Marc Weissbluth's Blog, page 13

SLEEP CONSULT: CHILD #3

#3

Marc Weissbluth, M.D., © 5/24/10

Night Wakings

2 years 3months

Two children

Father works from home; Mother is mostly stay-at-home who freelances

Full-time help

No Disagreements

4/23: Mother: My 2 year old son is a notorious problem sleeper. His issue is night wakings. Once he wakes up in the night he rarely, if ever, is able to put himself back to sleep. He's been this way since he was about 9 months old. He was doing pretty well at sleeping through the night (but with the 5 am wake-ups) until his baby brother was born 7 months ago. Then we had about 2 months of 3 am wakeups that finally abated. Now for seemingly no particular reason, the night wakings have started again. At this point, when we try crying it out he doesn't stop crying-he has cried steadily for an hour with no sign of letting up. And in fact the cries get louder and he gets more hysterical and upset as time goes on. Only Daddy can calm him down but even when my husband is able to get him back to sleep, he will wake up super early and does not "make up" for that lost hour or so of sleep in the night. His sleep deprivation has often affected his otherwise sunny disposition. Several of my friends have said to me "He is always smiling," but they don't typically see him at the end of the day when he is exhausted. But when he hasn't slept well or late enough, by around 4 pm he starts to get clingy, whiny and anxious to go home whether he is with me or his nanny. Also he is shyer and more fearful when he's exhausted as well as less social. I am beyond sleep deprived! For over two years I've been struggling with him not being a great sleeper, in spite of repeated Cry It Out efforts, his internal clock seems to be set somewhere between 4:30 and 5 am. He also goes through stages where night wakings are an issue. In addition to 2 year old, I have a 7 month old son, who although he is a much better sleeper already than his big brother, it still adds to the exhaustion level. There are some days where I literally do not know how I am going to make it through the day. As an individual it's impacted me in every way, I hardly ever have the time or energy to engage in activities I used to enjoy and even going out to dinner with my husband feels like it would cut into my forced early bedtime. It's extremely depressing as I feel trapped by a ridiculously early adult bedtime in order to get any rest at all.

Father: His sleep deprivation has impacted his disposition. He becomes more moody in almost a bipolar way-one minute he's happy and the next he's crying inconsolably. The more tired he is the more intense his mood swings and the more frequent and severe. Attending to him during the night and getting up earlier in the morning affects me greatly. I'm crankier, moodier and more worn out.

Weissbluth Method Infant Nap App.

Filed under: Sleep Consult

Friday Parenting Myth #1

I am starting a new feature called, "Friday Parenting Myth." Just for fun, I decided to debunk some parenting myths that are not related to my specific areas of interest-media and parenting- let me know if you enjoy them! -Daniel Weissbluth

Myth: Green mucus indicates a bacterial sinusitis.

The color of the mucus has no bearing on whether or not sinus drainage is due to viral, allergic , or bacterial causes. The greenish color comes from the iron containing enzyme that the body uses as a natural part of its immune system. The myth that clear mucus is viral or allergic and that yellow/green mucus is bacterial (hence requiring antibiotics) leads to the overuse of antibiotics and this overuse can cause antibiotic resistance. Although many viral infections can lead to green mucus, if there is lots of nasal congestion, swelling or tenderness around the face/cheek/nose or forehead or persistent cough or fever, then a bacterial sinusitis may be the culprit. But green mucus itself does not mean bacterial sinusitis. In a study of children who had yellowish/greenish mucus, the color of the mucus did not determine whether or not the child was more likely to have a bacterial infection nor did it predict that antibiotics shorten the course of illness.

Reference: Todd, J,K,N . Todd, J. Damato, and W.A Todd. 1984 "Bacteriology and Treatment of Purulent Nasopharyngitis: A double blind, placebo controlled Evaluation." The Pediatric Infectious Disease Journal 3 (3): 226-32.

