Create A Safe And Comfortable Environment Conducive To Sleep

The Baby Sleep Book : The Complete Guide to a Good Night's Rest for the Whole Family
by William Sears, M. D., Martha Sears, R. N., Robert W. Sears, M.D.

(Page 2 of 3)

Step 3

If baby's bedroom (or your bedroom) is too light, too dark, too noisy, too quiet, or too stimulating, your baby may have difficulty going to sleep or staying asleep. Some babies are more sensitive to their sleeping environment than others. The kind of environment that is best for your sleeping baby depends on her sleep temperament. Here are some ideas to help you set the stage for your baby to sleep.

Quiet the bedroom. Most babies can block out some noise, so you don't have to create a noiseless sleeping environment for your baby. Yet, some babies do startle and awaken easily with sudden noises. For noise-sensitive babies, oil the joints and springs of a squeaky crib and the door hinges and shut the windows.

Quiet the house. Quieting the house down at tired time will both give your baby the message that it's time to transition into sleep and also program her to associate this quiet routine with sleepy time. Lower your voice, close the doors, turn off the phone ringer, put the dog outside before he barks, slow down your movements, and minimize distractions. Turn off the TV and put on some calming music. Let your baby sense that the general mood is changing from one of activity to one of quiet. Don't bounce or jiggle baby. Remember, she may already be overstimulated.

I made sure he knew the difference between day and night. During the day I did not try to keep a very quiet house. The phone rang, the dog barked. I kept it dark and quiet at night. I would feed him by night-light, change him by night-light, and everything would be calm. During the day, we would sing at the changing table, at night we wouldn't sing. Now he understands that when the lights go out, it's time for bed and not playtime.

Darken the bedroom. Help your baby learn to associate darkness with sleep. Don't turn on any bright lights during the night, as this can trick baby's internal sleep clock into thinking it's daytime (and wake time!). Use a night-light or install a dimmer switch on the bedroom light so that you can keep the light level low during nighttime diaper changes. If necessary, close the curtains to keep out the morning (or evening) light. Opaque shades, which block out light completely, may get you an extra hour of sleep if you have one of those little roosters who awaken to the first ray of sunlight entering the bedroom.

We used a Redi Shade (available at Home Depot) room-darkening temporary shade, a heavy black pleated paper shade that quickly sticks to the top of the window.

Warm the bed. Always make sure baby's bed (or yours) is warm. Laying baby down on cold sheets is a sure way to shock baby awake. One creative dad told us he used to lie in bed with baby snuggled on his chest for five minutes before scooting over and laying baby down in the warm spot. Before laying baby down in a crib or cradle, warm the sheets with a warm towel from the dryer, a hot-water bottle, a heating pad, or an electric blanket (any of which you should remove before laying baby down, of course, for safety reasons). Use flannel sheets in cold weather.

Lessen physical discomforts. A baby who itches, hurts, or has difficulty breathing is going to wake up. Here are some tonsils-to-toes tips on helping your baby sleep more comfortably:

• Clear the nose. Babies need clear nasal passages to breathe. Use nasal saline and gentle suction to clear baby's nose as needed.

• Remove airborne irritants. Environmental irritants can cause congested breathing passages and awaken baby. Common household examples are cigarette smoke, baby powder, paint fumes, hair spray, animal dander (keep animals out of an allergic child's bedroom), plants, clothing (especially wool), stuffed animals, dust from a bed canopy, feather pillows, blankets, and fuzzy toys that collect lint and dust. If your baby consistently awakens with a stuffy nose, suspect irritants or allergens in the bedroom. Make your baby's bedroom as dust-free as possible. Besides dusting regularly, remove fuzzy blankets, down comforters, dust-collecting fuzzy toys, and so forth. If your baby is particularly allergy-prone, a HEPA-type air filter will help. As an added nighttime perk, the "white noise" from the hum of the air filter may help baby stay asleep longer.

• Relieve teething pain. Teething discomfort may start as early as three months and continue off and on all the way through the two-year molars. A wet bed sheet under baby's head, a drool rash on the cheeks and chin, swollen and tender gums, and a slight fever are telltale clues that baby is teething. If the teething pain seems really bad, with your doctor's advice, give appropriate doses of acetaminophen just before parenting your baby to sleep and again in four hours if baby awakens.

