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
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.
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.
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.
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.
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?
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.
Q: What happens to sleep training while teething?
A: It’s a good question. The answer depends on a lot of factors.
First: What is Teething?
I define teething as the process involved in the eruption of baby teeth. Some people prefer to define teething as the one or two bad days a baby has while the teeth are actually breaking through the gums. This is a good definition, but anyone who has actually had children knows that the discomfort associated with teething starts long before the teeth actually break through.
How many of you have found that the only way to soothe your fussy baby has been to rub her gums with your finger? You can call it what you want to, but it sure seems like teething to me!
First teeth often appear between 4 and 6 months months. The earliest first tooth I’ve ever seen was in a 9-week old baby! But the first tooth can sometimes wait until a year of age to break through. After that, the process will continue until all 20 baby teeth have come through. This can take up to two years!
There’s a long history of teething being blamed for all kinds of nastiness. In the early part of the 20th century, teething was still appearing on infant death certificates! Also on the historical list of teething symptoms is “blinking eyes, vomiting, neuralgia, severe head cold, weight loss, toxemia, tonsillitis, paralysis, cholera, meningitis, tetanus, and insanity.” Fortunately, we’ve stopped believing teething was fatal, but we continue to think all kinds of symptoms are related to teething.
Fever is probably the most common. The latest evidence from the medical literature suggests that teething can lead to an increase in body temperature, but not to a level that could be characterized as a fever (100.4 F rectally).
This is a good time to emphasize a point. A true fever should never be brushed off as “only teething.” If the baby has a real fever, you should pay attention to it. Contact your pediatrician if you have any questions or concerns about a fever in your infant.
These days, teething is blamed for causing diarrhea, facial rashes, diaper rashes, runny noses, and sleeplessness (more on this below!) But the best evidence we have today suggests that teething causes really only two things: 1) Drooling, and … 2) Teeth.
Can the Baby Do Sleep Training While Teething?
But let’s face it: for many babies, teething hurts! These babies are fussy more often. They want to bite on anything that gets near their mouths. They try to insert both hands in their mouths simultaneously (anyone seen a baby try this?) They swat at their ears (anything to get at those painful gums!)
One thing teething should not do is interfere with sleep. Teething pain almost never wakes a baby from sleep, but a baby who does not yet know how to sleep on her own will not be helped out much by a mouth that bothers her!
The Answer is YES
Sleep training while teething is possible. Sleep training while teething is doable. And I recommend doing it! If you’ve started the process of allowing your baby to learn to self-soothe, there’s no reason why you should stop because of teething.
If the baby has already fallen into a daily routine (because you’ve paid attention to her cues and provided her with structure!) then small disruptions from night time teething should not cause you despair. There are many things you can do to try and make her more comfortable, and to continue with your routine.
Always discuss dosing with your pediatrician before you give your baby Tylenol or Motrin. The doctor will probably tell you that you should not give Motrin to a baby less than 6 months of age. You should never give higher doses than recommended, and never more frequently than recommended. My own experience taught me that Tylenol is not anti-inflammatory enough to make any real difference to a baby who is dealing with gum inflammation from teething. So if she’s younger than 6 months old, you can try Tylenol, but rubbing her gums with your finger may be her only relief!
What you should not give is a topical anesthetic like Oragel or Anbesol. It’s true that the FDA has issued a warning that these medications should not be used in children younger than 2. But I have an even better reason to avoid these medications: they don’t work! The inflammation from teething occurs too deep below the surface of the gum to be touched by a topical anesthetic. It’s not worth it.
I confess I gave homeopathic teething tablets to both my boys when they were toddlers. Most teething tablets are made of Calcium Chloride, chalk basically. I knew these tablets would not actually treat teething pain. I also knew they were completely harmless. What they did do was convince my boys that their teeth would stop bothering them. The “placebo effect” worked. They would stand inside their cribs with their hands out waiting for the tablets every night. It became part of the bedtime ritual. Bedtime rituals are good! We stuck with it because it did no harm.
There are a ton of teething products on the market, but the truth is you don’t need to waste your money on them. If an item is clean and she can safely put it in her mouth, you can use it as a teether. We and other parents have tried the toothbrush. The frozen washcloth is always worth a try. But it my experience, nothing works better than the pad of a finger rubbing the baby’s gums. The problem of course is that you cannot keep your finger there all day.
Sleep Training While Teething Take-home Messages
- By all means, the baby can continue sleep training while teething.
