Scheduled Awakenings: The Original No-Cry Method

Long before there was a “no-cry” solution to baby sleep training, there was a thing called “Scheduled Awakenings”.

What? You’ve never heard of scheduled awakenings? There’s a reason for that. It’s really really hard to do. Too bad, though: it appears to work.

Scheduled Awakenings: The Original No-Cry Method

In 1980, Rita J. McGarr was completing her Bachelor of Science in Nursing degree at Stanford. For her thesis, project, she performed a case study of a 3-month infant with frequent night awakenings. The objective of Ms. McGarr’s study was to test whether a mother could shape her baby’s waking pattern. Just prior to the time the baby would wake up naturally, the mom would wake the baby up at intervals using a music box. Then she would gradually move “music box time” later in the evening. The baby went from sleeping 5 hours straight to sleeping 7 hours sleep. Not great, but enough to get published. And a new sleep training method was born.

The method Rita McGarr tested came from Behavioral Learning Theory. Briefly, the theory says that all behavior can be learned. What’s going on inside the learner’s head is not as important. The idea that any behavior, including sleep, can be taught leads eventually to parent-led sleep training methods.

Other investigators would later test the method. The best of these compared scheduled awakenings to other methods such as “graduated extinction“. It turns out to work very well.

Here’s How it Works

First, you have to keep a log. Keeping records became a lot easier in the 21st century with the advent of smart phones. There was no more taking notes in crayon on toilet paper!

First, you put the baby down the same time every night. This is an important first step in any baby sleep method. You write down the hour the baby wakes up. When she wakes up, you do what you usually do to get her to go back to sleep: rock her, feed her, etc. You should do this every night for as many nights as it takes to see a pattern emerge. Obviously, one night is too few. A week may be to many. I usually settle on three days.

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Once you have a schedule of the baby’s wake-up schedule, you set your alarm clock. Again, the smart phone comes in handy. You want to set the clock for 15 minutes prior to the time you’ve noted that the baby usually wakes up.

The waking up process should be as gentle as possible. I like Rita McGarr’s music box idea. When the baby is awake, you nurse or feed her as you usually do, and put her back down to sleep.

After about a week of this, you gradually increase the times you go in to wake the baby up. A good starting point is 15 minute increments. For example, if you had been waking her up at 1:00 AM, start waking her up at 1:15, etc. Do this three nights in a row.

scheduled awakenings

Then start dropping the awakenings. If the baby had been waking up only once, great, drop the scheduled awakening and you are done. If she’s doing it more than once, start dropping them in order: Drop the first awakening first, then the second, etc.

Et Voilà!

Now you have a sleeping baby! You did an awful lot of work to get here. There is a good chance that you would have about the same success with scheduled awakenings as you would have had with one of the extinction techniques, only without the crying.

Problems with the Technique

Schedule awakening training is difficult. I mean, it’s really difficult. Of all the sleep training techniques, it is clearly the most labor-intensive. It asks of parents that they wake themselves up, rather than being awakened by the baby. It also requires more time than other techniques. Even if there are no set-backs along the way, the entire process will require a minimum of two weeks. This is something to consider in light of the following facts: all the extinction techniques, including old-school Holtian cry-it-out, require 3-5 days; Extinction is at worst equally effective as scheduled awakenings; Finally, there is no evidence that extinction techniques have any negative effects on babies or bonding with caregivers.

Scheduled awakenings remains a viable option, especially parents who absolutely cannot stand hearing a baby cry. I know how to train a baby this way, and I can help you do it. How many parents do I know who have tried it? I have that number memorized: it’s zero. For most parents, especially sleep-deprived, stressed out parents, the scheduled wake-ups are more stressful, not less.scheduled awakenings 3

Nevertheless, if you’ve “tried everything” to get the baby to sleep, and you haven’t tried scheduled awakenings, you have not in fact tried everything! Behavioral learning works. It requires strength and patience. You got this.

 

How to Do Bedtime Fading: Best Sleep Training Method?

The so-called “cry it out” techniques for sleep training are getting a lot of attention. Meanwhile, there is another method that gets very little press, but which is highly effective. It’s called “bedtime fading”.

What is Bedtime Fading?

Bedtime fading is a method for teaching a child to fall asleep that is based on a simple principle: a child who is not tired will not go to sleep!

Babies and children are famous for “fighting” bedtime. Parents tell me that their child “fights” sleep. Or they tell me the child fights the parents at bedtime. The truth is that the child is fighting neither sleep nor the parents. She is fighting the time. She isn’t ready to sleep yet. Forcing the baby to bed earlier than she wants to is a recipe for conflict. Worse, the baby may develop negative associations surrounding sleep. This is never a good thing.

The Three Key Features of Bedtime Fading

One key feature of bedtime fading is finding the child’s “natural” time of sleep. This is presumably later than the perplexed parents want, but it’s what the baby wants. There are a couple of ways of finding out what the natural time of sleep is. See “The Bedtime Fading Technique” below.

Another key feature is “sleep onset latency“. This is nothing more than the amount of time it takes a person to fall asleep after getting into bed (or the crib in this case). Sleep experts agree that it’s never a good idea to have a long sleep onset latency, with a limit at about 20 minutes. Anything longer than that suggests the individual will not or cannot sleep. Ideally, you want the child to be falling asleep within 10 minutes. Less than 5 minutes, though ok, suggests that the child has a “severe sleep debt”. This is another way of saying “she’s totally exhausted”.

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The third feature are good sleep associations. We want the child to associate going to sleep with calm and quiet. We want her to feel comfortable and safe. This step is essential to teaching the child to self-soothe, and to wind herself down to sleep on her own, without assistance from caregivers.

How to Do Bedtime Fading

Step One

The first step is to determine the baby’s natural sleep time. There are at least two ways to figure this out. The first is to keep a sleep diary. Parents or caregivers write down the times the child falls asleep every day. They should do this for every nap as well. Doing so provides useful information for them and for the sleep coach. The last time she falls asleep is probably the time she is “set” to fall asleep.Print

A second method for determining baby’s sleep time is called the “response cost” method.

[A Digression: The official name of this method is called “bedtime fading with response cost”. I never liked this expression. It’s high-tech expression for a truly low-tech idea.]