• Change wet or soiled diapers. Some babies are bothered by wet diapers at night. Most are not. If your baby sleeps through wet diapers, there is no need to awaken her for a change—unless you're trying to get rid of a persistent diaper rash. Messy nighttime bowel movements do necessitate a diaper change. Here's a nighttime changing tip: If possible, change the diapers just before a feeding, as baby is likely to fall asleep during or after the feeding. Some breastfed babies, however, have a bowel movement during or immediately after a feeding and will need changing again. If you are using cloth diapers, putting two or three diapers on your baby before bedtime will decrease the sensation of wetness. Also, if baby is prone to diaper rash, slather on a hefty layer of barrier cream to protect baby's sensitive skin from the sensation and irritation of wetness. Cold diaper wipes are sure to startle baby awake. Use a wipe warmer or run wipes under warm water (a great job for dad!).

• Remove irritating sleepwear. Many infants cannot settle in synthetic sleepwear (some adults, too!). A mother in our practice went through our whole checklist of night-waking causes until she discovered her baby was sensitive to polyester sleepers. Once she changed to 100 percent cotton clothing, her baby slept better. Besides being restless, some babies show skin allergies to new clothing, detergents, and fabric softeners by breaking out in a rash.

Create a comfortable bedroom temperature. A consistent bedroom temperature of around 70° F is best for sleeping. Also, a relative humidity of around 50 percent is most conducive to sleep. Dry air may leave baby with a stuffy nose that awakens him. Yet humidity that's too high fosters allergy-producing molds. A warm-mist vaporizer can act as a heater in your baby's sleeping area, and it helps maintain an adequate level of humidity in homes with central heating (and the "white noise" of the consistent hum may help baby sleep longer).

Fill tiny tummies. The tinier the tummy, the more frequently a baby needs to be fed—both day and night. Babies have tiny tummies (about the size of their fist), which is why babies under six months of age need one or two night feedings. Some babies (especially breastfed ones) continue to need night feedings even in the second six months of life. You can maximize the amount of time baby will sleep after a feeding by being sure that baby fills his tummy as he feeds off to sleep and again when you feed him in the middle of the night. (See page 139 for how to comfortably fill tiny tummies for longer sleep.)

Swaddle your baby. Swaddling re-creates the womb environment. In the early months, many babies like to "sleep tight," securely swaddled in a cotton baby blanket. Older infants like to sleep "loose," and may sleep for longer stretches with loose coverings that allow them more freedom of movement. Oftentimes, dressing a baby loosely during the day but swaddling him at night can condition the baby to associate sleep with being swaddled. Make sure baby doesn't get too warm.

Once I started swaddling her, she slept through the night. At about three months, she got too strong to swaddle in the traditional way. She would get her arms out and rub her face and startle herself awake. I took a larger thin blanket and wrapped the sides individually over each arm and under her back so she couldn't get loose. It may sound like a cruel thing to do, but she smiled as I did it and slept peacefully all night long.

Babies usually start squirming out of their swaddling wraps by six months. Another possible problem with swaddling is that once babies get used to it, they have a hard time sleeping without being swaddled. The movement of their arms and legs wakes them up.

Dr. Bill cautions: Dr. Robert Salter, professor of orthopedics at the largest children's hospital in the world—the Hospital for Sick Children in Toronto, Canada—literally wrote the book on infant hip development. After the publication of the first edition of The Baby Book, in which we extolled the merits of swaddling and showed parents how to swaddle a baby, Dr. Salter wrote me a long letter. He believes leaving babies swaddled for too long, especially in the early months, can interfere with the development of their ball-and-socket hip joint. For this reason, we recommend that parents swaddle their babies only during sleep time. Be sure to give your baby plenty of time to "let loose" when he is awake.

Step 4. Create a Variety of Bedtime Rituals

You are learning where baby sleeps, when baby sleeps, and how to create a comfortable sleepy environment, and now we come to the next step in our plan: helping you figure out what bedtime rituals work best for your baby. As you use these same routines night after night (or alternate through several routines consistently), baby will learn to fall asleep easily and stay asleep longer.

Create Healthy and Relaxing Sleep Associations

A sleep association is not a nap-time playgroup or a group of sleepy parents who gather to yawn and complain about their baby's sleep habits. A sleep association refers to a connection made in baby's mind between falling asleep and the various activities, places, experiences, and feelings that precede his nodding off into slumber. The wiring in baby's brain is full of patterns of association. For example, if you usually nurse and sing your baby to sleep in a rocking chair, this setting will become programmed into your baby's mind as a sleep-inducing routine. He will remember the calm and drowsy feelings he gets from rocking and nursing, and this will help him fall asleep.

What kind of sleep associations do you want to teach your baby? Do you want to create attachment-based sleep associations or independence-based sleep associations?

