Want to Stop Cosleeping? Here’s How

In last week’s post, I talk about reasons why you might want to avoid cosleeping, because of SIDS risk in infancy, and the fact that it can be associated with poor sleep as children get older. Now, I wanted to offer some advice on how to stop cosleeping. [Note: as in the previous post, I use “cosleeping” to mean “bedsharing”; although this is a bit imprecise, I do think that it reflects the common usage of the term.]

When is cosleeping OK?
After putting up my post I got some great feedback from around the web from readers, friends, and colleagues. People I know and respect have chosen to cosleep with their children and have been happy to do so. One great example is Dr. Claire McCarthy, who wrote about cosleeping with her children on the Huffington Post.
This made me reflect on what would make me OK with ongoing cosleeping if a family asked my opinion. My goal for families is good enough sleep, which in this case means:

  • Your child is older than a year and thus the risk of SIDS is minimal.
  • Everyone is sleeping well
    • Enough space in the family bed (Thanks to Olli Orajärvi from Finland for this one)
    • Parents are not being disturbed during the night.
    • Parents and children feel well rested in the morning and are not sleepy during the day.

If all of these circumstances are not met, then I think you should stop cosleeping.

How to stop cosleeping

There is no magic bullet for fixing sleep problems. How you address this issue depends on how and why you are cosleeping with your child. But no matter your circumstance, there are some important elements to a successful transition. For more on why people fail to fix sleep issues, please read my post on Sleep Training Mistakes and Pitfalls.

General Recommendations:

  • Be consistent: The number one reason I see families fail at extricating their child from their bed is that they are inconsistent. Either your child is sleeping in your bed or he or she is not. If you relent even once in a while during the process of establishing a new sleeping pattern, you will reinforce the behavior you are trying to extinguish. Remember that intermittent reinforcement is a powerful mechanism for encouraging undesirable behavior. (Again— if your kid comes into your bed once a while, and you do not regard this as a problem, you don’t need to proceed with any of this).
  • Have a plan: To be consistent, you have to know exactly what you are going to do. It is hard to come up with good plans on the fly in the middle of the night. Make sure that all caregivers are on board with the plan.
  • Have a “quit date”: I highly recommend that you mindfully chose a time for a change and do not, say, start a change the day before a vacation, or before your mother in law comes to visit
  • Make your child’s room special: Some children may be apprehensive about spending time alone in their room. Spending fun and special one on one time. Take him to pick out some new pajamas and sheets. Pick out a new stuffed animal to use as a transitional object.

Based on type of cosleeping

  • Reactive cosleeping: Your child comes into your bed at night but in theory they are supposed to sleep in their room.
    • Addressing sleep onset associations:(): This is the most important thing to do: How your child falls asleep is the key to successful sleep. Sleep onset association are when your child falls asleep under circumstances absent during the night: usually this involves you being present when he falls asleep. These sleep onset associations may be subtle. Do you turn out the lights and then have to go back in to settle your child? Does he come out of the room multiple times at bedtime until you lay down with him.
    • One of the most challenging forms of reactive cosleeping is due to  early morning awakenings. Although it is really tempting to just relent at 4 or 5 in the AM, if you want your child to stop this behavior, they will not do it on their own. In this scenario, I recommend the OK to wake clock. The correct way to use this is to set the “OK to wake” alarm to 10 minutes after their usual wake time, and then move it 10 minutes later a day.
    • Sleeping bag on floor: For children who come into your bedroom on his or her own, I highly recommend that you provide them an option for sleeping in your room without disturbing you. A sleeping bag and pillow on the floor is a great solution for a transition. Many children will stop using this of her own accord with time, especially once they realize that it is not as comfortable as her own bed.
    • Bringing you child back to her room every time: If your child does not want to sleep on your floor and insists on disturbing you every night, you need to walk him back to their own room. Every time. Most kids will not pitch a huge fit in the middle of the night. If they do, you can employ the door closing strategy. This means bringing your child back to bed with the expectation that he will stay in bed. If he gets up and leaves the bed you close the door for one minute and hold it shut. If you open the door and he is not in bed you close it for two minutes, and increase as needed. This is a nuclear option, but sometimes it needs to be employed.
  • Intentional cosleeping: Your child sleeps in your bed every night for the whole night, and this is a long-standing pattern. In this scenario, many families want to stop once they are expecting another child, or their child hits a milestone such as kindergarten. In this scenario, you need to go gradually. Why is this different? Often your child does not know another way to sleep.
    • Discuss with your child at an age appropriate level. Often this transition may happen at an older age. Be honest. Tell her that she is a big girl now and is almost ready to spend the night in her own bed. Tell her that Mommy and Daddy (or Mommy, or Daddy, or Daddy and Daddy, or Mommy and Mommy) need some time by themselves.
    • Start moving bedtime into your child’s room: If your child spends the whole night in your room, start doing all of bedtime in his room and then moving him into your bed for a few days, as a dress rehearsal for spending the night in his own bed.
    • Napping in her bed first:If your child is still napping, this may be a good time for your child to practice sleeping on her own.
    • Bedtime fading (moving bedtime later) can be a big help with this transition.
    • Consider camping out If (you or) your child is very apprehensive about this, consider a “camping out” approach where you temporarily move to an air mattress on the floor of your child’s room. I would recommend NOT bedsharing at this point to smooth the transition.

