This chapter has been written to present the most important elements of this book in a way that is logical and compact. The six points made in the following pages reflect the tutoring which I give in my surgery. Those six points are :

1. Blocks of sleep contain multiple sleep cycles.

2. Sleep achievement is in part, cue dependent.

3. Cues of sleep are learned, can be changed and relearned.

4. Sleep achievement is usefully regarded as a learned skill.

5. Fatigue interferes with sleep achievement.

6. Parent independent cues of sleep are the most useful for family life.

(1) Blocks of sleep contain multiple sleep cycles.

Humans, like almost all other higher creatures, require sleep. We find that sleep is most effective when it is achieved in blocks lasting a number of hours. Most adults, for example, feel refreshed by achieving between eight and ten hours of sleep in a single block, overnight.

In recent years the development of technology has allowed us to study sleep in sleep laboratories. One of the interesting findings is that sleep occurs at different levels during a block of sleep. In particular, all people, from birth and through their whole life, experience awakenings during a block of sleep. The purpose of these shallow awakenings is not known. A block of sleep is thus divided into multiple sleep cycles. A sleep cycle is one circuit starting with wakefulness followed by a period of sleep and concluding in a waking episode. The length of these sleep cycles varies with age. For a young baby they may be as short as 40 to 50 minutes. In adults sleep cycles are approximately 90 minutes long.

Most of us will therefore have between five and six awakenings in an eight hour sleep. Fortunately we have little or no recall of these awakenings the next day. Despite this 'forgetability' these awakenings contain an element of awareness. It is in these episodes that we would recognise that a pillow has fallen off the bed, for example.

The importance of these awakenings or arousals with regard to infant sleep is that they conclude in a return to sleep. Thus a block of sleep contains not only multiple arousals but multiple episodes of sleep achievement. The length of a single block of sleep can vary from approximately three hours soon after birth to as long as 12 hours after some months. The individual sleep cycles within that block of sleep only change slowly over a period of years. Sleep cycles in the first few months of life last about 40-60 minutes. These cycles conclude with a shallow awakening which should be silent and last 30 to 60 seconds. The awakening will then be followed by a return to sleep. Of course if the block of sleep is now complete the arousal will lead to full awakening. For the arousals within a block of sleep the person in question will return to sleep silently and rapidly.

Thus to summarise this section;

- A block of sleep contains multiple sleep cycles
- Sleep cycles conclude in an awakening and then usually a silent return to sleep
- A block of sleep contains multiple episodes of sleep achievement.

(2) Sleep achievement is in part, 'cue' dependent.

Having made the point that a block of sleep contains multiple episodes of achieving sleep, then what helps this to occur? Going to sleep is in fact a complex event which sleep researchers continue to study. For the purpose of understanding and controlling infant sleep I suggest two causes as allowing the change from consciousness to unconsciousness which is represented by sleep achievement. I do not pretend that this explanation even attempts to reflect the complex biochemistry which is occurring at the time of sleep achievement. Despite this, my simple analysis is useful enough that we can all relate to it. Perhaps more importantly the analysis presented here leads to advice which works for most families.

What makes us go to sleep?

In my consulting room there is normally a very tired pair of parents sitting with me. They rarely have any trouble volunteering that tiredness causes sleep to occur. For many of the parents whom I see the tiredness has changed to exhaustion.

On a personal note I well recall when my children were very young, my wife appeared to be deeply asleep before her head hit the pillow. None of us have any trouble agreeing with the following statement. Tiredness leads to sleep. Unfortunately this simplicity is incomplete and as you will see in point 5 below, it is somewhat misleading when discussing infant sleep. However, for the moment, let us accept the statement because it is still largely true.

Despite the presence of tiredness other things are required for sleep achievement to occur smoothly and efficiently.

As an example imagine the following scenario:

You are very tired, the children are asleep, the house is quiet, all the important work is complete, and you are ready for bed and sleep. However instead of lying down in your normal bed, in your own bedroom, for my own reasons I ask you to lie on a portable bed, in a sleeping bag, on your own in the car port. Your tiredness is still complete, you are just as badly in need of sleep, but because the setting for your sleep achievement is so different, the ability to achieve sleep is decreased. I call these environmental factors the cues of sleep achievement. For normal sleep the ability to go to sleep is dependent upon a combination of tiredness and appropriate cues of sleep. The common cues are being in the right bed with normal sounds, smells, warmth, blankets, pillow, the correct company, and at the appropriate time of the day. The more we disrupt the cues of sleep the more difficult it becomes to achieve sleep.

SLEEP ACHIEVEMENT = TIREDNESS + CUES.

