Sleep training: 6 months

This is probably the most controversial topic in parenting for young children. So I'm just going to be 100% honest about our background and thoughts - no judgment.

Background on our situation: I pretty much held Little Bear for all of her naps until she was 4 months old. I know sleep books will say this is bad because she will form a negative sleep association, but I didn't care. She's only a small baby once and I wanted every second with her. By 4 months, the pediatrician told me that I really needed to start putting her in her crib for naps to avoid sleep problems later, so I did. I still hold her for one nap a day sometimes, but she takes the rest of her naps in her crib. She was always a pretty good night sleeper, meaning that she didn't wake up many times in the middle of the night. Since she was about 1 month old, she only wakes up once to nurse; it was around 2:30 or 3am when she was younger and then around 4-5am once she was about 4 months. Sometimes she sleeps through until 6 or 7am, though not regularly. A couple of months ago, she started fighting going back to sleep when she woke up in the middle of the night; she wouldn't go back down until 1 1/2 hours after waking (which was pretty much the length of time between naps during the day). It was maddening. But then she started sleeping until 5 or 6am, so it wasn't really an issue anymore because we would just get "up for the day" at that time. Now, she usually wakes around 5:30 or 6, is up for an hour, and then takes a morning nap. Her naps usually last 45 minutes - 1 hour, though sometimes she sleeps for 1.5-2 hours (more rare). She is awake for 1.5-2 hours between naps at this age (6 months); when she was younger, she was only awake for 1 hour between naps. Our bedtime routine includes nursing, reading books, then having Daddy walk her around and sing/look at stuff until she falls asleep. This used to work great, but now the walking around just stimulates her and it's been taking longer and longer to get her to bed, so we are in the process of trying to adjust our routine. Now we're in the week 26 Wonder Week, which is brutal. She refuses to go to bed until 10 or 11pm; if we get her down earlier, she will sleep for an hour and then wake up screaming. Nothing has worked to get her back to sleep except for holding her all night (not ideal); so for the past 4 nights we have slept holding her. Hence my research into sleep training (which we can't start until the Wonder Week is over anyway).

So, there are pretty much two schools of thought for sleep training: cry-it-out vs. no-cry. At first, we were firmly in the no-cry camp and I read the No Cry Sleep Solution by Elizabeth Pantley in preparation for the 4 month sleep regression (which didn't really hit us hard). I liked the book, but the problem is that we were already doing a lot of the things it recommended. Also, it seems more geared toward babies who wake frequently at night rather than babies who resist going to bed in the first place. I would say this is the "go to" book for the no-cry camp. We felt really strongly about not doing cry-it-out because 1) it just felt wrong to us to sit by and let baby cry and 2) I had read some research that baby's stress hormones remained elevated even after they learned to stop crying (more about that in a minute). Meanwhile, we were getting more and more frustrated with the fact that it sometimes took 2 hours to get her to bed at night but felt like we had to just suck it up because we didn't want to let her cry. Read any attachment parenting blog and they will go on and on about the horrible consequences of letting your child cry and how it will damage them for life. It's enough to scare anyone into just dealing with the horrible sleep patterns.

Next, I took a look in our Baby 411 book (which is really great, by the same authors as the Baby Bargains book, if you're familiar with that one). It has a brief description and comparison of all the popular sleep training methods. I really recommend taking a look at this section. There was a blurb from a doctor about how they didn't believe the attachment parenting line that letting baby cry it out would have a negative long-term impact. It made me stop and rethink my position; I decided to see what the research actually said on the topic rather than just relying on blogs and books, which don't always provide evidence for the advice they give.

A couple of online articles that I found useful were: http://www.parentingscience.com/Ferber-method.html and http://childrensmd.org/browse-by-age-group/newborn-infants/stress-cortisol-and-getting-your-baby-to-sleep/

I found one of the cortisol articles that attachment parenting websites reference (and that I had been relying on when forming my own opinion) and read the actual study myself. I found some issues (some of which are discussed in the online articles above) that led me to question whether those results could actually be generalized to my child. Here were my thoughts, from a researcher perspective:

1. the infants are sleeping in a strange environment, not their own homes

2. relatively small sample size

3. the mothers are not allowed to attend to babies at all during the night; all night care is done by nurses

4. they use an unmodified extinction procedure (no checking on babies when they wake up at all) rather than graduated extinction (check on them every 5 minutes, or at increasing intervals). Unmodified extinction works, but is no longer really recommended because it's too hard for parents to actually do.

