Managing sleep practices in babies


Matt Dwyer: Hi, I’m Matt Dwyer. Welcome to Sleep, where Professor Harriet Hiscock and associate Professor Emma Sciberras from the Murdoch Children’s Research Institute help you identify sleeping problems in your children from infancy through secondary school and give you easy-to-understand steps to improve their sleep cycles and overall health.

So, what do you generally do when a patient comes to you tired, frustrated, and wanting to fix the child’s sleep problems? Is this a case-by-case issue where you treat each one individually, or do you have more of a universal solution? 

Professor Harriet Hiscock: Well, Matt, I think the first thing I’ll often say to parents is, “What is your goal with your baby’s sleep, and what do you want to try to change?”

Everyone has different ideas about this, but there are a couple of common approaches that we use. One is called “the checking method” or “the controlled comforting method.” It’s previously been called “control crying” or the Ferber method. What’s really important to know is that this is not where you shut the door on your baby and leave them for the night.

So this is a method whereby you use a good bedtime routine, which should be common to all methods. So it might be: bath, feed time, having a look at a book in the lounge room with the television off, then when your baby starts to look tired, taking them into the bedroom. You might wrap them if they’re not yet rolling; otherwise, if they’re rolling, I might just put them into a sleeping bag, give them a cuddle and then try to put them down into the cot drowsy but still awake. That’s the critical thing. If you’re lucky, your baby will go off to sleep. They don’t go to sleep straight away. There’s a bit of a myth that they should go to sleep as soon as you put them in the cot. We don’t do that when we go to bed. So, it takes at least 10 minutes for a baby to fall asleep. During that time, they might grizzle, move their heads back and forth, or thrash around. Parents come to me worried about that, but the baby’s just self-soothing by doing that.

That would be like we might rock in a rocking chair to get to sleep. So if your baby’s doing that, know that you can leave the bedroom and that’s happy days that’s wonderful. But if your baby starts crying, then what do you do? And so, “control comforting” or “the checking method” is a method whereby the parent will go back and forth to their bedroom to comfort their baby.

The comforting might be stroking their baby’s forehead, patting them on their tummy, or patting them on their bottom. You need to do that patting at a really gentle rate, not a really fast rate, because that will just make your baby more, you know…

Matt Dwyer: What does the patting do?

Professor Harriet Hiscock: It’s just a rhythmic way of calming the baby and often calming yourself.

And what we recommend is doing one of those techniques for three or four minutes to see if your baby will calm down. So if you’re stroking or patting, you want to do it until they’re quiet but not asleep because you want to give your baby a chance for them to fall asleep by themselves so that when they wake up from their light sleep, their sleep cycle, they can go, “okay, I know where I am.  I’m in the car, I’m in my room. I can go back to sleep again”. So what we suggest with babies under six months of age, between three and six months, if you’re using this checking method is that you would stroke or pat them in the cot. When they’re quiet, you’d leave the bedroom and you’d only leave for a maximum of two minutes.

If you leave for any longer, little babies wind up so much and get so distressed that it’s hard for them to calm down again. So the maximum is two minutes. You’d go back in. You’d do the same thing, trying to keep them in the cot. If you can’t, if you’re having a night with them, “Oh, I can’t cope with this, ” or it’s not working, picking up your baby is OK. Give them a cuddle, give them a feed, and try again or say, ‘I’ll try again the next night’. So, up to six months of age, we say, “Keep that time interval”. When you’re outside the bedroom, two minutes maximum. After six months, you can start lengthening the time that you spend out of the bedroom; it might become three minutes, four minutes or five minutes.

And there’s no absolute time, it’s what you feel you can manage as a parent and also listening to your baby. So, if you can hear your baby’s crying for a couple of minutes but starting to quieten down, it’s probably better not to go back in because it might just rev them up again and make them upset. And, actually, they’re going off to sleep anyway. 

Associate Professor Emma Sciberras:  And Harriet, are there any harms associated with that technique, so letting babies cry?