Filed under: Common Myths

Questions and Comments 4-6 Months

Due to the difficulties of our readers in asking and answering each other's comments, we are going to create posts which separate sleep forums by age. Because there are so many questions, we ask that the reader states these items prior to each question:

1. Age of child (corrected age if born before due date)

2. Self-soothing skills: Yes or No?

3. Colic: yes or no?

4. Bedtime and nap time

5. Time required to soothe for bedtime and naps.

After answering these items, please try to create a brief narrative (~300 words max) that describes your problem- the long questions make the forums difficult to load and access by not only us but also the other readers. We believe that these changes will benefit all of the readers on the blog. We also added a category called "Questions and comments" on the sidebar.

Thanks, Marc and Dan Weissbluth

Healthy Sleep Habits, Happy Child

Weissbluth Method Infant Nap App 0-12mos.for iPhones/iPod/iPad

Filed under: Questions and Comments

Questions and Comments 2-4 Months

Due to the difficulties of our readers in asking and answering each other's comments, we are going to create posts which separate sleep forums by age. Because there are so many questions, we ask that the reader states these items prior to each question:

1. Age of child (corrected age if born before due date)

2. Self-soothing skills: Yes or No?

3. Colic: yes or no?

4. Bedtime and nap time

5. Time required to soothe for bedtime and naps.

After answering these items, please try to create a brief narrative (~300 words max) that describes your problem- the long questions make the forums difficult to load and access by not only us but also the other readers. We believe that these changes will benefit all of the readers on the blog. WE also added a category called "Questions and comments" on the sidebar.

Thanks, Marc and Dan Weissbluth

Healthy Sleep Habits, Happy Child

Weissbluth Method Infant Nap App 0-12mos.for iPhones/iPod/iPad

Filed under: Questions and Comments

Questions and Comments Age 0-2 Months

Due to the difficulties of our readers in asking and answering each other's comments, we are going to create posts which separate sleep forums by age. Because there are so many questions, we ask that the reader states these items prior to each question:

1. Age of child (corrected age if born before due date)

2. Self-soothing skills: Yes or No?

3. Colic: yes or no?

4. Bedtime and nap time

5. Time required to soothe for bedtime and naps.

After answering these items, please try to create a brief narrative (~300 words max) that describes your problem- the long questions make the forums difficult to load and access by not only us but also the other readers. We believe that these changes will benefit all of the readers on the blog. WE also added a category called "Questions and comments" on the sidebar.

Thanks, Marc and Dan Weissbluth

Healthy Sleep Habits, Happy Child

Weissbluth Method Infant Nap App 0-12mos.for iPhones/iPod/iPad

Filed under: Questions and Comments

Behavioral Book Review 8

At the time of the writing of the "Sensory Sensitive Child" (Smith and Gouze), "sensory integration disorder" was not a diagnosis included in the DSM IV. To the best of my knowledge, the verdict is still out as to whether it will be included in the next DSM in 2013. Although it currently is not considered a "diagnosis", sensory problems are well documented as associated features in a variety of known neurologic conditions. The authors of this book refer to sensory integration (or "processing") as a "lens" by which you can view the child.

After some discussion from the authors about their personal experiences, the book then describes the seven senses (including balance/position and posture). The next section talks about sensory integration which refers to three processes: sensory modulation, sensory discrimination, and praxis. "Praxis" refers to motor movements (which readers may think of as "output" if the senses are "input").

Then the book moves to an area of how to diagnose sensory problems and how to treat them. Treatment involves adjusting the home environment, the school environment, and changing the social dynamic among peers and other parents. All while addressing commonly associated psychological conditions if they occur- the book has a nice chapter regarding ADHD/depression/anxiety in this population.

The discussion in this book is balanced and fair and I would recommend it to a parent who is concerned that their child is "sensory sensitive." One question I had while looking up the DSM information was: Why does sensory integration/processing need to be classified as a "disorder" or a medical "diagnosis"? If parents and pediatricians are aware of sensory issues in children and refer them to the appropriate therapists, why a separate diagnosis? Is it for billing purposes or is it to strive for greater legitimacy for a documented but hard to quantify phenomenon?

-Daniel Weissbluth

Weissbluth Method Toddler Bedtime App (12-36 months)

Weissbluth Method Infant Nap App.

