The process of falling asleep is learned behavior. Most parents interpret the word "falling" in "falling asleep" to mean that it is as effortless and accidental as falling off a log. They think that if their child is tired, then he or she will sleep, and if the child will not sleep, then he or she is not tired. Parents do not appreciate the fact that a child who fails to learn to sleep well might he unable to easily fall asleep and stay asleep even when tired.
The process of learning how to sleep is similar to the process of learning how to walk. It is not instructional learning, but rather it is permissive learning in the sense that parents allow the natural expression of sleep patterns just as they permit the expression of gait development when the baby gets up and begins to walk. If parents greatly interfere with this natural development by using artificial devices such as swings for sleep or walkers for ambulation, then there is the opportunity for the development of unhealthy sleep patterns or an abnormal gait. The idea that sleeping well is learned behavior is not new. In 1943, Arnold Gesell and Frances L. Ug wrote in their book, Infant and Child in the Culture Today, "Sleep is behavior. . . The child has to learn to sleep in the same manner that he learns to grasp a spoon or learns to creep and stand and walk."1
The process of falling asleep comes from the brain, not the stomach.2 Most parents appreciate that the subject of nutrition is important for theit growing baby; however, they tend to exaggerate the effects of feeding on sleeping. Also, babies feed and sleep frequently and somewhat irregularly. This natural irregularity might also contribute to the false assumption among parents that if they feed their baby correctly, then he or she will sleep better. The pediatrician can use the parents' concern for wholesome nutrition advantageously to heighten their awareness about sleeping in two ways:
* Parents need to understand that feeding a baby junk food would not be healthy; similarly, sleeping a baby on a junk sleep schedule would not be healthy. This encourages parents to think of sleeping their baby as an active process, not as a passive process which now and then surprisingly occurs.
* Parents are usually willing to accept the inconveniences entailed by frequently feeding their babies and they should be encouraged to accept the similar inconveniences brought on by frequently sleeping their babies. Despite the analogy, parents should be taught that the biologic processes of feeding and sleeping are not tightly linked. Babies can and do fall asleep when they are not fed. Also, during sleep periods, they may have partial or complete arousals and then return to sleep without being fed.
Infant temperament is an important factor to consider when advising parents how to help their child sleep well.3 Regularity or irregularity of biological functions such as sleep is a temperament trait. Easy-temperament babies are by definition more positive in mood, more mild, more approaching, more adaptable, and more regular. Difficult-temperament babies are the opposite.
Parents of easy- temperament babies have an easier time recognizing their baby's drowsy period and these babies appear to be more self-soothing and more able to sustain longer sleep periods. These parents might be very comfortable being advised to place their baby in a crib after soothing when the baby is wide-awake because they know that he or she will fall asleep without crying. After all, the child is tired, and it is the right time for sleeping.
Parents of difficult-temperament babies, especially if this is their first child, might be advised to do whatever they can to help their baby sleep with walks, swings, or car rides. They are not to expect the baby to easily fall asleep or stay asleep very long unassisted, because whatever they do, falling asleep is difficult and the sleep periods are short.4 After a few months, the child learns to associate falling asleep with these activities, but at least there is some sleeping; later, the parents should try to establish more regular sleep patterns.
Gestational age also should be considered when discussing sleep with parents. The baby born early is sleepier than the baby bom later. Parents may be told that shortly after 40 weeks from the expected date of delivery, the brain begins to wake up. The baby appears more alert, scans with more wide-open eyes, and sleeps less. Many parents incorrectly attribute this change of increased alertness to the transition from the hospital to the home, their inability to be as soothing as the nurses in the hospital, or to indigestion. Indigestion, because of the increasing gassiness, is commonly blamed for the baby's increasing agitated wakefulness. Parents should be advised that air swallowing causes gassiness. This is especially true of difficult-temperament infants.
Parents' experience is another important factor. If the baby is a first child, then it is difficult for parents to decide between conflicting advice they receive from their family, friends, and magazines. Because it is difficult for them to appreciate the evolving circadian sleep-wake rhythms in their baby, they may fail to alter their parenting strategies, and because it is difficult for them to appreciate the unique temperament features of their baby, they blindly try to follow the currently popular expert's opinion.
