12. The Most Important Post in this Blog: Getting a Baby to Sleep Through the Night

When babies are two to three weeks old, I frequently hear these words from mothers: “My baby won’t sleep at night. I’m so exhausted, I feel like I’m going to die.” At this point in the conversation, I’m usually reaching for the tissue box.

When pregnant women go to sleep at night, their babies tend to be very active. This phenomenon continues for a few weeks after delivery, resulting in a flipped day-night schedule. Babies initially sleep all day and eat all night, which can make life physically and emotionally exhausting.

Here are some important survival tips for dealing with nighttime exhaustion:

(First) Enlist the help of your partner or another family member to take turns feeding the baby at night. If you happen to be married to someone working normal business hours, remind him/her that caring for a newborn is the definition of a fulltime job, and he/she is now the one with the part-time job. Assign shifts and work as a team to ensure that everyone is getting some sleep.

If you’re breastfeeding, try pumping some breastmilk, so that at least one (or more) nighttime feedings can be given by someone other than you. Keep in mind that bottles should not be offered until a good pattern of breastfeeding has been established. For some babies this takes a few days, but for others it might take a several weeks. In my experience, easy latchers—babies who latch onto anything with gusto, including your elbow—can safely be given bottles earlier than fussy latchers, usually within a few days after birth.

Why is fussy latching an issue? Unfortunately, some babies—especially those who are struggling with latching—will reject the breast if they receive lots of bottles early on. This isn’t nipple confusion—it’s nipple choice. Babies are smart. They learn quickly that it’s easier to get milk out of a bottle compared to the breast, especially before the milk has come in. If babies are struggling to latch and require supplementation, breastmilk or formula can be given though a feeding syringe placed over a finger or the mother’s nipple, rather than a bottle. Once a solid pattern of breastfeeding has been established, bottles can safely be offered, and they won’t interfere with nursing.

(Second) It’s never too early to begin sleep training, the process of teaching a baby to self-soothe and ultimately sleep through the night, even at the tender age of one day! In 1985, Dr. Richard Ferber published a seminal book called, Solve Your Child’s Sleep Problems, in which he formally described sleep training. Follow up books backtracked on some of these recommendations, but I’m convinced Dr. Ferber got it right the first time. Sleep training is critical to a family’s long-term health, happiness, and wellbeing.

Sleep training relies upon one principle—whatever condition is set when a baby first falls asleep will be required to soothe the baby whenever he/she arouses. For example, if a baby falls asleep on the breast and is then placed in a crib or bassinet, she will eventually awaken and need the breast to get herself back to sleep. Unfortunately for tired caregivers, babies arouse all night long. The expression “sleep like a baby” was undoubtedly penned by someone who knew nothing about real babies. Although sleep training can begin immediately, it should start in a stepwise fashion, as follows:

In the first week of life, whenever your baby is looking sleepy and getting ready for a nap, try placing him in the crib or bassinet with his eyes open. If your baby falls asleep while eating, gently arouse him (by changing his diaper of tickling his feet, for example) after he’s full. His eyes should be open, at least a little bit, before you put him down. Your baby may need to fuss or cry to get himself to sleep. Let him. Crying is a baby’s way of destressing prior to sleeping. Furthermore, studies have shown that allowing your baby to “cry it out” will not cause any psychological damage to the baby (only to the parents!).

Don’t rock your baby to sleep. Rocking sets a bad precedent, because you’re doing all the work for the baby. The less help a child receives, the better. If you don’t give your child the chance to develop self-soothing skills, he won’t.

Some texts on child rearing recommend sleep aids such as tight swaddling, white noise machines (which can damage a baby’s ears), and baby swings to simulate womb-like conditions. In my opinion, this is a wrong-headed approach to sleep issues and child rearing more generally.

 Remember, the best sleeper is a child who needs only his own body to go to sleep. Furthermore, life is much easier long-term when a baby adapts to a family’s lifestyle, rather than the other way around.