Other questions that may come up:

  • How long will this take? It is somewhat hard to predict. It may go really smoothly if your child is ready for this change and take a day or two. In other children, who may be more reluctant, you may need to go more slowly. I would expect this to take no more than two weeks. If you try to stop cosleeping and it is a disaster, I recommend discussing it with your pediatrician or a sleep specialist. However, remember the extinction burst: your child’s sleep will typically worsen before it improves, and such difficulties may occur 2–3 days in.
  • What if my child gets sick/has a nightmare, etc?I would encourage you to try to follow your plan as strictly as you are comfortable. A quick cuddle in the middle of the night in their room is OK; bringing him into your bed for the rest of the night may undo weeks of hard work. I would say that if you are not ready to be firm on this topic for a month, I would hold off for a bit. After your child is successfully sleeping in his bed for a month or so, I think that it may be OK to bring them into your bed if you really have to (e.g. if he is running a high fever) with the understanding that you may need to be a bit firm afterwards.
  • What if I’m not sure if I am doing the right thing? If you are ambivalent and telegraph that to your child, you are setting you both up for failure. Perhaps you should wait for a bit. However, if you have come up with a plan and started executing, I encourage you to follow through in spite of middle of the night misgivings. Give it a week. If you stop too soon, you and your child have suffered for nothing, and possibly made it more difficult for yourselves in the future. I think you can do it.

So this has turned into an epic post. Let me know if you have other thoughts on this topic, or questions I have not answered. Also, if you have successfully navigated this transition, please let me know what worked for you.

Do You Want Your Kid to Be a Good Sleeper? Don’t Cosleep

As a sleep doctor, and a parent, I have a problem with cosleeping. Cosleeping in infancy has been found to cause a small but significant increase in SIDS risk. We chose not to co-sleep with our sons. Since infancy, they have always slept better in their own beds, and so did we. [To be clear, when I say "cosleeping in this blog post, I mean bed-sharing and not room sharing]. It’s not just a safety issue, however. I think that kids and parents sleep better when they have their own space, and that learning to sleep well is an important life skill for children that is best learned at an early age.

Like many topics in parenting, cosleeping has become a political issue. I personally do not recommend it to friends or patients, because of the risk of death in infancy, and because it seems to lead to poor sleep for the whole family. (Here are some great illustrations of this). The likely mechanism is via inappropriate sleep associations. I also think it is unhealthy for parents’ lives to revolve around their children 24 hours a day, and that sometimes, children have to “fit within the frame”. That includes having children being able to be apart from their parents for the night. As I have stated previously, there is no evidence that sleep training harms children.  Moreover, I am unaware of any long-term studies which show direct benefit of cosleeping for children who are in otherwise loving homes. Parents who disagree with me may site Dr. William Sears’ work, but many of the researchers cited by him claim that their research was misrepresented.

