To CIO and Beyond! Making good decisions about extinction sleep training

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[00:00:00] Welcome to the Sleep Edit, a podcast devoted to helping tired kids and parents sleep better. We focus on actionable evidence-based sleep advice, so everyone in your home can sleep through the night. Now, a quick disclaimer, this podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice.
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[00:01:09] Craig Canapari MD: welcome back to the Sleep Edit, where we talk about all things kids sleep. Today we’re gonna talk about the thorny topic of Cry It Out, or CIO. I would like to introduce my co-host, Arielle Greenleaf. Arielle is a certified pediatric sleep consultant with nearly a decade of experience
[00:01:28] She has a common sense evidence-based approach and really brings in something that I don’t have specifically was working with a lot of people and children without health issues. She’s helped hundreds of families through one-on-one and group couching, and through corporate benefit programs.
[00:01:47] She’s trained and mentioned more than 50 sleep consultants through her consultant training program. So do you have like consultant grandchildren now? Have your consultants went out and made more consultants,[00:02:00]
[00:02:00] Arielle Greenleaf: no. no one that I trained has started their own training program, But they have definitely become, some of them have become very successful sleep consultants.
[00:02:11] Craig Canapari MD: Let’s talk about a topic that people love. Everybody loves doing this, talking about it right? Super popular. True story. When I wanted to call my book The Bedtime Habit ’cause I’m like, oh, we’re talking about habit psychology con conditioning, and I didn’t want sleep training in the title.
[00:02:27] the reason is sleep training as a term, has a certain valence to it. that’s because everybody thinks sleep training is just extinction sleep training sometimes abbreviated as CIO. And there’s some controversy about that, which we’re gonna get into. And of course my book agent was like, you have to have sleep training in the title because it’s a sleep training book and otherwise nobody will even know what it’s about.
[00:02:52] So that’s how I ended up with the title. As I’ve existed online for the last 10 years, unless I post [00:03:00] something about vaccines, this tends to generate the most controversy. Though I feel like it was worse eight or 10, eight years ago.
[00:03:10] I don’t know. I do you feel like cry it out as a topic that still generates as much heated debate as it is? I dunno. I don’t,
[00:03:18] Arielle Greenleaf: Yeah. I think, there’s this rise of gentle parenting, which I feel morphed from attachment parenting. So anytime there is a possibility of a child crying, that is a trigger for people.
[00:03:32] And so in my world, it is definitely still very dividing and it’s still a hot topic.
[00:03:41] Craig Canapari MD: So do you think we’re gonna get a little bit into attachment and stuff like that for the purposes of keeping this simple, should we call this cry out? Should we call it extinction sleep training? I think extinction sleep training is more precise.
[00:03:53] Arielle Greenleaf: I think the thing is that parents, anytime a [00:04:00] child is going to cry, they call it cry it out. Like I’ve seen plenty of people call Ferber cry out. So it’s important to define the different types of sleep training.
[00:04:10] ​
[00:04:10] Arielle Greenleaf: extinction, like Ferber chair method. And it’s also important to talk about different temperaments because parents will try to choose a gentle method and it actually only makes the baby or child more upset because the parent is sitting there.
[00:04:30] But not giving them what they’re used to, feeding, rocking, bouncing, whatever it is. And so in those cases, I find that parents, once they’re in it, parents are like, oh, okay, yeah, this is not working. This is making it worse. So it’s important to understand that just because you choose something that’s considered gentle doesn’t mean that it’s actually gentle.
[00:04:53] when you’re picking a sleep training method, it’s about goodness of fit for your child and parents sometimes have a feel for what’s gonna [00:05:00] work. if I’m seeing someone in clinic, I’ll present a couple of different options and I usually have an opinion about what I think they should do.
[00:05:06] Yeah.
[00:05:07] Craig Canapari MD: But they’ll have a feel for how do you think this would work for your child? How does this work for you? So I just wanna go through a few quick definitions. And then maybe we’ll talk about attachment theory and temperament,
[00:05:19] Arielle Greenleaf: yeah, that’s fine.
[00:05:20] Craig Canapari MD: so sleep training is just means any behavioral method to improve your child’s sleep. There’s one called positive bedtime routines, which is so obvious, but it’s if you don’t have a set routine your child enjoys, you should have one That is a sleep training technique. And techniques that are often lumped together as cried out are often. Behaviorally what we would call extinction methods of sleep training. in behavioral terms, extinction means ignoring a behavior you dislike more precisely. It refers to the gradual weakening and eventual disappearance of a [00:06:00] previously learned behavior due to the lack of reinforcement. So in this example, the learned behavior is your child needing a parent to fall asleep
[00:06:10] And when they wake up during the night and by an extinction sleep training method, you are usually pretty quickly removing the parent from the equation. And this signaling, which is sometimes crying in older kids that may be asking, yelling, what have you for their parent, will go away with time. Like the classic unmodified extinction is, okay, we are doing this now. I have been in your bedroom your whole life to fall asleep. Now I am leaving and closing the door, and I’ll see you in the morning. It’s it modified extinction, the most famous version of which is it was popularized by Dr.
[00:06:53] Ferber so popular that his name became a verb. I don’t know what could [00:07:00] b”Canapari-ize”es a kid.
[00:07:00] Arielle Greenleaf: Canapari
[00:07:01] I just, it doesn’t work. Greenleaf. You could greenleaf someone. Leaf izing?
[00:07:06] Craig Canapari MD: And then Arielle alluded to the chair method.
[00:07:09] Lots of different names for this. Hiscock in Australia called this camping out. I believe the sleep lady shuffle is also a chair kind of method that is actually considered to be extinction with parental presence. Meaning that you stay in your child’s room, but ignore them. So you’re present and not present.
[00:07:28] Now we can segue into temperament, right? How a chair method or a camping out method for some kids might work great and make them comfortable and other kids is worse, right? If you are considering one of these methods do you wanna talk a little bit about time for a minute?