It works like this: you put the baby to bed at the time you want (the desired bedtime). If the child doesn’t fall asleep within 15 minutes, you remove the child from the crib or bed and allow her to play (quietly) and otherwise stay awake for 30-60 minutes. This is the “response cost” to the child. Then you try again. If the child still won’t fall asleep within 15 minutes, you repeat the procedure. You do this until the child falls asleep rapidly. Now you’ve found the child’s natural bed time.

Step Two

For at least two days, you treat this later bedtime like the normal bedtime. This means establishing a steady, consistent bedtime ritual.  You want to aim for any activity that promotes calm and quiet.  I recommend starting the routine at dinner time, no matter how late. From then on the routine is completely predictable. It’s usually a mix of these activities: a warm bath, brushing teeth (if she has teeth), book reading, lullabies, prayer, etc.

Step Three

From here, you gradually fade bedtime earlier to your desired bedtime (hence “bedtime fading”). Experts differ as to the number of minutes to fade and the number of days to stay at each bedtime. Some recommend fading 30 minutes earlier every night until hitting the target. Others recommend moving in 15 minute increments. This is my preference. Half an hour is too big a jump for some children. I also recommend two days for each bedtime. This means the entire bedtime fading technique may require two weeks or more to complete. It is well worth the effort.bedtime fading 3

Setbacks can happen. Sometimes the child will revert to her previous “natural bedtime”. If so, I recommend repeating the fading technique, but this time taking it more slowly. Perhaps spend three days at each time point.

Other children might fall asleep well as a result of a successful bedtime fading campaign but will continue to wake up frequently at night. In this case, many experts recommend using an extinction method (since we don’t want to call it by its more infamous name. Okay, okay: cry it out.)

This is Great! How Come I’ve Never Heard of It?

bedtime fading 4
This lucky man got to hit in front of Bonds

Good question. Here’s a baseball analogy: Say your team has a power hitter batting in the clean-up spot (fourth in the order). He’s having a monster year. By the end of April he already has 12 home runs. People are already starting to compare him to Barry Bonds or even Babe Ruth. Camera crews follow him to every ballpark. He’s all they talk about during the sports segment on the evening news. Meanwhile, the guy hitting in front of him (the number three hitter) is quietly having a career year. He’s in the top 5 in just about every offensive statistical category. Why? Because pitchers don’t want to face the monster following him. So they throw strikes to the number three hitter, trying to get him out. And instead of getting him out, he’s getting hits. But no one pays attention because the monster sucks up all the headlines.

That’s kind of like what’s happened to bedtime fading. Extinction methods are like the home run hitter hitting clean-up. Bedtime fading is like the number three guy racking up all the amazing numbers that no one notices. Bedtime fading is an amazingly successful technique that is based on all the principles we know are essential for good sleep: a tired child, consistency, routine, and good sleep associations.

So keep this method in mind. If you need any help figuring out how to do it, that’s why I’m here.

 

Cry It Out is OK, Say Researchers

So it turns out that Cry It Out is ok, after all!

I believe that no major sleep expert actually recommends “cry-it-out”. Nevertheless, the term has become attached to a method formally called “graduated extinction“. The method is made most famous by Dr. Richard Ferber in his 1986 classic “Solve Your Child’s Sleep Problems”.

Graduated extinction was criticized by proponents of “Attachment Parenting” styles of sleep training, particularly William Sears. In “The Baby Sleep Book”, Sears makes frequent reference to the relationship between baby crying and elevated levels of the stress hormone cortisol. Lots of crying leads to cortisol going up.  Sears says this leads to all kinds of negative outcomes for baby. For example:

“Science (sic) tells us that when babies cry alone and unattended, they experience panic and anxiety. Their bodies and brains are flooded with adrenaline and cortisol stress hormones. Science has also found that when developing brain tissue is exposed to these hormones for prolonged periods, these nerves won’t form connections to other nerves and will degenerate. Is it therefore possible that infants who endure many nights or weeks of crying it out alone are actually suffering harmful neurological effects that may have permanent implications on the development of sections of their brain?”

It was a rhetorical question. Sears goes on to say that cortisol damages babies brains in all kinds of ways. In extreme cases, I will grant that chronic stress is bad for babies. But the “research” Sears cites has nothing to do with crying at bedtime. No one had ever measured levels of stress hormones at bedtime. Furthermore, no one had tested whether different sleep methods stressed out babies more than other sleep methods. No one had asked whether a particular sleep method damaged (or helped) develop a bond between baby and mother.

Until now.

New Research Says Cry It Out is OK

Investigators in Australia asked mothers in pediatric clinics if their babies had a sleep problem. The doctors recruited 43 babies between 6-16 months of age. They divided the babies randomly into three groups. One was assigned to try “graduated extinction” (AKA “cry-it-out”).  Another group would try “bedtime fading“. This is a technique in which you move bedtime later in the evening to match the child’s “internal” bedtime clock, then gradually move bedtime back to your desired time. For example, if you want your baby to go to bed at 8:30, but she usually does not fall asleep until 10:30, choose 10:30 as his temporary bedtime. Then move bedtime gradually earlier.

A third group in the Australia study was handed a list of sleep instructions. This was the “control group” for comparison to the graduated extinction and the bedtime fading group.

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During the study, investigators had the parents swipe a cotton swab on the inside of their babies’ mouths to measure the hormone cortisol. Motion sensors were given to parents in the study to measure baby’s wakefulness (actigraphy). The parents also filled out questionnaires to measure their own stress and anxiety. Finally, the mothers and babies took a standardized behavior test to measure their level of attachment.

Cry It Out is OK with Respect to Sleep
cry it out is ok

Compared with the control group, babies taught with graduated extinction and bedtime fading took less time to fall asleep (sleep latency, panel A). They also woke up at night less often (panels C). If these babies did wake up, they stayed awake fewer minutes than the control group (panel B).

You can see that the control group showed some improvements across the board. This suggests that sleep education helps. It also could mean simply that babies sleep better as they mature. This is why it is so important to include a control group. To study an intervention like a sleep method, you need to know what the “background” improvement is. Otherwise you’ll never really know if your intervention works.

Babies in the graduated extinction group got more hours of sleep in the early stages of the study. However, these gains appeared to disappear by the end (panel D).

Cry It Out is Ok? What About Stress?

cry it out is ok 6
The central issue in the Australian study was stress. Does graduated extinction really raise cortisol? Does the method damage the relationship between mother and baby? The answer was ‘no’.