Attachment-based sleep associations. Many parents like to "parent" their babies to sleep—by rocking, feeding, or snuggling while baby drifts off to sleep. Baby learns to associate falling asleep with a parent's presence. The advantage? A closer bond develops between parent and baby. The disadvantage? Mom or dad must be involved with baby falling asleep for months or even years. Depending on your own instinctive parenting style, you may actually view this as an advantage; certainly your baby would.

Independence-based sleep associations. Some parents strive to help baby learn a more independent way of falling asleep, without the need for parent involvement. The most popular method for getting baby to fall asleep independently is the cry-it-out method. The disadvantage? You don't teach baby to fall asleep, you force him to. Medical research has shown that excessive crying creates stress for a baby. So a baby learns to associate falling asleep with fear, stress, and worry. This is not healthy in the long run. (We will discuss sleep anxiety more on page 104 and the harmful effects of crying it out on pages 210 to 213.) We all want our babies to eventually learn to fall asleep independently using their own self-soothing strategies at an appropriate age. Our sleep plan helps you teach them how to do this rather than forcing them to sleep independently.

In our own families, we chose to create attachment-based sleep associations. We enjoyed the cuddling and closeness of our kids' bedtime routines, and we felt that just being there for our babies was easier than fussing with other stuff. You may feel differently about this, or you may be thinking that it's time for your older baby or toddler to start falling asleep independently. That's okay with us. What is most important is that you help your child develop healthy, happy sleep associations.

Why is it necessary for you to help your baby develop healthy sleep associations? Why not just put baby down in her crib, walk out of the room, and let her fall asleep on her own? Won't she learn that being in the crib means there's nothing to do now but sleep? Well, yes, she will begin to associate being left alone in the crib with sleep. Her developing brain is busy building patterns of association all the time. That's what brains do. But in the early months, babies do not have the developmental capacity to transition without help from a state of being awake to one of being asleep. A tiny baby left alone in her crib to fall asleep on her own is likely to cry fearfully and then sleep anxiously. Going to sleep anxiously defeats one of the goals of your sleep plan: to teach baby a healthy attitude about sleep—that sleep is a pleasant state to enter and a happy state to remain in.

Babies need to be parented to sleep so that they can form pleasant sleep associations. What kind of activities, experiences, and feelings do you want your baby to associate with going to sleep? Babies who fall asleep while breast- or bottlefeeding will learn to associate warm milk, rhythmic sucking, and being cuddled close to mom with sleep. Babies who are carried around or rocked to sleep will learn that motion and comfort, as well as contact with mom or dad, are what send them into dreamland. Babies who are put in a crib to cry themselves to sleep learn that sleep is a lonely time when they need to comfort themselves.

Remember, you want your baby to sleep not only longer but also happier. So, in considering any advice about sleep, including the advice in this book, ask yourself this:

Getting behind the eyes of your baby and imagining how you would want your parents to act in a certain situation is one of the most important parenting tools that we have learned during our years as parents and pediatricians. You will nearly always make wise decisions about how to parent your children if you begin your decision process by trying to understand the situation from your child's point of view. If you were a baby, would you rather be parented to sleep at the breast of your mother or in the arms of your father or just put down all alone in a crib and left to cry yourself to sleep?

We are now going to show you ways to create sleep associations that have one goal in mind—to help baby learn that sleep is a pleasant state to enter and a happy state to remain in.

Sleep associations and sleep tools. It's helpful to develop a repertoire of sleep associations and sleep-inducing tools that work for you. Think of your baby's primary sleep association as your main method of putting baby to sleep. Sleep tools are additional things such as soft music, dim lights, or stories that may help to calm a child and prepare her for sleep. Some parents will choose one primary sleep association as the foundation, and use several sleep tools to help. Others like to get baby used to several different primary associations for sleep so that they have more options at bedtime.

Which primary sleep association is going to work best for your baby? You won't know until you've tried them all. We suggest you go through a trial period of a few weeks to see what primary method of putting baby to sleep works the best. Try feeding baby to sleep a few nights, then try rocking or walking. Try snuggling with baby but not feeding him to sleep. Involve dad in the routine as well. Try a variety of methods until you learn what works best.

Primary Sleep Associations

Here are the primary associations to consider as you decide what will work best in your family: feeding baby to sleep, including feeding baby almost to sleep; lulling baby to sleep by rocking or walking; wearing baby down to sleep in a sling; and putting baby down to fall asleep independently.