Filed under: Behavior

SLEEP CONSULT: CHILD #2

4/20: Mother: We are prepared to carry out your recommendation – but are hesitant to put her to sleep at 5:30. This would mean Dad and I wouldn't see her at all at night. Can we move it to 6:30 or at the very latest 7pm? This would allow US to put her to sleep instead of the nanny. I KNOW you said we would have to sacrifice seeing her after work, but that is the one area I'd like to compromise on if you're willing. The graduated extinction plan instructions, when you say to do whatever we can to soothe her, that does NOT include breastfeeding her, right? Dad and I like to bring her into bed with us after one of the night waking around 4 am…is there any room for that in your plan?

4/20: MW: Here is the gentle version:

It is imperative that you both read the 4/12/10 Post entitled What's The Answer on www.weissbluthmethod.wordpress.com which specifically discusses the difficulty of a 5:30pm bedtime. Reading the Comments and Replies will go right to your heart.

The elements of her sleep solution are: Better quality night sleep, developing self soothing skills, and better quality naps. It's a package that works only when all the elements are in place. If the bedtime is 6:30-7:00 and biologically she gets a second wind ("a little rough around the edges" between 4-6pm and after 6pm, her "witching hour" begins…and quickly becomes needy and irritable…and is prone to fussiness.") than you will see no improvement.

Remember that this is a temporary means to an end. Because of your sensitivity regarding Extinction, I chose Graduated Extinction. Your attempt to soothe her should NOT include breastfeeding her because it tightens her association between mom/breast feeding/sleeping and it is precisely this association that has contributed to the sleep issues

Here is the harsh version:

You have to decide whether you want to meet her needs or do what Mom and Dad want for themselves ("This would allow us to put her to sleep…", "Dad and I like to bring her into bed with us…")

You know that we are ultimately talking about brain development or brain damage. It's your choice.

4/20: Mother: OK – we will put her to bed at 5:30. Few questions: The nanny will have to put her to bed – will this be confusing for her? If there are nights when I am home early enough to put her to bed, will this disruption in routine throw her off? How about if the nanny is the one to put her down, but I then go in to comfort her after the designated crying intervals? Will that throw her off?

4/20: MW: Timing is most important for her to sleep well. So she will not be confused if it is the nanny or Mom putting her down but for the next 3 nights, I urge you to let the nanny do it because we want the lights off at 5:30pm and there is the natural temptation for Mom to want to nurse longer beyond that time.

Similarly, for the next 3 nights, have Dad do the comforting after crying bouts to avoid the natural temptation to offer the breast to soothe in the middle of the night. Is Dad willing to do this?

After 3 nights, I think we can reconsider all of these items so Mom can become more involved with soothing at night.

4/21: Mother: Yes, I do agree that I would be more inclined to nurse her to calm her down.

4/21: Father: "Yes, I will be immersed in the process. Hero part sounds good to me."

4/21: MW: Here's a likely scenario. She cries and after 5 minutes, Dad goes in to do all the soothing he can (and yes, no bottle-feeding) until she is more settled. She is not intensely crying or screaming because she has calmed down a little. This might take several minutes or longer. But, and this is very important, our goal is just to take the edge off. Our goal is NOT to make her extremely drowsy because this is in conflict with giving her the opportunity to learn self-soothing. Therefore, Dad does NOT spend 30-40 minutes or more soothing her but instead he helps calm her down for 5-10 minutes. If she is a little calmer after 5-10 minutes, she is put down in her crib. If she is not a little calmer after 5-10 minutes, she is still put down in her crib because Dad put forth a good faith effort to settle her. Either way, he walks away.

At the moment of putting down or anytime thereafter, she may cry and this time, Dad waits 10 minutes before he returns to try 5-10 minutes of soothing. This process repeats itself over the night with incremental additional 5 minutes of delay time. The next night, you start over again with 5-10-15…minutes of delay.

Please agree as a couple to follow this plan so that there will be no 3am argument between Mom and Dad.

4/22: DAY #1 Mother: She has been up for 2 hours now, since 2 am. Both now, and earlier at bedtime she stands at the railing of her crib and will NOT sit or lay back down. Sometimes she falls asleep for a few minutes standing up but she always wakes herself back up and cries again. I don't see how she will be able to fall asleep like this, and I can't leave her in there for upwards of 2 hours crying multiple times per night. The first time, at bedtime, Dad finally went to soothe her and she fell asleep in his arms within minutes so he put her back down. She slept from 8 to 2.