Other researchers have shown that minor stressors can elevate cortisol levels in newborns; But this goes effect goes away at about 4 months of age. The Australian study only looked at babies older than 6 months. So you might think that this study misses an important point that Dr. Sears and others were trying to make.

However, the investigators did something clever to get around this limitation. Sears and others insinuate that cry-it-out sleep methods cause chronic increases in cortisol. These investigators measured cortisol twice, once in the morning and once in the afternoon. They saw no difference among groups. This suggests that cry it out is ok from the standpoint of stress as well.

So Cry It Out is OK for Baby: What About for Mom?

Mothers in both intervention groups reported less stress than mothers in the control group. You see this in panels C and D in the second figure I show here. The researchers also looked at mother-baby bonding one year after the study was over. They found no differences in the ability of moms and babies to bond with one another. The levels of attachment between the two appeared to be identical in all groups. Finally, the babies in the cry-it-out groups had no more emotional or behavior problems than the control babies.cry it out is ok 7

This last finding was similar to a much larger study published in 2012. That study, also done in Australia, involved 326 children. These investigators found that sleep method had no effect on attachment, bonding, and behavior. This study was five years after the intervention, suggesting that there was nothing was messed up permanently by allowing your baby to cry at bedtime.

Limitations: Maybe Cry It Out is OK for Some, But Not for All?

The investigators acknowledge that their study has some problems. For one thing, it was relatively small. There were only 43 babies involved. With small studies like this, there’s a chance that you cannot generalize the results to all babies. This includes your own baby! That is why the investigators were careful to compare their results to other similar studies. We can believe in your conclusion more strongly if you do your study in a slightly different way, but come up with the same answers.

They also noted that they didn’t measure cortisol continuously, or even at night when the crying was happening. It’s possible that cortisol does indeed go up in a crying baby. It would be surprising if it didn’t! But the study was looking at chronic elevations. That is, cortisol stays up over time. This, after all, is the accusation that Sears and others hurl at the Ferber method. Here, the investigators have a point: sleep method does not change cortisol long-term.

Implications

The investigators conclude from these data that sleep education alone may not be enough to get your baby to sleep. You may need an intervention if your baby has a sleep problem beyond 6 months of age. They propose an interesting combination of methods: Their results suggest that bedtime fading could be done first. Then graduated extinction could be used to reduce nighttime wakings.cry it out is ok 8

Conclusions

  • Graduated extinction (cry it out) and bedtime fading are both effective.
  • Extinction-based methods do not stress out a baby chronically
  • These methods do no have long-term effects on a baby’s emotional life or her attachment to her mother.

My suggestion: find a sleep method that works for you and don’t worry about it. Show your baby a lot of love and attention and you don’t need to worry about bedtime. Above all, stay consistent: find a routine that works for you and stick with it!

If you need help doing that, go ahead and contact me. I can help.

Premature Baby Sleep Training: When and How

Premature baby sleep training is a special kind of sleep training.

The basic principles of sleep training apply, with a twist. We have to pay attention to a couple key questions. “What is your baby’s corrected gestational age?” and “Does your baby have any special difficulties related to her prematurity?”

I will review some basics about preemies and sleep training. Then I’ll talk about which sleep training methods are best for premature babies and why.

Premature Baby Sleep Training

The most important thing to know about premature babies is the most obvious. They were born early! But it might be better to say that they were born before they were ready. Harvey Karp would argue that even full-term babies are born before they are ready to be here on earth, but that is another subject!

Sometimes a premature baby will be born before her lungs are ready to breathe air on earth. These babies obviously need to stay in the Neonatal ICU (NICU) until they can breathe on their own. Still other preemies are born before they are able to eat on their own. They too need to stay in at least a special care nursery until they can “remember to eat”.

But the most important difference for our purposes is premature baby sleep. Premature babies sleep differently from full-term babies because, just like their lungs and stomachs are immature, so are their brains.

Turn Down the Noise!

An important difference between us grown-ups and babies is that we have a filter. We can filter out sounds, feelings, smells, tastes, and sights that interfere with our ability to focus. Babies can’t do this. They have to pay attention to everything. And so it’s easier for babies to become overwhelmed by too much sensation. This is what we mean by “overstimulation”. When babies get overstimulated they get fussy, they cry more, they eat poorly, and they don’t sleep! Premature Baby Sleep Training 2

How ever you decide to sleep train your preemie, you have to keep this in mind, particularly if she is still younger than her due date. The risk of overstimulation can be too high with babies with a corrected gestational age less than 40 weeks. For these babies it may be best to put off sleep training.

So You Say You’re Ready for Premature Baby Sleep Training?

Maybe so, but is the baby ready? There are a couple of ways to tell. First, does the baby weigh around what a full-term baby weighs? If she weighs less than 5 lbs 8 oz, it may be difficult. She’ll need to do a lot a feeding for catch-up growth. I recommend discussing with the pediatrician if you want to start at a smaller weight.

Does the baby have any problems related to her prematurity? For example, many preemies have reflux. A premature baby with reflux may be fussy and have trouble settling. Other premature babies go home from the hospital needing oxygen. These are babies I might not recommend sleep training until they are breathing room air. Again, this is something to discuss with the pediatrician.

Premature Baby Sleep Training MethodsPremature Baby Sleep Training 3

All the various sleep training methods fit into two broad groups: baby-led and parent-led. Briefly, baby-led methods lean heavily on paying attention to the premature baby sleep cues. These are eye-rubbing, yawning, and beginnings of fussiness. Parent-led methods lean heavily on providing structure for baby sleep. This includes starting meals at the same time every day, and encouraging naps at the same time every day.

The reality of premature baby sleep training is much simpler: it’s a combination of baby-led and parent-led methods. This is sometimes referred to as “combination” sleep training. That is to say that the most successful baby sleep training that I know of involves a combination of following baby’s cues and providing structure. This is the method I recommend in my practice.

I do make a slight exception for premature babies. Because feeding and growing is so important, I lean more toward following her feeding cues. Your pediatrician may have given you target for the number of calories she should have every day. If so, it’s best to do what you can to make sure she gets enough formula or breast milk to do catch-up growth.

