention to how long it takes her to reach quiet sleep. Give it an extra 10 minutes as an insurance policy, and then place baby in the crib.
This way, you can perhaps avoid identifying with the person who tacked up a poster I saw in an office. It depicted a famous scene from Raiders of the Lost Ark. Harrison Ford is kneeling in front of that small but iconic golden idol, which is sitting on a pedestal in the middle of a heavily booby-trapped room. Harrison wants to steal the statue without triggering the booby traps. He has in hand a bag of sand, similar in weight to the idol, with which he hopes to quickly replace the statue. The poster shows Harrison poised at the tensest moment just before the exchange occurs.
The caption above Harrison’s head reads HOW I FEEL … and the caption below reads … TRYING TO LEAVE MY SLEEPING BABY SO HE STAYS SLEEPING.
I laughed so hard only because it rang true.
If you do the math, a change in the drowse/arouse cycle seems to occur every 90 minutes or so. This has been noticed by researchers, most notably famed sleep researcher Nathan Kleitman. He termed the 90-minute time frame the BRAC, short for Basic Rest Activity Cycle.
Adults’ drowse/arouse cycles are about the same length. But, of course, there is great variation in both babies and adults, and no one fast rule each child must obey. (Like I said, the variables are complex.) I suggest that parents time their baby’s active/quiet sleep cycles to find their child’s schedule.
When will this ride end?
How long will baby ride the Tower of Terror? With most newborns, you don’t see strong evidence of something approaching a socially acceptable circadian rhythm (as measured by melatonin production) for almost three months, and nothing approaching sanity—defined as getting five straight hours of sleep—for almost six months. Some kids take longer to learn to sleep through the night. My son Joshua did not successfully sleep five hours straight until he was 7 months old.
It’s not that babies don’t want to cooperate, however difficult this may be to believe. German researchers showed that just 48 hours after birth, babies were struggling to stay awake longer in the daytime than in the night. Japanese scientists demonstrated this effort had begun to pay off by the second week of life: infants had fewer arousals during nighttime sleep than during the day. The finding remained consistent even when babies were fed several times at night.
Infants’ efforts result in the eventual establishment of a sleep cycle. Authentic NREM sleep as part of a normal awake/asleep cycle has been detected in babies as young as 6 months old. But it does take a while to sync up. It is not unusual for an infant to wake up three times a night for the first six months of his life. He may still wake up once or twice a night before his first birthday, and may wake up once a night until his second. It takes a lot of time for a little one to leave the Tower of Terror and instead firmly plant themselves on the boring office elevator of the adults.
Bedtime routines
Sleep experts agree that one thing helps babies make this transition: having a consistent bedtime routine. This starts with choosing a time for bedtime, sometime around 6 months old. Around the world, bedtime depends upon baby and culture. Whatever time you choose, the advice is to make it consistent.
Next, create a series of predictable bedtime rituals. These rituals can be almost anything, from singing favorite lullabies to turning all the lights in the house down low. Part of the ritual may involve giving your infant a warm bath, followed by a nursing session to “top off” the child before slumber. If the child is a tough sleeper, your routine may involve a slow ride over a bumpy road. The Medina family found this to be the most successful method when sleep was a problem. Whatever the activities, they should be consistently applied: same content, same order, same environment. Babies quickly learn to associate these behaviors, especially when dependably applied, with the fact that sleep time is coming.
There is no guarantee they will always welcome it, however. Or that you will, as Samuel L. Jackson can clearly testify.
(Not) sleeping through the night
So let’s say it’s been six months since the birth of your child, your child isn’t sleeping through the night, and you’re dropping f-bombs like Jackson (or would like to). Many books out there are willing to give you advice, purporting to know the secret formula for getting baby to sleep. Many of them contradict each other, which is the most frustrating thing about reading multiple books about the subject.
Ava Neyer, a mom from Fort Bragg, North Carolina, got so frustrated with the plethora of incongruous suggestions out there that she wrote a post about it, republished on the Huffington Post with the title “I Read All The Baby Sleep Books.” Here’s an excerpt:
Put the baby in a nursery, bed in your room, in your bed. Co-sleeping is the best way to get sleep, except that it can kill your baby, so never, ever do it. If your baby doesn’t die, you will need to bed-share until college.