4/22: MW: I know how stressful this is to both of you and you cannot imagine that we are actually in the process of helping her. I have seen this scenario many times and you should not be afraid that we are hurting her. This is a major change for her but it will take here only a few nights to adjust. Either tonight will be a little worse or much, much better. If tonight is a little worse, than tomorrow will be much, much better. Please remain committed to this plan for two more nights. Was she fed once overnight?

Tell me, is it common or unusual for her to have slept from 8pm to 2am?"

4/22: Mother: Yes, I breastfed her once, at 2 am, and then left her to cry after she had enough milk. She fell asleep at the breast but awoke when I put her in the crib and cried, but I left. I'm concerned that both times, at bedtime and during this waking, Dad ended up (inadvertently) soothing her to sleep. Was last night all for nothing? Or was some progress made despite the fact that she ended up falling asleep at Dad's hand? But you're right; it is unusual for her to sleep from 8pm to 2pm. Tonight, I think, I will let Dad feed her for bedtime and handle all of the night waking/one feeding. We might just do full extinction tonight, maybe checking in after 30 min or so if she's really inconsolable. Today, she still had to soothe her to sleep for her nap, but the crying period (less than 30 minutes) was more of a protest cry and more intermittent, as opposed to yesterday's continuous cry. Is that progress?

So, all in all, she has not yet soothed herself to sleep. Also, one other thing to note – she was in a great mood this morning. Way more talkative than usual and really happy overall.

4/23: DAY#2 Mother: She successfully soothed herself to sleep at bedtime in an hour – half the time as the night before. She did wake up at 11:30, at which time I fed her, and then left her in her crib crying. She fell asleep in 10 minutes. However, she awoke again at 4 am with a more urgent cry. We tried for 5-10 minutes but just couldn't leave her to cry for a third time that night and she seemed pretty upset and very awake. We brought her into bed until she awoke again at 7.

4/23: MW: She is on the path to learning how to soothe herself to sleep. Try to not derail her by bringing her to your bed. It is a disservice to her to give her mixed messages: When I cry, sometimes they leave me alone so I might as well go to sleep and sometimes when I cry they bring me to their bed. Crying is hard but sleeplessness is harder. Let her cry to become a better sleeper.

4/26: DAY #5 Mother: "Dad and I THINK she seems happier and less fussy. I have noticed a huge improvement with her night sleep. She is getting 6-8 consolidated hours of sleep per night before she wakes for a quick feeding. This training is a huge departure from our normal parenting style, and though I do see it's working and knew from the beginning it would work, it is still very sad for me to be subjecting her to such angst. I worry she will feel differently towards me, lose trust in me that I will/can comfort her, and feel abandoned. On the positive side, I feel proud of the progress in all of us – she to soothe herself to sleep, and Dad and I to follow through with a tough choice that we know is in her best interest but is a difficult process. I feel more empowered as a mom, and a wife, and the "head" of our household (if I do say so myself) to make and carry through difficult decisions in the best interest of my family. I feel that our marriage, already so strong, has improved. We have more time for each other at night and can focus 100% on each other instead of knowing that our time will be fragmented and involve me going in and out of her room every two hours. We can enjoy a glass of wine together now that I know I don't have to nurse her before it's cleared my system. We can watch a movie in its entirety and eat our dinner while it's still hot. We've bonded over our shared sadness in putting her through this (though admittedly it's very difficult), and rejoiced in our pride that it's working.

5/13 Mother: The sleeping is going very well. Our routine is now as follows. Bedtime around 6/6:30 pm, at which point I breastfeed her to sleep, place her in her crib (asleep) and leave. She sleeps soundly until around 3 am, and I feed her briefly and she goes right back to sleep. She then wakes for the day around 5 am or 6 am. She seems to be much happier. She is learning things very quickly and making huge strides with her speech development. She is not very fussy at all during the day, except for when it very closely nears her bedtime. As an individual and a parent I feel great that we were able to commit to something so difficult for the betterment of my child. It was and is a hard road but ultimately benefited her so much. Our marriage has benefited as we have more time together at night.