The Ideal Age for Premature Baby Sleep Training

So what is the ideal age to sleep train a premature baby? The key is corrected gestational age. If the baby were full term, the ideal age for sleep training would be four months of age. Prior to that age, you have laid most of the groundwork already. You’ve learned baby sleep cues, and you’ve started providing structure to the baby’s day. You might not even need to sleep train at this point! If you’re doing premature baby sleep training, you want to aim for four months corrected. For example, if your preemie were born at 36 weeks (4 weeks early), your goal should be five months of age. At this point the baby can be expected, reasonably, to achieve the sleep patterns of a four month old full term baby.
Premature Baby Sleep Training 4
I say “ideal age” for premature baby sleep training, because this is the age at which I believe you’ll have the most success. Four months corrected is about the age when a girl baby can soothe herself to sleep. You can put these girls down in the crib fully awake. And they can learn to fall asleep without assistance. For boys, the age is somewhat later. Certainly by six months (corrected) a boy can master the self-soothing skills needed to settle himself… and to sleep through the night (if he’s well-fed!)

Summary

  • Premature baby sleep training is just like full-term sleep training, with some exceptions. You need to pay attention to any health issues related to prematurity. And you should lean more towards following her cues.
  • Providing structure is still important. Whichever method you choose to sleep train your preemie, she’ll do better if her day is as regular and as predictable as possible.
  • Expect a girl preemie to sleep through the night at around 4 months (corrected), and a boy by 6 months (corrected)
  • If there are any health concerns at all, please contact your pediatrician.
  • If the baby’s health checks out, you still are having sleep difficulties, I can help!

Sleep Training Twins

If you’ve got twins (or higher multiples!) I don’t need to tell you: it’s a lot of work. It’s not twice the work, it’s four times the work (exponential, not additive, for the math whizzes out there). Sleep training twins is not easy, but it’s not very different from sleep training “singletons”.

The books you may find on the subject will tell you basically the same things you’d learn from any general resource about baby sleep. There are only two basic differences in strategy. I’ll tell you what they are up front: 1) Keep a tight schedule. 2) Occasionally break the “never wake a sleeping baby” rule. Now, to the details!

Sleep Training Twins

1) Feed Both at the Same Time

Here’s where the rubber hits the road in sleep training twins. The question is not whether you should feed them together (or one right after the other). The question is when. If you want to avoid going crazy, you’re going to have to feed the twins together. If you’re okay with going crazy, who am I to judge? But if you want to maintain your sanity, here’s what you do:

From the time you come home from the hospital, depending on the gestational age of the twins, you’ll be feeding them every 2-3 hours. Hopefully, this interval is every 3 hours, for so many reasons! Not least among these, you’ll have to plan your day around feeding, and the entire process could last one hour. That leaves you 2 hour intervals to do everything else you need to do, like take them to the pediatrician, bathe yourself, eat, exercise, and most important, sleep!

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By “entire process”, I mean preparing the bottles (less time if you’re breastfeeding them. And if you are, congratulations!) changing diapers, changing clothes, and putting them back down. This truly can occupy one hour. Meanwhile, the clock has been ticking and twin A will need to start feeding again in three hours. So you have to be efficient and have a system down.

2) Waking the sleeper(s)

To do this, you may have to wake one or both of them up! This is a violation of the “never wake a sleeping baby rule”, but I cannot see a way past it. To do otherwise is to risk getting out of sync. Getting out of sync means chaos. And chaos is never good.sleep training twins 2

The good news is that you probably won’t have to wake one or both of them up for very long. If you do this right, they’ll fall into a pattern and “learn” to wake up around feeding time anyway. Which leads me to the next, and perhaps most important tip:

3) Consistency, Consistency, Consistency

There! I’ve said it three times. Their day should be as regular and as predictable as possible. That is to say, things should occur in the same sequence, at roughly the same time, every day. The fewer disruptions you introduce, the better. The disruptions will introduce themselves, believe me! There are a couple of tricks you can do to help you get a routine going.

  • Let night be dark and day be light. Sounds kinda Biblical, doesn’t it? But the one of the best ways to get your multiples on a schedule is to allow their own circadian rhythms to coordinate with the day-night cycle.
  • Get a white noise machine. All your babies’ senses are working and they can’t filter them out! The best way to help them through this problem is to distract them with soothing noise.
  • Keep a log. I know it sounds dumb. But you’re going to be sleep-deprived. Writing stuff down will help you keep track and avoid confusion.
  • Have them sleep together. As long as they are swaddled, placed on a firm surface, and there is no loose bedding, this will save you on precious time, energy, and laundry detergent!
  • Incorporate time for yourself in the schedule. Just because you are sleep training twins doesn’t mean you don’t have to sleep, eat healthy, and exercise. You still need all three. You can’t take care of multiples if you are a physical and mental basket case! Take care of you, too.

2-3-4 Nap Schedule

2-3-4 Go!

What is the 2-3-4 nap schedule?

It’s not a guideline. It’s more like an observation. And it’s particularly associated with the 6-month old baby.

The name “2-3-4” refers to the number of hours between naps during the day. It works like this:
[Just a note: What follows is complete fantasy. How we wish every day could be as perfect as the one I’m about to describe! But hey, we can dream, can’t we?]

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Baby wakes up at around 5 in the morning, refreshed from 8 glorious hours of uninterrupted sleep. She’s smiling and cooing in the crib, talking to her mobile. You know it’s time to go pick her up, change her diaper and feed her. Because if you don’t, she’ll become cranky with hungry. Depending on her temperament, she may get really cranky and start to cry. This is to be avoided.

The majority of American mothers have begun feeding the baby solids by six months. So in addition to breast or bottle, she might have 2-4 ounces of pureed vegetables (you’ve made this yourself, right? No? It’s easy. You should try it!)

The “2”

You might dress the baby, play with her. You’re certainly going to talk to her and watch her fascination at this “communication thing” you’re doing. She might even want to imitate you. Then, approaching 7 AM, she’ll start to rub her eyes (yes, babies really do this). You know it’s time for that first nap. You go through your “nap routine”: change diaper, sing her a song, a kiss, then place her down in the crib awake. Two hours have elapsed.

2-3-4
Cat nap (sorry, couldn’t resist)

The “3”

Two hours later, at noon, your little kitten begins to stir and stretch. You know the first nap of the day is over. So you change her diaper, change her clothes, and get ready for the day. Let’s say it’s a gorgeous July day, sunny and breezy. We dress in cool, long-sleeves, making sure to put on the hat to shield her face, and head out in the stroller.