Don’t let your baby sleep too long, except when they’ve been napping too much, then you should wake them. Never wake a sleeping baby. Any baby problem can be solved by putting them to bed earlier, even if they are waking up too early. If your baby wakes up too early, put them to bed later or cut out a nap. Don’t let them nap after 5 p.m. Sleep begets sleep, so try to get your child to sleep as much as possible. Put the baby to bed awake but drowsy. Don’t wake the baby if it fell asleep while nursing.
Funny—unless you’re the new parent who’s wondering what to do. These contradictory opinions are like a boxing match between two heavyweight philosophical ideas, fighting for the title of “Best way to get your baby to sleep through the night.”
NAP vs. CIO
In one corner, we have the Nighttime Attachment Parenting (NAP) styles of pediatric sleep consolidation. In the other corner, we have what people call Cry-It-Out (CIO) styles of pediatric sleep consolidation. The contenders have very different ideas about how nighttime sleeping issues should be addressed in the first year of life. Their fans regularly get into the ring, too, some of whom throw some pretty nasty punches.
NAP advocates’ underlying philosophy, as described by pediatrician William Sears, is this: “During the first year, an infant’s wants and needs are usually one and the same.” CIO advocates believe the two are not necessarily always the same. When an infant cries at night, NAP says the parental response should be instantaneous, to show your baby you’re there when he wants you. CIO says you should wait a bit, because your baby needs to learn how to fall asleep on his own.
Which side wins? At this point in sleep research, neither. NAP styles are not well studied (tough to do because parents implement them in such variable ways), and they are undergirded by attachment theory, a concept that’s in flux. CIO styles have been shown to get kids to sleep through the night more quickly, but science hasn’t weighed in on whether that’s best for baby or just more convenient for our modern culture. In the end, it’s up to you to decide what feels right, based on your baby.
We’ll detail how each method works and look at the science, inconclusive as it is.
Fighting for NAP: William Sears
Nighttime Attachment Parenting is an extremely infant-driven style. Advocates encourage feeding on demand rather than keeping to a schedule, both day and night; wearing your newborn in a sling during the day; and sleeping with your baby at night (whether in the same bed or in the same room), or at least making “comfort visits” to baby’s crib when baby cries. The idea is to have as much contact with your child as possible. Baby will be calmer and feel secure during the day, NAP advocates argue, and thus baby will be calmer and more likely to sleep at night.
Like Athena leaping from the forehead of an elderly Zeus, Nighttime Attachment Parenting styles spring from attachment theories first developed in the late ’60s (discussed in more detail in “Attentive, patient ping-pong,” on page 190). Needs not fulfilled when junior is a baby, the theory goes, create problems for junior as an adult. Ignoring your baby at night is a way of ignoring those needs, say NAP advocates; paying attention is a way of gratifying them.
NAP’s champion is the aforementioned William Sears. He is an experienced, handsome pediatrician, the epitome of a California doctor. To say he likes kids is an understatement. He and his wife, a nurse and parenting health advocate, have raised eight children. Three of them grew up to become practicing doctors, one with his own television show. Dr. Bill (as the elder Sears likes to be called) and his wife, Martha, have authored more than 30 parenting books. The most well-known of these is probably The Baby Book, which they wrote with two of their sons, Robert and James. More than a million sold, the book is chock-full of practical advice from the NAP corner of the sleep consolidation ring.
The Sears family doesn’t pull punches when it comes to defending their ideas. Here’s how one edition of The Baby Book describes the concept of sleeping in the same bed with your baby, called bed sharing:
Which do you think your baby prefers: to drift off to sleep peacefully at his mother’s breast or in his father’s arms, or to soothe himself to sleep with a tasteless, emotionless, rubber pacifier?
At another point, the Sears book goes on:
Is it all right to let your baby sleep in your bed? Yes! We are astonished how many baby books flatly put thumbs down on this most time-tested universal sleeping arrangement. Are they also against motherhood and apple pie? How dare self-proclaimed baby experts discourage what science is proving and veteran parents have long known—most babies and mothers sleep better together.
You can see why I opened this section with a prize-fighting metaphor.
To be fair, the Sears family is more nuanced about exactly how to practice sleeping with your child, describing several variants that range from sleeping in the same bed (bed sharing) to sleeping in the same room with your child (room sharing). The Sears family readily discusses alternatives to seven nights a week of co-sleeping. They also address important fears many parents raise about the practice, including:
• Will I create an unhealthy emotional dependency? (No.)
