In praise of Dr. Ferber

Ferber seems to take a lot of flak on the internet these days.  I’m referring, of course, to Dr. Richard Ferber, author of Solve Your Child’s Sleep Problems and founder of the Center for Pediatric Sleep Disorders at Boston Children’s Hospital.  His method of sleep training has become so well-known that it has its own verb: “Ferberizing.”  But spend any time on mommy forums and you’re bound to encounter science-y sounding proclamations about how terrible the so-called “cry it out” methods are for your baby.  Abandonment!  Brain damage!  Instant breastfeeding failure!

Those people are nuts.

I think when a lot of folks hear the words “sleep training,” they think of situations like the one described in this New York Times article, in which a doctor recommends leaving your 8-week-old alone for 12 hours, no matter how much he or she cries.  Don’t do that.  Don’t even think about doing that.  Seriously, that is a terrible, terrible idea.

That’s not what the Ferber method is about.

I actually read Ferber’s book, in its entirety, and it is the very opposite of ignoring your child’s needs.  His (in)famous method occupies just one chapter out of eighteen.  Most of the book deals with a variety of other sleep issues: nightmares, sleepwalking, bedwetting, circadian rhythms, etc.  It was clear to me that Dr. Ferber cares deeply about children’s well-being.  For instance, his recommendation for an older child dealing with severe anxiety is to do “whatever is necessary to help your child feel safe” – the italics are his emphasis, not mine.

My Little Boy stopped nursing himself to sleep somewhere around the 2-month mark.  Bedtime became progressively more and more of a struggle, as he grew less and less interested in being rocked or sung or swung to sleep.  By 3 months, it was taking a solid 90 minutes to put him to sleep at night, and then we’d be on tenterhooks for another 45 minutes in case he woke up at the end of that first sleep cycle.  The stress and lack of personal time was making my husband and me very unhappy.  Something was also making Little Boy very unhappy: he started crying the moment we took him out of his bath and kept it up all through his bedtime story and song.

That’s when we decided to sleep train.  Ferber’s book told us to lay him down in his crib with a kiss and leave for 3 minutes.  Go back in for more kisses and shushes and reassuring words.  5 minutes.  More reassurance.  7 minutes – wait, he’s quiet.  He’s asleep!  The next morning, Little Boy went down for his first nap with zero crying, and he cried for less than 5 minutes that next night.  Night 3 was a bit rough with 20 minutes of angry baby, but he’s been good at falling asleep ever since.

Now 7 months old, Little Boy falls asleep on his own and greets us in the morning with giant smiles.  He will sometimes grump for a few minutes when we leave him at night, but more commonly he happily babbles for a bit before getting comfy.  He sleeps well in strange places as long as he has a quiet, safe space to rest, and he’s added two teeth with extremely minimal sleep disruption.

We are happy, because nighttime is much less stressful.  Even more importantly, Little Boy is happy.  He stopped screaming during his bedtime routine, perhaps because he is confident in his ability to fall asleep.  (Ever been tired but unable to convince your mind and body to sleep?  It sucks.  It would make me scream, too.)  Sleep training has meant a lot LESS crying for Little Boy.

There are other methods of sleep training, with varying degrees of parental presence and intervention.  I liked the Ferber method’s balance of giving my baby the chance to fall asleep on his own while still allowing me to make sure he was OK.  We still check on Little Boy if he fusses for more than 5 minutes; on the rare occasion that this happens nowadays, it’s almost always because he needs a clean diaper.

Of course, you don’t need to sleep train your baby.  If you’re happily co-sleeping or just have a kid who sleeps easily and well – awesome!  Don’t fix what isn’t broken.  But if it takes hours just to put your baby to sleep at night, or if he’s waking up every 45 minutes all night long – the rest of this post is for you.

I call it “Crazy Grad Mama’s guide to (mostly) guilt-free sleep training.

Wait until your baby is old enough.  Most sources will say to hold off on sleep training until 4 months; some say to wait ’til 6 months.  The real hard-and-fast rule is to wait for the end of the “fourth trimester,” that 3-4 month period in which your baby is still adjusting to life outside the womb, his nervous system still developing to a point where it can handle the big wide world.  You can gently try to make your newborn sleep longer, but you can’t force it.

Sleep training is not the same thing as night weaning.  (In fact, they’re separate chapters in Ferber’s book.)  “Sleep training” should be about falling asleep, not specifically about sleeping through the night.  If your baby needs to nurse every hour because that’s the only way he knows to fall back asleep at the end of a sleep cycle, then yes, sleep training will mean fewer night feedings.  But you should never let your baby go hungry (duh, right?).  In our case, Little Boy had dropped to 0-1 night meals of his own accord before we sleep trained.  Since we knew that when he woke out of hunger, it was around 4-5 a.m., we decided to treat any wakings before 2 a.m. as not-hungry times.  (As it turned out, this happened only once.  I don’t remember what was bothering him, but his dad comforted him a few times, and he went back to sleep.)

