Breath-holding Spells at Bedtime

One of my most memorable clients is a 15-month old girl who threw tantrums at bedtime. Recently she had begun crying so hard she began breath-holding. One night in particular, she held her breath so long she collapsed. Her mother became so scared she called 911.

The little girl was fine. She woke up moments after collapsing, but it was too late for the 911 call. EMS was already on the way. When they heard the story, the paramedics and the doctors immediately understood what had happened. They had received many cases of breath-holding spells where someone panicked and dialed 911. But there was one funny twist to this story: mom witnessed the entire episode and she swears the baby’s lips did not turn blue before she passed out. She was quite sure the baby stayed her usual (somewhat pale) color throughout.

Breath-holding Spells

Of all the “normal things” that can happen to our children, breath-holding spells have got to be the scariest.  They are triggered most often by temper tantrums, but they can also occur when the child becomes suddenly frightened, frustrated or any other form of emotional upset.

They cry so hard they actually stop breathing. And anyone who stops breathing long enough will eventually faint from loss of oxygen to the brain. The good news is that as soon as the child faints and falls down, she starts breathing again, and “wakes up” often a moment later. Sometimes the child’s body will jerk briefly, causing witnesses to believe the child is having a seizure. These are myoclonic jerks, not seizures. These fainting spells are not harmful to the child and there are no lasting effects whatsoever.

Here’s the important point: the child is not doing it on purpose! It’s actually very difficult to make oneself pass out purposefully. Certainly no toddler can do it.

Tears Before Bedtime

breath-holding 1
She’s holding her breath

I hear a lot of stories from parents of toddlers who perform a consistent bedtime routine, at the same time every evening. But it always seems to end with the toddler dissolving into tears the moment she’s put in the crib, or when a parent leaves the room. In cases like these, the crying has become part of the routine! The toddler (and the parents) know the sequence: dinner, bath, PJs, book, bed, cry… then pick the child up, put her down, more crying, etc. Clearly, this isn’t the bedtime routine anyone wants.

This is the time to sit down and re-think the bedtime routine. Is the toddler really tired enough to go to sleep? It makes sense to keep a log of the number of hours she sleeps. At 15 months, she should be getting a total of 12-14 hours, 11-12 of which happen at night. If the toddler has had an afternoon nap, perhaps late in the afternoon, it could be that she’s not ready to sleep at the prescribed bed-time. In that case I recommend pushing the bedtime routine later in small increments, say 15 minutes at a time.

What if there has been too much time between the last nap and bedtime? Perhaps the child is overstimulated (some say “over-tired” – I say it’s the same phenomenon: tired brain). Or the child is overstimulated because her day is just too full of sensory overload? In these cases, it may be time to change things up.

Mid-course Correction

breath-holding 2
No more sweets, please!

Very often, in the course of a consult, the parents and I can identify some factor that we can adjust, and test to see if it has effect on bedtime tears.  Reducing stimulation is easier said than done, but it is often helpful. Paying attention to the child’s diet can be important as well.

Do you give her juice? You don’t have to. In fact, you shouldn’t! Juice is not fruit, it’s sugar-water. Better to have her drink water. The same goes for sweet cereals and snacks.

Some children are sensitive to the things that are added to processed foods, such as dyes, flavorings, and other additives. Very few children I know of react badly to real food. By “real” I mean food that resembles the thing that came out of the earth or the livestock pen.

Limits setting

It’s also possible that the toddler may tantrum at bedtime (even to the point of breath-holding), because she knows this will delay bedtime. In cases like these, I recommend that parents become actors. They need to pretend that they are not fazed at all when the child passes out. This isn’t easy to do, and should be considered a last resort. But just as you want to avoid bad sleep associations, you want to avoid convincing the child that breath-holding is an effective way to get you to stay with her. Like any behavior you want to modify, limits setting and enforcement are key to raising a happy, secure child.

Back to the Twist

What about the 15-month old who didn’t turn blue when she fainted from breath-holding?

breath-holding 4
Diet matters, folks

Because the EMTs took her to the emergency department, she had blood drawn. One test showed that the girl was severely anemic. Anemia is known to be associated with breath-holding spells. She was so anemic that she didn’t have enough red blood cells to turn blue when she passed out!

The anemia in this girl’s case was due to her diet. This girl drank about 40 ounces of whole milk per day. She ate very little or no food. Why should she? She was full of milk! In about 40% of infants, drinking cow’s milk causes them to lose small amounts of blood through their gut. Since this girl drank only cow’s milk, she became profoundly anemic as a result.

This girl’s anemia, and her breath-holding spells, were cured by taking her off milk and giving her an iron supplement.

So this breath-holding story had a happy ending. Virtually all of such stories do. The behavior goes away in a few months. If you have any questions or concerns about breath-holding, or if you are having a difficult time managing these episodes, consult your pediatrician.

 

 

Snoring: Why Your Toddler Does It

I can hear my kid snoring from down the hall!

She snores like an old man!

There are two kinds of snoring: the kind you don’t have to worry about and the other kind. How can you tell which is which?

Two Kinds of Snoring

There are two kinds of answers: the short answer and the long answer. The short answer is “see your pediatrician if you have any questions or concerns about your child’s snoring”. The longer answer is… well, read on!
Snoring is more than just loud breathing. When you sleep, the muscles in your upper airway (nose, mouth and upper throat) relax and become narrower. As you inhale, the upper airway wants to get even more narrow. This is because the air pressure goes down (you wouldn’t be able to inhale air into your lungs if the pressure didn’t go down in your airway – so this is a good thing).