A recent study in Norway supports my experience on this topic. The study found that children who routinely cosleep in infancy tend to be poor sleepers as toddlers. (Thanks to my friend Susan Curley at Joyeux Parenting for bringing this to my attention). This study surveyed over 55,000 mothers, taking into account factors such as breast- vs. bottle-feeding, sleeping practices, child sleep duration, and nocturnal awakenings. There were several important take-homes from this study:
1. Bedsharing at six months of age was associated with shorter sleep and more frequent awakenings at 18 months of age.
2. Poor sleepers at six months had were more likely to have problems at 18 months of age.
3. Breastfeeding at six months seemed to have a mild protective effect against awakenings at 18 months of age.
This is a strong study because it follows a large number of families from birth and sees what happens over time, as opposed to surveying parents who are having difficulty and asking them to remember what they were doing six months previously. (I don’t know about you, but I’m not sure what I was eating for lunch yesterday, let alone how my kids were sleeping a year ago).

There are two pathways to cosleeping which I have observed:

  • Intentional cosleeping: where parents have made it part of their agenda to bed share with their child
  • Reactive cosleeping: where parents get into the habit of having their child fall asleep in their bed at night, or bring them into bed in the middle of the night when they wake up.

Either way, this seems to result in poor quality sleep. I have found that both in the comments on this blog and in my clinic, habitual cosleeping seems to be associated with lousy sleep. Here’s a sample:

I really hope you can help us. We have a 15-month-old that from birth has been cosleeping. When we coslept, Emma would wake up 3–5 times to nurse since she didn’t know how to self soothe. About two weeks ago I weaned her completely off breastfeeding and after a week of weaning, she began sleeping through the night! Fast forward two weeks later. We are now transitioning her to her crib. It’s been about 5 days since we stopped cosleeping and we are still having problems with her waking up crying hysterically…It takes my husband or myself an hour or more to put her back to sleep. Katrina P

I really feel for this family. They are obviously having a hard time. This mother has been feeding this child three to five times per night for fifteen months. That adds up to a lot of poor sleep for both mother and child. I get grumpy if I get woken up even once at night, be it by a child or a page from the sleep lab.

Even outside of this, there is another significant issue with cosleeping: where does it end? It seems like children seldom give it up on their own. Do you try to transition your child out of bed when they stop nursing? When they start kindergarten? When they enter puberty? When they leave for college? Let me tell you the hard truth: it is much easier to fix a sleep problem at six months than six years of age. 

Perhaps I am way off of base here, and there are a huge number of children staying in their parents’ bed, where everyone is getting a terrific night of sleep. I certainly think that “if it ain’t broke, don’t fix it.” I’d love to hear your thoughts on this controversial topic.

But if you are not one of these happy cosleeping families, and have fallen into a cosleeping pattern you can’t break, have hope! Next week: a post on how to stop cosleeping and start sleeping well.

One Patient, One Year After a Double Lung Transplant

A little over a year ago, I had a guest post from a former patient of mine with end-stage cystic fibrosis lung disease. Renu Linberg wrote movingly:

I’m trying to get comfortable with being uncomfortable, with the stressful days, with the breathless, can’t-get-off-the-couch days. I am learning to sit through those moments, and acknowledge the anxiety, or fear, or stress. For once those emotions get acknowledged, they seem to have less of a hold on my mind, as though that’s all they wanted in the first place. However, as my body has slowed down, my ability to cope has changed. Where I was once able to go for a swim or a hike, I can now only walk very slowly with a lot of oxygen pumping into my nose

About one year ago, she received a double lung transplant. And now she has written about this for an online magazine called Hello Giggles. She describes waiting in the hospital immediately before her transplant:

I saw my hand, with the slightly curved nails, and the pale fingertips, signing my name, and I knew that it was a hand connected to my arm, connected to my body, yet the whole situation was too surreal to fully, in the moment, process.

With that signature, essentially, I was saying, “Permission to perform a double lung transplant, granted. Proceed forth with the utmost caution and delicacy, as I am rather fond of living, despite my own lungs inability to keep doing so.”

Fortunately, the surgery was a success, and things have gone well for Renu:

I am almost one year post transplant. I can now take the stairs again, and walk up hills. I have returned my supplemental oxygen and no longer have an IV pole as a dance partner. I can laugh and sing without wheezing and stopping to catch my breath. I am finally embracing my slightly different life, and realizing that while it may be an odd life, and wildly unpredictable, the best ones always are.