Have a plan.  Consistency is key to learning any new skill or habit.  The first couple of nights of sleep training will probably suck, so it’s important to be prepared.  It’s also important to implement a legit sleep training method and not a haphazard “I’m going to let my baby cry for a while and see what happens” approach.  Read a book (or books, if you’re me) or find a non-crazy internet site for reference.  Noob Mommy has a great explanation of Ferber, and BabyCenter’s Teaching Your Baby and Toddler To Sleep board is a good resource for sleep training options (this is only time I will ever recommend a BabyCenter forum, so take note).

Commit for a week.  Again, the first few nights will be the worst, but you should see noticeable improvement after that.  It’s also not uncommon to see some improvement, then have a random worse night (like our third night).  But if you stick to it, things should be better after a week.  If they’re not, stop and reevaluate; either you, the parents, have implemented something incorrectly, or your kid needs a different approach for sleep.  (If you have Ferber’s book, you can refer to the section titled “If Things Are Not Getting Better.”)

Remember the importance of sleep.  Some people dismiss sleep training as selfish, and it undoubtedly benefits parents.  But sleep is important for growing babies, too.  Memories consolidate during sleep; the mind and body refresh and renew themselves.  Solid sleep is as important a biological need as food and human interaction.

For those about to embark on a sleep training adventure, I wish you luck!

Where the pro-breastfeeding movement gets it wrong

Little Boy and I have been very lucky when it comes to breastfeeding.  I don’t say that to brag; quite the opposite, in fact.  Our success at breastfeeding is due to little more than luck and genetics.  Sure, I did a few things that helped – attending a breastfeeding class, for instance, and pumping after a few feedings a day once my milk came in.  But I didn’t work harder or want it more than any other mother.  Actually, since things went relatively smoothly for me, I worked a lot less hard than many new moms do.

I like breastfeeding.  It’s cheap and it’s portable, it gives my kiddo the benefit of my immune system, and it means that I don’t have to decide among the 85 different types of formula available at Target.  Avoiding complicated decisions is one of my favorite things.

However, I’m getting really, really fed up with the all the rhetoric surrounding breastfeeding.  There was another round in the news this week:  Breastfed babies have higher IQs!  Breastfed babies grow up to make more money!  Here’s some more guilt if you couldn’t or didn’t want to breastfeed!

That guilt is a big deal.  I know several women who were unable to exclusively breastfeed despite trying past the point of exhaustion.  I have read the stories of many, many more such women, some of whom cite breastfeeding problems as major factors in their postpartum depression.  The strident pro-breastfeeding messages seem to actively encourage this guilt – I’ve seen discussions on mommy forums where the attitude “I’d like to breastfed if I can, but if not, formula is fine” is dismissed as “doomed to failure.”  Anything less than 100% dedication must mean that you’re going to pull out the Enfamil the minute things get tough.

That’s not true.  And it’s horribly counterproductive.  We should be supportive of all interest in breastfeeding, not trying to make it into an elite club.  Breastfeed for a week?  Good job!  Breastfeed for six months?  Good job!  Breastfeed for three years?  Good job, but it doesn’t make you “better” than other moms.

“Formula is fine” is not only a healthy attitude, it’s the truth.  Let’s take a look at that latest study, shall we?  “The difference in IQ between the most extreme groups [breastfed for less than 1 month vs. breastfed for 6-12 months] was nearly four points, or about a third of a standard deviation.”  Woah, a whole third of a standard deviation?  In my field that would get you laughed out of the room; even results at the level of 2 or 3 standard deviations can be suspect.  Moreover, mean IQ actually goes back down a few points for babies breastfed longer than 12 months (vs. 6-12 months; see the study’s Table 3).  Is anyone jumping up and down to say that mothers should stop breastfeeding after a year?  Didn’t think so.  (On a related note, breastfeeding longer than 12 months is also associated with a small increase in rates of celiac disease.)

For comparison, that same study shows that a higher family income leads to IQs up to 15 points higher, or more than 3x the effect of breastfeeding for 6-12 months.  (See Figure 1 in the study linked above if you’re visually inclined.)  This is a common theme in breastfeeding research.  It turns out that not all women are equally likely to breastfeed; those who do are typically of higher socioeconomic status, meaning they have access to more resources, better childcare (or they have the money to stay home), more educational opportunities, etc. etc. etc.  Their children could be healthier/smarter/whatever because of all those things, not just because of the breast milk.  In fact, when breast-fed kids are compared to their bottle-fed siblings, the differences are negligible, strongly suggesting that family environment is the true key.  Similarly, another study noted that the apparent IQ boost of breastfeeding disappears when you account for mothers’ IQs.