Sometimes the airway becomes so narrow that the walls of the mouth and throat slap together audibly. This is the sound of snoring. If someone’s upper airway is narrower than normal, or floppier than normal, the more likely the “slapping together” is going to happen, giving rise to snoring.

Big Tonsils, Big Adenoids

One thing that can make an upper airway narrower than normal is big tonsils and adenoids.snoring

Before going on, we should talk a little about adenoids, because many people have heard of them but don’t really know what they are. As you can tell from the picture, one reason you may not know what adenoids are is that you can’t see them in most people’s mouths. They’re located high up at the place where the nose meets the throat.

Adenoids are part of your immune system. In people with allergies, adenoids can get large. They can get so large that they can partially or totally block off the nasal passages. People in this situation need to breathe through their mouths all the time. If they need to breathe through their mouths only during sleep, the person is more likely to snore. When adenoids are so large that they cause serious breathing problems, and trials of medical therapy do not work, patients and their doctors often choose to have them removed.

Snoring because of tonsils is easier to understand because you can see really big tonsils can get in the way of air flow. People with allergies can have big tonsils, as can people who have lots of throat infections. It used to be that frequent bouts of tonsillitis were the main reason tonsils were removed. This is no longer the case. Today, the most common reason for tonsillectomy is obstructive sleep apnea (OSA).

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What is OSA?

snoring 3
Uh-oh. Obstruction

The problem of OSA is defined by its name. The upper airway becomes obstructed during sleep, leading to pauses in breathing. Apnea literally means “cessation of breathing”.

It may be obvious why pauses in breathing can be a problem, but the consequences may not be well known. While snoring, people with OSA, including children, send signals to their brains that they are not inhaling enough oxygen. The signal causes the person in deeper sleep to arouse enough to shift, move, and sometimes fully awaken. Normal rhythm of sleep is disrupted. These people do not get enough restful sleep.

In children, this chronic lack of restful sleep can lead to behavior problems. In fact, many children who carry the diagnosis of ADHD are in fact suffering from chronic sleep deprivation due to OSA. I have seen a few children who had been diagnosed with ADHD cured by tonsillectomy/adenoidectomy.

For reasons that are not well understood, some children who wet the bed frequently do so because their breathing is disrupted during sleep. Again, many cases of bedwetting have been cured by treatment for OSA and other causes of “sleep disordered breathing“.

Young drivers with sleep disordered breathing tend to be less alert and are known to get into more frequent accidents.

Big Kids

Sadly, OSA is becoming more common in childhood because of the rapid rise of obesity. The thicker one’s neck is, the narrower the upper airway. Sometimes the only way to reverse airway obstruction is weight loss. And of course, the best, healthiest way to do this is healthy diet and exercise (see how diet, exercise and sleep all tie together?)

snoring
Not my fault I snore. I was bred this way

Does everybody who snores have OSA?

No. Sometimes it’s just plain “simple snoring”. This is loud breathing during sleep that does not lead to all the negative consequences I’ve detailed here. I lay out all this detail because it may not be immediately obvious that behavior problems or bedwetting may be related to sleep disordered breathing. The only way to tell sometimes would be to perform an overnight sleep study.

Non-surgical Therapies

Not everybody with OSA has to have surgery. For allergy sufferers who snore, even toddlers, the treatment may involve removing allergic triggers from the child’s environment, or simple over-the-counter allergy medications. Consult your child’s pediatrician about this if you suspect allergies.

Take Care of It Early

OSA can be annoying and lead to behavior consequences and bedwetting. But these symptoms tend only to occur in childhood. The reason to pay close attention to snoring in childhood is because over time, OSA can cause cardiovascular problems such as high blood pressure and heart disease. The sooner OSA is reversed, the easier it is to reverse these complications.

So if you have any question at all as two whether your child’s snoring is the normal, boring kind, or the kind that deserves attention, I recommend seeking medical attention. The impact on your child’s lifetime health and wellbeing may be substantial.

 

Bottle or Binky in Bed: Bad Idea!

Have you done this? This is for you parents who said they’d never do it. Your toddler sleeps with a bottle or binky in her mouth. You said you’d never do it, but there it is! How did it happen?

The Slippery Slope

It’s a real thing, folks. When you step out on to the edge of the slippery slope you end up at the bottom before you know what happened. bottle or binky 2

I’ve been there. Trust me, I know what it’s like to suffer from toddler-induced sleep deprivation. You will do anything (within reason) to get the little one to settle.

Perhaps you’ve even said this to yourself: “I’ll give her the bottle or binky just this once. I don’t want it to become a habit. I just need to get to sleep!”

A week, maybe a month later, you remember what you said to yourself and the feeling of guilt creeps in. Because the binky is still in the toddler’s mouth, or the bottle is still in the crib. I’ve been there as well.

The Problems Bottle or Binky Cause

Things seem ok for now. She’s sleeping after all, isn’t she?

bottle or binky1
Is that juice in that bottle?

Yes. For now she is. But what if the binky falls out and she goes looking for it? If she doesn’t find it and wakes up fully, she’ll be pissed! This is because the object in her mouth has become a sleep association. That is to say, something that she associates with going to sleep. If that thing is no longer present when she arrives at a shallow sleep phase in a couple hours, she may go looking for it and fully rouse herself.

