An understanding of sleep is needed to achieve control of your child's sleeping pattern. An acceptable sleeping pattern is essential for constructive family life. Good quality sleep is necessary for the baby's growth and development.

I do not believe that it is necessary to tell any young mother reading this that sleep is essential for well being. We all suffer quickly from a lack of sleep. Sleep deprivation affects our mood, our ability to think quickly, to learn skills, to cope with life's little frustrations and still smile. Who is smiling when the kids spill the cereal on the carpet and you've been up four times during the night?

To expand your understanding of sleep, I discuss various elements of sleep. At the end of the chapter are other related issues under separate headings.

SLEEPING

What happens when we are asleep? The answer to this is difficult to define although it is clear from recent research that it is a complex process.

It has been known for many years that sleep has different parts to it. Doctors sometimes divide sleep into levels such as REM or NREM. These letters stand for Rapid Eye Movement or Non Rapid Eye Movement. Another style of defining sleep components is simply 0, 1, 2, 3, or 4. Where 0 is awake, 1 sleepy and 2, 3, or 4 are different types of brain wave pattern while sleeping.

For the purpose of this book, however, I will focus on what I regard as some essential characteristics of sleep. These will be discussed at greater length later but can be summarised as follows.

- A normal block of sleep contains multiple times of being awake.
- Going to sleep is a process which is in part dependent upon the events which occur around us.
- Achieving sleep is usefully regarded as a learned skill.
- Tiredness interferes with the performance of all learned skills including achieving sleep.

We will return to these ideas under various sections of this chapter.

Sometimes it is easier to discuss the purpose of sleep by looking at the effects of not getting enough..

SLEEP DEPRIVATION.

Sleep deprivation is a terrible thing. When the mind does not receive enough sleep its function is decreased. All of us have experienced sleep deprivation to some extent. I find that women with young children have a better understanding of sleep deprivation than men. This is simply because young women with children have more experience with sleep loss. On average, women spend more time attending to children through the night than do their men. This is not said in any critical way, it is simply a statement of common practice. As a consequence though, many women spend quite significant lengths of time feeling very tired while their children are young.

When we do not get enough sleep our bodies continue to function. Our hearts beat and pump blood, our lungs continue to expand and give us oxygen. The bowel still digests and the other organs of the body continue to function. The brain however complains. The brain is in fact totally unenthusiastic about sleep loss. Of course there is a degree of resilience. We can all function well after losing one or two hours sleep. However as the number of hours of sleep loss expands and particularly if we are not able to get a full nights sleep to recover, the consequences of missing sleep increase. We all know about the tired mind. Memory is impaired. Things which we know that we know are more difficult to recall. I well recall a young mother having a difficult time who said to me, 'Doctor, I couldn't remember my own telephone number'. We all know about this as it is almost universally part of human experience to lose sleep at certain times in our lives. Most of us dislike it. (Although teenagers seem to need a phase in their lives where they actively seek out sleep deprivation.) With sleep deprivation mood is impaired. It is difficult to feel positive about the world when we are overtired. Once overtired we tend to see life through glasses which give a negative look to everything. The children's arguing is more difficult to handle. The pile of ironing looks even higher than normal. Frustrations are worse than normal. Problems are more likely to reduce you to tears.

Libido is decreased. Who feels like making love when we are so tired? This part of the brain seems to switch off early and turn back on late. It can be a cause of great worry in a relationship and requires great understanding and sympathy from the male partner. This is discussed at greater length in chapter 15 about sex. I enjoyed the comment from one of my more cheerful patients and a friend who suggested that the advice to men on sex should be repeated as every second chapter to get it through to them.