(3) Cues of sleep are learned, they can be changed and relearned.

I have made the point that a block of sleep contains multiple sleep cycles and therefore multiple sleep achievement episodes. The achievement of sleep is brought about by the sum of correct levels of tiredness and appropriate cues of sleep.

Cues of sleep achievement reflect your surroundings. Each of us has a subconscious list of cues which we recognise. These cues are learned and completely changeable. The example which I normally give to the families which I see relates to ourselves as adults. As single adults we have certain sleep skills. We achieve sleep and maintain sleep in, for example, our parents' home. We take these sleep skills for granted. At some stage we form a relationship and begin sleeping with a partner at a different home. Overnight all the cues have changed. A new bed, a new bedroom, a different house or flat, and two bodies in the bed. Most of us accept that our sleep skills are temporarily disrupted. It takes a little longer to achieve sleep, we are more conscious of arousals overnight, are aware of our partner turning over or snoring through the night. Thankfully the disruption to our sleep is short lived. Within a week or two the subconscious reprograms itself and our sleep skills return towards normal.

I talk about a 'computer program' which we store in our brain which has a title 'This is how I go to sleep.'. When we need to achieve sleep, we pull this program out from its file and use it as a reference point to assist us. When the lines in this computer program are changed, ie. when the cues of sleep are changed, our efficiency at achieving and maintaining sleep is decreased. Then over a period of days or a couple of weeks we rewrite the program. Old cues are erased and new cues are written in. As this new program takes shape our sleep skills come back towards normal. We do this so well that soon we need the new cues. For the majority of women that I see, their partners or partners were disruptors to sleep at first, but now if he is away for the night they do not sleep as well. So in adult life we change cues of sleep, suffer some sleep disruption, and then relearn new cues which allows our sleep efficiency to return towards normal. Another example which most of us can relate to is the temporary sleep disruption of changing house or flat. In the new environment we rapidly rewrite our sleep program and our sleep efficiency returns to normal.

In conclusion : Cues of sleep are learned, can be changed and relearned.

(4) Sleep achievement is usefully regarded as a learned skill.

This point is one of the keys in my method of caring for infant sleep. This way of analysing sleep achievement suggests that it is in part cue dependent. Cues of sleep are learned. By combining these two points we arrive at the above statement. Now I can not prove one way or another if sleep achievement is a learned skill. What is important is that if we accept this analysis of sleep then the advice which it leads to works. The advice also reflects what we see with infant sleep and, to an extent, adult sleep. So for the moment let's choose to look at sleep achievement as being one of our many learned skills.

(5) Fatigue interferes with sleep achievement.

It is difficult to overstate the importance of this point. This is a tripping up point for many young parents. It is a trap for the innocent and the well intentioned. This is where the majority of infant sleep problems have their origins.

The first problem is that on first glance this proposal seems wrong. 'Fatigue interferes with sleep achievement'? Haven't we already agreed that sleep achievement is the result of a combination of tiredness plus cues? Now I am saying that tiredness interferes with sleep achievement? Have faith, it all comes together soon.

Let us return to point 4. Sleep achievement is a learned skill. Now if this is correct then sleep achievement should behave like other learned skills. Our school tables, telephone numbers, our alphabet, appointments and what we have come to the supermarket to buy are all things we would more usually associate with memory and learned skills. So let's think for a few moments about these learned skills and the effect of tiredness. It is really not in the least controversial to suggest that tiredness interferes with the performance of learned skills. Almost universally the parents I see and in particular the mothers of sleepless infants are suffering from sleep deprivation of varying degrees. Almost all of these women agree that their memory is atrocious. They are having trouble remembering telephone numbers, shopping has become a bit random where afterwards several things are forgotten and they are having to write notes to themselves to avoid forgetting important events.

Our life experience teaches us quite clearly that fatigue interferes with the performance of learned skill.

Now I have stated above that sleep achievement is a learned skill. Therefore, if this is true then fatigue should interfere with sleep achievement. Once again, this point is one we can recognise and accept from our life experience. As mentioned several times already, parents of young children are often very tired. The mothers in particular have gone past tired, have become overtired, and then exhausted. Body and soul are crying out for sleep. Now the following scene emerges. The children are asleep, at last, the house is quiet, you badly need to sleep, you get to bed, lie down, close your eyes, and what do you find? The mind is spinning, your emotions are annoyed, on edge, and sleep is slow to arrive. You have become so tired that it is hard to get to sleep. Sleep is eventually achieved but it is slower than normal to come. During this time the mind is not relaxed and peaceful. Becoming overtired can interfere with efficient sleep achievement. Returning to the example of the computer program called 'This is how I go to sleep', you can become so tired that it becomes difficult to retrieve that program from its file. Just imagine your tired mind at two am after a busy day asking itself 'Now where did I put that note about sleep? Just can't find the darn thing at the present.'