5. Infant cortisol levels were high before they even started the sleep transition (!) "On average, on the first day of the sleep training program there was no significant increase in cortisol levels from before to after the sleep routine for infants (before: M = .453, after: M = .580). For infants, there was no significant change in cortisol levels from before to after the sleep routine on the third day of the program (before: M = .512, after: M = .412)." The study points out that cortisol levels were still high on day 3 even though babies weren't crying, and that's what gets capitalized on in the anti-CIO stuff -- they are still stressed, but just aren't crying. But they ignore the fact that the babies were already stressed before they even started the sleep training, probably because they were away from their mothers and in a strange place.

Based on that, I went to the library and got two books: 1) The Happy Sleeper and 2) Solve Your Child's Sleep Problems (Ferber). One thing I'll say right off the bat is that Ferber is not truly hard core "cry it out", which in the scientific literature is called "extinction." Also, both of these books recommend against cry-it-out methods for children younger than 5 months because they don't have the tools to be able to self-soothe yet. And both recommend solid bedtime routines be in place for everyone.

1. The Happy Sleeper has some good introduction chapters on the tug of war between cry-it-out and attachment parenting. They also have tips for babies 0-4 months and 5+ months. So this one would probably be particularly good for you. I really liked a lot of the methods they were recommending, but as far as I know this approach hasn't been tested scientifically. For <5 months old, they have a "sleep ladder" that suggests trying to help baby settle with the least invasive ways possible, working from just verbally reassuring them up to picking them up, stopping at whatever lowest step works. For older babies, they use a version of the Ferber method in which you let your baby cry for 5 minutes max, then go in and verbally reassure them, wait another 5 minutes, etc. They say that your baby has the tools to self soothe (after 5 months) and you have to let them learn how to use them. They equate it to your child trying to figure out a shape sorter and not being able to quite get the pieces in. They may get frustrated, but you have to let them work it out. If you just put the pieces in for them, they will keep turning to you for help and will never do it on their own.

2. The first thing that became apparent from reading the Ferber book is that many people who talk about how bad this method is haven't actually read the book. Ferber talks about how there isn't one solution for every family and how you should do things that you are comfortable with. He recommends putting baby down sleepy but awake and then letting them cry for increasing intervals ("graduated extinction"). So you might wait 3 minutes the first time before checking on them, then 5 minutes, then 10 minutes. Once you reach 10 minutes, you stop lengthening and check on them every 10 minutes if they are still crying. In his method, you can do a little more reassuring than the Happy Sleeper method (which dictates that you have a short script you repeat word for word every time you go in, and touching is not allowed). You can touch baby and reassure them, but avoid doing anything that will actually comfort them to sleep or they won't learn to do it themselves (ex. no patting on the back, etc.). The next night, you start with a longer period, like 5 minutes, 10 minutes, 15 minutes...and so on.

We haven't actually tried either of these methods yet, although I think we are going to start a Ferber approach tomorrow. Little bear has indicated that she is capable of putting herself to sleep -- she put herself to sleep in her crib for a nap yesterday and also did it once while lying on our bed at night. So I know she is able to self soothe. I think that us intervening now by picking her up is just making it worse and, in fact, sometimes she cries more when we hold her than when we just leave her alone to settle. So I can't give personal experience, but I did a literature search for these techniques and here's what I found:

There is ample evidence that a graduated extinction method helps babies go to sleep by themselves. This American Academy of Sleep review goes over the research for all the different sleep training techniques and analyzes which ones have the most scientific evidence to support them. I found the article really helpful, but the take-home points are that 1) full on cry-it-out works, but is hard for parents, 2) graduated extinction seems to work just as well, and 3) avoiding bad sleep habits in the first place is best (aka putting child down to sleep while they are awake from the beginning). There is no evidence that graduated extinction damages a parent's relationship with the child or has negative consequences of any kind. In fact, there is strong evidence that it has no negative effects on the child while simultaneously improving marriage satisfaction and reducing maternal depression (contrary to what attachment parenting websites say). One study assigned children to either graduated extinction or control group. Then they did a follow-up after 6 years. There was no difference between the groups on a variety of measures, including child stress, attachment, psychosocial function, etc.

In conclusion, there is scientific evidence that graduated extinction (aka Ferberizing) works, reduces stress for parents, and has no negative effects on children. So we've basically done a 180 on our position on sleep training. Like I said, we're going to start a Ferber approach tomorrow night. I anticipate that it's going to be hard, but at this point, she still cries at night even when we're holding her, so the crying might as well be in service of a larger goal.