• Will my baby ever learn to sleep on her own? (Yes.)
• What will happen to our sex life? (You will learn to be creative.)
• How long should you co-sleep with your child? (Depends on how long you can tolerate it.)
We are now ready to march over to the other side of the sleep-consolidation boxing ring, where overtired parents really love their kids, but also need to get up in the morning and go to work.
Fighting for CIO: Richard Ferber
It is not often a scientist becomes so engrained in popular culture that his name becomes a verb. But that is exactly what happened to pediatric sleep researcher Dr. Richard Ferber, a prominent advocate of the Cry-It-Out method. Dr. Ferber, founder of Boston’s Center for Pediatric Sleep Disorders, didn’t make up CIO. Core CIO ideas can be found as far back as the 19th century. But his name is so closely associated with the practice that parents who embraced his protocol were accused—yes, accused—of “Ferberizing” their children.
How does CIO work? Researchers call CIO methods “extinction styles.” In psychology, “extinction” is a general term for weakening a behavior by restricting its reward structure. The reward structure is attacked because it is the reinforcing agent keeping a behavior alive, a behavior whose extinction is desired.
With infant sleep, a reinforcing agent looks like this: (a) baby is crying at 3:00 a.m. for attention; (b) parent comes into the room, picks him up, and comforts him, providing the attention; (c) baby stops crying, thus reinforcing the behavior. The baby learns that crying is a good way to get attention, day or night. He cries in anticipation of parental response, creating an internal attitude called a “reinforcement expectation.” The parent learns that the most successful method to calm the infant at night is to go in and hold him, which rewards the crying.
The way to “break” this cycle is to not provide attention every time baby wants it. He must instead be taught to fall back asleep independently, CIO advocates say. Baby then learns to sleep on his own, and the nighttime crying is extinguished. This process is not usually greeted with enthusiasm on the part of the child. That’s why it’s called “crying it out.”
CIO can properly be described as a continuum between “unmodified extinction,” in which the parent refuses to respond regardless of how long the crying continues (researchers don’t recommend this), and “camping out” or “fading,” in which the parent is close but spends less and less time by the child’s crib providing assurance. In the middle of the continuum, we find “graduated extinction.” The parent does respond to the child’s nighttime cries, but on a strict schedule. The amount of time a child is allowed to cry gradually lengthens. The delays are deliberately timed and incremental, hence the term “graduated.” The schedule, taken from Ferber’s book Solve Your Child’s Sleep Problems, goes like this:
First day
Put the baby into his crib as usual, or perhaps even a little later than usual, letting him fall asleep. Then leave the room.
1. The first time you hear baby cry, break out the stopwatch and wait three minutes before reentering the room to provide comfort. Ferber calls this the “first wait.” Don’t spend more than one or two minutes reassuring your baby. Now leave the room again, even though he has not stopped crying.
2. Wait five minutes (the “second wait”) before reentering, leaving again after one to two minutes.
3. Wait a third time, for 10 excruciating minutes. For the rest of the night, the magic wait time will be 10 minutes. Continue this routine until the child awakens in the morning, generally between 5:00 a.m. and 6:00 a.m.
Second day
Continue this schedule, but make the first wait five minutes, the second wait 10, the third and subsequent waits 12 minutes.
Third day
Increase the first wait to 10 minutes, the second to 12 minutes, and the third to 15.
Fourth day and beyond
I think you get the picture. By the seventh day, the first wait has expanded to 20 minutes; the ceiling is 30 minutes. Babies don’t like it at first. Outbursts of crying may increase for a period of time (the “post-extinction burst”) just before the behavior subsides. Even so, by the third or fourth night, things should be substantially better.
Dr. Ferber emphasizes that these numbers are advisory only, and that a wide variety of schedules will work. (Some parents can stand only a minute at first.) But he is also very clear that, whatever schedule you design, the waiting intervals need to be consistently and progressively longer. That is the core idea driving the CIO models, the reason the crying behavior is eventually extinguished. Ferber calls this the Progressive Waiting approach. Other researchers call it controlled comforting/controlled crying. Critics call it “Ferberizing.”
Whatever you call it, you can see how different the NAP and CIO approaches are.
