Chapter One

Infants and children who are still of tender age [may be] attacked by ... wakefulness at night. -Aulus Cornelius Celsus, a.d. 130

Sleeplessness in children and worrying about sleeplessness have been around for a long time.

Healthy sleep appears to come so easily and naturally to newborn babies. Effortlessly, they fall asleep and stay asleep. Their sleep patterns, however, shift and evolve as the brain matures during the first few weeks and months. Such changes may result in "day/night confusion"-long sleep periods during the day and long wakeful periods at night. This is bothersome, but it is only a problem of timing. The young infant still does not have any difficulty falling asleep or staying asleep. After several weeks of age, though, parents can shape natural sleep rhythms and patterns into sleep habits.

It comes as a surprise to many parents that healthy sleep habits do not develop automatically. In fact, parents can and do help or hinder the development of healthy sleep habits. Of course, children will spontaneously fall asleep when totally exhausted-"crashing" is a biological necessity! But this is unhealthy, because extreme fatigue (often identified by "wired" behavior immediately preceding the crash) interferes with normal social interactions and even learning. You should not assume that it is "natural" for all children to get peevish, irritable, or cranky at the end of the day. Well-rested children do not behave this way.

Before electricity, radio, television, computers, or commuting long distances to work, children went to sleep earlier than children do today. Our current popular late bedtimes may be no more "natural" than the outdated "natural" belief that fatter babies are healthier babies. Commonly held or popular beliefs about what is natural, normal, or healthy are not always true. In addition, when you think of child rearing, it may appear "natural" for you to consider parenting practices performed in traditional cultures. That is, breast-feed frequently day and night and sleep with your baby, wear your baby in a sling or soft carrier, always be close to your baby, and always respond to your baby. This is not always practical for some families, and even for those families who choose this "natural" style, their baby's extreme fussiness/crying/not sleeping or "unnatural" factors can interfere.

Dr. Christian Guilleminault, who along with Dr. William C. Dement was the founding editor of the world's leading journal of sleep research, taught me to consider five fundamental principles of understanding sleep:

1. The sleeping brain is not a resting brain.

2. The sleeping brain functions in a different manner than the waking brain.

3. The activity and work of the sleeping brain are purposeful.

4. The process of falling asleep is learned.

5. Providing the growing brain with sufficient sleep is necessary for developing the ability to concentrate and an easier temperament.

Sleep is the power source that keeps your mind alert and calm. Every night and at every nap, sleep recharges the brain's battery. Sleeping well increases brainpower just as lifting weights builds stronger muscles, because sleeping well increases your attention span and allows you to be physically relaxed and mentally alert at the same time. Then you are at your personal best.

As you will discover as you read this book, when children

"NATURAL" VERSUS "UNNATURAL"

"Natural"

All babies have spells of fussing and crying.

These spells distress all parents.

All parents want to soothe their baby.

The more the baby fusses or cries, the less she sleeps.

The less the baby sleeps, the less the parents sleep.

The less the parents sleep, the harder it is for them to soothe their baby.

Relatives and friends want to help soothe the baby and are expected to assist parents.

Breast-feeding and sleeping with your baby are powerful ways to soothe your baby.

"Unnatural"

Urban stimulation (noises, voices, delivery trucks, shopping trips, errands) may interfere with baby's sleeping.

Day care (not being able to put your child to sleep when just starting to become tired or too much stimulation) may interfere with baby's sleeping.

Social isolation forcing only the mother to be wholly responsible to take care of soothing and sleeping may cause intense stress for the mother.

Busy modern lifestyles means that parents have many things to do and little time to do them; sometimes they have to take their baby with them even at sleep times.

Mothers have to work outside the house, miss playing with their baby, and keep their baby up too late at night.

Fathers or mothers have a long commute and return home from work late, want to play with their baby, and keep their baby up too late at night.

Grandparents interfere with sleep routines.