So let’s stop making formula-feeding parents feel like they’re dooming their children to an inferior life.  That’s not what the evidence says at all.

Moreover, let’s stop acting like giving your baby any formula inevitably ruins your attempt to breastfeed.  Yes, it has to be done carefully (and admittedly, it wasn’t done carefully 40 years ago), and yes, nipple confusion can be an issue in the first few weeks, but there’s some evidence that judicious formula supplementation can actually dramatically increase breastfeeding rates.  Plus plenty of parents combo-feed (some breast milk, some formula) for long periods.  It’s not an all-or-nothing situation, and presenting it that way hurts rather than helps. 

And don’t even get me started on the reverence of breastfeeding as “natural.”  Arsenic is natural, folks.  So are grizzly bears.  So is dying in childbirth, and so are high rates of infant mortality.  And yet so many doulas and lactation consultants (definitely not all lactation consultants, but a vocal subset) seem to harbor a bias against modern medicine, the very thing that is keeping those last two “natural” events at wonderfully-low levels.

Just yesterday, I ran across a blog, which I won’t link here, written by a lactation consultant.   One of her posts was a long warning about the dangers of birth “interventions” and elaborating at length about how important the hormones of labor are when it comes to successfully establishing breastfeeding.  The post was directed at moms-to-be, not doctors.  Here you go, moms: one more thing to feel guilty about!  Make sure to suffer through your labor – stay away from that pain relief!  And if you have to have a Cesarean, well, you’re totally screwed.

Again, this kind of attitude hurts mothers.  I had a C-section without ever going into labor, and yet had no trouble breastfeeding.  There is some evidence breastfeeding in the first 24-48 hours can be less successful if you’ve had an epidural (see here, for instance), but the long-term effects are unstudied and there could easily be other confounding factors.  Maybe mothers who ask for epidurals are already less likely to be interested in breastfeeding.

Even if epidurals are the direct cause, no mother should be made to feel guilty about easing her labor pain.  Change the medical culture to ensure epidurals aren’t pushed on women?  Yes.  Encourage further research into pain management options?  Yes.  Limit women’s choices and make them feel bad?  No.

As I said above, breastfeeding shouldn’t be a club of martyrs.  Nor should it be presented as though you have to do everything just right or else everything will go wrong.  You can gently guide your breastfed baby into a feeding schedule once your milk supply is established.  Your breastfed six-month-old doesn’t NEED to be fed every 2 hours all night.  It’s possible to breastfeed without sacrificing yourself, and it’s possible to be an excellent parent without exclusively breastfeeding. 

Because when it comes down to it, the question that matter is this: is your baby getting enough to eat?  If yes, then you’re doing a good job.

5 tips for newborn sleep

Everyone said, “Take her for a drive, that’ll put her to sleep.”  No, then we just had a screaming baby in the car.

– My dad, describing my behavior as a newborn.

Ah, sleep.  One of the great struggles of new parents.  For all I talk about the horrors of Little Boy’s early sleeping patterns, he has been in some respects a very good sleeper.  He was giving us a good five- or six-hour stretch at night by about 9 weeks old, and was regularly sleeping up to eight hours by 12 weeks of age.  Getting him to actually go to sleep in the evening was the hard part, as were his persistently short naps.

There are some good newborn sleep tips out there, but there is also a lot of highly impractical advice.  “Put your baby down drowsy but awake” – my baby just fell asleep nursing and I’m not going to wake him up, thank you very much.  Unlike me, Little Boy would usually fall asleep in the car, but then he would wake up again the moment we brought him back inside the house.

In no particular order, then, here are the sleep tips that worked for our Little Boy as a newborn.  I hope someone out there will find these helpful; however, as I’m extrapolating from a sample size of N=1 baby, I offer no guarantees.

1.  Recognize that sleeping babies are noisy.

As a new parent, your first reaction to any sound from your baby is to think, “Oh my gosh, are they OK?  What do I do?”  But newborn babies are loud sleepers: they grunt, snuffle, wiggle, and generally make a ruckus while they are still asleep.  Just like adults turn over or adjust the blankets without really waking up, babies go through periods of light, restless sleep.

More than once, I was wakened by an escalating series of grunts from Little Boy and was sure that I was going to have to drag my tired self out of bed for another feeding.  Except I was so exhausted that it took a minute – and then I woke up two hours later.  Little Boy and I had both gone back to sleep.  The first time this happened, I felt seriously guilty, until I realized that there was nothing to be guilty about.  Little Boy was fine.  If he had needed me, he would have let me know in no uncertain terms.