[00:07:43] It’s not something that I think about
[00:07:46] Arielle Greenleaf: Yeah, I think temperament is important. So here’s the thing. in my experience, when people come to me,
[00:07:54] they’re not sure they’re coming to me ’cause they don’t know what to do. They haven’t done this before. And so [00:08:00] I think it’s important for me to explain the different methods. But again, a lot of times parents think one way is going to be better than another.
[00:08:12] And so the majority of parents want to start with the gentlest of methods, which would be camping out. Chair method, sleep lady shuffle because parent is present
[00:08:24] But in some children, having the parent present while they’re upset, prolongs the crying makes it even worse because the parent is sitting there, they can see them, but the parent is not doing anything to help them not doing the same things that they’re used to.
[00:08:42] I find that camping out can be really helpful for two and a half, three year olds and up. But that being said, when people are coming to me, they’re at the end of their rope. They have already tried being in the room with a child.
[00:08:57] They’ve been in there for two hours, three hours, [00:09:00] And it doesn’t work. And parents will try the camping out method. They’ll go in with their three-year old and the three-year-old, just, it makes it they used to fall asleep at nine and no, she fell asleep at 11 because I was there And so I think the temperament thing is about setting boundaries. sometimes the parent being there is not setting enough of a boundary for them to learn to settle themselves without the parent there, which is the ultimate goal.
[00:09:28] Craig Canapari MD: so how would a parent know what clues might give about how their temperament might make some one of these general methods less effective for them?
[00:09:38] Arielle Greenleaf: I don’t think they do know. they have a lot of assumptions and so a lot of people with infants will come to me and say my baby is so high needs this baby’s gonna cry for five hours straight or all night long. I have literally never had that happen ever.
[00:09:53] I have, however, had parents who stay in the room and that extends things.
[00:09:59] I think [00:10:00] it’s really a trial and error thing, and parents start to see pretty quickly that, oh wait, this method is not working for me at all. bedtime just got even harder and longer and the kid was even more upset. So I think we can see within a night or two if something’s working or not.
[00:10:17] And if we have to move on to something else.
[00:10:19] Craig Canapari MD: And I think I wanna circle back to that, but that’s such an important point, is that your kid will not be crying for weeks and weeks with this. And if they are,
[00:10:30] Arielle Greenleaf: something’s
[00:10:30] Craig Canapari MD: I give you permission to stop and press pause and plan again. I just want to quickly talk about, why this idea of cried out is controversial.
[00:10:42] attachment theory came out, I think in the fifties and sixties two scientists named Mary Ainsworth and John Bowlby. And it’s essentially the idea that it focuses on the connection between parent and child, but it could also between romantic partners, but they’re looking at child development.
[00:10:58] And [00:11:00] it was really the idea that you should show your child affection and comfort them if they were upset. And this is. So obvious to us now, but in the fifties when they were doing this work, there was this idea that if you comfort your child, you would actually make them less independent and weaker.
[00:11:20] So I think it was both their work and the work of Dr. Spock said, Hey, no, actually, if your kid falls down and skins their knee, you should comfort them. And they did a whole bunch of experiments with animals showing that this was a good idea. But this kind of morphs into the idea of attachment parenting, which came out of the work of Dr.
[00:11:43] Williams Sears and his wife, Martha Sears, who wrote The Baby Book I think it came out first in 1990. And there were a couple of components to what they espoused bed sharing with your. Child throughout childhood, carrying your child everywhere, otherwise known as baby, wearing and [00:12:00] on-demand nursing.
[00:12:01] And at the time that this came out, this was really an alternative to mainstream parenting. I think that it, throughout the eighties you were having many more families where you had two parents, if it was a two parent household, you had both parents in the workplace as opposed to the very traditional structure of the man’s at the office and the woman’s home with the kids.
[00:12:23] And there was a feeling that people needed to do work on their bond with their child. ’cause it was very difficult for women who traditionally were expected to do everything in the home. And all of the child responsibilities were also now working outside of the home.
[00:12:39] There were, working women. My grandmother worked full-time in the forties and fifties, right? But that was not the sort of the cultural norm.
[00:12:50] And you know what? I agree with a lot of what the Sears espoused the idea that you should pay attention to your child’s need, do what you feel is right. my problem with [00:13:00] their philosophy was there was little room for the needs of the parents. There is this expectation the parents, especially mothers, were expected to soothe their children without limit. And this idea, I think which was toxic, was that if your child was crying, it was actually, and they literally say that if you let your child cry too long, it will cause brain damage. they really. were referencing work from like Russian orphanages where these kids were just never picked up for all of childhood. And they really had some developmental consequences, but that was not research that was based on somebody whose parents were appropriate and comforting.
[00:13:40] But the kids cried on occasion. My wife hates this anecdote that when I was writing this, my younger son was six and he came to me crying ’cause there was an ant on his donut. And I wasn’t worried at the time that he was gonna be brain damaged afterwards because kids cry all the time.
[00:13:56] It’s just the thing that they do, especially in infancy and younger [00:14:00] childhood. And the reason my wife hates that story is it makes our house sound gross. And I’m like, no. Sometimes their ants donuts are covered with sugar. Anyway.
[00:14:07] Arielle Greenleaf: Yep.
[00:14:08] Craig Canapari MD: Sorry honey, but you’re probably not gonna listen to this anyway.
[00:14:10] Arielle Greenleaf: And Arielle, this is interesting. When did you think this kind of morphed into the idea of gentle parenting? Because I will say compared to the early two thousands, I’m seeing a lot less baby wearing and family bed than I used to, Oh, that’s interesting.
[00:14:25] Craig Canapari MD: maybe ’cause the people that come to me have already stopped doing that or
[00:14:30] Arielle Greenleaf: Yeah.
[00:14:32] Craig Canapari MD: are perhaps looking for more science-based approach.
[00:14:36] Usually when things haven’t worked out well for them in terms of the, now they’ve got a 4-year-old who is nursing around the clock in the family bed and they want it to stop.