What about her new teeth? Could they grow in crookedly because of the rubber object in her mouth 8 hours straight? Yes, it could happen. She might also increase her risk for ear infections.

Then there’s the speech thing.

Don’t Talk With Your Mouth Full!

I have met dozens of mothers who worry that their toddlers aren’t speaking when they should. One look at the toddler can tell the story. If her mouth is full of binky, or if she has a bottle hanging from her lips at all times, she probably is going to have a tough time speaking! I’ve consulted on toddlers who do manage to learn to speak around their binkies, but I must say this is rare. Suffice to say these kids aren’t easy to understand. A friend who is a speech pathologist has managed more than one case by simply popping the binky out of her patient’s mouth!

More Teeth Problems

Another typical “slippery slope” story is the problem of “milk bottle cavities“. I’ve seen my fair share of kids who’s mouths look like this:

bottle or binky
Sorry for the disturbing photo, folks

It turns out that bacteria love sugar. When you bathe baby teeth in sugar for several hours at a time, bacteria that cause cavities have a feast! I know that these parents never wanted their toddler’s two top teeth to rot! I know they only wanted the little one to get to sleep and this was the “only way” to get it done. Well, of course it wasn’t the only way, but once you step out onto that slippery slope, you end up at the bottom before you know what hit you.

The sugar in breast milk or formula is fine for your baby; you’d have to admit it’s good for her! But it is meant to be sucked down and swallowed. Milk was never meant to pool in a human’s mouth for any length of time. The effect on teeth tells the story.

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What goes for milk goes triple for juice. Juice is not fruit. Juice is flavored sugar dissolved in water. There is no good dietary reasons for your baby to consume sugar. How much more so is there no reason for sugar-water to swirl around in her mouth. It does nothing but provide a tasty meal for those bacteria!

Bottle or Binky Before Bed?

As I’ve said before, I’m a big fan of the binky. It can be the breastfeeding mom’s best friend for the first six months of the baby’s life. Prior to 4-6 months, your baby needs some external source of soothing. Beyond this point, the baby is able to do it herself, so she doesn’t need soothing aids. This is when the binky becomes something much less than a friend. It becomes a habit that you desperately wish you had broken earlier. The longer you wait, the tougher it gets. A “window of opportunity” begins to close at around 9 months. By one year of life it takes a strong parent indeed to pry the window open again!

bottle or binky 4
Now see? She’s addicted to it!

As for the bottle, it has no place in the crib, ever.

If you absolutely must give a bottle to a toddler in a crib, it should be a bottle of water (sugar-free) and you should do this only on one particular situation (discussed in “The Three Temptations“). After the child has had her sip, she doesn’t need it any more and you can take it away.

Spiked Shoes

I once heard an ethicist say he wished he could climb down the slippery slope with spiked shoes. Sorry. You can’t do that. No one can. The best way to fix the problem of a toddler who won’t sleep without a bottle or binky is never to give either in order to make them sleep. For a binky, you have some leeway until 6 months. With the bottle, it should be easier:

Just. Say. No.

Climbing Back Up the Slope

But if you do find yourself at the bottom of that slippery slope, not all hope is lost. If your toddler really needs something with her in bed, you can replace the bottle or binky with another transitional (or comfort) object. Whatever it is, it should be something she can put in her mouth that will be safe for her. A blanket or stuffed animal can be a good substitute.

Another trick that works well for some parents is a “goodbye” ritual, timed to coincide with a big event like a birthday. My sister prepared a goodbye ceremony for her daughter’s binky when the girl turned 3. They went and threw away all the binkies in the dumpster, and then and bought a nice present for the little girl. My niece was very enthusiastic about the entire thing.

Of course, it’s ideal to be able to avoid transitional objects and goodbye rituals in the first place!

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Why Your Toddler Won’t Nap… And How to Fix It

Q: My toddler won’t nap! What can I do?

She is 2 years and four months old. Until about two weeks ago she took a nap every afternoon after lunch for two hours. Now at nap time she complains that she wants to do something else. Anything else but nap. By 6 o’clock she’s so cranky that she throws tantrums and she never throws tantrums! Help!

True story… This is a very common situation. I get a lot of questions like this. In order to answer them, I need a lot more information!

A: So, your toddler won’t nap!

First, I need a lot of background. I ask about the child’s sleep history and her developmental history. Was she full-term or premature? Did she feed and grow normally during the first two years (I ask specific questions about milestones). Then I ask a sleep history. What is her current daily routine like? I’m particularly interested in nighttime sleep: how many hours does she get? Does she sleep continuously or does she wake up? If so, how many times? I also ask about diet and exercise (Really! These things matter!)

With this toddler, it turns out she was getting enough sleep – but the way her sleep was distributed was a little screwy.

Her parents had a terrific bedtime routine: everything from dinner time to bedtime was completely regular and predictable. The girl went down without a fuss at 7PM sharp (in her toddler bed!). She would wake up at 7AM, have a bottle in her bed, and a short time later would fall asleep again until 9AM, when she’d be up for the day. For several months, she’d take a brief nap in the afternoon. Now she wasn’t napping at all, and the tantrums were beginning.

The Routine

toddler won't nap
I’M NOT CRANKY!!!

