"Hi, I'm Dr. Dennis Rosen. How can I help you today?"
"My 8 month old is only sleeping 6 hours a day, and it's killing me. I haven't had a good night's sleep since we came home from the hospital. This can't be normal!"
This is how my first meeting with the mother of my first patient on a wintry Thursday afternoon began a few months ago. " Anne", the proud but utterly exhausted mother of "Jacob", was at her wit's end. While absolutely adoring her son, who was sitting in her lap, babbling and smiling when he wasn't busy sucking on his fingers, alert and happy as a clam, she had come to the end of her rope. Not having slept properly for 8 months will do that to you.
When I asked her to describe her child's sleeping patterns, she told me that she was trying to put him to sleep at 7 PM, but found that it was taking between 1-3 hours for him to fall asleep. He would often appear to doze off in her arms, only to awaken immediately the moment she would try to put him down in his crib. Once asleep, he would stay asleep for 2-3 hours, wake up, cry, take between 5-60 minutes to fall asleep again (even longer if his mother didn't pick him up immediately), and repeat this 2-3 times over the course of the night. He would finally settle down again around 5 AM, and stay asleep until 8 AM, at which point he was up for the day.
"What about naps?" I asked, and was told that she would put him down for his first nap at 9:30 AM, because "he looks tired, and is rubbing his eyes". He would usually nap for 30 minutes, take a second nap between 12-1 PM, this time for about an hour, and a third nap at around 4 PM, usually for 20-30 minutes.
"What do you do to get him to fall asleep", I asked. The answer, it turned out, was complicated. Jacob was only able to fall asleep in his mother's arms while being stroked softly as she rocked gently back and forth in the glider. If she tried to put him in bed awake, he would scream and cry, sometimes so much that he would vomit.
Unfortunately, this is not an unusual story. In listening to Anne, it sounded like a number of things were going on. First of all, he was almost certainly getting more than 6 hours of sleep, though it seemed like that to her because of Jacob's frequent and prolonged awakenings. Second, I felt that he was being given too many opportunities to sleep over the course of the day. A child Jacob's age needs about 12 ½ hours of sleep/24 hour day, usually divided into a 9 ½ hour night and two 1 ½ hour naps. As faithful readers of this blog know, the 24 hour day is like a pie, with the amount dedicated to sleep being a specific portion of it, the duration and number of pieces being age dependent. If one slice of the pie is bigger, the others are necessarily smaller. Being given a 13 hour window to sleep at night, in addition to 2 more hours of naptime, was simply too much for Jacob. This not only made it very difficult to get him to fall asleep in the evening at the designated time, but also made him much more likely to awaken as he cycled between deep and light sleep over the course of the night.
The third issue was the sleep association disorder. Jacob had learned to associate falling asleep with being stroked while held in his mother's arms, and for him, this was the only way he could fall asleep. This meant that when he stirred during the night, what would otherwise have been brief awakenings from which he soothed himself back to sleep turned into drawn out affairs requiring his mother's physical contact to coax him back to sleep.
After a long conversation with Anne, we agreed that she would put him on a regular schedule, giving him a 9 ½ hour night and two 1 ½ hour naps. We discussed techniques of teaching Jacob to self soothe, and agreed upon the Ferber method, in this case putting Jacob into bed drowsy yet still awake, and letting him fall asleep on his own, with Anne checking in every few minutes to reassure him that she had not abandoned him, but without picking him up or stroking him. I also asked her to keep track of his sleep with sleep charts, and to bring those to the next appointment, 4 weeks later.
I am happy to report that the next month, when I saw them, while Jacob was still his very cute self (sporting more hair, some new teeth and an even wider smile), his mother looked transformed. The dark circles under her eyes had disappeared, and she looked... rested. These interventions, while very simple, had improved her quality of life immensely, and given her more energy to devote to herself, her husband, and their beautiful boy.