First-time parents want very much to do the "right" thing for their baby and this often confuses them because opinions of many popular writers say that it is never acceptable to let a baby cry. On the other hand, parents of more than one child have the experience to meet their baby's needs and practice entrainment -when the baby is wet or soiled, they change the baby; when the baby is hungry, they feed the baby; when the baby is wakeful, they pick the baby up to play, and when the baby is drowsy, they soothe the baby to sleep. These experienced parents know that these events will occur irregularly and that patterns will emerge over time, and they adjust their parenting behaviors accordingly.
SLEEPING: THE FIRST TWO MONTHS
During the first 2 months, the major variables to consider to help babies sleep well are the infant's temperament, the infant's gestational age, and the parent's experience. There is an association of increased wakefulness with increased crying and the difficult temperament.5 A clinical clue that the child has a difficult temperament is that during the examination, the child is quick to cry and has difficulty soothing him- or herself simply by being given the opportunity to suck. For babies with difficult temperments, sucking to soothe does not work well, and more complex and prolonged maneuvers are required to calm the baby. These babies appear to be excessively aroused and unable to settle easily and sleep well. First-time parents need education and support to develop coping skills because they have great difficulty in helping their baby sleep.
Experienced parents will see times in the mornings and early afternoons when their baby is more responsive to their soothing and is more likely to fall asleep. At those times, these parents will try to be at home where it is darker and quieter in order to help their baby take a nap. Parents should be advised that during a well-defined fussy period or evening crying spell, there is no benefit in letting the baby cry because the result is rarely a sleep period. These evening spells of agitated wakefulness or crying usually are most pronounced during the second month of life, especially at 6 weeks of age.6 After specific social smiling begins, at or shortly after 6 weeks, many babies will first begin to sleep longer at night and later take a longer morning nap.
SLEEPING AT ABOUT TWO MONTHS
Daytime sleep rhythms will soon emerge, but their orderly expression may be interfered with if there is too much ambient stimulation. This stimulation may come in the form of street noises, vibratory car rides, or gentle handling from a parent. If there is excessive stimulation during the time when the nap process is surfacing, then the child's natural curiosity or desire to enjoy the pleasure of the parent will motivate the child to maintain wakefulness and fight sleep. Conversely, if the child naps well, then he will sleep better at night automatically. The author uses Appendix 1, "Sleeping at About Two Months," as a handout to parents for guidelines on helping babies aged 2 months sleep.
SLEEPING AT ABOUT FOUR MONTHS
Sleep rhythms, which are biologically determined, are now more predictable, and parents can begin to use these rhythms to help their child sleep well. The term sleep quality means that not all sleep periods are created equal, and good quality sleep depends on three factors: the temporal placement of the sleep period, the duration of the sleep period, and the consolidation of the sleep period. Poor quality sleep produces only a partial reversal of tiredness, and the child often becomes increasingly irritable and fussy. The author uses Appendix 2, "Sleeping at About Four Months," as a handout to parents for guidelines regarding timing, duration, and consolidation of sleep for babies aged 4 months.
Parents need practical advice that is age-specific and tailored to their child's temperament and their own experiences. Sleeping well is an unappreciated health habit and most sleeping problems may be prevented when parents recognize and respect their baby's own sleep patterns during the first few months.
1. Gesell A, HE FL. Infant and Child in the Culture of Today. New York, NY: Harper; 1943;29d-299.
2. Weissbluih M. Healthy Sleep Habits, Healthy Opth. New York, NY: Fawcctt Book Group; 1987t?6-38.
3. Wtiisbliith M. Sleep-loss stress and temperamental uiifficultness: psychohioloyical prosesses and practical considerations. In: Kohnstamm GA. Bates JE. Rolhbart MK, eds. Temperament in CMtdhood. Chichestei, England: John Wiley & Sons; 1989:357-377.
4. Wi-issbluth M. Crybabies: What Tn Do When Bahv Won't Stop Crying. New York, NY; Berkley Publishing Group; 1989.
5. Weissbluth M. Sleep and the colicky infant. In: Guilleminauh C. Sleep and 1rs Disorders in Children. New York, NY: Raven Tress; 1987:129-141.
6. Weissbluth M. Sleep disorders and cnlic. In: Dershewit: RA. ed. Ambulatorii Petbamr Care. Philadelphia, Pa: JB Lippincott Co; 1988:138-141. 204-205.