User:LGrunner/sandbox

Infant sleep, or the lack thereof, is a concern that many parents, both new and seasoned, have likely faced. This article discusses several evidence-based approaches to helping infants sleep through the night, as well as training approaches for when infants have trouble falling asleep. The roles of food and temperament with regards to infant sleep are also discussed. First, a summary of the development of sleep patterns across the first year of life is presented.

The development of sleep over the first year
The ‘’’long sustained sleep period (LSP)’’’ is the period of time that a child sleeps without awaking. The length of this period increases dramatically between the first and second months. Between the ages of three and twenty-one months, LSP plateaus, increasing on average only about 30 minutes. In contrast, a child’s longest self-regulated sleep period (LSRSP) is the period of time where a child, without sleep problems, is able to self-initiate sleep without parental intervention upon waking. This self-regulation, also called ‘’’self-soothing’’’, allows the child to consistently use these skills during the nocturnal period. LSRSP dramatically increases in length over the first 4 months, plateaus, and then steadily increases at 9 months. By about 6 months, most infants can sleep 8 hours or more at night uninterrupted or without parental intervention upon awaking.

In terms of actual numbers, an infant from one to three months of age may sleep sixteen to eighteen hours a day in periods that last from three to four hours. By three months the period of sleep lengthens to about four or five hours, with a decrease in the total sleep time to about fourteen or fifteen hours. At three months, they also start to sleep when it is dark and wake when it is light. By 4 months there are 2 distinct napping periods, mid-morning and late afternoon. By 6 months the longest LSP is 6 hours and occurs during the night. There are two 3-or-more hour naps with a total average sleep time of fourteen hours.

Though sleep is a primarily biological process, it can be treated as a behavior. This means that it can be altered and managed through practice and can be learned by the child. Healthy sleep habits can be established during the first four months to lay a foundation for healthy sleep. These habits typically include sleeping in a crib (instead of a car seat, stroller, or swing), being put down to sleep drowsy but awake, and avoiding negative sleep associations, such as nursing to sleep or using a pacifier to fall asleep, which may be hard to break in the future.

Every child is different and each child’s sleep becomes regular at different ages within a particular range. In the first few months of life, each time the baby is laid down for bed and each time he or she awakens is an opportunity for the infant to learn sleep self-initiation and to fall asleep without excessive external help from their caregiver. Experts say that the ideal bedtime for an infant falls between 6 pm and 8 pm, with the ideal wake-up time falling between 6 am and 7 am. At four months of age, infants typically take hour naps two to three times a day, with the third nap dropped by about 9 months. By 1 year of age, the amount of sleep that most infants get nightly approximates to that of adults.

What Helps Infants Sleep
Many parents try to understand, once the baby is asleep, how to keep them sleeping through the night. It is important to have structure in the way a child is put to sleep so that they can establish good sleeping patterns. Researchers have found that babies learn how to fall asleep through a process called operant conditioning, by use of reinforcement. Sleep will reinforce the behaviors that precede it. Regular cues including those mentioned above, such as dimming the lights, singing lullabies, quieting the surrounding environment right before bed or the association of a fixed and specific place for sleep, act as stimuli for the behavior of ‘’self-sustaining sleep’’; that is, sleep that will be triggered by the child him or herself and last through the night. There are additional hypotheses as to what might help and hurt a child in falling asleep and staying asleep. Some researchers believe children who learn to fall asleep on their own have longer sleep cycles as opposed to falling asleep with Parental Presence (“See section: Parental Presence”). As well, comforting children, upon awakening, outside of their beds is associated with poor sleep consolidation. Comforting should take place within the child’s bed area. Parental attention will however act as reinforcement for signaling or calling out to the caregiver if intervention is too long or busy (such as feeding). Attending to the infant upon being signaled should be as short as possible, if the goal is to train the child to put him/herself back to sleep if s/he wakes up in the night. When the caregiver provides intense intervention, the infants’ crying is “rewarded” by the comfort of a parent. The child will deduce that if s/he cries, the parent will provide excessive attention.