Filed under: Sleep Consult

SLEEP CONSULT: CHILD #2

Here is our sleep solution (see child #1):

1. No sleep after 3 pm.

2. The nanny and/or parents will bathe, feed, and soothe her put her down, drowsy but awake, at 5:30pm.

3. Graduated extinction.

4. Naps. Independent of the wake up time, she is put in her crib drowsy but awake for a morning nap after soothing around 9am. 9am is your goal and if she appears sleepy at 7:30 or 8am, try to stretch her towards 9am the best you can. This pattern is repeated between 12-1pm but if there were no morning nap, you might put her down around 11-11:30am because she appears so tired. Your goal is to stretch her towards 12-1pm. [For child #1, nap rhythms are just emerging, especially the morning nap]

Do not have her in the car or stroller at 10am or 2pm if she did not nap in the morning or mid-day respectively because that would knock her out. It is as important that she not sleep out of synch with her biologically age-appropriate nap rhythms as it is for her to sleep in synch with these rhythms.

5. The improvement will be sequential, not simultaneous. First, you will see an improvement in night sleep. Secondly, the morning nap will become more regular and longer which will thirdly permit a regular and then eventually longer mid-day nap to evolve. This process will take a few weeks. Once it is complete, the bedtime may than be moved later.

You should be optimistic because you both agree that something needs to be done, Crying is just a means to an end, better sleep for the entire family.

There probably will be less overall crying if Dad assumes the role of project manager (puts her down and does the responding/soothing at night), when available, and if Mom leaves the house, as much as possible, when there is anticipated crying. The reason for this is that she knows that Dad cannot breast feed and by smell, when she knows that Mom is not there, she might as well sleep because she is tired anyway. This makes it easier for all three of you: She cries less, Mom does not hear the crying, and Dad is the hero! One scenario in the middle of the night or on week-end for naps is that Mom nurses quickly, passes her to Dad, Mom leaves the house, Dad does some brief soothing and puts her down.

Filed under: Sleep Consult

SLEEP CONSULT: CHILD #2

4/19: MW: Here is a synopsis of her sleep issues. She has "never learned to soothe herself to sleep" at sleep onset for night and naps and in the middle of the night. One reason is that she "associates sleep with the breast" and so Mom is "still a slave to feeding her to sleep." Another more subtle reason why she is unable to easily fall asleep unassisted at sleep onset and in the middle of the night is because she is allowed to fall asleep too late at night. Because her bedtime is too late, she wakes up in the morning in a state of higher neurological arousal which causes her to have difficulty or inability to fall asleep unassisted for naps. Additionally, she awakens in the morning too tired so she is unable to sleep in phase with her biological nap rhythms causing the naps to be less restorative.

"Cumulative sleepiness" means that her sleep debt is increasing and she "has become markedly worse in the past few weeks."

What would you suggest?

Marc

Filed under: Sleep Consult

SLEEP CONSULT: CHILD #2

#2

Marc Weissbluth, M.D., © 5/24/11

9 months

Never Learned Self-Soothing

Both Parents Work Outside the Home

Parents wants to Keep Baby Up Late so They Can Put to Sleep

3/22: (9months): Parents: I breastfed her frequently, including breastfeeding her to bed at night, and for naps. I am now still a slave to feeding her to sleep. When we are home on weekends, a nap for her requires me to lay down with her and nurse her until she eventually falls asleep. Bedtime is equally as problematic and complicated. I am the only one who is able to put her to bed as she is still exclusively breastfed and associates sleep with the breast. She has never learned to soothe herself to sleep, so she will frequently wake up within a few minutes of being gingerly placed in her crib and I'll have to go into her room, nurse her back to sleep for a few minutes, and then tip toe out again. This dance often occurs up to 5 times within the first hour of her falling asleep. There are nights when I shuttle back and forth between our bedroom and hers up to 5 or 6 times. Then, usually around 5 am I am so desperate for a few sound hours of uninterrupted sleep (that, and admittedly I like the cuddle time) that I'll bring her into our bed and allow her to nurse as she pleases as we both try to get some fractured shuteye.