Let’s compare graduated extinction, the most popular CIO method, to Nighttime Attachment Parenting in terms of a few issues of importance to parents: how each approach supports sleep consolidation (baby’s ability to sleep through the night); whether the parties involved get better sleep; the level of stress they cause baby; and how easy each is to implement.
Will baby sleep through the night?
CIO says: Wait to comfort baby
Graduated extinction has undergone the most scientific scrutiny of all the styles. Overwhelmingly, the evidence shows that it works—if you define “works” as getting the child to quit crying during the night so that everyone can sleep through the night. And it works surprisingly quickly, typically within a week. This is true whether you use the harsh unmodified extinction protocols, gentler graduated extinction methods, or room-sharing approaches.
There is an important caveat to these data, however. It comes from a secret Las Vegas slot-machine designers know well.
One of the hardest behaviors to quench in anyone is a habit that is only occasionally rewarded. Want to keep a gambler at a slot machine longer? Make sure the payout schedule is random. Studies show that people who experience random rewards in response to a behavior cling to that behavior much more solidly than those who don’t.
This is true for adults, but it is also true for the diaper-an-hour crowd. That’s why consistency is considered non-optional if you go down the CIO road. The fastest way to keep your child clinging to his cries at night is to make sure your attentive rewarding behavior is unpredictable. Go in sometimes. Don’t go in at other times. Like someone welded to the slots, the poor little baby will actually cry longer, harder, more frequently. He becomes increasingly disorganized if he can’t detect a regular pattern. The sleep goal is unmet, for both parent and baby, and everyone is miserable. So CIO works, but only if applied consistently.
NAP says: Make “comfort visits”
One hallmark of the NAP style is persistent parental nocturnal visitations to the crib, providing verbal/physical contact in response to the nighttime demands of the infant. A team of researchers from the United Kingdom specifically focused on whether this approach helps infants establish sleep consolidation.
The results were not reassuring. The more a parent “rescued” their infant at night, the more sleep problems the infant displayed over time. The infants displayed a marked reduction in the capacity to return independently to sleep after arousal, for example. “Comfort visits” also had consequences for childhood sleep far past the first year, other researchers discovered.
Actively “rescued” children at 18 months old still had problems getting a solid night’s rest (now defined as six uninterrupted hours). Things were not substantially better when the children reached their second year of life. Excessive interference at night appeared to be a gift that kept on giving, but it was not the gift the parent wanted.
Will our family sleep better?
Co-sleeping, and the ease of breast-feeding that comes with it, are often pitched by the NAP crowd as a way for both parents and babies to get more rest at night.
A number of laboratories studying this have uncovered a surprising finding: nocturnal breast-feeding is negatively associated with a stable sleep cycle. As you know, I am a real fan of breast-feeding. If a mom is at all capable, she should do it. Nonetheless, the on-demand style of nocturnal breast-feeding was correlated with a greater frequency of nighttime arousals, even when the rates were compared to infants fed on formula, and infants were fed at roughly comparable rates.
This mom’s post at TruuConfessions.com illustrates what a problem that can be:
I am such a mess. My 13 mo still does not sleep through the night and is addicted to the boob like a crack fiend at night. She wants to nap with my boob in her mouth too. I’m exhausted and sleep deprived and my patience is running real short with her now. I feel like a horrible mom because out of frustration I have ignored her crying and have not been the happiest person to be around. She favors my husband over me and I think it’s because of this … Today I cried for hours in front of her while she watched cartoons.
When it comes to co-sleeping, studies have found that co-sleeping babies cry less. However, studies also have found that both parent and infant sleep more poorly, with more interruptions per unit of time for each.
That’s quite a finding. Up until these newer data emerged, co-sleeping was thought to work like a warm, friendly sleeping pill for both parties. To resolve the conflict, researchers decided to eavesdrop on the infant’s brain using polysomnographic assessments when bed sharing. Polysomnography is a general term for physiological overnight tests generally employed to evaluate human sleep. The assessments can include EEGs (measuring surface electricity at the scalp), airflow measurements through the patient’s nose and mouth, blood pressure, heart rate, and gross motor movement.
When such technology was used to evaluate infant brain activity during bed sharing, researchers uncovered why their sleep was more unsettled. Baby’s sojourns through the “quiet phase” of sleep was shorter than for infants who were not co-sleeping. They also woke up more often during that phase than their independently sleeping controls, so even the quality of the quiet phase they got was disturbed.