Learn to sleep well, they also learn to maintain optimal wakefulness. The notion of optimal wakefulness, also called optimal alertness, is important, because we tend to think simplistically of being either awake or asleep. Just as our twenty-four-hour cycle consists of more than just the two states called daytime and nighttime, there are gradations-which we call dawn and dusk-in sleep and wakefulness.

In sleep, the levels vary from deep sleep to partial arousals; in wakefulness, the levels vary from being wide awake to being groggy.

The importance of optimal wakefulness cannot be overemphasized. If your child does not get all the sleep he needs, he may seem either drowsy or hyperalert. If either state lasts for a long time, the results are the same: a child with a difficult mood and hard-to-control behavior, certainly not one who is ready and able to enjoy himself or get the most out of the myriad of learning experiences placed before him.

With our busy lifestyles, how can we keep track of nap schedules and regular bedtime hours? Is it really true that I can harm my baby by giving him love at night when he cries out for me? How can I be sure that sleep is really that important? Am I a bad parent if my child cries? If he cries at night, isn't he feeling insecure? These are questions many parents ask me. Parents will often mention that articles or books they have read seem to support different ideas, and so they conclude by saying that since this whole issue is "so controversial," they would rather let matters stay as they are. If you think your child is not sleeping well and if you disagree with the suggestions in this book, then ask yourself how long you should wait for improvement to occur. Three months? Three years? If you are following the opinion of a professional who says you must spend more time with your child at night to make him feel more "secure," ask that professional, "When will I know we are on the right track?" Don't wait forever. Consider what Dr. Charles E. Sundell, the physician in charge of the Children's Department in the Prince of Wales General Hospital in England, wrote in 1922: "Success in the treatment of sleeplessness in infants is a good standard by which to estimate the patience and skill of the practitioner." He also wrote: "A sleepless baby is a reproach to his guardian, and convicts them of some failure in their guardianship." So don't think that worrying about sleeplessness is just a contemporary issue.

The truth is, modern research regarding sleep/wake states only confirms what careful practitioners such as Dr. Sundell observed over eighty years ago. He wrote:

The temptation to postpone the time for a baby's sleep, so that he may be admired by some relative or friend who is late in arriving, or so that his nurse may finish some work on which she may be engaged, must be strongly resisted. A sleepy child who is kept awake exhausts his nervous energy very quickly in peevish restlessness, and when preparations are at last made for his sleep he may be too weary to settle down....

Regularity of habits is one of the sheet-anchors by which the baroque of an infant's health is secured. The reestablishment of a regular routine, after even a short break, frequently calls for patient perseverance on the part of the nurse, but though the child may protest vigorously for several nights, absolute firmness seldom fails to procure the desired result.

Each baby is unique. They're like little snowflakes. Babies are born with individual traits that affect the amount of physical activity, the duration of sleep, and the length of periods of crying they will sustain. But babies also differ in more subtle ways. Some are easier to "read"; they seem to have predictable schedules for feeding and sleeping. These babies also tend to cry less and sleep more. Regular babies are more self-soothing; they fall asleep easier, and when they awaken at night they are more able to return to sleep unassisted. But don't blame yourself if you have an irregular baby who cries a lot and is less self-soothing. It's only luck, although social customs may affect how you feel about it.

In those societies where the mother holds the baby close all the time, and her breasts are always available for nursing and soothing, there are still great differences among babies in terms of fussiness and crying. The mother compensates by increasing the amount of rhythmic, rocking motions or nursing. She may not even expect the baby to sleep alone, away from her body. As she grows up, a child might share the bed with her parents for a long time. This is not necessarily good or bad; it's just different from the expectations of most middle-class Western families.

So not only do babies sleep differently, but every society's expectations condition parents' feelings in different ways. Remember, there are no universally "right" or "wrong" ways, or "natural" versus "unnatural" styles, of raising children. Less-developed societies are not necessarily more "natural" and thus "healthier" in their child-rearing practices. After all, strychnine and cow's milk are equally "natural," but they have altogether different effects when ingested.