Her parents didn’t count the 7 AM bottle as an awakening and a nap, they counted it as part of her nighttime sleep. This little girl was getting 14 hours of sleep per day, which is on the high end for a toddler of her age. But she was getting all this sleep basically in one shot.

When most children drop down from two naps to one, it’s the morning nap that goes. They tend to keep the afternoon nap. This child kept her morning nap but lost the afternoon nap. As a result, by bedtime she would have stayed up 9 straight hours, which was a lot for her. She would become overstimulated and cranky. This actually made it more difficult for her to go to sleep at night!

Her fix

toddler won't nap
I LOVE daycare!

I explained to these parents that their daughter was getting great sleep at night: 12 hours! By the afternoon, she was not getting sleepy, because she had already taken a two-hour nap in the morning!  I thought that when she woke up in the morning, she should be up! But instead, she was conditioned to have her bottle and fall back to sleep. I pointed out that what she was doing was holding on to her morning nap beyond the point where she really needed it. She probably still needed the nap, only later in the day.

The fix was remarkably simple. Frankly, I was surprised how easy it was. I recommended that at 7AM, mom should start a new morning routine. She’d invite the girl to get up, have her bottle in the kitchen, eat a healthy breakfast and start her day. This activity alone was enough to stimulate the girl enough to convince herself she was awake and ready to play. By 1 o’clock in the afternoon, she began to get sleepy and went down for a nap. She’d get up at 3, and then would go down for the night at 7PM.  No crankiness, no tantrums.

Need a SLEEP COACH?

Overstimulation

There are many other reasons why a toddler’s nap schedule can get screwed up. Some toddlers have the kind of temperament that makes them sensitive to stimulation. In order to nap, they need low light and quiet. If there is too much sound, light, or activity, they will want to pay attention and stay awake.

Many toddlers nap badly at daycare. Even though most daycares do a terrific job of lowering the lights, playing soft music, and limiting noise and activity, sometimes it doesn’t work. The sensitive toddler won’t nap because she’ll be stimulated by whatever sound and activity is going on at nap time.

On the other hand, some parents tell me that daycare sleep is great but the toddler won’t nap at home! With further questioning, I usually find that the toddler is being overstimulated at home more so than at daycare!

toddler won't nap
Yeah.. no

In both these situations, if your toddler won’t nap and the reason is overstimulation, the fix is to try to reduce the amount of activity, sound, and light as much as humanly possible.

The Cheetos Sweetos Nap

Diet matters. Sorry, folks, it just does.

Here’s another true story: I did a consult for a family that had three children. One in first grade, a pre-schooler (age 3), and a baby just turned one. The reason for the consult was that the 3-year old wasn’t napping.

The mom had all three children with her when we sat down to talk. I spotted the sleep problem immediately before we even started getting to know one another. There was an open bag of Cheetos Sweetos being passed around and all of them were eating them… even the baby! Everyone had a sippy cup of juice.

Sure, they’re tasty. But Cheetos Sweetos is not food. It is the enemy of sleep. These poor kids were so amped up on sugar that it’s a wonder any of them slept at all. They got plenty of activity – this was obvious from watching them, but their diet was awful.

The Three Legs

I never get tired of reminding people that all of health and wellness stands on three legs: diet, exercise and sleep. All three of these are closely related to one another. Good habits in one domain reinforce the other domains. For example, kids who eat well tend to get better exercise, and they sleep better. Kids who sleep well tend to have more energy for exercise… and so on.

But you can also see how poor habits in any one domain can throw off the others. In the case of the Cheetos Sweetos family, poor diet was probably the most important key to understanding why the toddler won’t nap. So the take home messages are identical to the three legs of health:

  • Eat Real Food: If it doesn’t look like it did when it came out of the ground or from the animal, it’s not real.
  • Get Plenty of Vigorous Exercise: Humans are meant to move. Make sure the kids get at least an hour of real physical activity every day.
  • Get Plenty of Sleep: Keep consistent, predictable schedules, as much as possible. Avoid overstimulation. Listen to sleep cues, but provide structure!

 

 

 

 

 

How to Get Your Toddler to Sleep in Her Own Bed

Half the battle is over: You moved the baby from a crib to her own bed.

Well… let’s say that one-quarter of the battle is over. Now you have to figure out a way to get her to sleep in her own bed. Maybe you’re one of the lucky few whose sweet little angel sleeps all night in her brand new bed. Not likely, though. Here’s how to close the deal:

How to Get Your Toddler to Sleep in Her Own Bed

Step One: Lay the Groundwork

If possible, let the toddler know her “big girl/big boy” bed is coming. This may not be possible if you had to buy the bed in a hurry on the day she climbs out of the crib for the first time. But if you do get the chance, let the little one know that a terrific present is coming. If she can stand it, you might even go shopping for the bed with her. Be as positive about the event as possible. If you are genuinely enthusiastic about the toddler bed, she’ll pick up on your enthusiasm.

Some parents score by buying the bed and setting it up in the toddler’s room before she makes the transition. You might even have her try to take a nap in it. This is a similar technique that works in toilet training: you introduce the potty long before the child actually sits on it to poop! In a similar way, the toddler bed becomes an “acquaintance” before it becomes a “friend”.

What if There’s No Time to Lay the Groundwork?

What if one day you hear “the thud” followed by the cry of the frightened toddler who didn’t realize it was that far to the floor when she climbed over the rail? No time to introduce the bed (although there may be time to shop)? In this case, you may need to rush the process of introducing the her own bed… like down to less than a day. Your toddler might not like the idea of such a dramatic change. I understand.

