Sleep Strategies

3/4/2024

Dear Parent or Guardian of Aaron,

Thank you for taking the time to speak with me. For additional questions, please
reply to this email.

If you would like to schedule a future phone or video appointment with a health
educator (topics include: sleep concerns, feeding/picky eating, parenting/behavior
and toilet training), please email me back or call one of our Healthy Living
Centers. We are open Monday through Friday, 9:00 a.m. to 5:00 p.m.

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Your plan:
Here is an overview of what we discussed today:

-Establish consistent sleep routine that coincides with feeding schedule

-At five months t is recommended that babies get 3-4 hours of daytime sleep. It
should be split into three naps: Late morning, mid afternoon, late afternoon.

-Keep sleep environment consistent. For night time sleep and daytime sleep place
him in the bassinet, so he is used to associating it with sleep

-Create pre-sleep routine during day as well as night. Ensure a dark, cool room
environment with sound machine (white noise)

-Wait a few minutes to see if baby will calm down before picking him up.

Soothing Ladder Method for night wakeups:

1. Go into room, your presence by bassinet
2. Use your voice- talk, sing, shush
3. Replace pacifier and or lovey
4. Touch baby- patting back, tummy, rubbing head or tummy, hand over top of head or
face
5. Jiggle baby in bed
6. Pick baby up to gently rock to soothe but still awake
7. Feed baby
(from The Happy Sleeper)

Adjust sleep environment

Remember the ABC's: Babies should sleep ALONE, on their BACK, in their own safe
CRIB
• It's best for babies to sleep near you, in the same room, but not in bed with
you. Use a safe bassinet or bedside sleeper (sometimes called a co-sleeper) in your
room until your baby is 6 months to 1 year old.
• It's fine to bring your baby in bed with you to nurse or snuggle. Be sure to
return them to their own safe sleep space before you get sleepy.

Set up the room to encourage sleep.

• Keep the room dark, even for naps. If your baby needs to be fed or changed while
sleepy, keep the light low and don't talk or play. Consider black-out shades.
• Run a fan or open a window to keep the room cool.
• Use a "white noise" machine at a low volume.
• Remove visual stimulation. If there's too much to look at, it can be hard for
your baby to settle down.
Establish a pre-sleep routine
Establish regular, predictable bed and naptimes and follow a consistent routine.
• Set an early bedtime for your baby.
• Start to wind down an hour or so before with a bath, books, songs-anything quiet
and calming.
• Watch for cues that your baby is getting sleepy. These include rubbing eyes,
closing eyes halfway, relaxing arms and hands, and sucking that slows down or stops
(if feeding).
• Don't wait until baby is over-tired to start the routine.
• Do a shorter version of the routine before naps, to help reinforce the
associations.
• Put your baby in their bassinet or crib when they're sleepy, but still awake.
This helps them get used to falling asleep in their own bed, instead of in your
arms.

Adjust schedules
Goal is to increase the total number of hours of sleep. Baby is tired, just not
currently sleeping well.
• Set and stick to a consistent bedtime.
• Schedule naptime and guard it carefully. Most babies need 2 naps a day: late
morning and midafternoon.
• Don't wait until your baby is fussy to put them down. Babies don't fall asleep
easily if they're over-tired or upset.
• Choose a schedule you can stick to. Consistency is key with trying to modify any
sleep behavior.

Boost positive associations with falling asleep alone

(BABY does most of the soothing)
• Have baby spend a few minutes in the bassinet or crib when they are calm and
awake, with you nearby.
• Give them a small, favorite stuffed animal or thin blanket, or even a piece of
mom or dad's t-shirt or nightgown that smells familiar.
• Offer a pacifier, if your baby likes using one.
• Set up a music box or a mobile they can control on their own (safely attached to
the crib).
• Put them in the crib while they're sleepy, but still awake.

Reduce the associations with parents soothing them to sleep

(PARENT does most of the soothing)
• Try responding to crying another way, if you're sure nothing is wrong. Instead of
picking your baby up each time, reassure with just your voice, or a gentle touch.
Wait a few minutes to see if they settle.
• Be consistent. Expect your baby will protest when you make changes to the
routine. It's okay to let the baby fuss for a while, if you're confident nothing is
really wrong. (Don't let very young babies cry alone for more than a few minutes.)

Consider sleep training (babies at least 4 months)

There are multiple "methods" to help babies learn to fall asleep on their own and
comfort themselves when they wake in the night. It's best to wait until your baby
is at least 4 months old, when they're less likely to need milk during the night.
• Some methods are more "supportive" than others-parents do more soothing,
checking, staying nearby.
• In other methods, parents step back and allow baby to figure out how to calm
themselves with less help.
• All of these methods are safe when done correctly and consistently. Sleep
training will not hurt your baby physically or emotionally. Most parents who sleep
train their children are glad they did.
• Some parents are more comfortable than others letting their baby cry for a while.
It's up to you to decide what works for you and your family. If you have a partner,
make sure you're on the same page.
• Research suggests separating "falling asleep" training from any "falling back
asleep/middle of the night" training by at least 1 week. There is some evidence
that by focusing first on "falling asleep" middle of the night wakings will happen
less often.

