One of life’s regrettable realities is that you can’t be right all the time. I know that we in the medical profession receive some appropriate criticism when we unfortunately fall for the trap of believing that the above rule of life does not apply to ourselves. It is thus with deep regret that I announce that my advice is not universally successful. Over the years I have used these failures as an opportunity to observe and learn why they occur. This chapter attempts to explain the common causes of failure in achieving acceptable sleep patterns.
Young parents are under immense pressure from both their personal expectations and those of their family and friends. Our society places a high value on parenting and as it is one of our major endeavours in life we try hard to do it very well. This high expectation is accompanied by the realities of tiredness and often little experience. When a young parent confronts a baby who is crying for what seems to be hours and hours, things sometimes go wrong.
I am very much aware that the parents who come to see me for their first visit have often received advice from people from different organisations and of different philosophies. Occasionally the parents will report to me that they have just come from a respected organisation which has given them exactly the opposite advice. Parents are often left with the unenviable task of making a choice between opposing points of view. I am not in the least surprised when the people I am seeing, after having thought through the information I give them, choose another philosophy for the care of their children. In fact, I am regularly impressed and grateful to the proportion of young parents who are willing to give my ideas at least a try. Despite this, there are still failures and I have been encouraged to document the common causes of failure in achieving good control of infant sleep.
The causes of failure can be discussed under a number of broad headings. Each of these will be discussed individually in greater depth.
In general terms the causes include the following. They are in no particular order:
- (a) lack of spouse support
- (b) an inconsistent approach
- (c) genuine ill health
- (d) hunger
- (e) sabotage
- (f) an incompatible philosophy
- (g) difficult children
- (h) lifestyle
In addition, in any given family there may be a combination of one or more of the above factors.
(a) Lack of Spouse Support
As mentioned extensively elsewhere in this book, when assisting a child to learn independent sleep skills there will be a majority of infants who spend time crying. It is distressing and tiring for a parent to spend time doing nothing while an infant is crying itself to sleep. I know from my own experience as a father that at two o’clock in the morning, doing nothing while your baby is crying, is much harder than doing something. It takes a considerable commitment from parents. To a certain extent in the initial days of the program, before improvement occurs, it is an act of faith to do nothing. This time spent doing nothing is not restful, with you, the parent, wide awake. It may be that one of the parents is less convinced than the other and will not support the idea of waiting until sleep is achieved. A variation on this theme is the partner who makes the comment ‘I have got to work in the morning. I need my sleep. Get up and do something about the baby!’
These points of view are entirely understandable. However they do put the mother in a difficult position. Sometimes this pressure will be so significant that she is unable to continue to ignore her infants crying, is forced to attend to the child, and the pattern of developing their sleep skills is lost. Unfortunately this turns a short-term problem into a long-term problem. The sleep problem which may have been controlled in one to two weeks is now converted into a trend which continues to occur for months, and, in some unfortunate cases, for years.
There is no magic solution to the problem of inadequate support from one’s partner. In consulting, I attempt to get both partner and wife to the first consultation. If I explain the philosophy to both it is far more likely that they will support each other.
Parenting is a challenging job, particularly when learning new skills while being tired. It is made doubly difficult if your partner fails to support you. This text may prove useful in obtaining help from your companion.
(b) Inconsistent approach
Inconsistency is probably the dominant cause of failure. The sequence of events is relatively easy to explain. Families that come to see me are often trying multiple methods recommended by several advisers. Everyone has an opinion. Everyone has advice. As the method used by the family varies from day to day, little may be achieved. As has been mentioned elsewhere, the underlying philosophy of the book is that we are teaching the children a skill. That skill is the ability to achieve sleep independently. When teaching any skill, be it the alphabet or tables, how to kick a ball or to sleep successfully, a consistent approach usually produces the best outcome.
The dangers of inconsistency are twofold. Firstly, many methods are being tried and no method is taken to a successful conclusion. The second is more profound and can have negative effects in the long term. This second area of inconsistency works as follows.