Honestly, this brought a smile to my face, and (I confess) a tear to my eye. Renu is a success story, and there are many others like her. However, not everyone is so lucky, because there is a shortage of organ donors.  According to Organdonor.gov, almost 120,000 people are waiting for organ transplantation, and eight die every day. One donor can save eight lives. If you aren’t already registered, please do so.

Daylight Savings Time And Your Child: Avoiding Problems When “Falling Back”

Ahh, autumn. Halloween costumes, fall foliage, carving Jack-O-Lanterns and enjoying the crisp bite of a fresh apple. Those of use who live in New England often cite this season as the finest of the year, prior to the long nights and cold days of winter. There is one part of it that I don’t look forward to as a parent of small children, and a sleep doctor: the end of Daylight Savings Time (DST) when the clock falls back by one hour. This year, clocks in the United States will fall back by one hour at 2 AM on Sunday, November 2nd. There is some evidence that DST is associated with adverse health and safety effects, but this is controversial; Ezra Klein nicely outlined this in the Washington Post.

If you don’t have children and don’t work nights (medical residents on call that night– I feel for you as you will be on call for another hour), congratulations! You get an extra hour of sleep. For those of us with little children who get up earlier, however, this can be painful. The reason is that little children tend to get up earlier than their parents would like them to. (Teenagers are a different story as they usually have problems with getting up late– thus they struggle with the beginning of DST, or “springing ahead.“) Thus, a child who is sleeping from 8 PM to 6 AM will now be on a 7 PM to 5 AM schedule. The sleep period has not moved, but the clock has.

Fortunately this is pretty easy to address. Move your child’s sleep period later by 30 minutes for three days before “falling back” and then back to their old schedule on the “new time”, effectively moving their sleep period an hour later. In this example, you will have your child go to sleep at 8:30 PM to 6:30 AM for three days before falling back, then move them back to the old schedule at the new time (8 PM to 6 AM).

Not everyone’s child will sleep in 30 minutes later but the important thing is to move bedtime. This approach will hopefully cushion the landing from “falling back” and help you get a little more shuteye.  I have found this to be useful in my household and my clinic, where the ramifications of DST seem to extend beyond a simple shift; many children seem to have disrupted sleep at night as well around this transitional period. In my experience, these difficulties may be exaggerated in children with autism, so it may be worth a more gradual transition in sleep periods. If early morning awakenings remain an issue, here are some more strategies for addressing them.

I’d love to hear about your experiences with this. Has this been a problem for you in the past?

The view on the left is much easier on your sleep than the one on the right.

Going on a “Light Diet”: Avoid Insomnia By Managing Your Screens

When I was growing up, I rarely used my home computer for school work. In college and med school, it was more common but I still used it mostly to write papers. However, there has been a huge shift in the way that we consume information and produce work. We now use screens much of the time. Teenagers have the special challenge of too much homework and too early school start times, limiting how long they can sleep at night. I call this phenomenon structural sleep deprivation. Social media and gaming certain can account for some of this, but I also think that teens (and grown-ups) are up late looking at bright screens. The problem with this is that blue-white light emitted from our screens is similar to the light wavelengths from the sun. It is important to remember that light exposure is like caffeine. It tricks our bodies into staying up later by moving melatonin secretion later in the day. In this diagram, light exposure in the PM is indicated by the blue arrow.

Circadian 3

The technical term is circadian phase delay and it can result in a phenomenon one sleep expert described as “social jet lag” whereby your body is on a different schedule than school, work, etc, resulting in feeling tired all of the time. Going on a “light diet” by managing your light intake can help you sleep better. Here’s how:

  • Install f.lux on your computer: f.lux (for Macs), or t.lux (for Windows) is a free piece of software which alters the color temperature of your computer depending on the time of day. After sunset, it adjusts the color of your monitor so it is more yellow and less blue-white– similar to how your lights in your home are different from the sun. I recommend this to all of my teenage patients with insomnia (and their parents) and I use it myself. Best of all, it is free. You can obtain this software at Just Get Flux.
  • Reduce brightness on your phone or tablet and use “night mode” if available: If you are working on a tablet or phone, things get a little more complicated. You can manually dim the brightness of your device. Some software allows you to invert the look of your screen to minimize light exposure. Look at this example from Instapaper on my phone. The one on the right is much better for reading at night:
The view on the left is much easier on your sleep than the one on the right.