The relevance of this to infant care is as follows. We as adults can become overtired to the point that sleep achievement is difficult. Infants have much less stamina than adults, and are more prone to overtiredness. They will achieve the overtired state rapidly. For the newborn this can occur within one day or even less. The older infant and later the toddler are more resistant but will eventually achieve overtiredness if they miss enough sleep.

Most parents have little trouble recognising a scene where their children have missed a sleep, and are then late for bed. An afternoon birthday party is a great example. The children have been playing vigorously, much food has been eaten, they have begun to be silly and the tears begin to flow. You know that they are tired, and then overtired, so you suggest bed. Do they go off to sleep easily? No! As their tiredness increases, their ability to go to sleep decreases. Mum and Dad then pay the price for their children's lack of sleep. Fatigue can interfere with sleep achievement.

Before concluding this section on fatigue interfering with sleep achievement I will point out something more about sleep. In terms of sleep for infants I look at three individual components of sleep.

a) Sleep achievement. The ability to change from the conscious to the sleep state.

b) Sleep maintenance. The ability to return to sleep from a normal arousal within a block of sleep.

c) Sleep depth. The ability to remain asleep despite background noise.

Being overtired will interfere with all three of these elements. Thus if your baby takes a long time to achieve sleep, is tearful every 45 to 60 minutes at the end of each sleep cycle or is easily woken by creaking doors or floorboards then overtiredness is often the cause.

(6) Parent independent cues of sleep are the most useful for family life.

This final point brings all the previous elements together into a logical whole. Let's revisit the cues of sleep as mentioned above in point 2. Children do respond to cues from an early age. By six weeks of age the hormonal cycles of the body are responding to day and night. The child has begun to return a smile and as parents we can feel the first flickering of a personality emerging.

For my purpose I divide cues of sleep for infants into only two broad groups.

a) Parent dependent.
b) Parent independent.

Parent dependent cues contain an element of protracted parental care. Common examples include patting, rocking, holding till asleep, breast feeding till asleep, pushing the pram around the house, or driving the baby around in the car. From the child's perspective these are powerful and effective cues. Children are deeply connected to their parents by emotions. Mum and Dad's attention and love are the most significant reward structures for a young child. Parental contact is more important than food and certainly more important than sleep.

These parent dependent cues are thus rapidly written into the sleep program. The process of sleep achievement is then triggered in part by parental activity. Parental attention works. We now have a problem.

A block of sleep contains multiple sleep cycles. Sleep cycles conclude in an episode of waking. The return to sleep is driven by a combination of tiredness and cues. As the block of sleep continues during the night tiredness decreases as the 'batteries recharge'. As the tiredness decreases the return to sleep from a normal, healthy arousal is increasingly cue dependent.

If a child is recognising parent dependent cues then as the block of sleep proceeds it becomes increasingly likely that the parents will be politely requested to return to provide the care which triggers sleep.

This sequence works. How many of you find that you have only to get out of bed each hour or two to pop in the dummy or pat for a few minutes to get the infant back to sleep.

Unfortunately this then fragments a block of sleep for several members of the family. It does not need me to point out that one eight hour sleep has a different effect on your sense of well being than eight one hour sleeps.

Parent dependent cues of sleep thus lead to disrupted blocks of sleep.

Parent independent cues of sleep also exist. I generally talk about these cues being a full stomach, a clean dry nappy, the baby's pyjamas, their blankets, their basinet or cot, and their room. Say goodnight.

The child will incorporate these cues into a sleep program to develop what I call independent sleep skills.

Thus during a block of sleep the child can have hourly arousals, do a cue check, find that all is normal, and then return to sleep. This process will occur silently or nearly silently. Mum and dad can then continue with their important task of being asleep and recharging their own batteries. Given a full nights sleep the parents feel refreshed and have more energy and affection to give. The children are thus able to receive more affection and time from a happier, stronger more confident parent.

Parent independent cues are thus more useful for family life.

To complete this chapter I will simply list the six points which work together to suggest a philosophy of care which works to the advantage of many families.

1. Blocks of sleep contain multiple sleep cycles.

2. Sleep achievement is in part, cue dependent.

3. Cues of sleep are learned, can be changed and relearned.

4. Sleep achievement is usefully regarded as a learned skill.

5. Fatigue interferes with sleep achievement.

6. Parent independent cues of sleep are the most useful for family life.