As discussed, below are the sleep training methods Kaiser promotes to help babies
learn to fall asleep on their own. All are safe when done correctly and
consistently. Sleep training won't hurt your baby physically or emotionally. Most
parents who sleep train their children are glad they did. The different methods are
described below.

Method 1: Cry it out-No soothing from parent, baby self-soothes

How it's done:
• Follow your usual pre-sleep routine. Make sure your baby's needs are met (e.g.,
they're fed, not in pain or ill, have a dry diaper). Put your baby in the crib
while still awake, but drowsy. Say goodnight and leave the room.
• Don't go in to check or comfort at all if your baby cries.
• They will eventually stop protesting and fall asleep.

What to think about:

• When done consistently, this method can help your baby learn to fall asleep alone
within a few days.
• Some parents are comfortable letting their baby cry for a while. Both partners
need to be on board.
• Resisting the impulse to go comfort your baby can be very difficult, and "giving
in" reinforces the association you're trying to break. The first 2 nights tend to
be the hardest. Crying can last anywhere from 20 to 90 minutes the first night.
Over the next several nights, crying time decreases (30 minutes on average by the
2nd night; 10 to 15 by the 3rd night) and protests are less intense. (In general,
the older the baby is, the longer they cry.)

Method 2: Check and comfort ("Ferber or graduated extinction")-Limited soothing,

lengthen time between checks
How it's done:
• Follow your usual pre-sleep routine. Put your baby in the crib while still awake,
but drowsy. Then:
o Sit with them for a few minutes. You can talk or sing quietly or do whatever
works for you. Some variations of this method also include lightly patting their
belly.
o Say goodnight, leave the room, and set a timer for 5 minutes.
o Wait until the timer goes off before going in to check and soothe if they cry.
Don't pick your baby up. Keep the lights off. Reassure them with your voice, say
goodnight, and leave the room. This takes only 5-15sec or so.
o Set the timer again for 10min and repeat the steps above.
o Set the timer again for 15min and repeat the steps above. Stay with the 15min
intervals.

What to think about:

• This method is effective when done consistently. It's a good fit for parents who
are okay with some crying, but don't want their baby to cry alone for too long.
• Parents should be aware the checking is for them, not the baby.

Method 3: Camping out ("moving chair")-Limit soothing, gradually decrease presence

How it's done:
• Before you start your bedtime routine, place a chair right near your baby's crib.
• Do your usual getting ready for sleep routine. Put your baby in the crib while
still awake, but sleepy.
• Sit quietly until they fall asleep. With this method, parents are there just to
reassure the baby with their physical presence.
• Try responding the same way every time: "It's time to sleep. I love you. Good
night." This "broken record" is boring, but it still allows you to respond instead
of "ignoring" your baby altogether.
• Every 2 or 3 nights, move the chair a little farther away from the crib.
Continue moving the chair each night until you are at the door, and then outside
the door.

What to think about:

• This method takes patience and consistency. It can take babies anywhere from a
few days to a few weeks to fall asleep without you in the room.
• Some parents find it very difficult not to interact: they worry that they are
"ignoring" the baby.
• This is usually considered a "no cry" or "less crying" technique.

Method 4: Fading ("No Cry")-Usual soothing, gradually shorten routine

How it works:
• Follow your usual pre-sleep routine. If you usually rock, nurse, or sing your
baby to sleep, do that. Note how long it takes them to fall asleep. Place your
baby in the crib.
• Follow your usual pre-sleep routine the next night but shorten the amount of time
by 5 to 10 minutes.
• Continue to reduce the amount of time you read, rock, or nurse a little each
night.

What to think about:

• This method is effective when done consistently. It can take a long time to
implement.
• Parents who don't want their baby to cry alone at all may find this method is a
good fit for them.
• This method is less effective in helping your baby manage middle of the night
awakenings.

Method 5: Bedtime fading-Push bedtime back to later

How it works:
• Temporarily shifts usual bedtime to later. Your child is truly tired, and falls
asleep more easily.
• Do your usual pre-sleep routine, but start it later. Keep evening activities calm
and relaxed. (Don't actively try to "tire them out.")

What to think about:

• This method is effective when done consistently. It can be combined with other
techniques above.
• Some children can get over-stimulated and end up more difficult to settle

Reminders:
Whichever method you try, all sleep training should begin with a bedtime routine
you consistently follow every night. Start at the same time with soothing
activities to calm your child – bath, books, quiet songs, cuddles. It should be a
short process – about 30 to 45 minutes.

During this time, gradually dim the lights and make your movements slower and your
voice calmer. Don’t play with your baby in any way that might stimulate them.

Avoid nursing or feeding your baby as the last thing you do before putting them
down – you want to lay them down drowsy but awake, and give them a chance to figure
out how to soothe themselves to sleep.
Understanding these options will help you find a way to help you and your baby get
more rest.

Helpful Web sites:

Helping Your Child Sleep: Newborn to 12 Months
Sleep Training Your Baby – Is It Right for Your Family?
Healthy Children - Sleep
Sleep Council

Healthy regards,

Capriccia Thomas
Clinical Health Educator
Kaiser Permanente

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