The view on the left is much easier on your sleep than the one on the right.

  • Android users can try apps like Darker or Screen Filter to dim and/or change the color temperature of their devices. (Thanks to Joe Naylor who provided this tip on Google +!)
  • Go on a “light diet” before bedtime: It is really helpful to avoid any screen exposure for 30 minutes before bedtime.

It’s easy to understand how caffeine can affect your sleep. Light has similar, powerful effects. So being conscious of light exposure in the evenings can help you get a better night’s sleep.

Are you sensitive to light? Do you notice that it affects your sleep? Let me know in the comments below.

“Le Pause”, Avoiding Sleep Problems, and Why You Won’t Break Your Kids

This weekend I met my friend Samuel at the park. A native of Brittany, he’s describing my children as “the mysterious French man”, but like me, he is a suburban dad here in Connecticut. This reminded me of an article I read several years ago about the book Bringing Up Bebe, about parenting insights gleaned by an American mother living in France. The author, Pamela Druckerman, is amazed by the fact that the babies of some of her French friends sleep through the night, even as early as two months of age. The philosophy behind this she describes as, half jokingly, Le Pause:

Waiting is the key: the French do not do instant gratification. It starts more or less at birth. When a French baby cries in the night the parents go in, pause, and observe for a few minutes. They know that babies’ sleep patterns include movements, noises and two-hour sleep cycles, in between which the baby might cry. Left alone it might “self-soothe” and go back to sleep. If you dash in like an Anglophone and immediately pick your baby up, you are training it to wake up properly. But if a French baby does wake up and cry properly on its own, it will be picked up. Result? French babies often sleep through the night from two months. Six months is considered very late indeed. From The Guardian

While I am a bit skeptical that your average French infant is sleeping through the night without interruption at two months of age, I do see the value in this parenting philosophy. Infants do frequently cry out in their sleep, due to the the immaturity of their nervous systems. Literature on infant sleep refers to some children who are “signallers,” and are more likely to cry out at night; if parents run in every time their child grunts, they are reinforcing the night wakings and creating problems for themselves down the line.

For better or worse, the default mode of parenting in America seems to have become quite intensive and hands-on. The excessive form of this is “helicopter parenting” where every need the child is met immediately, and every possible risk eliminated. In the arena of sleep training, parents worry that they will harm the child but I can reassure you that this is not the case. Parenting fads come and go, and it’s hard to know what we are doing now that will seem ludicrous 50 years from now. Libby Copeland has a great article in Slate on bad parenting advice which includes such gems as, “an 1878 book called Advice to Mother informed said mother that she should not give her baby gin to relieve flatulence.”

When I asked Samuel about the difference between American and French parenting he demurred, as has only been a parent here. I asked him about the concept of cadre, which is mentioned in Druckerman’s book. After I spelled it for him as he could not understand my abysmal French pronunciation, he said:

Cadre means frame, like the frame of a painting. So children are definitely part of the painting (in the frame), but they are more in the background, not the main subject of the painting.

I think this gets at the heart of it– the idea that children are supposed to fit within the family, and that their needs don’t always necessarily need to be foregrounded. For me, this is reflected in the idea that kids should be able to sleep through the night on their own– not just because it is an important life skill, but because it is good for their parents as well. Different parents make different choices about sleep, about feeding, about discipline and a thousand other challenges which they face day-to-day. The fact is, if you love your kids (and you do) and you try your best (and you will), your kids will be fine. And so will you.


			

What Makes A Great Bedtime?

In this week’s post, I’m talking a little bit about creating a successful bedtime. Specifically, creating a bedtime that is predictable, linear, goal directed, and brief (e.g. less than 30–40 minutes). I would also love to hear what has worked for you and what has not? What are the rituals at night which you hate to miss? What has not worked for bedtime in your home?