At the park, for some reason, every stay-at-home dad in town has brought a baby to the park, and every one of these men is the spitting image of Cristiano Ronaldo (I said we can dream, can’t we?) You enjoy two hours holding court as each Cristiano takes turns ooh-ing and ah-ing over your sweet angel, who smiles and laughs at each face she sees. You nurse her as well at the park, because this is the 21st century and we can do this, right? At 2-ish, everybody gets back into their strollers and heads home.

By 3 o’clock, baby girl is rubbing her eyes again and it’s time for nap #2. Three hours have elapsed.

The “4”

Exactly 2 hours later, 5 PM, baby girl is up and ready for the home-stretch of her day. You change her diaper and take her into your living room (which has been transformed into the baby’s living room) and watch her play with her toys for a while. She may be sitting up by herself at this point, so you might put her in a bouncy seat and watch a short video with her. At about six, your partner, Cristiano Ronaldo, comes home, delighting baby girl.

At 7 PM, it’s time for dinner. She takes her seat (high-chair) at the table to eat with her parents, family-style. Nursing or bottle, 2-4 ounces of pureed vegetables and fruits.

2-3-4
Do not disturb

At about 8PM, the bed-time routine begins. This is the most regular and predictable part of the day. The baby knows exactly what will happen, and in what sequence. There will be a fun bath, changing into pajamas, then quiet hanging out with parents, a song-and-kiss, and time for bed. She goes down in her crib awake and drifts off blissfully at 9PM. Four hours have elapsed.

Really?

I actually wrote that without laughing. It was tough. Of course no day is as perfect as this one (although, I hope you get at least one, or a few, like this). But roughly speaking, this is the way the 2-3-4 schedule works, with or without the dream-like elements. It isn’t planned. It just turns out that way.

Where did 2-3-4 come from?

Good question. The earliest mention of it I could find in a Google search occurs on December 12, 2005 at AskMoxie.org:

Once babies hit 6 months or so, many of them will settle into a 2-3-4 pattern. That means that they’ll take their first nap 2 hours after waking up in the morning. They’ll take their second nap 3 hours after waking up from the first nap. They’ll go down for the night 4 hours after waking from the second nap. Not all kids do this, but a surprising number of them seem to.

Moxie had said at the opening of her post that this idea is not “unique”, by which she may mean “not original”. I believe her, but since I can’t find an earlier reference, I’ll credit Moxie with coining the term.

Problems with 2-3-4

Moxie is careful to note that babies “settle into” a 2-3-4 pattern. It’s not set for them by their parents, but neither is it entirely baby-led. Any kind of pattern like this is a result of what I call the “follow her cues but provide structure” approach to sleep scheduling. The pattern that emerges is a neat observation, not a prescription.

The two hour interval seems a bit long to me. Dr. Weissbluth might agree. He says that the first nap should be though of as a continuation of the night’s sleep, complete with REM phases and all the rest. At six months of age, one and a half hours after waking in the morning sounds about right. Some will stay awake longer, some less.

The period of a baby’s life where she’ll nap with this pattern is really very brief. It may start around 4 months and last until 9 months at the longest. Most 9-month olds nap only twice per day.

When 2-3-4 might be useful

This is not to say that the expression is completely useless. If you have a six-month old whose nap schedule is all screwed up for whatever reason, and you need a guideline to get back on track, 2-3-4 may be the way to go. It may require nudging nap times around a little. I would only do this in small quantities: 15 minutes at a time. I do not recommend waking up a sleeping baby to try to achieve any nap pattern. That’s a sin!

But say your 6-month is fighting sleep at 8PM and she’s only been up for three hours. Think 2-3-4.

How Much Should My Baby Nap?

Parents often ask me how often the baby should nap, and for how long. Often what they’re really asking is “Am I doing this right?”

Sometimes they ask because their friend’s baby is the same age as yours and she’s napping three times per day and yours is only napping twice. Or maybe it’s the other way around.

Behind all these questions is the very real and important question: “Is my baby getting enough sleep?”

How Much Sleep Does My Baby Need?

I’m indebted to my colleagues at “Get Your Baby to Sleep” for creating the tables and charts below (so that I didn’t have to make them!!!)

Baby Age Nighttime Sleep Daytime Naps Total Sleep
Newborn to 2 months 2-4 hours between feedings 4-5 naps 16 to 18 hours
2 to 4 months 4 hours between feedings 3 naps 14 to 16 hours
4 to 6 months 5-8 hours 2-3 naps 14 to 15 hours
6 to 9 months 8-10 hours 2 naps About 14 hours
9 to 12 months 10-12 hours 2 naps About 14 hours
12 to 18 months 11-12 hours 1-2 naps 13 to 14 hours
18 to 24 months 11-12 hours 1 nap 12 to 14 hours

 

I should emphasize here that not every baby has “read the book”, or even “Googled it”, as I guess I should say these days: these are averages. Some babies sleep more than others. That’s why I like to provide ranges and use terms like “about”.

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Total Hours of Sleep

For readers who prefer graphs (as I do) this one gives a better idea of how total sleep decreases through the first year of life. Out of a 24 hour period, the average newborn (0-30 days) will sleep 18 hours! This will gradually decrease to 12 hours, or half the day, by a year of life. Take home message: babies sleep a LOT!

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Total Hours of Sleep per day, by age

How Many Times Per Day Should the Baby Nap?

In some ways the question begs another question: what do you mean by “nap“? The indispensable Dr. Weissbluth (see below) explains that, starting around 4 months of age, the first of the day’s three naps is basically a continuation of the previous night’s sleep! This nap is rich in REM sleep, when we believe the baby does much of her learning and processing of all the information she’s been receiving during the brief times she’s awake. The three naps per day generally decreases to two naps by 6 months of age.

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Number of naps by age

 

When Am I Going To Sleep Through the Night Again???

The answer to this question, as with so many other parenting questions is “it depends”. In this case, it depends on what you mean by “through the night”.  Some parents define it to mean the usual 8 hours they enjoyed before baby came in to their lives.  They should be so lucky! To other parents, “through the night” means  “the baby wakes up once to feed but the whole thing lasts five minutes so I don’t even count it”. For me, “through the night” means six hours straight, followed by the delightful early morning awakening which lasts 1-2 hours, followed by a few more hours of blissful sleep. This schedule can be achieved at about 6 months for most babies (see the table above).

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Uninterrupted sleep, by age

 

Well, How Did I Get Here?