Breastfeeding or bottlefeeding your baby to sleep. If babies could vote, going off to sleep the warm way would win the Best Transition Award. A high-touch continuum from warm bath, to warm arms, to warm breast, to warm bed is a winning recipe for sleep. Snuggle next to your baby in your bed and nurse her off to sleep. If you nurse baby to sleep in your arms, be sure to wait until she is fully asleep before you try to transfer her into her own bed. Once baby is asleep, just ease away. Check out Martha's de-latch technique (page 140) to learn more.

Breastfeeding seems to be nature's plan for comforting babies and helping them fall asleep. In fact, breast milk contains a sleep-inducing protein that helps lull baby into dreamland. (As an added advantage, as baby relaxes, so does mother, thanks to the hormones released when baby sucks at the breast.) Young babies also fall asleep very easily while bottlefeeding.

We recommend that you not place any limitations on your baby's nursing to sleep during the early weeks of breastfeeding. In the first four to six weeks after baby's birth, you are learning to read your baby's hunger cues, your baby is learning to tell you when he is hungry, and your milk supply is adjusting to baby's needs. Relax and enjoy the breastfeeding experience.

A smart baby will come to love this feeding-to-sleep association and enjoy and expect it for as long as you breastfeed or use bottles. On the one hand, this means that you will be able to count on feeding as an easy way to get baby off to sleep. Even a baby who is fighting sleep will eventually succumb to the relaxing feelings that come from sucking. On the other hand, mom's breasts (or the bottle) have to be there at bedtime, and again later, when baby awakens in the middle of the night. Even if feeding is your baby's number-one primary sleep association, you may want to help him learn other associations so you have other ways to put him to bed.

In developing our sleep plan, we asked mothers of frequent night wakers, "For your next baby, what will you do differently?" The following answer, from our daughter Hayden (formerly the star of our Fussy Baby book and now a new mother), is representative of what many moms told us:

I cherish those precious times of nursing Ashton to sleep, as I realize they will pass all too soon. Yet, for our next baby, I will not use just one way of putting her to sleep. I'll do a variety of things so she's not so set on only one way of falling asleep. This will include my husband, Jason, putting her to sleep now and then, so that when she's older, he can put her to sleep in his own way.

Many parents tell us that nursing baby at bedtime and a couple more times during the night works very well for them if they are co-sleeping. Baby is content, and mother manages to get enough sleep because baby is sleeping close by and she can nurse baby back to sleep without waking up completely herself. Mom may wake a little more often, but she feels that the benefits outweigh any inconvenience for her.

Some moms, however, have told us that at age six months, twelve months, even eighteen months, their babies continue to wake up (sometimes several times!) each night to nurse and that they can no longer cope with this much night nursing. They wish that their babies would learn that there is more than one way to fall asleep. Well, babies can learn other ways to sleep, and later in this book we will share ways to teach a baby new sleep associations. For now, we want you to know that many mothers nurse their babies to sleep for many months, including during the night, and still manage to get enough rest. If you currently enjoy nursing your baby to sleep, we don't want to get in the way of a good thing. One of the lessons we want you to learn about parenting is to enjoy the moment. We want you to get attached to your baby without worrying about a lot of what-ifs.

Feeding baby almost to sleep. Many breastfeeding moms who want dad to also be able to put baby to sleep teach their baby sleep associations beyond breastfeeding. Baby breastfeeds at bedtime, settles down, and starts to feel drowsy. Then, using walking or rocking while patting baby's back and other methods for easing the transition into sleep, dad takes over while baby drifts off to sleep. Bottlefeeding parents can use this approach, too, if they don't want their baby falling asleep with a bottle in her mouth. This approach helps baby learn that there are other ways to fall asleep besides relying on the comfort of sucking. When you use this approach with an older infant who no longer needs two or three nighttime feedings, baby may be less likely to wake up at night and may be more willing to go back to sleep with just some gentle patting or snuggling from either mom or dad.

The main reason for getting baby used to other sleep associations is to avoid mother burnout from frequent night nursing of an older infant (the most common sleep concern we encounter in our pediatric practice). In the wonderful world of night nursing, babies absolutely love going fully to sleep at mother's breast and having instant access to this warm and cozy prop when they wake up. If it's working for you, please don't change. Yet, it often helps to add the finishing touch of another prop after nursing to help baby go from being awake but drowsy through light sleep into a state of deep sleep. Try these finishing touches:

• Nurse, then pat, sing, or rock baby to sleep. Instead of nursing baby completely to sleep, nurse until she starts to slow down her sucking and closes her eyes but is not yet asleep. Ease your nipple out of her mouth and then rock, pat, or sing her down until she is completely asleep.

• Mother-nurse, plus father-nurse. Near the end of the nursing, ease baby gently into father's arms to add the finishing touch. Then, hopefully, when baby wakes up, she will be more likely to accept dad or another caregiver putting her back to sleep by using the same finishing touch.