Still, the practice of co-sleeping is still alive and well. In indigenous cultures, such as the Efé tribe of the Democratic Republic of Congo, families typically sleep together in a small hut. The population regularly includes adults, children, babies, pet dogs, and visitors. Co-sleeping also is the dominant arrangement in crowded urban settings, where living space is at a premium. Nearly 60 percent of Japanese families practice co-sleeping. The US figure is much lower (around 15 percent, though this is in dispute).
From an evolutionary perspective, co-sleeping was probably the typical nighttime behavior, for millions of years. As hunter-gatherers, we kept our babies in close physical contact day and night. Infants didn’t evolve in that harsh world to sleep by themselves—or live in isolation for any length of time—because they would be lunch. Surely optimal brain development occurs under any model that seeks to replicate this history. That’s what NAP advocates argue: It’s supposed to be this way.
Though I am deeply sympathetic with evolutionary arguments, we no longer live in a hunter-gatherer society. While the system may have been optimized for roaming around the Serengeti, you should deploy it mainly if you choose to parent while also roaming around the Serengeti. Or if your living arrangements otherwise require it. If not, it makes sense to explore alternatives relevant to contemporary life and times.
Which method causes baby less stress?
NAP advocates make a developmental argument for their side, having to do with something we call object permanence. Object permanence is the ability to understand that something will still exist even if it is covered up. Babies are not born with this insight. They think if an object has been removed from their visual field, it also has permanently disappeared. NAP advocates argue that since object permanence is not available at first, leaving an infant alone at night can be a truly catastrophic experience. If Dad leaves the room, will Dad ever return? If Mom goes away now, will she ever come back? True in the daytime, true at nighttime, true at all times. Infants should be around their parents as much as possible.
We used to think object permanence was not established until after baby’s first birthday. There is now convincing evidence for its formation in the first eight months of life, and maybe even the first three or four months of life. Since most professionals do not advocate any sleep interventions until after 6 months of age, object permanence may not be an issue by the time you have to decide whether you are in the NAP or CIO corner of the ring.
NAP advocates also say their style produces less-stressed children. They cite studies that have examined nighttime levels of infant cortisol. As you recall, cortisol is a stress hormone; elevated levels are usually a reliable sign of stress. In one UK study, infants who experienced NAP styles of nighttime parenting did indeed experience lower levels of cortisol compared to matched controls. You could still see these lowered levels as the kids turned 5. However, this doesn’t prove NAP caused the lower stress.
Just as importantly, we have no idea what the typical cortisol values should be for a Western infant. Cortisol levels are heavily modulated throughout the day if you are an adult, but in children they take a while to reach their mature circadian form. To date, infant regulation is mostly a mystery. Until we have a better baseline, we can’t start to make sense of the cortisol findings.
Finally, NAP advocates argue that kids are at risk for real and permanent psychological harm with exposure to CIO. Specifically, they point to the fact that crying is a behavior designed to bond the parent to the child. The child is in distress, they say, and the parental response of comfort provides the relational adhesive necessary for proper attachment to occur. CIO advocates point to the fact that attachment is a slow, gradual process. It takes years to develop—or to destroy.
The little attachment work that has been done suggests that kids turn out just fine whether you co-sleep with them or practice some form of crying it out. Leading researchers on the subject of sleep and infant development noted this in 2010:
Concerns have been raised that behavioral intervention involving infant protest and crying may compromise infant-parent attachment relationships. However, to date, there are no published studies demonstrating such adverse effects, and … sleep intervention studies that have measured proxies of attachment found no evidence of derived infant problem behavior or parenting difficulty, which are linked to insecure infant attachment.
Can I stick with it?
One of the most consistent research findings about CIO, besides the fact that it works, is that CIO is very hard on parents. Responding to a child’s cry is something we may have been built to do. The fact that it is superimposed on an asymmetric cultural schedule where parents need to sleep at night so that they can go to work the next day does not change these feelings.
To which proponents over in the NAP-style corner respond, “Hello. Of course CIO is hard on parents. It’s as unnatural as a punching bag, and you were never supposed to do it!” One parent commenting on a blog post summed up the sentiment:
I never understood [Ferber’s] method. Why would you sit in a chair near your child and watch them cry. How horrible! How could you do that to your baby? Clayton started sleeping through the night at one year old. I could not imagine listening to him cry and not doing anything.