Professor Harriet Hiscock: Yeah. So, this is not letting them cry for long periods. So with the research we’ve done at the Murdoch Children’s Research Institute, we’ve done some studies, and we’ve followed babies who have done these sorts of strategies at 12 months of age, two years of age, and six years of age and we’ve asked parents about their baby’s sleep and the child’s behaviour. We’ve actually taken cortisol, saliva swabs from children as they’ve gotten older, and we have found no harm from this approach. So at two years of age and six years of age, these children, actually at two years of age, have fewer sleep problems.

But their behaviors and saliva profiles are the same as those of babies who didn’t go through this approach. This follows on from some work done by Michael Gretta and colleagues in South Australia, where he did a study looking at cortisol in babies before starting sleep strategies and immediately afterwards.

And 12 months later, actually, and again for the babies, he compared a group who got these strategies with the group who didn’t get the strategies. There was no difference in their cortisol or in their attachment to their parents or their mother at those time points as well.

Associate Professor Emma Sciberras: What are some of the benefits of this intervention approach, apart from improving the child’s sleep? Are there benefits that you see? 

Professor Harriet Hiscock: Well, indeed, the parents come back often to me and say, “Gosh, I wish I’d tried this sooner”. So I think one of the most significant benefits is parents get to sleep, and with “control comforting” or “the checking method,” it’s usually a three to five-night program that you have to do.  So you do have to be in for that period of time. Partners need to be on board together. Because it’s awful at 2:00 AM if you’re there saying, “I can’t do this,” and you’re fighting with your partner about it. So everyone has to be on board, but I think the most significant benefits are that the child sleeps better, is happier, and feeds better. Usually, during the day, once they sleep better, their interactions are more lively, and the parents rate their relationship with their child as better. And we certainly know from our studies that parent mental health improves with this approach as well.

Associate Professor Emma Sciberras: How effective is it, Harriet? Are there families that you say where this approach just doesn’t work? 

Professor Harriet Hiscock: Yeah, look. The checking technique probably works in about 70% of babies and toddlers, but it doesn’t work with everyone. It’s really hard to tell exactly ahead of time who it’s going to work for and who it won’t work for.

Yeah. But indeed, I have said to parents, “When you put your baby to sleep, and they are protesting, is it an angry protest, or are they sounding fearful or sad?” If it’s an angry protest, I often suggest going with the checking method first, but if it’s sad or ‘I’m really stressed out, you’re leaving me’, then there’s a second technique that we use and have good evidence for, and it’s called “the camping out technique”. And this is where the parent places a camp bed or a chair right next to their baby’s cot. They will pat or stroke their baby off to sleep the first few nights. After a few nights, when the baby’s falling asleep, within 10 or 15 minutes of doing that, they might just sit there and they might just pat the mattress while their baby falls asleep.

After a few nights of that, they’ll sit there and not touch the mattress or the baby. And after a few nights, they’ll start to move their camp, bed, or chair a foot away from the cot and gradually out of the bedroom. So, this is a much slower technique. It takes two or three weeks to work. And some parents say to me, “That’s fine, I don’t want my baby to cry”. They really much prefer this technique to “the checking method”. Other families say, “there’s no way I can do that over two or three weeks, let’s do something that’s going to work over three to five nights”. So that’s a choice and that’s great for parents to have that choice of what will work in their family.

But I do think that the babies would get anxious when their parents leave the bedroom. It’s better to use “the camping out technique,” as it is more gradual. 

Associate Professor Emma Sciberras: And do you ever get stuck at a step with that? Does it kind of go nicely and sequentially through that? Or do you ever get to a point where you’re kind of stuck in the hallway? 

Professor Harriet Hiscock: Look, a lot of parents do get stuck in the hallway, and sometimes it’s more about their anxiety than their baby’s anxiety.

And so what I say, if your chair is in the hallway, “why don’t you try coming and going from the chair every couple of minutes, go into the kitchen and do something for a minute or two, and then come back to the chair?” And the aim is that when you come back, you hope your baby or your toddler has fallen asleep without you there.

Associate Professor Emma Sciberras: And what about co-sleeping? Is that something that people use as a strategy?