Let us assume that the family has decided to try the method outlined in this book. The child is well, gaining weight, and no problem can be identified which could cause wakefulness. When the baby is fed, bathed, and prepared for bed, he or she is left on their own for gradually increasing periods of time. The child is reassured for short periods of time by a gentle touch, gentle rearrangement in their bed or cot or basinet, and a few affectionate words. The child is then left to settle off to sleep alone. Contact time might be 30 to 90 seconds, and separation may be 5, 10, 15, 20 minutes or more. Let us also assume that the child is being taught to sleep independently, as opposed to achieving sleep in mother’s arms and then sleeping for large parts of the night in the parental bed. On the first night the parents are determined and they eventually find that the child achieves sleep, but after a considerable amount of crying. On the second night they are again determined, and although the crying is less, it still disturbs their sleep. On the third night, all is quiet until two am. Then the baby awakens with a loud cry. After 30 minutes, one partner has had enough. (Let’s blame Dad in this example.) Dad says, ‘Look I know what we should be doing, but I’m tired. I’ve got to work early tomorrow. Let’s bring the baby into bed, get a decent sleep, and start again tomorrow.’ The trap here, in what is a very understandable scenario, is that we have given mixed messages to the infant. For two nights, the reward of parental company was stopped or minimised. On the third night the reward of parental company for the behaviour pattern of crying for attention is given. This is called intermittent reward. Intermittent or irregular reward is like the occasional win at the poker machine. It is a powerful training tool for the behaviour pattern of continuing to try. The baby has thus been rewarded for crying for two nights. This has now become useful behaviour. We now have a baby who has been rewarded for persistent crying. The problem is worse than when it started.
The moral of the story is that once the family has decided to use parent-independent cues of sleep, and once you have decided to help the child learn to achieve sleep alone, continue until you are successful.
Not everyone has the determination or the family circumstances to allow this. My pointing out the pitfall may help you to avoid it.
(c) Ill Health
One of the assumptions of this book is good health. Not all children are well. There are children who suffer genuine painful reflux, pyloric stenosis, urinary infections, asthma, pneumonia, severe prematurity, or a host of other serious conditions. This illness can make the teaching of sleep skills difficult, impossible, or inappropriate.
It is difficult to give guidelines about ill health and sleep disorders. Each case has to be treated on it’s merits. The most useful general comment is that when struggling with ill health, good sleep is to everyone’s advantage. If it is not dangerous to the child to teach independent sleep skills, then try to achieve good quality sleep as soon as practical.
One of my three year old patients was born with a fatal disease. The child’s life expectancy was six months. Quite clearly, in this setting, sleep is not a priority. Through one of life’s miracles, the disease did not proceed to damage the child. By age three, she was bright, capable, healthy, (considering her disease), and completely in control of the family. Bed time, according to the young lady, was between midnight and one am, and then only if she was held in mum’s arms. The family was exhausted. I did find a solution for them, but the focus of this section is health problems. I am reciting this story here as an interesting paradox. I am not suggesting that illness should be ignored. If your child is experiencing genuine ill health then that should be given priority over teaching sleep skills.
It is understandable for a child to wake up and demand attention when genuinely hungry. This is possibly the second most common cause of sleep problems, particularly in the first three months. Checking hunger as a cause of sleeplessness can be difficult when breast feeding. It is touched on elsewhere in this book. The easiest technique is to check weight gain. If the baby is growing at a rate of 30 gm per day or better during that first three months, then hunger is probably not the cause of sleeplessness. Having said that I must add that some infants do achieve very rapid growth, and the occasional infant, often male, can gain weight at a rate of 50 – 60 gm per day.
Advice on supporting successful breast feeding is given here.
Mothers who are bottle feeding usually have less cause for concern about hunger as the volume taken is so easily observed.
Hunger is a possible cause of sleeplessness and crying. It needs to be addressed before attempting to teach sleep skills. The hungry baby will understandably resist any attempts at training to achieve prolonged sleep.
This is a most interesting area.
Mum and Dad have decided that they wish to pursue a particular style of sleep for their family. Sometimes this includes an amount of ‘crying down’. Other relatives may not approve and this may be shown in different ways. It may present as direct opposition.
‘How can you let my grandson cry. It’s not healthy. He will develop a hernia. Let me pick him up. See, he’s quiet in my arms. This is your first baby. I’ll show you how. I will rock him to sleep.’
There are two problems here. Firstly, relatives go home and leave you with the problems they cause and secondly, the child is once again receiving mixed messages about cues of sleep which interferes with the learning process.
The second type of sabotage may be more subtle. Sometimes a relative shares the care of a child. For example, a grandparent may look after the child for a couple of nights, or a couple of days per week because the child’s mother works part-time. The time when the grandparent (or any other carer) is sharing care can be used by them as a time to use a different style of sleep achievement. This may be constructive or destructive.
There is only one solution and that is to explain the program to your relatives in as much detail as you need to obtain their support. Consistency is very important to the process of learning.