One of the joys and fascinations with baby sleep is that the tables and graphs I’ve shown you do not depend at all on the type of sleep method you employed to get your baby to sleep! Whether you are an on-demand feeder, a baby-led scheduler, a parent-directed feeder, a contented baby enthusiast, a Baby Whisperer, or an attachment parent, all methods seem to lead to the same result: by one year, baby sleeps 10-11 hours and takes two naps!

I believe that all methods end up like this for a very important reason: Sleeping, and napping, are natural parts of a baby’s life. Given the right combination of reading the baby’s cues and providing structure, every parent can have a happy, healthy baby who sleeps well!

More from Dr. Weissbluth:

Cry It Out: Is There Such a Method?

Cry It Out: You read so much about it on the internet, you’d think it’s a thing.

Is it?

Cry it Out IS a Thing. Sort of.

Every day, on internet forums, there will be dozens of discussions of “CIO”, as it’s referred to. Almost without exception, CIO is help up as a sinister element that lurks out there in the world. I’m almost tempted to read CIA.

Sometimes I wish I could send a group message to the tens of thousands of mothers (and fathers): STOP IT!

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But then I have to stop myself and think: Thousands of mothers on the internet refer to CIO, so whether I like it or not, Cry It Out exists. Sort of.

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We have ways of making you sleep

Cry It Out did exist. Once upon a time. 1894, to be exact, with the publication of “The Care and Feeding of Children” by Luther Emmett Holt. Here is what Holt had to say on the subject, in its entirety:

How is an infant to be managed that cries from temper, habit, or to be indulged?

It should simply be allowed to “cry it out.” This often requires an hour, and in extreme cases, two or three hours. A second struggle will seldom last more than ten or fifteen minutes, and a third will rarely be necessary. Such discipline is not to be carried out unless one is sure as to the cause of the habitual crying.

Note that Holt places the expression in quotation marks. This suggests to me that the phrase had some currency in the late 19th century. Perhaps CIO was the preferred method? But now read closely: Holt recommended CIO only in the case of an infant who already has a sleep problem that was the result of what we’d call today a bad “sleep association“. I’m speculating as to the meaning of  “temper”.

Okay, so this is now the 21st century. Does any modern sleep expert recommend Cry It Out as a sleep training method? Again the answer is ‘No. Sort of.”

Meet Gina Ford

Gina Ford, the author of over 30 parenting books, is a Scottish-born former maternity nurse. In 1999, she published “The Contented Little Baby Book“. The major distinguishing feature of “CLB”, as it became known, was Ford’s recommendation of strict scheduling, down to chunks of five minutes. Despite scathing criticism, CLB has become a best seller. The closest Ford comes to recommending Cry It Out is her reference to something called “crying down”.

It’s a Scottish Thang

Prior to reading Ford, I was unaware of the expression crying down  as a troubleshooting method. Perhaps it’s a Scottish phenomenon. I can’t be sure. Here’s what Ford has to say about “crying down”:

Crying down can be particularly helpful when feeding problems have been resolved and a baby or toddler has only mild sleep association problems or has difficulty falling asleep because he is over-tired or over-stimulated… Reassurance must be kept to a maximum of one to two minutes. Parents should then wait a further 10– 15 minutes before returning. For this technique to work it is essential that the baby is not picked up and that he is allowed to settle by himself in his cot… Provided a baby has been well fed and is ready to sleep, I believe he should be allowed to settle himself. [Crying down] works not only for over-tired babies but also for babies who fight sleep…

It is my belief that, in the long-term, allowing your baby to develop the wrong sleep associations and therefore denying him the sound night’s sleep he needs in order to develop both mentally and physically is a worse option than hearing him cry for a short while. Allowing your baby to learn to go to sleep unassisted is your aim, and it is important to remember that this will prevent much greater upset and more crying if waking in the night is due to your baby not knowing how to go back to sleep after having woken in light sleep (emphasis added).

I’ve quoted Ford at some length because I wanted to highlight three things. First,  Ford’s similarities to Holt’s advice (already cited) emphasizing that crying to sleep might be necessary only for a baby with a bad sleep association or who was overstimulated (I regard “over-tiredness” and overstimulation as the same thing). Second, Ford emphasizes that neither a hungry baby, nor a baby who is not tired, should be put down to sleep. Finally, Ford places herself firmly in favor of good sleep associations, over most other considerations.cry it out

So is there really such a thing as “Cry It Out”?

Gina Ford tells us, correctly in my view, that crying down should not be necessary in the first place. Ford identifies the “need” crying down as bad sleep associations and allowing a baby to become overstimulated. She believes both could be avoided if the baby were put on a schedule from the get-go. Ford truly does not want your baby to cry to sleep. I don’t believe anyone want this, including Luther Emmett Holt.

In fact, if you read closely, Gina Ford is more of a “combination scheduler” than you might think at first blush. It’s true that she advocates a fairly strict schedule. But notice also that Ford insists that you make sure the baby is well fed. Notice also that she doesn’t recommend putting down a baby that isn’t tired!

Slightly Different

Just as virtually all 21st century sleep experts, Gina Ford joins the consensus about baby sleep, if perhaps in slightly different form. Like Baby Wise, Ford might say: Provide structure, but follow the baby’s cues. Sears and Spock might say “Follow the baby’s cues, but provide structure”.

Either way we end up with a method that recognizes a broader consensus about all of human behavior. We are not just a bunch of genes (the “Nature” part of “Nature vs. Nurture”). But neither are we blank slates, requiring inscription by good parents (the “Nurture” part). We all are born with certain biological traits that are then molded and shaped by our environments. And for virtually all babies ever born, the first and most important “environmental factor” is mom.

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Attachment and Sleep: Dr. Sears is Wrong

Sears, W, et. al. “The Baby Sleep Book”. New York: Little, Brown, & Company, 2005, or “Attachment Theory Takes a Holiday”

Attachment Theory: It’s about the Baby, not the Mother

Lots of people talk about “Attachment Parenting” (AP), but not a lot of people know what it is. I’m not sure the Sears family knows either.

attachment

We owe Attachment Theory mostly to John Bowlby and Mary Ainsworth, two psychologists working in the mid-20th century. Put simply, the theory says that infants need to develop a relationship with at least one caregiver in order to learn to regulate their own feelings. On the “Nature vs. Nurture” spectrum, Bowlby and Ainsworth fit solidly on the “Nurture” end. Their type of theory is what we’d call “behavioral”.  Behaviorism stands opposite the “Nature” end, what we’d call “biological determinism”, or “your genes explain everything”.
The truth probably lies somewhere between.