Professor Harriet Hiscock: Yeah. Look, co-sleeping is really common, but probably a lot of parents won’t often admit it to health professionals. Co-sleeping is when you share the actual bed space and surface with your baby.

So it’s not when you’ve got a side cot or cot right next to your mattress. It’s there in bed with you. We recommend against co-sleeping in the first year of life because of SIDS. There is evidence that if you sleep on the same sleep surface as your baby does increase the risk of SIDS, mainly if it’s a doona or if the mattress is not correctly fitted into the bed. They can get stuck between the bed and the floor, or the mattress and the frame of the bed, or if you drink alcohol, or if you’re overweight and obese, or if you take any sedating medications. There are cultures that have been co-sleeping with their babies for centuries. A lot of parents I see say that the only way they can get their baby to sleep is co-sleeping.

But I think we need to think about ways to do this a bit differently. And there have been some studies in New Zealand where they’re actually using Maori woven baskets with firm, flat bases. They’re putting their babies in there, which has been shown to be quite effective. So I will always counsel parents not to co-sleep on the same surface but think of a cot alongside the bed or something like one of these Maori little baskets that have got a firm sleep surface and don’t have the bumpers or anything. The child can then be placed between the parents in the bed for a safe, split sleep space. 

Associate Professor Emma Sciberras: That’s great, Harriet. I had a bassinet that I was trying to come up with what I was gonna get. After much thought, I got this bassinet, and I could not get my child into it.

I was looking up different things, and we ended up hiring one of those co-sleeper attachments to put next to the bed. 

Professor Harriet Hiscock: And how did that go? 

Associate Professor Emma Sciberras: It was a lifesaver for us. 

Professor Harriet Hiscock: Yeah. Fantastic. 

Associate Professor Emma Sciberras: The tricky thing for us was that our little one rolled early, so it meant that we couldn’t leave her in there for too long. It was really good for the first couple of months, but because she was rolling out, we were worried that she would…

Professor Harriet Hiscock: rolling onto your bed…

Associate Professor Emma Sciberras: And exactly. It was a short-lived experience, but it actually worked for us, and it was quite enjoyable. 

Professor Harriet Hiscock: I think it’s also a really good idea to be able to hire those sorts of things and not spend hundreds of dollars on equipment. 

Associate Professor Emma Sciberras: Yeah. After spending all the money on the initial furniture, it had to be hired.

Professor Harriet Hiscock: Yeah.

Matt Dwyer: You mentioned that dummies can be a lifesaver, but are there any dangers around that? 

Professor Harriet Hiscock: The big issue with dummies, well there’s a couple of issues. There’s, “I’m having to get up and replace it overnight”, which can be exhausting, and I’ll talk about management of that. Also, dummies, if on too long of a chain, there’s theoretically a risk that it might wrap around the baby’s neck and cause harm. So there’s a couple of options. If dummies are a problem and your baby’s waking up multiple times overnight, one is to get rid of the dummy. But a lot of parents say, “Oh, I can’t do that.” They can put their own dummy in their mouth from the age of seven months. They’ve got the fine motor skills to do that. So, often, attach a cord or a string with a dummy arm to your baby’s pyjamas, but that has to be less than 10 centimetres in length so that they can’t possibly wrap that around themselves. Then when your baby wakes and they need the dummy, don’t put it in yourself, slide the baby’s hand down the chain onto the dummy and into their mouth. Usually, after two to three nights, your baby will know where the dummy is and how to put it back in again. So that’s the interim plan. 

Then, when you’re feeling rested and strong enough, you can start to get rid of the dummy. Some parents do that by removing it from daytime sleep first and then doing it for nighttime after that.

Instead of settling with the dummy, the babies will use one of these other strategies: “camping out” or “the checking method.” Often, after a few nights, the babies are okay. Again, parents will say, “Gosh, I wish I’d done that earlier.” 

Matt Dwyer: [00:13:32] One thing I wanted to ask is, have you found that all these different methods apply to parents who have multiple children in different age groups?

Professor Harriet Hiscock: Yeah. In our studies, we’ve had parents who’ve used these strategies, first-time parents, second, third, and fourth-time parents, and they can certainly apply to different age groups as well. Both the camping out and the checking method can really take you through to, what would you say, Emma? The end of primary school, potentially.