- Consult your pediatrician about pain reliever doses and dosing intervals
- Don’t give Oragel! It doesn’t work!
- If you try all these things, and you need a sleep coach, I can help!
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.
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.
Ferber, Richard. Solve Your Child’s Sleep Problems (2nd ed) New York: Simon and Schuster, 2006
One Saturday afternoon I was sitting on a park bench watching my kids play in the sandbox, and listening in on other people’s conversations. (I know you shouldn’t do this, but c’mon! Who doesn’t?) Two women were discussing diets. “I’m trying Atkins,” one said. “So you’ve read the book?” her friend replied. A silence. Then, “What book?” It turned out the woman “trying Atkins” hadn’t actually read Dr. Atkins’ book on dieting. She was going to make some kind of dietary changes, but it was not the Atkins Diet. She hadn’t read what Dr. Atkins had to say!
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This is pretty much exactly the same thing that happens with Dr. Ferber and his book. Most people who “try Ferber” have not read Ferber. They should.
Rescuing Ferber From the Critics
Ferber has come to be associated (incorrectly, in my view) with the so-called “cry-it-out” method of sleep training babies. “Ferberization” has come to mean leaving your baby to scream herself to sleep in the crib, while mom and dad cover their heads with their pillows. [By the way, how many pediatricians do you know whose names have been turned into verbs? Dr. Ferber is the only one I know of!].
The thing that has made Ferber most famous (or infamous, I should say) is Figure 5 at the end of Chapter 5 (in the first edition), entitled “Helping your Child Learn to Fall Asleep with the Proper Associations; number of minutes before going in to your child briefly”. What follows is a chart with number of minutes a parent should wait to re-enter a crying child’s room. If Figure 5, had been the only page in “Solve Your Child’s Sleep Problems”, the critics might have a point.
How many pediatricians do you know whose names have been turned into verbs?
- The chart is not to be used for sleep training
- The chart is a guide for caregivers whose children have developed bad sleep associations
- Ferber explains at length that “cry-it-out” is not a method for getting children to sleep and he does not recommend it!
- “[C]rying does not help in developing appropriate sleep associations…we try to keep crying to a minimum (p. 67, 1st edition)”
I believe it’s fair to say that most (all?) critics of Dr. Richard Ferber and his book “Solve Your Child’s Sleep Problems”, have never read the book! If Ferber should be famous (or infamous, if you insist), he should be known not for the cursed Figure 5, but for his “Pillow Story” he tells at the beginning of the Chapter.
“Think for a moment what it would be like if you had a normal waking during the night, turned over, and found your pillow gone. It would feel ‘wrong,’ and rather than simply returning to sleep you would wake more completely and begin to look for your pillow… what if your pillow was really gone? What if someone took it as a prank? It’s unlikely that you would simply go back to sleep…You might get angry, curse, and show the same type of frustration that a child shows when he cries.”
In this one little story, Ferber crystallizes the overwhelming majority of childhood sleep problems: bad sleep associations. Ferber explains that the most common sleep difficulties are created when children fall asleep surrounded by one set of things (mom, breast, bottle, pacifier) and awaken at the end of a sleep cycle surrounded by another set of things (crib, blanket, no pacifier, etc). In other words, parents too often metaphorically prank their children and steal their pillows in the middle of the night.
Ferber’s Gift to the World
Ferber’s major contribution to the baby sleep literature is his thorough explication of sleep associations and how to develop good ones. Every major sleep expert in print acknowledges sleep associations: from Gary Ezzo and Gina Ford on the “parent-led” side of the spectrum, to William Sears and the “attachment parenting” crowd. You could say that all sleep training methods are variations on the theme of developing good sleep associations, and fixing bad sleep associations. All these methods are slightly different pathways to arrive at the same endpoint.
This is not to say that I agree 100% with everything Ferber has to say in his book. For my taste, Ferber insists too much that a baby needs to sleep in her own space starting some time during infancy. For most of human history, it was not possible for children to sleep apart from their mothers. For many millions today, this remains the case. It’s a minor quibble, however.
“Cry-it-out” may be a “sleep training method”, but no reputable authority that I know of recommends it. Oh wait! There IS one. It’s Luther Emmett Holt, who wrote a baby and child care guide that was all the rage when it was first published in 1894. Since Benjamin Spock led the revolution against “scientific pediatrics” in the mid-20th century, cry-it-out has been obsolete.
Ferber gets it right, in my view. If you must read one sleep book (though you probably should read several), read Ferber.