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But changes happen in her life, often suddenly and she always adjusts. This time will be no different.

Step Two: Be Consistent

One thing doesn’t have to change, and that’s your bedtime routine. For me, the “bedtime routine” begins at dinner. After that time, every single thing that happens is regular and predictable. Dinner should be at the same time. Bath at the same time. Book reading at the same time. Everything. Consistency is the key to troubleshooting any sleep issue and this one is no different.

own bed
They’re not sleeping, but they’re happy!

As long as you are staying consistent, it is best to use the same mattress she slept on in the crib, with the same sheets and bedding. Most toddler beds are designed to accommodate a standard crib-size mattress. Perhaps you had already splurged and purchased a crib that converts to a toddler bed. Even better! The point here is that the surface the toddler lays on will feel exactly the same as the crib. This is important to her keeping good sleep associations. You might even consider placing the toddler bed in the same place where the crib stood.

Step Three: Set Limits

If you have a perfectly normal bedtime routine and your little one drifts off to a blissful sleep, then you’re done. But more likely than not, your toddler is going to want to get out and find you at night. Most likely this will happen sooner rather than later.

If you have not done so already, this is the time to baby-proof your house. Gates should be placed on stairs. Cords and outlets should be safely secured and out of reach. Every item of furniture that could be pulled down, including chests of drawers, should be secured.

If you haven’t gotten into the habit of setting limits with your child, this would be a terrific night to get started. The first limit ought to involve your bed. Just because the little one has her own bed, doesn’t mean she can sleep in any bed, least of all yours. Now, some parents are fine with this and I cannot judge them. However, if any or all occupants of the bed are not okay with this arrangement, then it’s not okay, period! Also ask yourself if you still want the little one in your bed in four months. Or what if there’s a new baby coming? What if the new baby has already arrived? Clearly, a limit should be set.

own bed
Now THAT’S what I’m talkin’ about!

The limit goes something like this: “You’ve got your own bed. [Partner] and I have our own bed. Everybody sleeps in their own bed!” Simple and matter-of-fact. No reasoning and explanation is required. If you do not know already, you should know that your toddler does not care about reasons! All she wants to know is: What are the limits and are you (mom) going to enforce them?

Step Four: Enforce Them

Here’s the toughest part. Once a limit is set, it’s got to be enforced. Among the worst things you can teach a child is that the limits you set are phony and you aren’t really serious about them. Children who grow up without enforced limits are more anxious and less happy. They may not show it, but they need limits! Kids test limits not because they are unhappy or imp-ish, but because they need to know that the limits are there and are being enforced by the “Limits Setter(s)”.

Every time she gets out of bed and comes to yours, you should bring her back to her own bed. The tough part of this act is doing it calmly and without emotion. I cannot stress this enough. Remember: no explanation or reason is going to help. It’s just wasted breath. Your toddler is never going to say to you “Gee, Mom! I never thought of it that way! Thank you for explaining it to me”.

Step Five: She’s Got Her Own Bed, Now She’s Got to…

When you return her to own bed, the routine should be the same. Brief, matter-of-fact, and to the point. This is much easier said than done. Your toddler’s main job in life is to find the chinks in your armor and plunge through them. Maybe she’ll ask for water, or a bottle (don’t get me started on this one!) It will be tough, but you are tougher. Stay firm, stay calm, and stay consistent.

The Easier-Said-Than-Done List

  • Be Consistent: Keep the entire bedtime routine exactly the same as it was when she slept in a crib.
  • Set Limits: Everybody sleeps in their own bed. Children thrive on limits. Without them they are lost.
  • Enforce the Limits: No limit is any good if you don’t enforce it. Remain calm. Take deep breaths. And enforce the limits you set. You’ll be glad you did. So will your toddler.

Best Toddler Beds

Half the battle is over: You’ve moved the baby from a crib to her own toddler beds.

own bed
A bed of her own

Well… let’s say that one-quarter of the battle is over. Now you have to figure out a way to keep her in the toddler bed. Maybe you’re one of the lucky few whose sweet little angel sleeps all night in her brand new bed. Not likely, though. Here’s how to close the deal:

Toddler Beds

If possible, let the toddler know her “big girl/big boy” bed is coming. This may not be possible if you had to buy the bed in a hurry on the day she climbs out of the crib for the first time. But if you do get the chance, let the little one know that a terrific present is coming. If she can stand it, you might even go shopping for the bed with her. Be as positive about the event as possible. If you are genuinely enthusiastic about the toddler bed, she’ll pick up on your enthusiasm.

Some parents have had success by buying the bed and setting it up in the toddler’s room before she makes the transition. You might even have her try to take a nap in it. This is a similar technique that can be successful in toilet training: the potty is introduced long before the child actually sits on it to poop! In a similar way, the toddler bed can become an “acquaintance” before it becomes a “friend”.

What if There’s No Time to Lay the Groundwork?

own bed
See? She LOVES it!

What if one day you hear “the thud” followed by the cry of the frightened toddler who didn’t realize it was that far to the floor when she climbed over the rail? No time to introduce the bed (although there may be time to shop)? In this case, you may need to rush the process of introducing the her own bed… like down to less than a day. Your toddler might not like the idea of such a dramatic change. That’s understandable.

But changes happen in her life, often suddenly and she always adjusts. This time will be no different.