Parents do a more or less good job of helping babies learn to regulate their emotions, according to Attachment Theory.  That’s the whole theory in a nutshell. Nowhere in this theory is there any suggestion that babies should remain physically attached to parents for as long as possible. Nor does the theory say anything about sleep. Or even breastfeeding! The theory is not even about parental behavior; it’s about infantile behavior. That is, it was only about the baby, until the Sears family got a hold of the theory.

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Attachment, Sears Style

I suspect that William Sears (the father of the clan) read “attachment” and took the word literally. Bowlby and Ainsworth only meant the term figuratively. And yet, Sears appreciates that attachment is a subtle and nuanced thing. Here’s how he describes it in his sleep book:

…[A]ttachment parenting (AP) is not a new way of raising children that we and others have dreamed up. It’s what mothers and fathers would do instinctively if they were raising their baby on a desert island

attachment
Attached

Note that Sears is careful not to say that parents have always been this way. He knows enough anthropology to know such a suggestion is wrong. But he does say that attachment behavior is instinctive. Where he gets this idea is a mystery. Perhaps attachment theory predicts the way that modern parents would raise a child on a desert island, far away from parenting books, pediatricians, and pop psychologists. But it is not the way aboriginal parents ever raised children for all but an eye-blink of human history. According to this research it’s doubtful that mothers developed close emotional bonds with their babies, because of the extremely poor chances that the baby would survive infancy! It was not until infant mortality plummeted in the developed world (in the 20th century!) that mothers developed the inclination to bond with their babies. Such a bond is certainly not instinctive, not on the part of the mother anyway.

So what if attachment parenting is a modern invention? So what if it’s a peculiar distortion of Attachment Theory. Is Sears wrong to recommend it?

Yes, He’s Wrong

The sleep book opens its defense of AP with this stunner:

A frequent criticism of attachment parenting is that it puts baby, rather than parents, in control. But can parents actually control their babies anyway? Parenting your baby at night forces you to come to terms with the realistic fact that you can’t control your child’s behavior

You can’t control your child’s behavior? One wishes, in vain, I fear, that Sears doesn’t really mean this. But let’s suppose for the moment that this incredible “realistic fact” were true: how is this going to help us get our baby to sleep? Sadly, Sears never really tells us. In fact, Sears goes on to explain that parents really ought to nudge babies in the right direction. This is what all good so-called “combination schedule” advocates claim. By the way, are “realistic facts” different from other kinds of facts?

When in Doubt, Cry It Out

Sears goes on at length to criticize what he claims to be a virtual army of baby sleep books that allegedly recommend the cry-it-out (CIO) method:

The dictum “let your baby cry it out” has been standard advice in childcare books for more than a century starting with Emmett Holt in 1894

Sears does not provide any examples of this “standard advice”. This is for a very good reason: apart from Holt and experts of his era, there are no such examples. No modern sleep expert recommends CIO. Even Ferber, as I’ve pointed out elsewhere, explicitly rejects CIO. Why Sears constructs this straw man (or should I say “straw pediatrician?) is a mystery.

attachment
Attach THESE, Bill!

A particularly precious argument against the phantom CIO is offered by Sears the Younger (Bob). Dr. Bob tells a story of a mother who lets her 1 month old cry himself to sleep. Years later it turns out the boy has ADHD. Leave aside the the absurdity of letting a one-month old cry himself to sleep: no one who knows anything about infant development would recommend such a thing. How can Dr. Bob draw such a connection? Wait, it gets worse.

Later, Sears suggests that “research” points to a connection between CIO and ADHD. The study in question is about “persistent crying”, not “CIO methods”. There’s an obvious chicken and egg problem here. Are hyperactive 8-10 year olds the way they are because they cried a lot as babies? Or are we looking at a group of children with a biological vulnerability to cry as babies and fidget as school children? The biggest weakness of the study was the finding that these children’s parents but not their teachers saw a difference between the behavior of the supposedly hyperactive group and the control group. Teachers are often much more likely to label a child hyperactive than are parents.

There is much more “neuromythology” dispensed on the subject of crying and ADHD about which I will say only this: just because they’re doctors doesn’t mean they know what they’re talking about. No one has any idea what neurotransmitters have to do with behavior. Don’t believe anyone who claims to know.

Attachment and Co-sleeping

attachment
OOH! These will attach things!

Though Sears claims he believes that babies can sleep anywhere, he clearly prefers that babies sleep in bed with the parents. I wonder if anyone but a board-certified pediatrician could get away with making such a suggestion? Regarding studies demonstrating the dangers of bed-sharing, Sears argues “when there is a conflict between scientific studies, or between science and common sense, suspect that somewhere there’s a fault in the science”.

There is not a word of that sentence that is true. Scientific studies often give variant results. Why should it be otherwise? The bit about common sense is too precious: Common sense suggests that the earth is flat and that the sun revolves around us. When scientific studies demonstrate that the opposite is true, is the “fault in the science?”

The American Academy of Pediatrics has issued several strong warnings about bed-sharing, which is a risk factor for sleep-related infant deaths. Perhaps the Sears book indemnifies itself by going on at length about safety and sleep. But this hardly mitigates the dangerous recommendation. There are an almost infinite variety of sleeping arrangements and devices that parents can use, such as co-sleepers.  Sears comically suggests that, for safety, parents buy the largest king-size bed available. This assumes the reader a) can afford such a bed and b) has the space for one.

attachment
This’ll work too

But Sears isn’t done with the “science”. He suggests that babies are “physiologically safer” when they co-sleep. One has to take his word for it. I will not. It’s a nonsensical suggestion. Sears even claims that babies are protected from SIDS because carbon dioxide is protective and parents exhale carbon dioxide. Nonsense piled upon nonsense. I won’t have any more of this. Neither will epidemiologists. No amount of pseudoscientific piffle will make bed sharing any safer.

The worst part of all of this is that you don’t have to sleep with your baby in your bed in order to develop attachment.