The First Four Months
‘’’Infant sleep disturbance’’’ or ‘’’ISD’’’ is defined by frequent night awakening, crying, delay in falling asleep (the onset of sleep) and co-sleeping not of the parents’ choice but as a result to the disturbance. During the first four months, babies sometimes lack the ability to put themselves back to sleep upon waking up in the night. This is what produces sleep onset delays. Sleep onset delays are described as the unfortunate delay of the onset of sleep whether the baby is by itself, attempting self-initiation (trying to put themselves to sleep by sole effort), or if they are with the parent or caregiver. Methods to remediate this onset delay will be discussed below. Babies of approximately four months of age may be capable of going to sleep with minimum adult intervention, and some are capable of sleeping through the night without needing to be fed. Therefore, parents may begin at this time to consider the various methods that exist to help train their child to sleep better at night and at naptime. Training methods are usually implemented when infants reach five months of age.

Five Months and Older
Before embarking on a sleep training endeavor, however, parents should consult with their baby's pediatrician to determine whether their baby has any special needs, medical concerns, or other issues that may affect his or her sleep, or whether the physician has any general concerns about the baby's sleep and the parents' plan.[2] Experts typically agree that before any sleep training occurs, it is optimal that the infant be well rested. This may mean putting the child to bed very early for a few nights preceding the anticipated training in order to make up for prior sleep deficits. The more well rested the child is, the less difficult it should be for him or her to fall asleep during training.[3] The manner in which a parent chooses to train their child to sleep can often be a matter of controversy. Most approaches to treatment involve some version of scheduled ignoring.

Focal Feeding
‘’’Focal Feeding,’’’ which is a method of feeding an infant at one time between 10pm and 12pm, is used to “teach” infants how to sleep through the night. Consistency must be maintained as to the time of feeding, even if it requires waking the infant up. This treatment has been shown to yield infant’s sleep behavior and temperament as more predictable. Three weeks of this treatment has yielded significantly longer sleep episodes at night. Eight weeks of treatment may find the infant sleeping entirely through the night compared to infants who practice no training at all. This method even yields better sleep patterns for parents, for they do not have to wake up in the night to care for a crying baby. With this treatment, infants are feed less frequently in the night and may compensate for the relatively long nighttime sleep interval without a feed by consuming more milk in the early morning.

Controlled Crying or Ferberization
The ‘’’Controlled crying’’’ approach was popularized by pediatrician Richard Ferber, and has accordingly taken on the title of ‘’’ferberization’’’. Controlled crying, or ferberization, refers generally to the practice of putting a child down for bed in his or her crib awake, following a predictable, loving bedtime routine. The parents are to respond to the child's crying in graduated increments of time, and for a limited duration. The parents' response time is gradually lengthened, and the parents, when they do respond, can provide the child with soothing words and pats but are not to pick up or feed the child. The purpose of this approach is to allow the child to gain the ability to fall asleep on his or her own.[5]

Minimal Check
‘’’Minimal check’’’ involves checking on the infant briefly at regular intervals during the time of the child’s signaling. ‘’Signaling’’ is when the child signals for the parent through the use of crying or screaming. Thus, if the child is crying parents are allowed to attend to him or her and must give themselves a set time period of 2 minutes, for example. Then the parent must return to the room from which they came at the end of the 2 minutes. If the child is still crying, the parent is allowed to go back into the child’s room but only after another set period of time, say 3 minutes. This cycle is repeated until the child has stopped crying and has settled back into sleep..