Be Consistent

One thing doesn’t have to change, and that’s your bedtime routine. For me, the “bedtime routine” begins at dinner. After that time, every single thing that happens is regular and predictable. Dinner should be at the same time. Bath at the same time. Book reading at the same time. Everything. Consistency is the key to troubleshooting any sleep issue and this one is no different.

own bed
They’re not sleeping, but they’re happy!

As long as you are staying consistent, it is best to use the same mattress she slept on in the crib, with the same sheets and bedding. Most toddler beds are designed to accommodate a standard crib-size mattress. Perhaps you had already splurged and purchased a crib that converts to a toddler bed. Even better! The point here is that the surface the toddler lays on will feel exactly the same as the crib. This is important to her keeping good sleep associations. You might even consider placing the toddler bed in the same place where the crib stood.

Set Limits

If you have a perfectly normal bedtime routine and your little one drifts off to a blissful sleep, then you’re done. But more likely than not, your toddler is going to want to get out and find you at night. Most likely this will happen sooner rather than later.

If you have not done so already, this is the time to baby-proof your house. Gates should be placed on stairs. Cords and outlets should be safely secured and out of reach. Every item of furniture that could be pulled down, including chests of drawers, should be secured.

If you haven’t gotten into the habit of setting limits with your child, this would be a terrific night to get started. The first limit ought to involve your bed. Just because the little one has her own bed, doesn’t mean she can sleep in any bed, least of all yours. Now, some parents are fine with this and I cannot judge them. However, if any or all occupants of the bed are not okay with this arrangement, then it’s not okay, period! Also ask yourself if you still want the little one in your bed in four months. Or what if there’s a new baby coming? What if the new baby has already arrived? Clearly, a limit should be set.

own bed
Now THAT’S what I’m talkin’ about!

The limit goes something like this: “You’ve got your own bed. [Partner] and I have our own bed. Everybody sleeps in their own bed!” Simple and matter-of-fact. No reasoning and explanation is required. If you do not know already, you should know that your toddler does not care about reasons! All she wants to know is: What are the limits and are you (mom) going to enforce them?

Enforce Them

Here’s the toughest part. Once a limit is set, it’s got to be enforced. Among the worst things you can teach a child is that the limits you set are phony and you aren’t really serious about them. Children who grow up without enforced limits are more anxious and less happy. They may not show it, but they need limits! Kids test limits not because they are unhappy or imp-ish, but because they need to know that the limits are there and are being enforced by the “Limits Setter(s)”.

Every time she gets out of bed and comes to yours, you should bring her back to her own bed. The tough part of this act is doing it calmly and without emotion. I cannot stress this enough. Remember: no explanation or reason is going to help. It’s just wasted breath. Your toddler is never going to say to you “Gee, Mom! I never thought of it that way! Thank you for explaining it to me”.

She’s Got Her Own Bed, Now She’s Got to…

When you return her to own bed, the routine should be the same. Brief, matter-of-fact, and to the point. This is much easier said than done. Your toddler’s main job in life is to find the chinks in your armor and plunge through them. Maybe she’ll ask for water, or a bottle (don’t get me started on this one!) It will be tough, but you are tougher. Stay firm, stay calm, and stay consistent.

The Easier-Said-Than-Done List

  • Be Consistent: Keep the entire bedtime routine exactly the same as it was when she slept in a crib.
  • Set Limits: Everybody sleeps in their own bed. Children thrive on limits. Without them they are lost.
  • Enforce the Limits: No limit is any good that is not enforced. Remain calm. Take deep breaths. And enforce the limits you set. You’ll be glad you did. So will your toddler.

Transition Time: When to Move From Crib to Bed

I have a confession. Whenever parents ask me when to transition their toddler from the crib to a bed, I’m tempted to give a smart-aleck answer. “When she leaves for college”. Even though I sound like a jerk when I say it, there’s a reason for my answer, as you’ll see.

I know that parents are really asking a different question. It depends on the age and developmental stage of the toddler. Maybe they are expecting a new baby. I asked myself the same question twice, once for each boy. There was a different answer for each one, which I’ll get to.

The Transition Question

Many parents are justifiably afraid that the toddler is going to climb out of the crib and hurt herself. This is totally understandable. Surely we’d like to be able to predict the very moment that the toddler becomes physically able to climb out of the crib, and transition her to a bed the day before!

Unfortunately, it’s difficult to know when exactly she’ll have the upper body strength and coordination to accomplish the escape maneuver. And even if she is both strong enough and coordinated enough, it is not a stone-cold certainty that she’ll use those abilities.

I know, I know… it’s like Murphy’s Law of Toddlers: if she can do it, she will do it.  Perhaps, but not necessarily.

transition
I’m bushtin’ outta here, shee?

So it may be impossible to know when exactly when she’ll try to make her getaway, but she’ll probably give you clues. Most toddlers will try to climb out right in front of their parents! The first move, and this is a key one, is to get one leg to the top of the rail and to work it over as in this picture.

Stand and Deliver

One thing is for certain: no toddler is going to climb out before she can stand up on her own! When your toddler can do this, it’s time to lower the mattress so that the rail is relatively higher. I recommend lowering it as far as it will go. One web site even recommends performing surgery on your crib to lower the mattress all the way to the floor. I don’t recommend doing this unless you are absolutely certain that a) you won’t destroy the crib in the process and b) the crib continues to be a safe place for the toddler to sleep. In other words, you don’t want the mattress or parts of the toddler to get stuck on underneath the crib!