Once we figured this out, my husband and I instituted a rule for night sleep: “If he’s not crying, let him be.”  I give a lot of the credit for Little Boy’s early extended nights to this rule.  We still use it now: Little Boy sometimes wakes up in the wee hours of the morning, babbles happily (but loudly) to himself for a while, and falls back asleep on his own.

2.  Encourage full meals.

A key contributor to those middle-of-the-night wakings in the early days is hunger.  Newborn stomachs are tiny, and their food digests quickly.  You can’t – and you shouldn’t – dictate how long new babies go between meals, but there are some ways to gently encourage longer stretches.

I wasn’t actually thinking about sleep when I first started using these techniques.  Rather, I was a paranoid brand-new breastfeeding mother worried about making sure her baby was getting enough of the fatty “hindmilk” that comes later in a nursing session.  In addition to letting Little Boy nurse as long as he wanted, I didn’t assume that he was finished on one side just because he needed to burp.  Instead, I’d offer him the same side again, and only switch him to the other side when he was really truly done with the first.  The downside to this approach was that each meal took a long time, usually upwards of 40-50 minutes in the early weeks.  Thank goodness for cable TV.

The other part of this strategy is this:  If your little one gets fussy and it’s been less than 90 minutes since the start of the last feeding, try other methods of comfort before offering more food.  Breast milk digests quickly, not immediately.  Your baby might be tired and need help falling asleep, or gassy, or maybe just bored.  Obviously, you should always feed a hungry baby, even if the period between meals is short.  But do consider that not all cries indicate hunger.

3.  Focus on getting calories in during the day.

A baby who gets plenty of food during the day will (hopefully) be a baby who needs less food at night.  We didn’t start focusing on this until Little Boy was closer to 3 months old, because I was having trouble figuring out how to transition from purely on-demand feedings to something resembling a predictable schedule.  If I had to do it over again, I would start sooner.

What this tip means in practice is offering food on the early side of your baby’s hungry range.  Little Boy was typically going 3-4 hours between meals during the day, so we started offering him food every 3 hours.  (Alternately, you could consider the number of feedings your baby typically wants during daylight hours.  If, for example, he usually wants to eat 5-7 times, you would then try to encourage him to eat 7 times every day.  Yes, this might mean waking a sleeping baby during the day.)

4.  Know your S’s.

The 5 S’s, that is.  As explained in Dr. Harvey Karp’s The Happiest Baby on the Block, the 5 S’s are designed to soothe your newborn by mimicking the environment of the womb.  We never used the side / stomach position during sleep because we were afraid of SIDS (and because Little Boy passionately hates being on his stomach), but the other 4 S’s came in handy.

  • We started swaddling Little Boy for sleep when he was about three weeks old.  Like many babies, he initially fought the process of actually being swaddled, but then would relax when he realized how comfortable it was.  Swaddling prevents babies from waking themselves up with their own startle reflex; it also prevented a slightly-older Little Boy from getting so worked up about how interesting his hands were that he couldn’t go back to sleep in the middle of the night.  When his swaddle-escaping skills became too much for the regular Velcro swaddle blanket, we moved to a double swaddle.
  • As adults, my husband and I still sleep with the noise of a loud fan in the background, so it made perfect sense to use white noise (“shush”) for Little Boy.  We initially used a special baby sound machine toy, but now just turn on a regular ol’ fan.  The white noise prevents outside noises from disturbing Little Boy.  Turning it on also acts as a cue that it’s time to go to sleep.
  • Little Boy liked to suck on a pacifier, but he never took to it the way some babies do.  It was helpful for getting him to relax in the early days, although it took a lot of parental effort to keep putting the pacifier back in his mouth every few minutes.  By 3 months old, he was pretty much over pacifiers.
  • The baby swing was a lifesaver.  I feel obliged to mention that the American Academy of Pediatrics recommends against letting your baby sleep in a swing for prolonged periods of time.  Nevertheless, it seemed a lot safer than letting everyone fall asleep together on the couch out of sheer exhaustion.  Little Boy slept almost exclusively in his swing for more than two months.

5.  Watch the wake times.

My sister-in-law raved about Dr. Marc Weissbluth’s book Healthy Sleep Habits, Happy Child, so I read large chunks of it in preparation for Little Boy’s arrival.  The book is honestly a bit tough to get through in places, but one of its key messages is this: a baby who is overtired is a baby who doesn’t sleep well.  And brand-new babies get overtired really quickly.

This article over at Troublesome Tots has an excellent chart of how long your baby can stay awake as a function of age.  In the beginning, your kiddo should go down for another nap just 45-60 minutes after waking from the last one.  (There was a period when Little Boy was about a month old when he literally did nothing but sleep, wake to eat, fall asleep eating, and then sleep until his next feeding.)

Readers, any other tips to add?  What worked (and didn’t work) for getting your newborn to sleep?