[00:14:47] Arielle Greenleaf: I think there’s a big distinction about what you just said though, because. Some people, they’re comfortable with having a 4-year-old sleeping in bed with them and nursing [00:15:00] around the clock. And I truly believe that what works for your family works for your family as long as everybody’s safe and healthy.
[00:15:09] And so I know for a fact that cry it out or sleep training is not for everybody. And that’s okay. We’re here for people. Who need their sleep. most of them have, two parents working like you said. And sleep is essential for so many different reasons.
[00:15:26] It’s important for the parents in order to function at work, their relationship with one another. And it’s extremely important for the parent to be well rested enough to enjoy the company of their child. Because if you’re sleep deprived, you’re just slogging through every day.
[00:15:45] And in my experience, the, if a baby’s sleep deprived. They’re going to seem more. Like I said, a lot of people come to me and they’re like, oh, my baby is so high needs, and once we get the baby sleeping, it’s like they have a new child. babies [00:16:00] cry when they’re hungry or they’re tired or they need to be changed.
[00:16:04] And the tired thing really does play a huge role in how much the baby’s crying. What I do know is that many studies have been done about, what is the best way.
[00:16:17] Now don’t get me wrong, I’m not gonna judge people’s parenting styles, I’m not gonna say this is the best way and it’s the only way. However, studies have shown that children In families where parents provide more boundaries and authoritative not authoritarian, parentinggives the child an advantage moving forward to be more independent and self-assured and more confident with gentle parenting, attachment parenting.
[00:16:44] They’re finding that children are so dependent on their parents that they’re unable to do things independently as they get older. I’m just sharing what the research has said. I think also the biggest thing, like you said, is that.
[00:16:56] people will come to me and they’ll say I’m worried that my baby’s going to be brain [00:17:00] damaged. they actually want to see studies and understand the idea what is the actual evidence? And people don’t understand that the attachment theory, they were looking at, broken attachment.
[00:17:13] insecure attachment.
[00:17:14] this insecure attachment. So they think that insecure attachment is gonna come if they let their child cry at all.
[00:17:21] When in reality the studies were in, Siberian orphanages, where these children were essentially abandoned. They had a dirty diapers and they were left dirty and crying. They were hungry, and they were left hungry and crying. Not children that are otherwise healthy, cared for.
[00:17:39] And they’re not abandoned, they’re getting attention,
[00:17:41] Craig Canapari MD: I’d say that if you’re, like if you were talking with your pediatrician about your concerns about your child’s sleep, you’re sleeping sleep consultant, you’re reading a book about it, your child is probably not neglected. And you really have to look at the cost benefit of a short period of crying.
[00:17:57] ’cause it generally is short versus [00:18:00] everybody in the house sleeping better. And sometimes, people who are tired don’t always make good judgements about what is the best use of their time and energy, right? When your energy is low, it’s hard to imagine changing anything.
[00:18:12] ​
[00:18:12] Craig Canapari MD: So I’d like to talk about extinction based or cry out methods work and how quickly do they work? these are probably the best studied sleep training techniques they’ve been around, since the seventies. Ferber didn’t invent them, but he did do some of the research on them.
[00:18:29] And his book came up early in the eighties. a friend of mine named Sarah Honnaker, who’s in Indiana, did this really nice study it was essentially a quote unquote, real world trial of sleep training. And what that meant was they didn’t actually send a trainer to the house or something like that.
[00:18:45] they solicited mothers who were interested in. Pursuing sleep training, gave them information about how to do it. And then when they did it, they had them do sleep, diaries for a couple of weeks afterwards. what they found [00:19:00] was the peak of crying was generally
[00:19:02] the first day. The worst day of crying was maybe on average 35 to 45 minutes. And that the crying was done within a week. after the peak of crying on day one or two, it was talking like five or 10 minutes of crying.
[00:19:20] It works very quickly. as a sidebar, every pediatrician I know who sleep trained, their kids just did extinction sleep training. And the reason is. It’s so quick. it’s not easy to do because it’s hard to listen to your child cry.
[00:19:38] But it’s, easy to understand. it’s not an elaborate plan. And we can talk about the, I think we took talk about the mechanics of others in a little bit, but let’s talk about the this, I want to go into this concern Does it hurt your child? There’s no evidence that it does.
[00:19:53] And I, Arielle made such a good point is that if everybody in your house is miserable all the time, [00:20:00] I would say that’s probably worse for your child than your child crying for an extra, hour or two in their life if you do this. Because they’re probably crying hundreds of hours anyway.
[00:20:12] The it’s developmentally normally for kids to cry. I think the best study on this was a little bit of an older study coming outta Australia called the Kids Sleep Study. And it followed kids for six years. And this is really the challenge with this sort of research, right?
[00:20:28] Like it’s much easier to do a study over a month than it is for six years. And they were looking at people that had sleep, trained their children before two years of age, and they found that they slept better at two years and the mothers were less likely to be depressed at six years.
[00:20:48] Everybody’s sleep was the same. Whether or not they had sleep trained. And they looked specifically the stress hormone cortisol, which if you read a lot of the sort of nuttier stuff about [00:21:00] sleep training, brain damage, your kid, they’re like, oh, their cortisol grows up. Cortisol is a stress hormone.
[00:21:05] Your cortisol grows up for many different stressors in your life. It’s a normal adaptive response.
[00:21:10] Arielle Greenleaf: Ask you a question about that, because one of the things that I’ve always read is that when you are overtired or you’re sleep deprived, your cortisol is always at a higher level. Is that true?
[00:21:23] Craig Canapari MD: It tends to be higher and having high cortisol all the time in the context of chronic stress, I. Is a problem, right? Like people who are, chronically elevated cortisol levels. It’s one of the mechanisms that we think that chronic stress is related to poor health outcomes in a lot of different dimensions.
[00:21:41] ​
[00:21:41] Craig Canapari MD: And actually this is thought to be one of the mechanisms of why, for example patients of in individuals who are in minorities that ha historically been disenfranchised, actually live for less, they have shorter lifespans. they may have a higher incidence of chronic diseases like diabetes,
[00:21:59] ​
[00:21:59] [00:22:00]
[00:22:00] Craig Canapari MD: But this isn’t, cortisol is a hormone that your body makes to help you overcome stress. It’s not good to have it elevated all the time. What I like about the Baby Sleep Study is it puts the cortisol thing to rest The kids at six years of age, their cortisols were the same as kids that sleep trained, no higher incidents of behavioral problems, attachment issues, et cetera, with their parents.
[00:22:23] And the flip side is whether or not people were sleep trained, the majority of their kids were sleeping fine by six years of age. people would be like, oh, you must not like that result. it says that you don’t have to sleep train, If you feel like, I’m annoyed that he cries once or twice a night, but it really doesn’t.
[00:22:39] it’s fine. I don’t wanna rock the boat. I’m functioning well, my kid’s functioning well. But if you’re thinking my life is miserable because I haven’t had a normal night of sleep for six months. It’s okay to want to do something about that. there’s so much guilt that parents have. But I think yes, we should [00:23:00] want our children to be happy and safe, but not at the expense of our physical and mental health. Because if we get broken down, we’re gonna be worse. Parents, it’s just a
[00:23:10] Arielle Greenleaf: Correct. Yeah.
[00:23:11] ​
[00:23:11] Arielle Greenleaf: And I also think that we need to, there are so many studies coming out now that show how important sleep is to children and babies. people will often say, oh, the parent is being so selfish for sleep training.
[00:23:27] But that’s not our society
[00:23:29] I would say in every single case, once a parent gets the child sleeping no matter what their age is, the child is so much better, happier, healthier it’s life changing.
[00:23:42] It changed my life, which is why I do it. I have hundreds of emails and text messages, you truly saved my life. I never thought I would be here in just a short week of time. so I think we need to [00:24:00] stop having this stigma around. crying.
[00:24:02] And second of all, sleep training. I, what would you do if your toddler said, I want chocolate for breakfast, lunch, and dinner, and if you don’t give me chocolate, I’m not eating. You wouldn’t give them chocolate.
[00:24:14] And they would probably get upset and they would cry. But if you continued to say no, here’s what you get, then within a couple of days they would realize you’re not getting, they’re not getting chocolate for every meal because that’s not healthy. Similarly, it’s not healthy for anybody to be waking up multiple times a night once they get us to a certain age.
[00:24:35] I don’t think we need to look at as sleep as a luxury. It needs to be looked at as a necessity.
[00:24:41] Craig Canapari MD: Yeah, for everybody really. Let me ask you this extinction sleep training methods, what’s the age range that you apply them for?
[00:24:52] Arielle Greenleaf: Four months and up.
[00:24:54] Craig Canapari MD: What’s the, do you have a ceiling on that?
[00:24:56] Arielle Greenleaf: Oh, yeah. I do. in most [00:25:00] cases, as toddlers get older the chair method or more parental presence can be helpful. That being said, there are some toddlers that you give them literally a centimeter and they’re gonna take a mile.
[00:25:15] So sometimes being there is never gonna work, so you just need to, check in. And there are other tools. I have a toolbox for toddlers and preschoolers, but I do think the older they get the more it might be necessary for the parent to be present.
[00:25:31] But not in all cases.
[00:25:32] Craig Canapari MD: I would agree. for the classic extinction stuff, infancy is where it’s at. they need to be in a crib. they need to not be able to exit the room.
[00:25:42] Arielle Greenleaf: Yep.
[00:25:43] Craig Canapari MD: and I used to, from older kids. if you’re getting a kid that’s in a bed, an 18 month old can cry for a lot longer than a five month old.
[00:25:52] it’s gonna be miserable. I move to other methods if I can. Let’s talk about sleep training in the era of room sharing, [00:26:00] because this has changed the game a little bit. from a SIDS prevention standpoint, the recommendation now is room sharing, but not bed sharing for at least the first six months.
[00:26:10] when this recommendation first came out, I think it was in 2012, I was skeptical. The evidence That room sharing actually, prevented sids, but there’s been some more recent data that really does suggest that it’s it’s important to room share with your infant.
[00:26:25] some places, some countries the recommendation is for a year. Some it’s for through six months. six months is probably fine, but what would you say to a parent if, okay, I’ve got a five or six month old, they are sleeping in my room.
[00:26:39] Arielle Greenleaf: Yeah.
[00:26:40] Craig Canapari MD: How does that change the calculus of sleep training here?
[00:26:44] Arielle Greenleaf: So I usually have,
[00:26:49] Craig Canapari MD: I.
[00:26:49] Arielle Greenleaf: I would say so many of the people that I work with are breastfeeding, and it’s important to understand that when a breastfed baby is in proximity of their [00:27:00] mother, they can smell their mother’s milk.
[00:27:03] So I’ve never had this not work. I have mom move out of the room temporarily, dad can stay. And then once the sleep training is complete, mom moves back in This child is no longer waking. And I try to move the baby out of the sight move down to the end of the bed or something like that so that it’s not so tempting to see like their face.
[00:27:29] ’cause if you make eye contact, you know what? That happens. Don’t make eye, don’t make eye
[00:27:32]
[00:27:32] Arielle Greenleaf: But I’ve done this successfully 100% of the time. Anytime I’ve used that, it’s worked. so if you ever work with a sleep consultant that tells you have to move your child, you should fire them or not hire them.
[00:27:47] There are absolutely ways to keep the baby in the room. I agree with you. it’s much easier if the child is not in the room But like you said, as I found that study, I brought it to you, the more recent one and you’re like, let me look [00:28:00] into this.
[00:28:00] And you’re like this is actually a pretty good study. I think that was up to six months showing that it is a protective factor for sids and obviously anything we can do to protect a baby from SIDS is essential I just think it can be done and I’ve done it successfully many times.
[00:28:18] Craig Canapari MD: Yeah. I think a visual barrier, a sound barrier, like a sound machine, if you don’t wanna put a curtain in your room or you don’t have a place to position the baby I like those they almost look like Chinese or Japanese screens. You can get, you could give ’em like home goods or something like that and put them up just to create a visual barrier.
[00:28:35] So we’ve talked about age range. Who else might one of these extinction methods work well for?
[00:28:44] Arielle Greenleaf: If you wanna know my opinion, I think everyone should use one of these methods because in what I’ve seen, They work as long as other things are in place. So you’ll often hear people, I tried it for two weeks and it didn’t work. But then you find out like the [00:29:00] baby or the child hadn’t taken any naps that day and went to bed at 11 o’clock at night.
[00:29:04] This baby is tired. they’re crying and upset because they’re just so worked up from not sleeping all day. So there have to be other pieces in place. you can’t just use a method. sleep training is not just about a method.
[00:29:18] So I personally think it’s the least harsh. I know that sounds weird, but it is. It works really quickly. It is always successful if everything’s in place It doesn’t give some sort of weird temptation to the child. ’cause I almost feel like being in the room, but not giving them the things that they’re used to is more harsh.
[00:29:43] It’s almost like dangling a dog, treat over a dog, but you’re not gonna give it to them. So that being said, I support parents in whatever feels right to them. And I’m always open to doing that.
[00:29:55] In many cases, they discover very quickly that’s actually more upsetting to the [00:30:00] child.
[00:30:00] Craig Canapari MD: Yeah, I know in a day or two I know with my kid that just didn’t work. Let me ask
[00:30:04] Arielle Greenleaf: No, same with
[00:30:04] Craig Canapari MD: In that, going back to that example of you had of a baby, the parents were like, for two weeks it’s not working, and the kid’s not napping during the day.
[00:30:11] Where should they start then?
[00:30:14] Arielle Greenleaf: By hiring a sleep consultant?
[00:30:17] Craig Canapari MD: but what would you do? And I, again, I know it’s hypothetical, but what would,
[00:30:20] Arielle Greenleaf: yeah, sure. I think if you don’t have the right age appropriate schedule in place,
[00:30:26] ​
[00:30:26] Arielle Greenleaf: it is absolutely not going to work. these influencers say, your baby is six months, these are the wake windows that you need. And they try those wake windows and it’s not working, and they’re like, why isn’t this working?
[00:30:40] Is there something wrong with my baby? Is there something wrong with me? And I think the majority of people that come to me have a child that’s outside Of those wake windows that they’re seeing on Instagram and TikTok. So schedule’s really important, but it can be very nuanced and that can [00:31:00] really lead to failure if it’s not right for your child.
[00:31:05] But schedule’s important, routine is important. Making sure that you are not having the child fall asleep in your arms on the breast, on a bottle in the car, making sure that they’re, they know where they are falling asleep because when they wake up, they’ll be like, okay, this is where I fall asleep.
[00:31:24] So I think, routine is essential and making sure that. The child is falling asleep independently, which is, the goal, that’s why you use a method. But also the schedule without a good schedule in place, people set up for failure.
[00:31:38] Craig Canapari MD: I feel like we should do an episode like we’ve talked about a napping episode because I know naps gave us the
[00:31:43] Arielle Greenleaf: Oh, yeah.
[00:31:44] Craig Canapari MD: especially with my older son, but it’s so hard to make specific prescriptions ’cause every kid’s a little bit different, but
[00:31:50] It’s, curious to hear your, we could go through the first year of life
[00:31:55] And what parents should start expecting and trying to do in those different ages [00:32:00] because honestly I can tell you in and this is a problem with medical training, we’re not, we don’t learn a lot about healthy sleep in a practical way.
[00:32:08] Naps are always harder. They just are. I think just from a, you’re talking about hormones. Melatonin is the sun goes down, the melatonin naturally releases, we get sleepy. That’s not happening at nap time. some kids just are not good nappers.
[00:32:28] Arielle Greenleaf: So understanding what to do if they’re not good nappers and you’re trying to push them to a later bedtime, that has caused trouble for many of the people that I’ve worked
[00:32:40] Craig Canapari MD: Yeah. I think it it’s really so hard. I know I wrote my book when I wrote an article about this. I’m like, it’s naps are hard, but let’s put a pin in that for later who is extinction sleep training for? We talked about being for infants, it’s for parents that wanted do a fixed quickly, right?
[00:32:57] If they’re like, okay I’m going back to, [00:33:00] I’m going back to work.
[00:33:01] Arielle Greenleaf: yeah.
[00:33:02] Craig Canapari MD: I want to do this. That’s a good fit. And really it’s for parents who can deal with some degree of crying, And it’s okay if you can’t. And in my house I got a certain amount of tolerance for kids crying, especially as a resident.
[00:33:14] Where will you be doing IVs? Blood draws, all this stuff all the time. Is it different when it’s your own kid? Yes. But my wife, I, in retrospect, one of the things I would’ve done differently with my older son who, for him and I put this in my book and my worst review on Amazon, you guys can look it up, is someone saying me, just telling my truth, which was night one, my older son, who is a stubborn kid he cried for he cried for, I don’t remember, for 90 minutes or two hours.
[00:33:43] Night two, we cried for 20 minutes night. Three we were done. And if I had known that was gonna play out, what would I have done differently? I might’ve adjusted his bedtime a little bit and I might’ve, I probably would’ve sent my wife out to movies.
[00:33:54] Arielle Greenleaf: yeah. absolutely.
[00:33:56] Craig Canapari MD: and
[00:33:57] Arielle Greenleaf: Having help is important. I think you bring up a good point there [00:34:00] because I think having help, and if there’s one parent, I always find that there’s one parent that’s a little more sensitive. And if you’re able to enlist the help of a partner a grand, even a grandparent, anybody who you feel could support you if you’re not comfortable with it or vice versa, that makes a big difference.
[00:34:19] Craig Canapari MD: absolutely. And it’s not always the mom that has a harder time with the crying. In fact, often it’s the dad. Having that conversation and just being like, okay, I’m gonna, you’re gonna go out and see your friends or have an activity.
[00:34:32] Arielle Greenleaf: Yeah.
[00:34:33] Craig Canapari MD: You make a play date for your partner so they can go out
[00:34:38] Arielle Greenleaf: Yeah.
[00:34:39] Craig Canapari MD: and what are the pitfalls of this sleep method?
[00:34:41] Oh, that’s hard. I honestly don’t feel like it’s a very difficult thing to mess up. I think one thing. Okay, so here’s one thing. If they’re, if you’re using like a Ferber method, so a modified cry out modified extinction I [00:35:00] do not go in the room unless the child is full on crying. Don’t go check on a baby that’s just fussing or kicking around or, grunting here and there, like starting to cry, but then stopping and then starting again. they’re learning.
[00:35:15] ​
[00:35:16] Arielle Greenleaf: I find that a lot of times parents will go in, even if the child isn’t
[00:35:19] Craig Canapari MD: oh my God.
[00:35:20] Arielle Greenleaf: crying or making any noise and they’re just kicking around.
[00:35:23] And that’s when I’m like, put your video monitor away, because if the child is content in their crib, there’s no reason to go in if they’re awake, you can’t force them to fall back asleep. So I think parents screw it up by just going in too much.
[00:35:38] Craig Canapari MD: Get babies are very smart and so are toddlers. with a turn.
[00:35:42] Arielle Greenleaf: Yeah. they’re much smarter than we give them credit for, and they catch on quickly if we are consistent. it’s difficult to be consistent when you’re tired and it’s difficult, like you said, to hear a child cry.
[00:35:55] Craig Canapari MD: you just have to put your game face on and be ready. as long as you follow [00:36:00] my instructions well, you’re gonna succeed. If you go rogue, then I can’t help you. I’d say that, yeah, be consistent. I think having a clear plan, like I’ve seen parents be like. It is they decide at 10 o’clock at night that they’re gonna sleep during their child at night. Because they have just had it. And then they do it a weird way and it doesn’t work.
[00:36:23] the problem with doing, doing a plan that isn’t a really, a good one. Again, the plans don’t have to be complicated. You could read a book or a blog post and come up with a plan, but not having a plan at all and just winging it is that you’re inconsistent. And then a lot of times these behavioral methods if you do it halfway and it doesn’t really work, then it’s gonna be less effective the next go around.
[00:36:47] So I’d say give yourself the best chance to do it, have a clear plan. I’m just thinking the two parents you ever see the Modern Family episode where their sleep training
[00:36:54] Arielle Greenleaf: I need to
[00:36:55] Craig Canapari MD: it’s the two dads with their daughter and one of, one of the real sort of order [00:37:00] rules-based guy is trying, is like just wants to do this so badly and Cam, the more emotional, like chaotic energy kind of guy is running into the room and they’re like wrestling and they fall through the door and the kid’s just looking at what’s going on? It’s really funny.
[00:37:14] Yeah. I think what, like what you’re saying is important though, because I have seen that you’re like, you’re saying, you’re asking about like things that could cause it to not work. It’s one parent, you guys need to be on the same team because if one parent is going in and the other parent is not, you’re not gonna succeed.
[00:37:34] Arielle Greenleaf: It’s just not gonna work.
[00:37:35] Craig Canapari MD: I think that in behavioral terms we talk about the extinction burst, and that is again. I think this is less common than we, I used to think it was, but it is possible that a night, two or three, you might get more crying.
[00:37:47] I’ve had that happen on night five or six you get a few really great nights and then all of a sudden you’re back to it. the hard part is the word extinction is horrible. use it ’cause it’s [00:38:00] precise, but you’re not making your child go extinct. You, they’re annoying behaviors. You’re trying to make them go
[00:38:05] Arielle Greenleaf: It’s right, an extinction burst sounds horrible, but if you were trying to stop eating ice cream every night, and you did well for a week, then had a bad day and slipped up and had some ice cream, that’s an extinction burst. If you’re like, go back to it and then you get back on track
[00:38:24] You just have to get through it. It’s trying to break a habit, which isn’t always seamless.
[00:38:30] Craig Canapari MD: I think the key is extinction burst. It’s not gonna be like weeks of crying. And if you are not seeing progress within a couple of nights it is worth looking at a couple of things. my checklist.
[00:38:41] make sure there’s no medical problem, right? we’re not talking about big ticket medical problems, but like your kid’s got bad eczema, your kid’s coughing at night.
[00:38:49] Arielle Greenleaf: Ears.
[00:38:50] Craig Canapari MD: yeah they have fluid in their ears. If you’re struggling with sleep. Go talk to your pediatrician, like maybe even bring them in to be checked out. Your pediatrician may be [00:39:00] able to provide some guidance for you about this process too. And, it’s just another especially honestly, a lot of time the, maybe the pediatrician, maybe the nurses in the office that like, they’ll just take your call the next day and you’re worried, right?
[00:39:13] ’cause not everybody has the resources to hire a sleep consultant, but like in, in our country, almost all the kids have pediatricians and have somebody have someone you can reach out to. It’s tricky with friends or people online because people’s parenting beliefs are different.
[00:39:28] And I feel like it was more the heyday of like Facebook parent groups where people would just say wild stuff if somebody was like talking about sleep training.
[00:39:36] Arielle Greenleaf: They still
[00:39:37] Craig Canapari MD: I tend not to read comments anymore.
[00:39:40] I don’t reply to comments anymore. I used to get enragedI just block
[00:39:43] Arielle Greenleaf: about? This is not the truth. No, I just ignore it. if that’s what you think and that’s how you feel, that’s your thought. you didn’t ask for my opinion, so I’m not gonna give it
[00:39:52] Craig Canapari MD: So I say the other things for implementation, make sure you’ve got a good bedtime routine. Consistent routine, two or three activities that somebody [00:40:00] does with your child every night. It’s like bath book song, quick cuddle, goodnight.
[00:40:05] Nursing, if you’re nursing them you may do that. Sometimes it’s something as simpler as moving the last feeding from the last thing they do before they fall asleep. To before before you do everything else. That’s all you’ve gotta do.
[00:40:18] Arielle Greenleaf: Also say with the bath thing, some kids are stimulated by baths and they freak out. So if that’s the case, move bath time to a different time. But you do not have to start with a bath if your child freaks out in the
[00:40:31] Craig Canapari MD: You don’t even need to bathe their kid every day unless they’re visibly dirty because they don’t have body odor. And I shouldn’t admit this in media. My mom used to give me a bath every time she changed my diaper.
[00:40:46] Arielle Greenleaf: Oh
[00:40:48] Craig Canapari MD: Oh man. My Dr. Henry rest in peace. You dealt with a lot of calls from my mom and yeah, that was, it was some wild stuff apparently going on back in [00:41:00] the seventies.
[00:41:00] I’d say making sure everybody in the house is on board with the plan. And, put your bed put your kid to bed, drowsy but awake starting at four months and just see what happens. Try that out a couple of times. It may just work. You might be gearing up for this big plan and people have these catastrophic ideas and look honestly a lot.
[00:41:17] There’s usually some crying,
[00:41:19] Arielle Greenleaf: Yes.
[00:41:21] Craig Canapari MD: I would say for
[00:41:22] Arielle Greenleaf: Let me ask you,
[00:41:23] there’s no such thing as a no cry sleep solution. that’s what I was just gonna ask you. I was gonna ask you, because I know some people say there is, and I just feel, if you really wanna teach a child or baby to fall asleep independently, they’re probably gonna be upset if you’re taking something away they’re used to. So I know there are people out there that say, I have the no cry sleep solution, but do they?
[00:41:49] Craig Canapari MD: Yeah. I’d say also if you have people that are like, oh, I’m running to sleep train, but their kids’ sleep was pretty good anyway, there may not be a lot of crime. [00:42:00] But if if they’re struggling, if they’re reaching out to someone like you or me, there’s probably gonna be some crying. unmodified extinction is easy to understand.
[00:42:10] A modified extinction for my son, was like, those checks were like pouring gasoline on the fire, So we have this idea that the Ferber method, modified extinction, you go in and you check on your kid, and we I think we fell prey to one of the mistakes that you mentioned,
[00:42:27] He’d be like winding down the crying and we’re like, oh, it’s five minutes. We’re gonna go in and check now. And then he’d ramp up again. But really, the checks are mostly for mom and dad as opposed to the child. But a check is short.
[00:42:42] You go in you can look from the door, you don’t have to say anything. Or you can say, I love you. Go to sleep. Goodnight. You don’t pick them up. you don’t cry in front of them yourself. If you’re gonna do that outside of the room. It should be less than a minute. You’re in, you’re fine.
[00:42:59] Go to sleep. [00:43:00] You’re out of the room. A check is not picking up your kid, rocking them, nursing them, et cetera. There’s nothing magical about the intervals that Ferber puts in his book. You could check every five minutes. You could check every 10 minutes.
[00:43:14] Arielle Greenleaf: Yes. That’s something that I customize to each family because. there’s nothing magical about that formula. It’s just a suggestion and I find that some parents are like I don’t even think I should go in at five minutes. I think I need to start at 10 minutes and just stay there.
[00:43:28] Cool. If you’re comfortable with that, great. Some other ones are like I think I really need to do every three minutes. We can start with that, see how it goes. But there’s no like specific, if you don’t do the ferber intervals, you’re not gonna mess it up.
[00:43:43] Craig Canapari MD: Yeah, no, I think Ferber was successful because any plan is better than no plan. If you were like, okay, I’m gonna check, when he gave you a formula can be helpful if you don’t know what to do, right? But there, there’s nothing magic about those numbers.
[00:43:58] The this is an important thing too. [00:44:00] What do you recommend if someone is doing an extinction sleep training method? What do you recommend the parents do in the middle of the night if their child wakes up crying?
[00:44:08] Arielle Greenleaf: I think it depends on the age because there are some babies that need a feeding. It’s very important to log feedings too throughout the day to understand is this baby being nursed enough? Is this baby gaining weight appropriately?
[00:44:26] Is this baby getting enough ounces of formula, because they could be reverse cycling overnight because they’re not eating during the day and that we don’t wanna starve the baby. So then we have to figure out how can we start to get more calories into this kid during the day?
[00:44:39] But there are definitely babies on the younger side and sometimes there’s a child that the doctor recommends one night feeding at whatever age before 12 months. The way we look at feeding is it needs to just be dark room, no eye contact, very little. You go in, you feed the baby, [00:45:00] you put them back in the crib and you leave.
[00:45:03] I would definitely avoid diaper changes unless the child has had a bowel movement. They’re so stimulating and a lot of times parents are like she doesn’t like a wet diaper. I promise you they’re so absorbent. She’s not sitting there feeling like she’s sitting in a wet diaper.
[00:45:20] She’s upset because. She wants help or she wants you to rock her to sleep Babies don’t really have that kind of preference at that age. So I think feedings are important. I would never tell anybody to wean a feeding unless their doctor suggested that.
[00:45:39] And or the doctor said, it’s okay to stop feeding three times a night. Let’s figure out how to slowly get rid of the feedings. But otherwise, night wakings need to be treated exactly the way you started. we go back to the consistency. The child needs to understand that you’re going to respond the same way no matter what, beginning of the night, middle of the [00:46:00] night, et cetera.
[00:46:01] Craig Canapari MD: Yeah I’m of two minds about this. ’cause I remember when I was training my mentor, Judy Owens was like, you, our patients’ families are usually busy professionals. And if they’re doing extinction sleep training at bedtime, let’s take the feeding out of this,
[00:46:15] One is you can just soothe your kid back to sleep, if they’re learning to fall asleep independently at bedtime, then those night awakenings will start to drop out over time. The flip side is if you really wanna put your foot on the accelerator, get rid of everything more quickly, then you can ignore them in the middle of the night too.
[00:46:31] But for me, I’m usually like, okay. Fix bedtime, get them to fall asleep independently. We’ll, ’cause I don’t see people that often. I’m like, we’ll circle back in around a month and if your kids’ awakenings aren’t significantly improved, we may implement this in the middle of the night. But the fact is, there are lots of different reasons.
[00:46:47] People may not wanna let their kids scream in the middle of the night. They’ve got neighbors, they’ve got other kids in the house, or they just can’t deal. So I think you can go either way on this. And when you get into other methods, say the chair method, which takes a [00:47:00] lot longer at bedtime, there’s no way you can
[00:47:01] do that in the middle of the night, You’re gonna be in the room for six hours.
[00:47:04] Arielle Greenleaf: It’s,
[00:47:04] Craig Canapari MD: And
[00:47:05] Arielle Greenleaf: I agree.
[00:47:06] Craig Canapari MD: So what are the alternatives for a parent that really, I don’t know.
[00:47:10] I wanna try some other stuff first because I. This just doesn’t fit with my parenting philosophy, or I feel like this isn’t the right fit for my kid.
[00:47:20] Arielle Greenleaf: It is not the right fit for everybody. And sometimes parents will start and they just say, I can’t do this right now. Can we regroup in a month or something like that? I will never. Say no to that. Like your book, it’s never too late to sleep train.
[00:47:38] there are other ways, especially with the younger babies. some babies will do just fine with a pickup put down method. Baby gets upset, you pick them up, you try to soothe them, you put them back down, you give ’em a little space, see how they do.
[00:47:51] If they’re still upset, you pick ’em up again and you just go through that process.
[00:47:54] Craig Canapari MD: the baby might not soothe.
[00:47:56] can you expand a little bit on pickup put down? ’cause I’m less familiar with that, but I remember [00:48:00] I was corresponding maybe with Jody Mindell, who’s down at Penn, which maybe have on sometime, and she’s I’ve moved more towards pick put down versus extinction for a lot of my patients.
[00:48:10] So I’d be interested if you could just talk a little bit more about the mechanics of that.
[00:48:15] Arielle Greenleaf: Sure. I am not overly familiar with it myself because I only use that really with newborns. But with newborns it can be helpful to teach them how to fall, into their sleep space, drowsy, but awake.
[00:48:30] So essentially, I and I could be wrong honestly because I don’t use this very much I think it’s just as simple as it sounds. You place baby in the crib. If they’re upset, you pick them up, you hold them, you soothe them, but they’re not falling asleep in your arms and then you put them back down.
[00:48:50] And again, attempt. And you can, they put ’em back down the crib, you can rub their belly or rub their head And if they get upset again, you pick them up, you put them down. So that is my [00:49:00] understanding of it. it’s just way too stimulating for
[00:49:02] Craig Canapari MD: there’s a variant of that called bedtime fading. It can be just moving your kids’ bedtime later to harness their sleep drive. Often we do this in older kids but bedtime fading and infants or usually means or like young toddlers, like eight, one to two. It’s you put them in their bed, you let them fuss or cry for 15 minutes. let’s say their bedtime’s at 8:00 PM they’re not asleep by eight 15. They’re still crying. If they’re talking to themselves, it’s fine. Then you get them up and you just hang out with them, do soothing activities till nine.
[00:49:35] Then you try to put them down again. You about 15 minutes of, some people call it controlled crying. If they’re not asleep, then you get them up again. this does a couple of things. First of all, kids have strong sleep drive.
[00:49:45] Eventually they’re just gonna fall asleep. you are essentially sleep depriving them for the next day. So they’re gonna have a crappy day the next day, but unless you let them say, extend their nap in the afternoon or fall asleep at six [00:50:00] o’clock, then they’ll fall asleep easier the next couple of nights.
[00:50:02] And the extinction sleep extinction or cried out window. they weren’t quite old enough for the three or four year olds. we can reward the behaviors we do as opposed to ignoring the behaviors we don’t like.
[00:50:14] But really in a one and a half year old, that’s not gonna work. And the parents where this was the right fit, it worked very well. And it’s a sucky nights and days But then it gets people on
[00:50:25] I mean that, that’s true for any sleep training. It’s gonna be a couple sucky nights. So I think this is good.
[00:50:30] Anything else you think we should talk about?
[00:50:33] Arielle Greenleaf: No, I think
[00:50:35] Craig Canapari MD: fixed it
[00:50:36] Arielle Greenleaf: yep, everyone should do Cry it out.
[00:50:40] Craig Canapari MD: it’s for everybody.
[00:50:41] Arielle Greenleaf: I had to do extinction with Ashley. Going in was, like you said, it’s like dumping gasoline on her. It was just
[00:50:48] Craig Canapari MD: But she’s like the most lovey, adorable child. In fact, she was so much happier after I did it.
[00:50:55] Yeah for my son, I’d say he was the same. But, [00:51:00] and he’s a pain in the ass now, but I don’t think that’s ’cause of this, the
[00:51:04] Arielle Greenleaf: No.
[00:51:04] Craig Canapari MD: and it really was hugely impactful for my wife and I.
[00:51:08] Arielle Greenleaf: No, I was really not well, it, completely changed my life.
[00:51:13] Thanks so much for listening to the Sleep edit. You can find transcripts at the web address Sleeped show. You can also find video of the episodes at that address as well as in my YouTube channel. You can find me at Dr. Craig canna perry.com and on all social media at D-R-C-A-N-A-P-A-R-I. You can find Ariel at Instagram at Ariel Greenleaf.
[00:51:43] That’s A-R-I-E-L-L-E-G-R-E-E-N-L-E-A. If you like the flavor of the advice here. Please check out my book. It’s Never Too Late to Sleep. Train the Low Stress Way to high Quality Sleep for babies, kids, and parents. [00:52:00] It’s available wherever fine books are sold. If you found this useful, please subscribe at Spotify or Apple Podcast and share it with your friends.
[00:52:09] It really helps as we’re trying to get the show off the ground. Thanks.