How much we are bothered by infant crying or poor sleep habits might partially reflect our own expectations about how to be "good" parents. Do we want to carry the baby all the time, twenty-four hours a day, or do we want to put the baby down sometimes to sleep?

Here's a true story. A Saudi Arabian princess came to my office for a consultation, accompanied by her English-trained Saudi pediatrician, her English-trained Saudi nanny, and two other women, to discuss sleeping habits for the royal family's children. The pediatrician described child care arrangements that had been popular among British aristocrats in the nineteenth century. Like trained baby nurses in nineteenth-century England, the Saudi Arabian nanny was always able to hold the princess's baby while the child was sleeping for the simple reason that the Saudi nurse had her own servants! These subordinate nannies were not as well trained and were assigned the menial domestic chores associated with child rearing.

The majority of parents do not have child care staffs. They have to rely on their own skills. So if we are greatly bothered by our baby's crying or our guilt about not being "good" parents, this may interfere with our developing a sense of competence. We may feel that we cannot influence sleep patterns in our child. Unfortunately, this way of thinking can set the stage for future sleep disorders.

Sleep problems not only disrupt a child's nights, they disrupt his days, too, by making him less mentally alert, more inattentive, unable to concentrate, and easily distracted. They also make him more physically impulsive, hyperactive, or lazy. But when children sleep well, they are optimally awake and alert, able to learn and grow up with charm and humor. When parents are too irregular, inconsistent, or oversolicitous, or when there are unresolved problems between the parents, the resulting sleep problems converge, producing excessive nighttime wakefulness and crying.

Please do not simply assume that children must pass through different "stages" at different ages, and that these stages inevitably create sleep problems. The truth is that after three or four months of age, all children can begin to learn to sleep well. The learning process will occur as naturally as learning how to walk.

The bad news is that some parents create sleep problems. The good news is that parents can prevent sleep problems as well as correct any that develop.

Parents who favor a more gradual approach (controlled crying or graduated extinction) over an abrupt approach (ignoring or extinction) often complain of frequent "relapses." The general reason why a gradual approach tends to be less successful in the long run is that it takes longer and there are always natural disruptions of sleep, such as illnesses or vacations. The subsequent reestablishment of healthy sleep routines using a gradual approach becomes very stressful to the parents. Several days or weeks of a gradual approach often wear down parents, so they give up and revert to their old inconsistencies. Parents who have successfully used extinction know that they might have one, and only one, night of crying after they return home from several days on vacation or from a visit to a relative's house.

The truth is that some parents swing back and forth between firmness and permissiveness so often, they cannot make any cure stick. They often confuse their wishful thinking with the child's actual behavior. This is why a sleep log, which I will describe later, can be an important tool to help you document what you are really doing and how your child is really responding. After all, short-term "successes" might only reflect brief periods when your child crashes at night from chronic exhaustion. Or the actual improvement in sleep habits may be so marginal that the normal disruptions of vacations, trips, illnesses, or other irregularities constantly buffet the still-tired child and cause repeated "relapses" in which he wakes often during the night or fights going to sleep.

In contrast, parents who successfully carry out an abrupt retraining program-the cold-turkey approach-to improve sleep habits see immediate and dramatic improvement without any lasting ill effects. These children have fewer relapses and recover faster and more completely from natural disruptions of sleep routines. Seeing a cure really "stick" for a while gives you the courage to keep tighter control over sleep patterns and to repeat the process again if needed.

I cannot emphasize enough how important it is for parents to start early to help their child learn to sleep well.

PRACTICAL POINT

If you start early with sleep training, you will be well along the path to preventing sleep problems.

When you start early, there are no long bouts of crying and no problems with sleeping.

(Continues...)

Excerpted from "Healthy Sleep Habits, Happy Child" by Marc Weissbluth. Copyright (C) 2003 by Marc Weissbluth. Excerpted by permission. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher. Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.