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Murphy’s Law for Toddlers in Action

If your toddler is doing the “leg thing” despite your having lowered the mattress as far as it can go, it’s time to transition to a bed. Here’s why (and it’s the main point of this post):

The crib has one purpose and one purpose only: to keep your child safe. The moment the crib stops being a safe place for her, you need to move her out.

Some parents try to prevent the child from escaping with tents or other contraptions. I’m not even going to provide a link to these devices. Murphy’s Law applies. At best, toddlers figure out how to climb out despite the tent. At worst, they kids get stuck and hurt themselves. I do not recommend tents. If your toddler is motivated enough, she will find a way out.transition

Moving Day

No one wants to risk a toddler hurting herself badly. I’m certain that there have been some very bad accidents resulting from a crib escape attempt. Here’s the thing, though: in over 20 years I’ve never seen one. I’ve seen injuries from babies rolling out of bed (don’t get me started on that one!) I’ve seen injuries from falls down stairs. I’ve seen injuries from dad’s tripping over toddler gates while holding the baby in his arms… but never a crib escape injury. I don’t say that to give you the green light to let your toddler climb out. I only say it to try and reassure you that if she climbs out, the result is probably not going to be catastrophic.

So when to parents typically make the transition? The honest answer is: the day they hear the “thud” of the sound of the toddler having made a successful escape. I call this “moving day”.

This is that day that parents rush out and buy a bed if they have not already done so. I cannot blame them. Remember: the crib is meant to keep the baby safe. It has no other purpose. The moment it stops doing its job is the moment to move her out! This was the case for our first child. We heard the thud. We bought the bed. Easy decision.

New Arrival

transition
Life is a transition

Another common reason for making the transition is that mom is expecting a new baby, and there’s only one crib. In these cases, common sense tells you that you should move the toddler out well before baby comes home. That way, the toddler won’t feel like her place is being taken over by the intruder. Even though this is common sense, I have to confess I do not know if the idea has ever been tested! I have never seen or read of any cases where the toddler was kicked out of her crib on the day the baby comes home. So the truth is, we don’t know what the effect will be.

One thing is for certain. If mom is pregnant, the toddler knows that something is going on. Mom’s behavior changes: she’s tired more often, maybe she’s grumpier than usual. Maybe the stress level in the house is rising. Toddlers read all these signals and respond to them. I’m not sure the timing of the transition makes all that much of a difference: the toddler already knows that something is going on and may be anxious about it.

About those explanations…

It doesn’t do much good to explain to her that there’s a baby in mom’s belly. Even if your toddler is intelligent enough to understand it, there’s no way she’ll be prepared when the new baby arrives. Here’s why: there’s no way YOU will be prepared when the new baby arrives! Even though you understand it conceptually and intellectually, you are never prepared for the reality. How much more so for a toddler who hasn’t developed abstract reasoning skills!

Some experts recommend making the transition when the baby comes home from the hospital. The theory is that the baby will be sleeping in moms room for around four months, so the toddler would have time to adjust to the new situation. Again, I get it. It makes sense. But I have no idea if the psychology works.

The best advice I can come up with is this: have the toddler sleeping elsewhere before you put the baby down in the crib. How you get it done is entirely your choice.

We Really Need the Room

transition
Seasons change. So do beds

What if the child never climbs out? Is it possible to keep her in the crib for too long? I’m not sure it is possible! This is why I make the joke about college. Remember, the purpose of the crib is safety. As long as she’s sleeping safely, why rock the boat?

By the time Boy#2 was about 2 1/2, he had not ever tried to climb out of his crib. Maybe he was physically able. He simply didn’t want to climb out. But his 5 year-old brother was sleeping in his own bedroom, and we really wanted to convert the nursery into an office. So at dinner one night we asked the boys “Would you guys like to share a room?” We asked this while nodding our heads and smiling (I call this “the Jedi Mind Trick“). They enthusiastically agreed and that was that.

The next day Boy#2 had his bed. The transition didn’t go so well. He refused to sleep in his new bed, but he did agree to sleep on the floor next to it. Problem solved.

Transition Points

Making the transition from crib to bed is never easy. Sometimes it’s traumatic, for parents as well as the toddler. How to smooth the transition is the subject of another post. But the decision of when to make the move should be easy:

  • If she climbs out of the crib, the crib is no longer a safe place to sleep. Time to move!
  • If she doesn’t climb out, and she’s sleeping well, there’s no reason to rush the move.
  • If you need the crib for a new baby, make the transition before you’re ready to put the little one in the crib, but exactly when you do this does not matter much.

 

transition3 transition2 transition1

TSA Traveling with Baby

Since September 11, 2001, travel by air has become much more complicated than it used to be. If you’re traveling with an infant or a small child, it’s become even trickier. The TSA has it’s own rules, and each airline has particular rules as well.  It’s imperative that you know this stuff before you fly! Here are some TSA traveling tips that hopefully will make your trip smooth and uneventful.

TSA Traveling Tips for Tourists

When buying your ticket, make sure you know whether you have to buy one for your infant or toddler. If she occupies her own seat, obviously she’ll need her own ticket. But if she’ll be sitting in your lap, some airlines will permit you to fly two-for-the-price-of-one. Now, if you’re not going to buying a ticket for the baby, the airline is going to want to verify that the baby’s identity somehow. These rules vary by airline, especially if you are flying internationally. If you’ll be traveling to another country, the baby will need a passport!