Sex and the Sleeping Baby

Here’s an obvious objection: Dr. Sears, many folks would really rather have sex without another person in the room. Call it bourgeois if you must, but that’s a fact. How does Dr. Sears suggest you accomplish the feat? First suggestion: put the baby in the crib first. Okay, great idea! To which I reply, why not leave her there? Second suggestion: play “musical beds”. In other words, have sex with your husband with the baby in another room. This includes keeping the baby in your room and having sex in the den, or the nursery! Finally, the most puzzling suggestion: morning sex. What, the baby disappears in the morning? I don’t get it. Finally, Sears tips his hand. He’s okay with you having sex in front of your baby. Fine for him and Martha (I really could do without descriptions of Sears’ own sex life). We Philistines value our privacy.

Sears the Lumper

Much as he tries to squeeze baby-led sleep schedules out of his Attachment Parenting system, at the end of the day, Sears can’t do it. He’s a combination-scheduler as much as Ferber, Spock, and Tracy Hogg, the Baby Whisperer. The place where Attachment Parenting falls down is its failure to appreciate the dangers of developing bad sleep associations. I’ll qualify that statement. If mothers and their sleeping partners are okay with a toddler who shares their bed wakes up every three hours to nurse at night, then God bless them!  Who am I to judge? But when they come to me for help them get the child to sleep through the night, I do indeed have an an argument. An argument with Dr. Sears.

The Baby Whisperer and Combination Schedules

What are “Combination Sleep Schedules“?

They are considered to be compromises between “Parent-led” and “Baby-led” methods. According to Babycenter.com, “…combination schedules provide the consistency that babies and parents need without the hassle of a more rigid, timed-to-the-minute routine.”

The best example of the method is Tracy Hogg’s “Secrets of the Baby Whisperer“, co-written by Melinda Blau.

combinaiton
Word to the Whisperer

I argue (here, and here, for example) that pretty much everybody in the baby sleep world offers some kind of compromise between both camps. It’s only a matter of degree. But Hogg (who left us far too early in 2004) provides us with the best explanation of a common-sense baby care, spun in a Yorkshire accent.

Combination or Common Sense?

I will not be the first reviewer to point out that, for all it’s acronyms and British accents, “Baby Whisperer” essentially offers good old-fashioned common sense. As such, Hogg places herself in the tradition of Ben Spock. Hogg concludes her book, in part, like this:

My wish for you is to relish every moment, even the tough ones. My goal is to give you not merely information or skills, but something even more important: confidence in yourself and in your own ability to solve problems.

Sound familiar? It should. It’s a version of Spock’s famous “Trust Yourself” formula that rocked the parenting world fifty years prior. By 2001, it was old-fashioned advice!

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But the book is not entirely derivative, and there is even a fair amount of innovation (Hogg’s acronyms, E.A.S.Y., and S.L.O.W. (see below) are unique, as far as I know). Her major contribution to the field is her emphasis on parents paying attention to their babies, engaging them in a kind of conversation. Hogg is on to something here. It is almost certainly the case that human communication begins at a very early age, perhaps the earliest of ages. Hogg is right to suggest to parent that they appreciate the “messages” that their babies send them, and to communicate back in real human language.

Baby Talk

My only quibble with Hogg’s suggestion is her tendency to echo an annoying pattern of speech in which parents refer to themselves in the third person. “Mummy will be right back”. “Mummy doesn’t like it when you do that”.

Pronouns are hard. Pronouns are hard for anybody learning a language, even their first language. Anybody learning a new language knows that you understand more than you speak at every point along the learning curve. Children understand you when you say “I” and “me”. They will muff the pronouns when they try them out, but they understand you. For heaven’s sake, people, if we are to converse respectfully with our children, let us respect their ability to understand pronouns!

S.L.O.W. Down and Take it E.A.S.Y.

Hogg doesn’t say this explicitly, so I just did it for her: Baby Whisperer philosophy is based on slowing down, taking deep breaths, and listening to your baby. Both acronyms, as corny as they sound, help anxious hurried parents get to know their babies.

S = Stop; L = Listen; O = Observe; W = What’s up? (Hey, she needed a “W”, right?)  In other words, absorb what you’ve heard and seen and evaluate what’s going on for your baby. It’s a bracingly simple and effective tool. I wish I had such an acronym to recite while walking the floor with my colicky first-born! Cleverness aside, it’s important to remember that your baby is a human being that is learning to interact with the world via communication. Hogg reminds us we do better to start early.

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Yet more possible combinations

Another of Hogg’s contributions to the baby sleep literature is her clever E.A.S.Y. acronym. E = Eat; A = Activity; S = Sleep; Y = You. The innovation is the insertion of activity between eating and sleeping. This way, parents will avoid the temptation to allow their babies to develop bad sleep associations. To do this, it’s important to separate feeding from the moment of sleep. The activity needn’t be anything stimulating: to the contrary, stimulation prior to sleep is never a good thing. Hogg recommends changing the diaper, singing a song, reading a book, etc.

As for the “Y”, I suspect Hogg needed another letter to spell a nice word. Otherwise, I can’t see why she included it. Hogg really doesn’t need to tell mothers to eat, take a shower, sleep, etc. She doesn’t go as far as Baby Wise Gary Ezzo, who recommends “Date Night” for parents. Indeed, for parents without extended family or disposable income to pay a baby sitter, the latter really isn’t possible. Hogg’s Hollywood clientele could afford it perhaps, but not us normal folk. Surely mothers need to care for themselves, otherwise they’d soon be incapable of taking care of their babies. I’m just not sure they need to be told this. I’m going to stick with the suggestion that she needed the letter “Y”.

One More Abbreviation

Hogg ends the book with an excelling “troubleshooting” chapter, featuring the mnemonic ABC. A = Antecedent. What came before the sleep problem? (Kudos to Hogg for using the word “antecedent”: it’s a dying word, I fear). B = Behavior. What is your baby’s part in starting this sleep problem? C = Consequences. What was kind of pattern resulted from A and B? Usually, the problem to be solved is a bad sleep association, and Hogg walks us through the disassociation process. But I suspect that the ABC method could help unpack other sleep problems as well.

Finally

As I’ve said before, I’m a lumper and not a splitter. And as such I’ve argued that we’re all basically “combination schedulers” now. I say this because experts from Ezzo at the parent-led end of the spectrum, to Sears at the baby-led end, all recommend following a baby’s cues, but providing her with structure. To Tracy Hogg’s credit, she says this explicitly.

We’re all Baby Whisperers now. Or we should be anyway.

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