Smack! Like I said, it’s a prizefight.
On the other side, some parents find that accommodating baby’s every want is unsustainable, as this mom’s TruuConfessions.com post illustrates.
Dear son is 11 months and still wakes up 1-2 times during the night. I’m still nursing him, so I always wake up with him. He screams if husband walks in instead. I am one exhausted mom, and as much as I hate to do it, I see sleep training … in his near future.
So misery isn’t uncommon in either corner of the canvas.
What to do?
It may seem that the evidence points in favor of CIO, but I am not ready to put my full weight on CIO methodology. There isn’t enough science to be conclusive in either direction. So on which side of the ring are you ultimately going to find yourself? The most confusing part of this prizefight is that both ideas seem to have merit.
I love the idea advocated by the Sears family of parenting consistently across the day, spending truckloads of time with your baby. Not only will it allow you to get to know your baby, it will allow you to spend more time with him on a developmental journey that goes way too fast as it is.
And I love the idea that graduated extinction methods have been evaluated and found to have worked very well, and in multiple cultures. Since you have picked up this book with the idea that you wanted clear science to guide your decisions, CIO methodologies have been the ones most rigorously tested. Not only do they work well, they work better than the NAP approach, if your goal is to get junior to quit disrupting your sleep.
Is it possible to hold two contradictory pieces of information in one’s head at the same time? F. Scott Fitzgerald thought so. He wrote:
The test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function. One should, for example, be able to see things as hopeless and yet be determined to make them otherwise.
If Mr. Fitzgerald is on to something, then parents with newborns must be geniuses.
Kidding aside, there may actually be a way out of this dilemma. I have constructed a to-do list that I propose you follow, a protocol with five steps. The protocol is especially useful if you have a child still struggling with sleep issues at the half-year mark. It is based on everything we have talked about in these previous paragraphs.
John Medina’s plan: Test before you invest
Step 1. Choose a side before baby comes into the world
Professor Medina has some philosophy homework for you to complete prior to the big day. I am asking you to tentatively commit to which side of the ring you enter the boxing match, because you need a rational starting point. So choose A or B:
A) Do you agree with Sears that the wants and the needs of a baby are the same thing in the first year of life? That when baby wants your attention at night, it is because he needs your attention at night?
B) Do you agree with CIO advocates that they can be split? That just because baby wants your attention at night does not a priori mean baby needs your attention; she may need just to go to sleep?
Since science does not know which one you should choose, I have nothing to say to you regarding your choice. Nobody else does, either. That’s as it should be, because your child is your child, and nobody else’s. You are allowed to be the captain of this choice. Your decision will determine how you proceed in the next four steps.
Step 2. Start with a modified NAP style
When baby comes into your home, on-demand and nighttime visits will be a normal, regular part of your routine for the first three months. Whether you also co-sleep during the night and wear a sling during the day depends on what you decided in Step 1. If you have decided that needs and wants are the same thing for the first year, engage the NAP model full tilt. Share both your shoulder and your bed.
Step 3. At 3 months old, record your baby’s sleep habits
Why three months? By this time, you should see real signs of the sleep pattern your little one is developing. For the first three months, you are practicing on-demand parenting, but that doesn’t have to be your permanent reaction. For the next three months, make notes about the changes you see in your baby, and get ready to adapt.
Step 4. At 6 months old, make a decision
The behavioral tracking you have done the previous three months may reveal a pattern that fits your lifestyle just fine. Or it may reveal a pattern that does not fit your lifestyle at all. Note that I am asking you to wait six months before you judge. Why? The answer is biological. Sleep interventions are mostly useless until baby’s brain is ready. If you try to intervene before that time, you may end up fighting biological forces over which you have very little control.
At the six-month mark, go down one of two paths:
A) Take Sears seriously
If you and your baby have settled into sleep habits that fit your lifestyle and family needs well, fully embrace the Sears methodology. This might be an easy transition, for you have been doing a modified version of his on-demand counsel for the past six months. Sears explains what to do in greater detail in The Baby Book: Everything You Need to Know about Your Baby from Birth to Age Two. Buy it, read it, and implement his recommendations in earnest.