Finally under this heading, I should note that occasionally grandparents send messages of protest to me via the family I am seeing. ‘This baby sleeps too much.’ ‘When can I get a chance to hold my grandchild?’ The answer to such an enquiry/protest is that the child will be a member of the family for a long time. Please let us establish good feeding, sleeping, and growth. The child will grow quickly and within a few months there will be ample time for playing and all the other joys of being an active grandparent.
(f) Incompatible Philosophy
The underlying philosophy of this book is that good quality sleep promotes happy interaction between family members. Sleep achievement is in part a learned skill. Sometimes a child must be left alone and given the chance to achieve sleep independently or with only a little parental input and reassurance. This may include some ‘crying down’ to sleep.
For some parents this is not a philosophy which they share. It is argued by some authorities, that particularly in the first six months of life, the baby’s cry is a signal representing a genuine need. They may add that to ignore the cry is harmful to the child’s psychological well being.
Working with children has taught me that the above analysis is incomplete and can lead to unsuccessful approaches to sleep routines. It is a philosophy which fails to recognise the role of fatigue. This is the dominant cause of infant crying, in my experience. If the cause of the crying is tiredness, then the solution is sleep. Endless hours of rocking or patting or feeding or driving around the block may provide periods of quiet, but they do not provide the good quality sleep which is required. In fact, all this handling may keep the child awake, decrease the amount of sleep achieved, increase the level of tiredness, and thus worsen the problem.
Another element of the above mentioned philosophy is often that the more physical contact between child and parent, the better. One reference suggests that if you want to be a serious mother you should hold your baby 24 hours per day for the first five years.
My answer is as follows. Parenting is wonderful. It should be fulfilling, engaging and pleasurable. It is difficult to feel pleasure, to enjoy any relationship with any member of the family, or even think logically, if your brain is numbed by fatigue. Sleeping times are for sleep, feeding times are for feeding, and play times are for play. When it is time for a child to sleep, let the child sleep. Let the parents have some time for each other and then enjoy a full night’s sleep. They can then awaken in the morning looking forward to spending the day with their child.
If a family’s philosophy is incompatible with this book, then my advice will be irrelevant. In fact, these people have probably given up before reading this far. Let’s hope that their children belong to that 70% of children who sleep well anyway.
(g) Difficult Children
Some children have medical problems which interfere with mental development. Mental retardation, brain injury, and autism are just a few examples. This is a complex area and the family involved will require specialist advice. This book assumes that you are dealing with normal healthy children.
The sleep literature discusses children with difficult ‘temperaments’. The argument goes that children with difficult temperaments may sleep poorly. Which comes first though, the difficult temperament causing poor sleep, or poor sleep resulting in an understandably negative temperament?
The policy which I use is that almost all children have a pleasant temperament once they have adequate food, sleep and love. As with all philosophies, life will occasionally choose not to agree. It seems to work almost all of the time. I hope your children fit the pattern.
Having said this, there are children who may be extremely testing. As early as approximately six months of age, some children appear to be able to hold a clear image of what they wish to achieve. Their parents may report that they know it has become a battle of wills. Some parents even tell me that they are aware of ‘having lost the battle’. They are sure that the child or baby is in control. My advice is to take control. Almost always you do know best about what is correct and in the baby’s best interest.
Over the years I have observed some heroic battles between parents and children. One of the interesting little ironies to this situation is that the child who wins about food or sleep almost always makes a bad choice. For example, they may behave in a way which results in limited sleep. They are then overtired and unhappy. The children who are led by their parents to constructive and appropriate feeding and sleeping patterns tend to be happier.
Have you ever heard someone say at a social gathering, ‘We’re expecting our first child, we’re really excited but we’re planning to continue our present lifestyle, the baby will have to fit in with us’. Those of you who have children may smile reassuringly and think, ‘They’ve got a shock coming’.
The reality is that children bring a major change in lifestyle for almost all of us. Our personal needs, wants and desires take a back seat to caring for a wonderful new human who is totally reliant upon us, and who doesn’t happen to know the meaning of the words, ‘Please be reasonable, Mum needs some time out right now’.
Most families make the necessary adjustments to their lifestyle, and enjoy the pleasures of parenting. Some, however, continue to have irregular meals times, bedtimes, and a general absence of day time routines. This does not work to the advantage of young children developing feeding and sleeping patterns. It can, however, be an insoluble problem if this is the established pattern for the family. These lifestyle problems tend to continue through the different generations of a family.
Not everyone will be successful in achieving good sleep patterns for their children. The causes of failure are multiple. The most common are tiredness (of the infant), hunger, and an inconsistent approach by the parents. Other problems with partners and relatives also occur. The relevant sections above should give you some useful guidance.