• Add a variety of sleep tools. You can use any of the tools listed on page 16 and discussed in this section to lull your baby to sleep after feeding. If these techniques are not working and baby insists on feeding to sleep, consider that a baby who is not willing is not yet ready. Give your baby a few weeks for her sleep patterns to mature and then try again.

Parenting baby down to sleep without feeding. This is more easily said than done. Because of the sleep-association principle discussed above, if baby always falls fully asleep the same way, especially at the breast, he will expect, demand, or even scream for the same prop—usually the breast—to get back to sleep. Occasionally try putting your baby down in his bed when he is sleepy but not totally asleep. Showing him how to fall asleep without feeding teaches him that it's okay to go to sleep in other ways. Your baby may fuss when you first try some of the sleep-inducing tools. If he fusses more than just a little, remember this important parenting principle: Don't persist with a bad experiment. Yet, even if just once or twice a week you try to put your baby down when he is only partially asleep, at least you've planted a bit of the "I can do it" association.

Rocking or walking down. Try rocking baby to sleep in a bedside rocking chair, or walk with baby, patting her back and singing. To keep the motion going (and keep baby asleep), ease her into a cradle and continue the rocking motion at a rate of about sixty rocks per minute. This is the heartbeat rhythm your baby was used to in the womb.

Wearing down in a sling. Place your baby in a baby sling and wear her around the house for a half hour or so before the designated bedtime. When she is fully asleep in the sling, ease her out of the sling onto your bed. Or, if she's not fully asleep, lie down with her in the neck nestle or warm fuzzy position on your chest. When baby is fully asleep, roll over on your side, slip yourself out of the sling, and let baby lie on the bed on her back using the sling as a cover. Wearing down (or what we also dub "slinging down") is particularly useful for the reluctant napper. When baby falls asleep in the sling, you can both lie down and enjoy a much-needed mutual nap.

Putting baby down to sleep independently. Some parents like to set up a more independent sleep arrangement early on, in which, hopefully, baby learns to settle himself down to sleep without much parental interaction. They reason that a baby who learns to fall asleep on his own will also be able to settle himself back to sleep on his own when he wakes during the night. This type of sleep training has become popular with some parents because it results in a "low maintenance" baby at night. It has also received a great deal of criticism because of the amount of crying that babies experience during the training phase. It ignores the fact that babies are born with an innate need for comfort and security while falling asleep, upon waking, while going back to sleep, and in some cases even while sleeping.

Ideally, the comfort they seek is supplied by a human caregiver. Babies who sleep independently usually need to have various sleep-inducing tools handy to calm them when they are falling asleep and again when they awaken. They may need motion, such as the rocking, swinging, or bouncing movements of a cradle, swing, or baby hammock. They may depend on a pacifier. Perhaps they learn to associate soft music or other sounds with sleep. Parents develop a routine that lulls baby into dreamland. Use the variety of sleep-association tools we discuss on the following pages to help your baby learn to fall asleep independently.

To train babies to fall asleep lying in a crib by themselves without any comforting sleep associations would be very tough on them. In chapter 10 you will learn why we discourage this "tough love" approach to sleep training when it involves crying it out. Research shows that a sleep-training method that involves extended crying alone (without parent comforting) is not emotionally or physically healthy for babies—or for parents. Very easygoing babies may be able to learn to fall asleep independently with only minimal fuss, and in chapter 4 we will offer suggestions for how this can be done in an appropriately sensitive way. Remember, our goal is for you to create stress-free sleep associations for your baby that result in a happy, healthy sleeper.

Copyright © 2005 by William Sears, Martha Sears, Robert Sears, and James Sears

About the Author

William Sears, M.D., received his pediatric training at Harvard Medical School's Children's Hospital and Toronto's Hospital for Sick Children. He has practiced as a pediatrician for more than thirty years.

Martha Sears is a registered nurse, childbirth educator, and breastfeeding consultant.

Robert Sears, M.D., earned his medical degree at Georgetown University School of Medicine. Having had the privilege to help raise three active boys, "Dr. Bob", as he likes to be called by his little patients, has grown fond of the "parenting" side of pediatrics. He has appeared on the Dr. Phil show to offer advice on child behavior and parenting issues. He has also appeared on the Ellen DeGeneris show and has appeared on CNN's House Call with Dr. Sanjay Gupta to offer advice to first time fathers. Dr. Bob is a regular guest on "A Place of Our Own" on PBS, helping parents and caregivers understand a variety of child health issues.