Graduated Scheduled Ignoring
‘’’Graduated scheduled ignoring’’’ uses the same frame as minimal check. Parents check on the child for a certain amount of time and then wait a predetermined amount of time before checking on the child again. The difference that is significant with Graduated Scheduled Ignoring is the time before responding to the crying; in other words, the amount of time the parent waits before responding is increased with each instance. For example, a parent may wait 2 minutes before attending to the child. The next time the parent may wait 4 minutes and then the next time the parent will wait 6 minutes. The amount of wait time is increased with each interaction. 2. ‘’’Decremental graduated scheduled ignoring’’’ differs in that the time spent interacting with the infant during bedtime (or settling) and night awakenings is systematically decreased, compared to the time before answering to signaling. This is a second way to enforce Graduated Scheduled Ignoring, by decreasing the amount of interaction time. A parent may comfort the child for 5 minutes, the next time 3 minutes, and continue until there is almost no checking at all. 2.

Extinction
‘’’Extinction’’’, also referred to as ‘’’Unmodified Scheduled Ignoring’’’ by other sources refers to the practice of allowing a child to cry indefinitely at bedtime and up to one hour at naptime (or 20 minutes for infants who were colicky in their first four months) in order to learn to fall asleep and return to sleep unassisted. Marc Weissbluth, physician and author of ‘’Healthy Sleep Habits, Happy Child’’, makes room for a variety of approaches in his text but argues that the extinction method provides results more quickly than ferberization, and accordingly may be easier on the child. The text discusses the harmful consequences of poor sleep habits and inadequate sleep, arguing that these consequences clearly outweigh the consequences that critics of the extinction method claim children suffer while undergoing sleep training.[6] ‘’’Unmodified scheduled ignoring’’’ is just like the technique of extinction, placing the infant to bed with no further intervention (unless the child is sick, etc.) The only difference is if parents do check in whenever the child signals, they are to respond minimally “if there is no apparent reason for the crying”. 2.

Parental presence
‘’’Parental presence’’’ is similar to co-sleeping, but is broader because that parent and infant may sleep in the same room, not the same space or bed. The parent is to offer minimal comfort to signaling. The point is for the child to be able to see the parent, but not for the parent to intervene. Parents using this method may be advised to begin their efforts when the child is at least 6 months of age and continue until the child is about 2 years; at this point, more explicit reinforcers of sleep (such as blankets and fixed space) come into play.

Fading
‘’’Fading’’’ is when properties of the checking interaction are made to be less rewarding such as offering water instead of milk during a night awakening.

Medication
‘’’Medication’’’ is another treatment option and is said to not be as effective in treating ISD when used alone. Its use may result in “temporary increase in the likelihood of an infant sleeping through the night, but its effects are neither consistent nor durable”. This is due to the variability in responses of infants to the medications. Doses of sleep sedatives such as Trimeprazine Tartrate are commonly used and must be given under the direction of a physician. 2.

Other influences on infant sleep
A number of factors have been shown to be associated with problems in sleep consolidation, including a child’s temperament, the degree to which s/he is breast-fed vs. bottle-fed, and his/her activities and sleepiness during the day. Moreover, co-sleeping, which is defined here as sharing a room or bed with parents or siblings in response to an awakening, can be detrimental to sleep consolidation. It is important to note that none of these factors have been directly shown to cause children’s sleep consolidation issues. In terms of infant feeding, breastfeeding is has been found to be associated with more waking at night than bottle-fed infants because of the infant’s ability to digest breast milk more quickly than formula. Thus, breast-fed infants have been observed to begin sleeping through the night at a later age than bottle-fed infants: bottle fed infants tend to begin sleeping through the night between 6-8 weeks, while breastfed infants make take until 17 weeks before sleeping through the night. Seventeen weeks of age is still within the first 4-5 months of the infants’ life; therefore, this cannot really be considered a delay in sleep consolidation. There are many benefits to breastfeeding infants, Lastly, temperament also seems to yield correlations with sleep patterns. Researchers believe that infants classified as “difficult,” as well as those who are very sensitive to changes in the environment, tend to have a harder time sleeping through the night. Parents whose infants sleep through the night generally rate their infant’s temperaments more favorably than parents whose infant continue to wake; however, it is hard to determine if a given temperament causes sleep problems or if sleep problems promote specific temperaments or behaviors. Temperament