Australia: "He's up all night and cries so intently."

It was an honor to be called into this Australian home by the grandmother of a charming 5-month-old baby, Julius. I had met Gran in the US while she was attending a conference. We had planned to make time for dinner when Jim and I traveled to her part of the world, but, I was delighted to have THIS special invitation as well.

She explains that her grandson (her first) has been a "handful" since birth. His mother and father had eagerly anticipated their child's birth and had prepared themselves for early parenthood with education, family support, and all the necessities of a cheerful nursery.

Though they understood that this stage of life could be challenging, they simply cannot believe the level of sustained exhaustion and confusion they've experienced so far.

Julius's mother has committed to breastfeeding. Though she has adequate supply, this child is constantly on the breast. That is because the breast has been the only way she knew to comfort her son when he "got going." Lately, even the breast will not calm him down, though. When he is obviously tired at night the parents take turns walking him, rocking him, and singing (until hoarse) to him. Sometimes all of these actions would make NO difference. Consoling him and getting him to sleep seems impossible.

When Julius would finally get to sleep, he would sleep soundly for 45 minutes, stir, and then wake up screaming. These dedicated, sensitive parents had seldom seen their child sleep more than one hour at a stretch in his short five months of life.

Clearly this is a crisis. Mom is ready to give up breastfeeding. Dad is struggling to be faithful to his job responsibilities and to care for both his wife and their young one.

I have spent decades hearing and responding to stories like this one, and I've developed a template for evaluating, diagnosing, and treating families in a sleep predicament.

I begin by understanding that children do not sleep well for one (or all) of three main reasons:

• Developmental Issues
• Child Centered Issues
• Parent Centered Issues

Developmental Issues refer to the fact that when healthy children during infancy and early childhood have a developmental surge (e.g., they are about to learn something new), they predictably have difficulty with their sleep patterns. Dr. Brazelton refers to these developmental surges as Touchpoints, and I used this information in developing my Roadmap to Breastfeeding Success.
Predictable surges in a baby's development include:

1. 2-week-old's normal increase in crying
2. 1-month-old's developing clear deep and light sleep patterns
3. 4-month-old's increased distractability while nursing
4. 6-month-old's drive to eat solids
5. 9-month-old's separation/stranger anxiety
6. 12-month-old's learning to walk
7. 18-month-old's second round of separation/stranger anxiety
8. 2-year-old's negativism 

Parents can be taught to anticipate these development surges, and to appreciate them as SUCCESSES in their child's development. However, parents also need to know how to comfort a baby through these new, up-at-night activities without increasing breastfeeding as the only way to comfort the child. Although this may sound counter-intuitive, mothers may need to learn strategies beyond the breast--precisely in order to keep breastfeeding!

Child Centered Issues refer to a child's basic temperament. Initially, parents do not recognize that some challenging behaviors are temperament driven. Though Thomas and Chess originally enumerated eight aspects of temperament, I find the following characteristics most relevant to issues of a child's sleep habits: intensity, persistence, sensitivity, and regularity. Helping parents appreciate their child's temperament will increase their ability to make plans that take their particular child's personality into account, rather than imaging how to handle the "average" baby.

Parent Centered Issues refers to the presence (or not) of depression, family stress (such as family violence, alcoholism), and unrealistic parent (and family) expectations. Significant pregnancy losses (miscarriages or infertility) increase parental anxiety, as does a mother's need to return to work sooner than she would like. All of these factors can be considered "Parent Centered Issues."

I hear a brief history from the grandmother, mother and father. Clearly this was a planned pregnancy in a stable family that is blessed with ample extended family support. There were some challenges at birth but no significant history of pregnancy loss, and symptoms of depression are present in neither mother nor father. 

So far I gather from this story that one "diagnosis" is sleep association. Since birth this child has associated breastfeeding with getting from active sleep back to deep sleep. 

Initially, Julius is playing contentedly, swiping at a toy in front of him. When he makes a hint of a whimper, his mother immediately leans over, readjusts his blanket, pats him, reassures him, and coaxes him back to his mobile. Though seemingly playing contentedly, his behavior changes significantly when I sit beside him. He glances at me--and immediately moves his arms rigidly to his side and looks at his mother. He then looks back to midline, seemingly ignoring his toy, me and his "mum" as she and I talk. I "broadcast" his actions and suggest that they show impressive sensitivity for a baby this age. Both parents agree that Julius has always been quick to notice changes in his environment and that he initially retreats from strangers.

During this quiet time I explain to parents how a child's temperament, as well as active and deep sleep patterns, contribute to sleep issues. A sensitive child needs his parents to respond more often and quickly. And, a very attentive mother (as this mother clearly is) may continue to respond so quickly that the child does not learn to contribute to his own settling. As is often the case, this duo has found that breastfeeding seems to be the most convenient way to settle a baby, and the baby has been taught to associate breastfeeding with going from active to deep sleep. 

My tea cup makes a bit of a clang when I set it down on the glass table top. Julius startles and without hesitation breaks into THE MOST intense, persistent cry I have seen in a child this age. I am good at calming babies, but I can not "break through" the intensity and persistence of his cry.

So the diagnosis emerges:

• Developmental Issues - Emerging cognitive burst expected around 4-5 months. Inability to get from active to deep sleep without breastfeeding.
• Child Centered Issues - Sensitive, intense, persistent temperament traits (ALL characteristics which will bring this child GREAT success in life).
• Parent Centered Issues - An extremely sensitive mother who is increasingly (and understandably) anxious.

The need for this baby, at this age, is for his parents to take a loving but less robust response to helping him settle and to helping him transition from active to deep sleep.

"When you respond to him, you now 1) talk to him, 2) look at him, 3) pat him, 4) pick him up, 5) rock him, 6) breastfeed him. When you put him to bed now, start by dropping off 1) and 2). For a few nights go to him without speaking and glance to the side. Then take your other loving actions as needed. When he is accustomed to this, drop off 6), then 5). You will be bringing out the best in him by helping Julius learn to contribute to his own calming. Also, when he awakens at night, take this same approach so that he will learn to wiggle back into deep sleep, on his own.

The intensely crying Julius gives Mum a chance to practice. She turns her gaze slightly to the side and calms him without speaking. Julius looks puzzled, but is quickly ready to play again. The strategy of doing more by doing less is working!

I called this mother three days later and was delighted with the results she reported. Julius is now sleeping from 10 PM to 4 AM, at which time he gets up to nurse. The parents hear him stir in active sleep but leave him to find his way back to deep sleep. Mum reports, "Yesterday I felt like a new woman. I made some cookies, took the baby for a walk, and was singing when my husband got home from work." She shares that she now hesitates a moment before responding to her son--and sees his increased capabilities as both reassuring and exciting.

In closing the conversation, I review upcoming developmental changes that will impact this remarkable little guy's sleep again, and discuss how his parents can best respond to the milestones ahead. The success they are all starting to experience will provide a foundation for this loving family's future parenting successes!