Associate Professor Emma Sciberras: Yeah, sure. Definitely. I’ve even done some checking method activities with kids, even in year seven. So it just depends. And I think, especially if there’s high anxiety, that you might end up using those strategies for a much longer time in the child’s development.

Professor Harriet Hiscock: Yep. 

Associate Professor Emma Sciberras: And are there children for whom checking and camping out doesn’t work, in your experience?

Professor Harriet Hiscock: Look, if neither of those work, the checking or the camping out, it’s tricky. There’s a third method: parental presence. That is where you have your bedtime routine, you put your baby or toddler into their cot, and then you stay in the bedroom. So you stay there for seven nights straight. The lights are out; you might just be sitting there. Some parents I know look at stuff on their iPhones, but the screen is turned away from their baby, or they just are in the rooms putting away clothes and things, and that can actually work quite well and be quite reassuring.

I’ve had parents do that and do the odd “shh, shh” while they’re in the room, which worked really nicely. So that’s the third option that helps. Very occasionally over the age of one, certainly not under one, and perhaps even older, we might combine some of these strategies with an antihistamine, but that’s gotta be done under the advice of a specialist.

Associate Professor Emma Sciberras: And what about the room environment? So what do you suggest to families about preparing the room? Should you put them to sleep in a light room, or should it be dark? how do you manage all of that?

Professor Harriet Hiscock: That’s a great question. It’s gotta be dark and cool. I find that, particularly in those first few months, babies might sleep quite well in the living room when they first come into the world. After a few months, they might start sleeping and not sleeping in that living room because it’s light, there are people coming in and out, and the radio is on. So really, where they sleep should be the same for daytime and nighttime.

The bedroom should be calm and dark. Some babies seem super sensitive to light, and parents will put up garbage bags, and it almost blacks out the room, and then their baby sleeps really well. So there are just some babies who are like that and need that really dark room. I think the other thing is trying to avoid too much in the way of video monitors, monitors, music, those sorts of things. You don’t need them. You might use music for the first few months when you’re trying to get through that crying phase, but then start to turn down the volume and phase that out. Because, again, it’s another sleep association like patting or fading might be. And if the baby can only fall asleep to music, they want that music when they wake up, two or three times a night, and they’ll expect that.

Associate Professor Emma Sciberras: So, does that mean if you were using music? For some kids, you’d have to have it on all night.

Professor Harriet Hiscock: Yeah, so some parents put the CD on repeat. What I’ll say is, “Once you’re getting your child to learn to go to sleep, then start to turn the volume down on that and get that out of the room.” I’m very keen on turning monitors off as well.

So, as we said earlier on, babies are very restless sleepers. I often have parents saying, “Oh my gosh, my baby’s roused,” and they rush into the baby’s room. Then the baby wakes up and goes, “Oh, there’s mum, there’s Dad. It’s party time.” And start to anticipate that that will happen. So if you are confident that if your baby’s crying and you’ll hear them from your bedroom, turn the monitors off, turn the video monitors off. 

I once heard a funny story from a maternal and child health nurse who said there was a parent who lived in a cul-de-sac. The house two doors down had the baby monitor on, and everyone could hear every argument and everything the baby did overnight.

Associate Professor Emma Sciberras: And what about things like teething and other kinds of conditions like eczema, and how do they affect sleep? 

Professor Harriet Hiscock: Yeah. Look, the teething causes nothing but teeth. So a colleague of ours at the Murdoch Children’s Research Institute did a whole study on teething and looked at whether or not it was associated with things like sleep problems and temperatures and diarrhea, and actually, it was associated with none of that. So, I think teething gets blamed for a lot of things. It’s probably not the end of the world, but we don’t want parents getting into a cycle of using stuff like Panadol a lot for teething. 

Things like eczema are definitely associated with sleep issues. Children, if they have eczema, are overheated, or have very dry skin, will tend to be really irritated by that and itch a lot overnight. So, that’s something that needs to be managed with good medical input to try and manage the eczema as best you can so that it’s not impacting nighttime sleep.