When parents lay out clear expectations and boundaries, babies rise to the occasion, especially when it comes to establishing good sleeping habits. This principle holds true for children of any age.

Which raises another important point. To parent effectively, adults need to take charge and lay down some ground rules; otherwise the baby will be in charge, which is not a pleasant way to live. From experience I can assure you that a family’s quality of life markedly diminishes when they raise a 20-pound tyrant (see blog post #1 titled, “How Not to Raise a 20-pound Tyrant”). Sleep training is just one example—and probably the most important example—of an arena in which parents should establish rules and try stick to them.

Notice I used the word, “try.” We aren’t robots, and it isn’t possible to be rigid all the time. Circumstances will sometimes necessitate giving in to an unhappy, crying child, and that’s okay.

(Third) Despite your best efforts, your baby will likely use the bottle or breast, to some degree, to get himself to sleep. Eventually you will need to separate the process of eating and sleeping. Usually this is done at around two to three months of age. When you think about it, adults don’t need to eat to get themselves to fall asleep (most don’t, anyway)—and children shouldn’t, either.

To separate eating from sleeping, your baby’s last feeding of the day should be given at least 45-60 minutes before bedtime, in a well-lit room with plenty of distractions. After the feeding, engage the baby in some stimulating activities, such as taking a bath or reading a book. At bedtime, place your baby into the crib without offering the breast or bottle. Then leave the room, give the baby the opportunity to fall asleep, and try not to interact until the next feeding. For a two-month-old baby, the next feeding might reasonably occur two hours later. A four-month-old baby, on the other hand, is physiologically capable of sleeping through the whole night without eating for eight to 10 hours. Though your baby may cry at bedtime, and it may be difficult to listen to that crying, resist the urge to pick her up. Remember, you’re giving her the opportunity to develop self-soothing skills, a critical investment in your family’s long-term sleeping future.

The process of separating eating from sleeping can begin early. Various sources recommend sleep training at three months of age, but in my opinion, it should start much earlier. A case in point, when my third child was five-weeks-old, I was desperately tired. One evening I looked at her cute little face (good thing she was so cute!) and said, “You need to sleep all night, or else mommy is NOT going to survive.” An hour after her last feeding, I put my youngest into her crib and walked away. After 20 minutes of crying she was fast asleep, and that was it. She didn’t wake up until 5 am—morning time! Nearly 10 years later she’s still a great sleeper.

Unfortunately, not all kids are this easy to train. With my second daughter, I made the mistake of waiting until she was five-months-old to begin the same process. On the first night of this lovely experience, my stubborn child wailed for three hours. To cope with the incessant screaming, I was forced to use ear plugs (my mother tells me she did laps around our yard when she was sleep training me). The second night she fussed for 20 minutes, and after that she stopped crying at bedtime. The good news is that sleep training usually takes just a few days to complete and rapidly gets easier. Keep in mind that even with successful sleep training, some children will continue to cry themselves to sleep for months. While frustrating, this sort of fussing is harmless. Babies often need to cry to exhaust themselves enough to fall asleep.

When I recount these stories in my office, parents often ask, “How long should I let my baby cry?” The answer is always the same—until she falls asleep (note: this principle doesn’t apply to babies with tetralogy of Fallot, a heart condition in which crying can cause hypoxia, but for healthy babies it’s safe). For sleep training to work, 100% follow through is essential. If a baby cries for an hour and then gets picked up, the only thing the baby has learned is that lots of fussing will garner attention. As Yoda once said, “You must unlearn what you have learned.” A baby needs to learn that when placed in the crib, it’s his job to sleep until the morning. When parents run into and out of a crying baby’s room, they are delivering mixed messages and potentially causing anxiety. Bedtime should be unambiguous.

One last point. If parents know from the outset that they won’t be able to follow through with sleep training, then I usually recommend waiting and not attempting it until they’re ready.