Episode 2: Managing sleep practices In babies


Matt Dwyer: Hi, I’m Matt Dwyer and 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 to 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, 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 is it that you want to try and change?”

Because everyone has  different ideas around that but there are a couple of common approaches that we use. So one is called “the checking method” or “the controlled comforting method”. It’s previously been called “control crying” or the Ferber method and what’s really important to know is 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 and that 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, giving them a cuddle and then try to put them down into the cot drowsy, but still awake. That’s the key thing. Now, if you’re lucky, your baby will just go off to sleep. They don’t go to sleep straight away. There’s a bit of a myth that they should just 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, they’ll often move their head back and forth, or thrash around a bit. Parents come to me worried about that but the baby’s just self-soothing doing that.

That would be likes 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 into their bedroom to comfort their baby.

The comforting might be stroking their baby’s forehead or patting them on their tummy or patting them on their bottom. You need to have 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 actually 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 themselves up so much and get so distressed that it’s really hard for them to calm down again. So 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, it’s fine to pick up your baby. 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 or 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 the 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 a number of studies and we’ve followed babies who have done these sorts of strategies at 12 months of age, 2 years of age, and 6 years of age and we’ve asked parents about their baby’s sleep and about the child’s behaviour. We’ve actually taken cortisol, saliva swabs from children as they’ve gotten older and we have found no harms 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, the same as babies who didn’t go through this approach, their saliva profiles are the same as well. And this follows on with 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, their mother at those time points as well.

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

Professor Harriet Hiscock: Well, certainly the parents come back often to me and say, “gosh, I wish I’d tried this sooner”. So I think one of the biggest 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 at for.  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 biggest benefits are the child sleeps better, they are happier, they feed better. Usually during the day, once they’re sleeping better, their interactions are more lively and the parents actually rate their relationship with their child is 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, it just doesn’t work? 

Professor Harriet Hiscock: Yeah, look, absolutely. So the checking technique probably works in about 70% of babies and toddlers, so 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 certainly 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 a 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. The first few nights they will pat or stroke their baby off to sleep. 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 parent leaves the bedroom. It’s better to do “the camping out technique” as it has a more gradual approach. 

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 or? 

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 something that’s really common. And 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 that does increase the risk of SIDS, particularly if it’s a doona or if the mattress is not properly fitted into the bed and 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. Having said that, there are cultures who 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’s 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 and that’s actually been shown to be quite effective. So I will always counsel parents not to be co-sleeping on the same surface, but think of a cot alongside the bed or something like one of these Maori little  baskets which 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, I got this bassinet after a lot of thought and I just could not get my child into it.

I was looking up all kinds of 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. And 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 and 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 an enjoyable experience. 

Professor Harriet Hiscock: And I think being able to hire those sorts of things and not spending hundreds of dollars on equipment is also a really good idea. 

Associate Professor Emma Sciberras: Yeah. I think after spending all the money on the initial furniture, it had to be a hired one.

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 just get rid of the dummy. But a lot of parents say, “Oh, I can’t do that.” From the age of seven months, they can put their own dummy in their mouth. They’ve got the fine motor skills to do that. So, often, attach to your baby’s pyjamas a cord or a string with a dummy arm, 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 sort of the interim plan. 

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

Instead of the babies settling with the dummy, they’ll use one of these other strategies of “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, have you found that with all these different methods that they apply to parents that have multiple children in different age groups?

Professor Harriet Hiscock: Yeah, absolutely. So in our studies we’ve had parents, first-time parents, second, third, fourth-time parents who’ve used these strategies 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 think I’ve even certainly 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 where 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, then it’s really 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 actually 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 iPhone, but the screen 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 and that’s 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 things that you suggest to families around kind of preparing the room should you put them to sleep in a light room or should it be dark, or 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, you know, 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 and there’s 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 cool and dark. There are some babies that seem super sensitive to light and parents will actually 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 actually 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 then they want that music when they wake up, two or three times a night, and they’ll be expecting that.

Associate Professor Emma Sciberras: So does that mean if you were using music? You’d have to have it on the whole night for some kids.

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. Its 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 had a funny story once from a maternal and child health nurses who said there was a parent who lived in a cul-de-sac and 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 things do they effect 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 things like Panadol a lot for teething. 

So things like eczema definitely are associated with sleep issues. Children, if they have eczema or they’re 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 with screen time? I know we’ll get into that in a lot more detail or in terms of…

Professor Harriet Hiscock: Oh, no, I think it’s really important, Matt, because more and more we’re seeing screens on prams and in front of babies 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, certainly 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 also with screens is not just the content, but it emits something called blue light, which blocks the melatonin. And actually melatonin is produced in babies from a few weeks of age. So if you’re interfering with the brain’s production of melatonin you’re potentially interfering with them setting up good sleep habits and good sleep cycles. 

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

Professor Harriet Hiscock: Massive 

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

Professor Harriet Hiscock: Yeah. And then certainly very few studies in really young babies.

Most of the studies are in teenagers and school-aged children and looking at the impacts on sleep and their mental health. For example certainly the best form of entertainment is 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: Yeah, this is often a very 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 that they don’t have to feed overnight.

But if a parent wants to keep feeding up to 12 months, 18 months, 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.

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

And what they can do in that time is look at a book, do some reading with their baby with the television or lights down low in the living room. Then take them into the bedroom and settle them with one of the methods we were talking about before: the checking method or the camping out method.

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 your breastfeeds 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.” And the best way to stop is by putting your little finger inside your baby’s mouth and taking them off the breast, giving them a cuddle, 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 just to stop those feeds altogether once you get to 60mls.

Matt Dwyer: Sleep was presented by Harriet Hiscock and Emma Sciberras and produced by me, Matt Dwyer. Audio production done by Darcy Thompson and our executive producer is Jen Govern. For more apps, go to podcast one.com.edu. Or download the podcast one app and listen for free.

If this series resonated with you, you might also be interested in the concussion podcast. It’s hosted by neuropsychologists and concussion expert at the Murdoch Children’s Research Institute, Vicki Anderson. And in it, she explains to me what really happens during a concussion. The physical and mental effects concussions can have on children and how to tell if that knock on the head could have caused a concussion. Just search concussion podcast to start listening.

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