Matt Dwyer: [00:18:38] In terms of stimulation, is there a difference between say a baby playing with their toys and then a baby playing on an iPad or screen time? What are your recommendations for screen time? We’ll get into that in more detail or in terms of…

Professor Harriet Hiscock: Oh, no. I think it’s really important, Matt, because we’re seeing screens on prams and in front of babies more and more, and it’s a big no-no.

So the American Academy of Paediatrics has come out with some guidelines around this, and they certainly don’t recommend screen time, especially for those under the age of one and probably not under the age of two. Certainly for the older, maybe under the age of two, if you’re going to, it’s gotta be supervised with the parents so that it’s interactive and educational. Certainly not under the age of one. The big problem with screens is not just the content; they emit blue light, which blocks melatonin. Actually, melatonin is produced in babies from a few weeks of age. So if you’re interfering with the brain’s melatonin production, you’re potentially interfering with them, setting up good sleep habits and sleep cycles. 

Matt Dwyer: The popularity of screen technology right now is just so…

Professor Harriet Hiscock: Massive 

Matt Dwyer: Yeah, and I guess there haven’t been any long-term studies on the long-term effects that could happen to infants. 

Professor Harriet Hiscock: Yeah. Indeed, very few studies have been done on really young babies.

Most studies are on teenagers and school-aged children and look at the impacts on sleep and mental health. For example, the best form of entertainment is for you as a parent and for your baby: talking to them, singing to them, interacting with them. Or siblings, when they have siblings, they’re another great form of entertainment, but staying away from screens, particularly under one.

Associate Professor Emma Sciberras: So, Harriet, we were talking before about feeding overnight. How long do children or babies need feeding overnight? How long should we keep it going? 

Professor Harriet Hiscock: This is often a personal preference for families. So, from a strictly nutritional point of view, from six months of age, babies can get enough of their requirements during the daytime so that they don’t have to feed overnight.

But if a parent wants to keep feeding up to 12 months, 18 months, or 2 years of age, that’s totally up to the parent, and that’s absolutely fine. The big issue, if your baby is feeding (overnight), is not feeding them and leaving a bottle in the cot with them because there is sugar in formula milk as there is in breast milk.

We know that this can lead to dental caries. So I’ve certainly seen babies who go to sleep on the breast after 12 months of age or go to sleep on the bottle after 12 months of age, and they come to me with dental caries because of that.

Matt Dwyer: What are dental caries, sorry?

Professor Harriet Hiscock: Teeth cavities. Because of the sugar in the breast milk and the formulas. So I would certainly say it’s a parent’s choice, but after six months if parents come to me and say, “I’m exhausted. I don’t want to get up three times a night to feed my baby.” That’s fine, and we can help them. The sort of thing we do is to look at how are you getting your baby to sleep at the start of the night.

So if the baby is falling asleep on the bottle or the breast, that’s an asleep association, and we need to teach the baby to fall asleep without that. So the very first thing I’d say is to give the last breastfeed or bottle feed outside the bedroom. At the start of the night, make sure there are about 20 minutes before finishing that feed and going to bed into the cot.

During that time, they can look at a book, read with their baby, and turn on the television or lights in the living room. Then, they can go into the bedroom and settle them with one of the methods we discussed before the checking or camping out methods.

Then when your baby wakes overnight, if they’re used to having three feeds and you just stop them, they will be furious. So rather than just stopping straight away, we would slowly cut down. So I say to breastfeeding mums, “Time you breastfeed and cut down by two minutes every couple of nights, and when you get to four minutes of breastfeeding, that’s a snack. So stop.” The best way to stop is by putting your little finger inside your baby’s mouth, taking them off the breast, giving them a cuddle, and putting them back down into their cot. If they’re bottle feeding, I say reduce by 20mls every two nights.

Again, once you get to 60mls per feed, that’s a snack, time to stop that. A lot of parents will say, “Can I give them water instead?” but that’s just a different liquid. That’s still a habit for the babies. So it’s better to stop those feeds altogether once you get to 60mls.