If you and your baby have settled into a sleep pattern that does not fit your lifestyle and family needs well, it is time for a change—especially if you have decided that baby’s wants and needs are not necessarily the same thing. Consider one of the CIO methodologies, either camping out or the graduated extinction. (As stated earlier, researchers do not advocate for the unmodified extinction model under any circumstances. I am one of them).
Two important caveats: As we have discussed, it is quite normal for newborns to awaken many times during the night. Sometimes, however, the arousals occur (or continue past the newborn stage) because of a medical condition. Problems range from acid reflux to lactose intolerance to undetected infections. Babies can even suffer from obstructive sleep apnea. So ask your pediatrician to rule out any physical problem before you implement a CIO strategy. Graduated extinction should be deployed only if baby is crying because he wants attention. If by the seventh day you see no improvement, or things have gotten substantially worse, you are supposed to stop the program and consider alternative solutions.
The book with the most detailed protocol is Ferber’s book Solve Your Child’s Sleep Problems. Buy it, read it, and get started on your journey.
Step 5. Deploy, evaluate, and adjust
Continue to write down what you are doing and how baby is reacting so that you can remember what is occurring (the first thing to go with sleep deprivation is your memory). NAP styles take longer to assess, if assessment is even the right word, but you can know if graduated extinction is working after only a week’s application. If what you do is working, then congratulations, you are done with my protocol.
If your baby is still not sleeping through the night, change strategies. There are many dialects of NAP styles, and many CIO styles, too. Consider this adaptation to change normal. Parenting is an amateur sport, filled with trial and error. Even simple pediatric projects are usually error filled, and getting baby to sleep through the night is hardly a simple project. Your decision about wants vs. needs may determine your starting point, but it by no means determines where you end up. Keep experimenting until you find the secret sauce that works for your child.
Reassurance for this flexible counsel comes from an unlikely source, Richard Ferber, whose reputation for being hard-nosed is completely undeserved. He writes:
Over the more than twenty-five years I’ve spent working with families and children with sleep problems, I’ve come to the conclusion that children can sleep quite well under a surprisingly wide range of conditions… . The techniques may vary somewhat, but most problems can be solved regardless of the philosophical approach chosen. No choice is irreversible; parents are free to try one approach, and then change their minds if they find it did not work as well as they had hoped.
Because every brain is wired differently, you may have to try several methods before you find the one that works. A method that worked with Baby No. 1 isn’t guaranteed to work with Baby No. 2.
Baby is trying
Remember, baby is not your enemy in his struggle to learn to sleep independently, just a very inexperienced ally. Your goals are naturally aligned, after all. From an evolutionary perspective, it is in his brain’s best interest to learn how to stay awake during the day, then learn to sleep through the night. Though it is as much a struggle for him to get it right as it is for you to teach him, you can’t give up.
After all, that’s the heart and soul of parenting. The constant theme of this book is that babies are people, but they are not adults. You have to teach them everything. At least at first, you have to be willing to be the professor 24 hours a day.
I once saw a video of a little boy who illustrates nicely a previous night’s struggle to stay awake. The clip starts with the child in a high chair, slowly chewing food. But he’s sleepy. His eyes are closed, head perilously cocked 90 degrees to the chair. It becomes obvious he is simultaneously trying to eat and stay awake—and he is not able to do much of either. It is funny, and touching. The little guy nods off, starts to chew, swallows, then nods off again, slowly listing to one side as if he were a ship taking on water. He catches himself, tries to right his body, puts more food in his mouth (eyes still closed!), loses the battle, and face-plants into the high-chair tray. He is sound asleep!
Yes, sleep is a challenging proposition for little ones. And they are trying to get it right. It’s hard on parents, too, who are also trying to get it right. The good news is that all babies eventually find a way to sleep through the night. The bad news is that they almost never do it on an adult’s schedule. You should be used to this by now. It is the largest lesson of Parenting 101: The instant you decide to bring a child into the world, you give up absolute control over the rest of your life. Welcome to the world of parenting.
Key points
• The central fact of newborn sleep is that it is nothing like adult sleep. Newborns only have two speeds: “active sleep” and “quiet sleep.” They ride the Tower of Terror.
• There is no one-size-fits-all answer for sleep issues.
• Do you think baby’s wants and the needs are the same thing during the first year of life? Or not? It’s up to you. Science does not know which one you should choose.
• Once baby is 6 months old, choose a plan for better sleep, evaluate your efforts, and then get ready to change your plan.