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What’s ok to carry on to the plane?

TSA traveling
Happy smiling TSA agents!

There was a great deal of confusion about this issue in the beginning, but the TSA has taken pains to make the rules about baby stuff clear and concise. Formula, breast milk and juice are now exempt from the “3 ounce rule” that holds for other liquids and aerosols (not that you’ll be packing juice, right?) So go ahead and pump as much as you can and fill those bottles! Ice packs and baby food jars are also allowed in carry-on bags.

You have to tell the security agent that you’re carrying these things in your bag. They’ll have to go through the x-ray scanner.  Do not worry about this. X-rays will not harm breastmilk, formula, or anything that the baby will be eating or drinking.

Will they pat down the baby?

Yes, they can if they want to. The picture above shows TSA agents in Kansas City, MO, patting down an infant after her stroller set off an alarm for explosives. The incident got some press, but TSA did not apologize and procedures have not changed. The agency maintains that they can pat down any child, although children under 12 get to keep their shoes on. Infants and toddlers in strollers can be carried through the scanner in a caregiver’s arms.
TSA traveling

The photo on the right shows a TSA traveling agent checking for explosives and weapons that might be strapped to this young child’s derriere.

The fourth amendment to the American Constitution states

The right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated, and no Warrants shall issue, but upon probable cause, supported by Oath or affirmation, and particularly describing the place to be searched, and the persons or things to be seized.

To date, TSA screening has not caught any terrorists at airport security, though a number of suspected terrorists have successfully flown in the US without being identified as such by the TSA. Several guns and weapons have been confiscated by the TSA, none belonging to a terrorist.

Thank you for flying with The Essentially Healthy Child!

 

Is There a 9-Month Sleep Regression?

A common question I get comes from a mom and dad worried that the reigning champion sleeper is suffering from the dreaded 9 month sleep regression:

Is there such a thing as a 9 month sleep regression?

The short answer is ‘no’. As I’ve been saying in this series, there is really no such thing as “regressions” when we’re talking about normal infant development.  Sleep becomes disrupted when babies (and toddlers, but wait a sec) achieve major developmental milestones.

Good news and bad news

The good news first: this sleep disruption at around 9 months means your baby is growing and developing right on schedule! This is expected and desired! Now the bad news:

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Toddler-hood has begun

9 month sleep regression
This too is a toddler

Yes, folks, toddlerhood begins well before the superstar takes her first steps. Many parents fear this stage because they associate it with tantrums, willfulness, defiance, all the rest. And all that is true… But so many wonderful things start happening, that it would take several blog posts to describe them.  I will outline just one that relates to sleep.

Object permanence

I had heard the expression “object permanence” in college, but I confess, even though both halves of the expression are common English words, I had no idea what the phrase really meant until I was well into my professional years. How it works is like this:

Prior to about 9 months, the baby is not aware that anything exists outside of her ability to sense it (see it, hear it, touch it, smell it, taste it). If she can’t sense it, it doesn’t exist! Out of sight, out of mind. This is what psychologists call “solipsism”, the belief that nothing exists outside the individual. So when mom leaves the room, the baby says to herself “Gee, I really liked that lady! Too bad she’s gone!”

9 month sleep regression
Once again, toddler

Then, at around 9 months, the baby begins to realize that objects have permanence, in other words, when they disappear from her senses, they still exist! This is why toddlers throw food off the tray and look down to see where it went: they are playing with this new concept of object permanence.  Ditto when they play peek-a-boo: Babies love peek-a-boo. When they hide their face and then remove their hands and you’re still there, it’s a big kick! (9-month olds are easily amused, as you must know by now)

Okay, Rob, what does this have to do with sleep?

Now here’s the point I’m trying to get to. Now that the baby has acquired object permanence, she knows that when you leave, she can get you to come back! That is most often the reason why she’ll cry when you leave the room.

9 month sleep regression
This is not a toddler. This is a monkey

This is a very important stage in her life. Object permanence is a great insight (that we take for granted but it’s great nonetheless), but it can develop into a bad sleep association.  Please please PLEASE try to avoid the temptation to answer your baby’s pleas for your return. If you don’t, you could end up at the bottom of the slippery slope of leaving-and-returning that you wish you never had traveled down!

Here’s what you do instead:

  • Consistency consistency consistency. I can’t stress this enough. Babies (and other humans) with consistent schedules sleep better. To the greatest extent possible, try to make the day predictable and consistent.
  • If you have no other routines during the day, start with an evening routine. This begins at “dinner”. At this point, everything else that happens should be in the same order, same time of day, etc. For example:

6:00 PM Dinner

6:20 Bath

6:40 PJs

6:45 Book

6:50 Song/Kiss/Prayer Good Night

  • If  you feel like you’re losing it, get help if possible. Have dad or another caregiver help you out.
  • Transitional objects are a big help. A transitional (or comfort) object, is nothing more than an object (blanket, lovie, doll) that helps the baby transition from contact with you to being alone. I don’t consider transitional objects do be bad sleep associations, with the sole exception of the pacifier, which is a subject unto itself!

It’s a great stage of life and I hope you cherish it.  How many times have I wished I could still carry my boys (both in high school now) on my shoulders? Enjoy it while it lasts!