Moving back to babies for the moment however, I ask you to consider the effects of sleep deprivation on children. Our newborn infants have very little stamina. This 'weakness' applies to all of their abilities. Would we expect a newborn to go without feeding for 12 hours? As adults we do routinely. Would we expect a newborn to walk 50 metres. As adults we do routinely. Would we expect a newborn to eat with a spoon without help? Babies are fragile in many ways. They are less tolerant of many things than are adults. This is normal and expected. It hardly needs stating. But remember babies are less tolerant of sleep loss. Their minds do not have the stamina to cope well with sleep deprivation resulting from a failure to receive enough sleep. Their mood will be irritable and tearful. Their ability to learn new skills and then to perform them will be decreased. This is a very important point which will be discussed again under cues of sleep achievement.

To conclude this section. Sleep deprivation is easily recognised. Its main effect is upon the brain and shows up most clearly as irritability and a decreased ability to perform learned skills.

BLOCKS OF SLEEP.

We don't really think about sleep a lot until we don't get enough. It is a statement of the obvious that we sleep in blocks lasting hours. The average adult will have between six and nine hours sleep per day. This is taken as a single block of sleep. During our sleep the brain does function. In fact sleep is a time when the brain is doing many things but we are largely unconscious of its functioning. Sleep contains periods of physical movement, periods of lying quite still, periods of dreaming and periods of no dreaming. Sleep contains important parts of the process of learning. Recent reports from the Institute of Technology in Arizona and the Weizmann Institute in Israel have shown that new skills are 'replayed' by the brain during sleep. In addition if sleep is disrupted the learning of new skills can be disrupted. Sleep appears to be a time when learning is consolidated.

Babies function differently in many areas. Blocks of sleep are shorter. For the newborn, sleep is interrupted for feeding which will occur at three to four hourly intervals. This is not surprising when we consider that before birth the baby receives continuous nutrition from the placenta. It takes time for children to develop the reserves to cope with longer periods of fasting.

We understand as adults, particularly after parenthood, that broken sleep is not as useful as continuous sleep. For babies as well it is easy to observe that if their blocks of sleep are broken, then there are consequences. If instead of five or six blocks lasting three to four hours a newborn baby gets say 10 sleeps each lasting 1 hour then there are problems. These babies become overtired, are tearful, feed erratically, occupy much of their mothers' time and in particular are difficult to settle to sleep.

One of our fundamental aims as parents needs to be the achievement of blocks of sleep. These blocks need to be of appropriate lengths for both our children and ourselves. The early establishment of good sleep patterns in newborn infants is the road to sanity and happiness. Constant sleep interruptions for our babies and ourselves leads us in a different direction.

WAKING EPISODES

This is a key topic.

Please read this section carefully. If you understand this well it will aid your child tremendously.

Below is a graph of sleep levels. It shows a 'block of sleep'. It is easiest to understand if we consider it for ourselves as adults. So for the present look at the graph and think of it as showing a full night's sleep from say 10 pm to seven am. (Remember the days when that was normal. It will come again soon. Promise.)

At the left end of the graph is shown the change from being awake (0) moving through drowsiness (1) to various levels of sleep ( 2,3,4). Once asleep, our brain does what it wishes or needs. To the best of my knowledge we have no control over the activities of our brain once asleep. At some time during the night the line moves back to wakefulness (0 and 1). This waking is repeated a couple of hours later.

I need to make a few points about these waking episodes.

Firstly, all humans from very early in life have episodes of wakefulness during blocks of sleep. This includes babies.

Secondly, the waking episodes are short lived. Normally we recall the episode of wakefulness the next day as simply a period of becoming comfortable, rolling over, adjusting our pillow or cuddling into our partner. In fact as adults we often forget them until specifically asked. For newborn infants studied in sleep centres there are generally 2 or three per block of sleep each lasting 1 to 2 minutes.

Thirdly, being awake always needs to be followed by a sleep transition. Once awake our minds need to go through a sequence of steps which results in us being asleep again. This is a sleep transition or a sleep achievement. Thus for a baby a normal block of sleep will contain about three sleep transitions. This will include the first sleep transition at the start of the block of sleep.

Fourthly, a waking episode in a block of sleep is in normal situations a period of hazy consciousness. We do not wake completely. It is generally a time of minimal body movement and no language. For our babies, they should be silent. You should be unaware of them waking unless you were at the cot side.

In conclusion. All humans experience waking episodes in blocks of sleep. They are short and should be silent. They are a normal event in normal sleep. Their biological purpose is unknown. If you have any confusion about this concept please read it again. It is important to grasp this well to plan the development of our baby's sleep pattern.

SLEEP ACHIEVEMENT.

In the above section, I pointed out that blocks of sleep contain several sleep transitions or achievements. Blocks of sleep are divided into sections which I call sleep cycles. Each cycle starts and finishes with an episode of waking.

Going to sleep is a more sophisticated thing than you might think. When I ask patients why we go to sleep they generally say because we are tired. While this is true it is only part of the story.

Achieving sleep is something which we can do in one of two ways. Firstly there is normal sleep achievement. We feel tired, it is the correct time of day, we move to our normal place of sleeping, lie down, close our eyes and go to sleep. For a baby this is equivalent to having a good feed, a nappy change and then being placed in their cot or bassinette. The baby is awake, may whimper for a short time and then goes to sleep.

The second method of achieving sleep is the sleep of exhaustion. We are tired, overtired or may feel profoundly tired. It is difficult to stay awake. When sitting we doze off, when horizontal the mind is unable to stay conscious. If awake we know that our mind is having great trouble functioning. For babies this is equivalent to a situation which you may have seen. I will describe it for older children. They, the children, have been busy, active, noisy. They are walking or running around. It is late at night. When encouraged to go to bed they refuse. If put down they complain vigorously. Eventually at 10 or 11 pm or later they crash. The unconscious children are found around the house in strange postures. They are then carried off to bed. For newborn babies this style of sleep occurs upon a background of sleep problems. They have short sleeps. Often they only achieve sleep with parental reassurance. The child may doze in mother's arms or be patted or rocked off to sleep and then awaken tearfully a short time later calling the parents back into service.

There are some major differences between these two methods of sleep achievement. I will ignore the effects of broken sleep here. That is dealt with elsewhere. For this section the important thing is that the two styles of sleep are fundamentally different.

In the first or 'normal' sleep transition there is a sequence of events which must be gone through. There are a number of factors which need to be present which I will discuss under the heading of Cues Of Sleep Achievement. A normal sleep transition is usefully regarded as a skill which we learn. It contains a learned element. It can be likened to gently applying the brakes of a car at the correct time until it comes to a stop.

In the second or the sleep of exhaustion the mind is grinding to a halt. The mind is so fatigued that it is refusing to move any further. It lacks a learned element. It lacks predictability. It can be likened to a car stopping because it has run out of fuel. This will always occur eventually if we don't fill the tank. It may not occur at the most convenient place and it certainly interferes with the appropriate continuation of the journey.

To conclude. Achieving sleep involves a transition from consciousness to unconsciousness. This should occur predictably, at certain times and in certain places. It is useful for success to regard achieving sleep through a sleep transition as a learned process. The sleep of exhaustion lacks the elements of a learned skill and does not reinforce the development of that skill.

CUES OF SLEEP ACHIEVEMENT.

As explained above, blocks of sleep contain times of wakefulness. These are normal. Returning to sleep requires a sleep transition. I argue that these sleep transitions are usefully regarded as learned skills.

I now wish to expand upon the process of learning to go to sleep. I know that this sounds a strange concept. Please bear with me. This is a fundamentally important topic and needs to be well mastered before you can understand and develop your child's ability to sleep. We go to sleep everyday. The process is generally regarded as occurring because we are tired. We all understand that concept. I ask you now to regard achieving sleep as being dependent upon 2 factors.

Firstly, tiredness. Secondly, everything else which is happening around you.

Tiredness does not require explanation. For the audience who have an interest in this book tiredness is a part of most of your days. It is a constant companion whom you would love to leave behind. I hope that I help you succeed. Tiredness is relieved by sleep. This is known and understood by us all.

The really interesting part is the second factor or group of factors. The things which are happening around you at the time of sleep achievement are the cues of sleep.

The cues of sleep achievement for a baby may include the following;

- the time (eg. following a breast feed)
- the place (eg. in the babies usual cot or crib)
- smells (eg. the smells of mother and feeding)
- sounds (eg. the normal sounds of the home)
- internal comfort (eg. a full stomach)
- external comfort (eg. warm clothes, tight wrappings)
- comfort objects (eg. a soft toy or a dummy)
- parental care (eg. holding, patting or rocking).

Any and all of these can be learned as part of the process of sleep achievement. Now this may all seem a little obscure, so let me give some examples. I have to totally convince you of the importance of this concept. If I fail at this point then everything else fails. This is the key to it all working for you, your child and your family.

To convince you of the significance of cues of sleep transitions let's consider ourselves as adults.

Imagine that I am talking to a woman who normally lives in her own home with a stable family. In this example you, the woman, are going to a motel in an interstate hotel. You are alone, the bed is too small, the pillow too thick, the man across the corridor looked a little strange and the building next door is a bus depot. Will you achieve sleep normally? Will you stay asleep normally? The answer is no, and we know from life experience that when we change the cues of sleep achievement so greatly, it is difficult to achieve sleep and stay asleep.

Thankyou to the lovely patient who listened to my story from beginning to end and then said politely 'No, Doctor I can sleep anywhere. I'm an air-hostess'. Luckily she could see my point. She and her baby succeeded very well. Now some of you may well say that the example is too severe. The situation has been changed too greatly from normal. So let's think of a less severe example.

You wake normally at 2 am. It is a normal episode of wakefulness in a block of sleep. It should normally last between 1 and 2 minutes or even less. Tonight your pillow is gone. You reach out for it, half asleep. (You are not allowed to steal your partner's.) It is not in reach. You wake up some more and reach for it again. Still not there. Eventually you would probably be sitting on the edge of your bed with the light on looking for the pillow. You find it, lie down and go quickly to sleep.

The points I am making are two fold.

Firstly, even small objects can be important parts of the process of sleep achievement. The presence or absence of a pillow can reinforce or interfere with the process of going to sleep. A pillow is one important cue of sleep achievement. In the absence of the normal cues of sleep there is an elevated level of consciousness. As we fail in returning to sleep we become even more wakeful.

Secondly the elevated level of awakening is followed by cue seeking behaviour. We do something to regain the cue. In this example we will seek out our pillow before returning to sleep.

Now I have convinced you that cues of sleep achievement exist. My next task is to show that cues of sleep achievement are learned. Again let's use adults as examples, as they are easy to relate to.

Imagine yourself as a single person. You sleep alone. You are used to sleeping in your bed, your room, your house. Then overnight everything changes. You are in a different bed, a new room, a new house and there is another body in the bed. Going to sleep is different. For some days the process of sleep achievement is interfered with (not just by him). After a number of days or perhaps a couple of weeks you adjust to the new cues. You have erased the old cues and learned new ones. A similar thing happens when we move homes. After a few days in the new home we adjust to the different noises during the night and our sleep performance returns to normal. We learn the new cues of sleep.

The process of sleep achievement is in part cue dependent. Cues are learned. They can be changed and re-learned.

What does this all mean? So what is the significance of these arguments?

Let me use the following graph to develop the argument.

In the graph below I have now added the two elements which participate in sleep transition. These two factors are tiredness and cues.

This graph is the same as the previous one in this chapter with one addition. For each of the sleep transitions or waking episodes, I have added a circle. Within this circle there are the two influences leading towards sleep. T for tiredness and C for cues of sleep achievement. Now the important point here is to notice the different contribution of each as the block of sleep proceeds. If we use an example from adult life again. All of us can relate to the analysis that sleep achievement, at the start of the night, say at 10 pm is driven largely by tiredness. As the night proceeds the situation changes as we accumulate sleep and become less tired. Many of us can wake at say five am for a minute and then return to sleep. Obviously by five am our tiredness is largely gone. If need be, we could get up and go about our days work. However, we don't. We go back to sleep. This return to sleep is partly a response to tiredness, but is now largely cue dependent.

Thus as we go further into a block of sleep, sleep transitions becomes more cue dependent. The cues which have been learned to help achieve sleep at the start of the block of sleep will become more significant as the person sleeping moves further into the block of sleep.

Now let me show how this affects our care of children.

Babies rapidly learn cues of sleep in their first weeks of life. Within the first month to six weeks styles of sleep are emerging. Let us divide the cues of sleep for babies into two simple groups. Firstly those involving parental participation. Anything will do. Feeding, holding, walking, patting, rocking. For the really desperate there is driving around the block. They all work. They will all provide an environment within which sleep is achieved. The parental care will be accepted by the child and learned as part of the complex process of going to sleep.

The second group of cues exclude parents. Once there is a full stomach, a clean dry nappy, appropriate wrapping, their cot, their room, normal smells and background noises the child will achieve sleep. If details of the environment are provided consistently they will be 'learned' as the cues of sleep.

Let's try putting this all together.

Our baby is normal. During sleep he or she will have episodes of waking which should last 1-2 minutes. The transition back to sleep is partly dependant on cues from the environment around the child. These cues can be changed and re-learned. As a child moves further into a block of sleep the cues become increasingly important in the return to sleep from a normal arousal. If the cues of sleep achievement include parental participation then it is likely that we, the parents, will be called back later in the block of sleep to participate in another sleep transition.

Isn't it fun to understand why you are up every 90 minutes through the night?

Let's do something about it.

The cues of sleep achievement which are most useful for baby, mother, father and family life are those that are parent independent. A baby goes to sleep with a full tummy, a clean nappy, appropriate wraps, in an appropriate bed and room and alone.

TIREDNESS AND SLEEP ACHIEVEMENT.

An understanding of the role of tiredness in a babies sleep performance is critical to developing good quality sleep skills in your baby. I once asked an eminent paediatric scholar as to the effect of fatigue on sleep achievement in young children. He stated publicly that as they became more tired they were more likely to go to sleep. This answer staggered me. Mothers know that the reverse is true. This point appears to have received little recognition in the medical literature. The following points are simple and useful guides in parenting.

Those children who are sleeping well go off to sleep most easily.
Tired children are difficult to get to sleep.
Very tired children are very difficult to get to sleep.

Now these observations are so universal in young families that I will not defend the above statements. What I will do is try to explain why it is so.

In the previous section I argued that sleep was in part cue dependant and that this element of sleep achievement was learned. Now if going to sleep is a learned skill then it should behave like other learned skills. And it does.

Tiredness interferes with learning new skills. Overtired adults have difficulty recognising the lessons that life is presenting. This is the same for babies. As we become more tired it becomes harder for new skills to be learned.

As children become more tired they have more trouble performing their first learned skill. This is the skill of achieving sleep. The tired child has trouble achieving sleep. The very tired baby has great trouble achieving sleep. The reverse of this situation is also true. The baby who is well rested is better able to perform a learned skill. Thus the baby who is ready for bed but has not yet become overtired achieves sleep efficiently. In addition the more often the baby achieves sleep in a given situation the sooner those cues are learned. Just as we learn our alphabet and our tables by repetition, so repeated exposure to certain cues of sleep achievement helps their being learned.

The better the child sleeps the better they sleep. The worse the child sleeps the worse they sleep.

I do not find many men who have experience of the situation of profound fatigue. Unfortunately a reasonable number of the young mothers who I see do. In this situation the patient is so tired, so desperately tired, that once they get to bed and close their eyes, they can't sleep. Once the eyes are closed the mind is spinning. You know that sleep is essential, you crave for it. You get to bed at last and the brain has trouble reading the code for sleep achievement. Eventually sleep is achieved but after much longer than normal. This is just the same for young babies. Once they are profoundly overtired they have very great trouble achieving sleep.

The key point here is that avoiding overtiredness assists in the performance of sleep skills.

DEPTH OF SLEEP.

Once children have gone to sleep they become less responsive to what is happening in the house. