Wednesday, August 01, 2012

Ferber and 'Ferberizing'

I read Richard Ferber's book ' Solve your child's sleep problems', expecting to hate it.  After all, he advocates leaving a baby to cry for long periods, alone, doesn't he?  Didn't he make 'crying it out' acceptable?  Maybe these distasteful ideas are in one of his other books?

Later, I read the preface, in which Ferber explains his method of 'graduated extinction' ( leaving a baby to settle for longer and longer intervals and giving 5-10 minutes of comfort at each 'visit' as a reaction against full 'extinction' methods where small babies were left in their beds until to following morning, regardless of whether the baby settled and went to sleep or was crying for the duration.  Ferber has also done a lot of work with co-sleeping families and families who implement other 'attachment' methods of settling.  He only urges changes when they fit with the families and their parenting ideology.  What a guy!

Ferber's approach is of course, clinical, he is a pediatrican and the Director of a Pediatric Sleep Disorders Unit at a Children's Hospital.  His case studies generally feature children over 6 months up to 6 years of age. His book cites actual sleep disorders diagnosed and resolved, not your average baby that cries a few times a night.

A real strength of ferber's book is his knowledge of the physiology of sleep in adults and infants.  If you want to read about sleep cycles and REM and non-REM cycles, it is quite comprehensive.  However, if all you want to know is 'Why does my baby wake more between the hours of 10pm and 5 am?',  well, apparently babies enter deep sleep in the first part of their night and lighter sleep in the later part before re-entering deep sleep again between 5- 8 am.This is why babies may wake a lot more after a certain point but usually sleep really well in the early part of the night.  It is also why babies may still demand a feed at the time despite being strapping 15 kg toddler on three hearty meals a day.  These are usually the cases he works with.

Another helpful point Ferber makes is that 'naturally' our circadian clock is at odds with the 24 clock we all must work, eat, sleep and live by most of the time.  'Naturally' left to our own devices we would operate on a 25-26 hour clock, according to Ferber, which is why unless we implement a routine with babies, they take some time to 'find their own'.  Some babies never find their own and toddlers have long ranging sleep problems from being allowed to follow their own 'clocks', so if you were trying to find optimum nap time every day would be like hitting a moving target and that bedtime would get later and later until it was at 2am and then eventually became 7 again, you get the idea.
Hence he encourages  relatively set times for feeding and naps especially in the early days, even if these times don't really 'stick'. Don't have a cow about making baby have a X hour schedule and exactly two 2 hour naps a day and catnap, but keep persevering, as you are attempting to show an infant/child some order to give structure to their sleep.

Ferber doesn't only advocate crying methods but particularly when the disorders are extreme ( drinking 20 bottles a night and only taking a little bit then waking after 4 bottles with soaked nappies), Ferber recommends graduated ( with timed intervals set by parents and their capacity to cope) crying sleep methods. In some cases when parents do not want to use a crying method, such as the all familiar multiple bottles one above, a toddler was given fewer bottles in the night over the course of a few weeks and when the final bottle was removed, some crying 'for five minutes' over two nights occurred. Sounds ok, yes?

He gives a checklist to create good sleep habits, most of which we see echoed by the Gina Ford's, Tizzie Hall's and Tracy Hogg's of this world and it was frankly good to see where these (usually unreferenced) ideas come from.  Hogg doesn't like Ferber thoughand believes he does not pay enough attention to baby temperament, ( Cooke, p.139) I can't comment on that as it wasn't really apparent from this book. However, a lot of what we know about sleep, routines and the order ( or lack thereof) of baby sleeping and waking patterns is covered by Ferber in a well laid out sort of a way.

Anyhoo, here is that checklist he advocates for teaching your baby/toddler to sleep if you're unhappy with the current state of affairs.

1) Correct the sleep association for the CHILD's benefit, not your own convenience ( i.e decide what they need and be consistent, don't pike because you are having second thoughts or chop and change to a different way each night)

2) Sleep associations/conditions ought not be stimulating or continuous.  ( i.e baby falls asleep in moving car/swing/arms/near buzzing tv) How can a baby stay in deep sleep if the swing stops, the sucking of a dummy stops ( when it falls out) the bottle is empty or the tv changes from soothing infomercials to reruns of 'Two and a half men?' Also, the quality of sleep while in motion is less beneficial than sleep in bed/motionless place according to his studies of brainwaves. He doesn't rule out motion methods but when sleep training he recommends a bed and no tv!

3) Baby wakes where baby falls asleep.  Don't transplant baby from your arms to bed and expect him to stay there all night! When he wakes again, he will need your arms again. He does an illustration for you about how you would feel if you went to sleep in your bed and woke somewhere else - i.e the floor and the blanket was different or you were suddenly wearing pajamas.

4) Wait until the baby is old enough to have props changed/removed.  Ferber suggests 5 months as a good age to change sleep associations although he does say you can change things for little babies ( maybe not breastfeeding to sleep for example can be changed relatively easily earlier) but to be quick to stop if baby responds badly. Tread carefully, a lot of sleep props can be fixed later so don't stress too much.

6) Different sleep associations can exist at different times and places - this is ok.  You may take baby for a walk for afternoon nap and not need to walk them at bedtime, they may need their alligator at Nana's but their cuddle blanket at home etc.  You might find feeding your baby to sleep for naps is fine but bedtime causes middle of the night waking for unnecessary feeds... Whatever the associations, they are not necessarily problematic in themselves for some conditions. They can be changed if they start to cause trouble.  You may find a similarity with Pinky McKay here.

7) If baby can settle well during naps but not in the middle of the night, don't fret, the self settling itself shows they will sort it out and that they are able to re settle. He doesn't say not to do anything but just says that it is a good thing.

8) Back to sleep cycles and times of night, waking is more frequent between the hours you REALLY need to zzzzzzzzzz. ( 10pm to 5 am)

9) Don't worry about 'spoiling' your baby by breaking the rules for travelling, sickness, nightmares etc.  Just be firm and go back to the limits you originally set when illness is over and you are home from holiday.  He has a chapter on nightmares and night terrors that I didn't read which you may find helpful if you have a child with these issues. The complexity of sleep phases is something I would like revisit some day.

10)  LOTS and LOTS of love during the day is vital if you allow some crying methods for settling at night, the context of a loving home is essential or don't bother with a crying method.

11) Be consistent in what you do. ( notice a trend?)

12) Be consistent in the amount of time you leave a child to cry to settle ( i.e don't shorten the time to 2 mins if it was 5 mins the night before - however if baby sounds likes they are settling and you think they are not stressed but falling asleep, wait longer if need be)

13) Share settling responsibilities if you have a partner, the milk lady can often have trouble re-settling a night waker who no longer needs the milk but can smell it maddeningly within reach.

14) Vomitting.  Hmm, this is where I think most people would pull the plug or throw the book across the room, he says toddlers can often arc themselves up to vomit a lot and that it often passes, just clean it up and stay the course ( don't forget we're talking a doctor who works with extreme sleep disorders, not a tiny baby whose needs are not being met). Robin Barker says something about this too but dryly mentions that vomitting is pretty inconvenient so it may be hard to stay the course if you are cleaning up vomit 4 times a night.

15) Stick to the settling technique, if its crying, don't fear waking an older child as they tend to be more resilient than you. ( ??? Not sure about this one)

16) Explain crying to neighbours and that you are not just off watching tv or surfing the interwebs but poised outside toddler/baby/s door.  This if just for your own peace of mind, or not, if your walls are paper thin.

17) DIY - don't get babysitters to look after kids with settling regime in place, unless you can involve them in the process. (Again ?) Trusted babysitter is emphasised, no strangers, preferably family and someone who can stay the course.

18) Last but not least, once your baby knows how to sleep, try not to stress if things fall apart temporarily but stay the course and don't let slips become the new settling regime.

So there you have it, Ferber.  A very interesting and helpful read.  Overall, quite reassuring that often night waking is more sleep than hunger after a certain age and that changes can be made - it will be difficult, but there are ways to make it happen if you are committed to it.