4/6-18: Mother: It has become markedly worse in the past few weeks. She has now been waking up nearly every hour, and is ONLY able to fall asleep at the breast. She is unable to soothe herself to sleep. Again, we have to put her in her crib when she's sound asleep. I regret the many tears she's shed, in pain over her extreme fatigue but ultimately unable to do anything about it, having never learned how to properly put herself to sleep. As a full time working mom, I am very sleep deprived! I frequently awake upwards of six to seven times per night, going back and forth between her room and ours, to nurse her back to sleep. I've frequently fallen back asleep in the chair in her nursery, only to awake hours later with a sweaty baby attached to me and an awful kink in my neck. I sleepwalk through most of my days at work and have difficulty concentrating and finding motivation. I return home, excited to see my daughter, but oftentimes unable to summon the necessary energy to properly entertain her. Obviously this is incredibly depressing. As a parent, I am upset that I've failed in teaching my daughter this important skill, although psychologically it is of course easier to fool yourself into thinking you're doing the best for your child by responding to her every cry – even though the intellectual side knows it's really a disservice to her. As a wife, my husband and I have been unable to even go out to dinner and leave her with family or a sitter. Needless to say, after nearly 10 months, my husband and I are desperate for a few hours to ourselves. In the "Sleep Smarts" document, I found sobering – to read in no uncertain terms the ill effects of sleep disorders on all areas of mood and development. Frankly, I'm surprised that we have taken such a laid back stance on sleep, given our dedication to organic, healthful food. Nobody has had success putting her down awake but drowsy. Between 4 and 6 pm she is mostly calm but a little rough around the edges. As long as she is getting her way, and enough attention she is in pretty good spirits. Usually after 6pm is when her "witching hour" begins. At that time, she's in a great mood when we first come home from work but quickly becomes needy and irritable…requiring literal acrobatics to give us a smile or laugh. She is prone to fussiness. Mornings are great for her. However, after an hour to 90 minutes she is fussy again and very needy, ready for her first nap.

4/18; MW: Some babies have difficulty falling asleep unassisted and returning to sleep unassisted. Parents discover that the only way the baby will calm down and sleep a little is when they put forth heroic efforts to soothe their baby by holding, rocking, swinging, feeding, singing, or other calming maneuvers such as massage, lullabies, and so forth. These babies have a proclivity to fuss or cry when they do not receive all of this attention. Some babies (about 20%) have this tendency to be irritable, fussy, or cry for more than three hours per day for more than three days per week for more than three weeks. The fussiness can occur anytime but it tends to be more focused in the late afternoon or evening and it tends to peak at about six weeks of age. These babies are described as having colic but an important point that is not well appreciated is that they may not cry at all if parents/nanny put forth intense efforts to soothe and sleep. About 20% of babies are this way and at 3-4 months they can be described as parent-soothed. They were unable to learn self-soothing. Other children become parent-soothed because of habit or nanny style and never learn self soothing during the first few months of life. Obviously, this is not sustainable forever. Furthermore, because she cycles between light sleep (arousal) and deep sleep throughout the night, she is unable or less able to return to a deep sleep state after a normally occurring arousal from sleep unassisted.

She needs to learn self-soothing so she will have the benefit of uninterrupted (consolidated) sleep, so that Mom and Dad can restore their sleep deficits, and so she can be raised by well rested parents.

I would like to "rip the band aid off" and quickly fix everything. Extinction will work quickly and if you are worried about ignoring your baby's crying, look at the Posts on www.weissbluthmethod.wordpress dated 7/20-22, 7/31, and 8/10/09. If you want a slower approach, graduated extinction, that's all right too. The method check and console won't work well at her age. You will have a new family soon!

4/18: Mother: I don't believe she had colic, but we definitely always have put forth great efforts to keep her happy and calm. At the slightest whimper or protest we'd pick her up and soothe her, never letting her cry in her stroller or in her crib. We've always thought of her as a good, happy baby, but again, this could be in large part due to our soothing efforts and constant attention. For the past few months she wakes frequently, rarely sleeping beyond 3 to 4 hours at a time. Regarding the extinction method, obviously Dad and I are terrified but I do believe this is one of the only ways to fix her sleep issues. I'd probably like to try a more gradual method first.

Weissbluth Method Infant Nap App 0-12mos.

Weissbluth Method Toddler Bedtime App (12-36 months)

Filed under: Sleep Consult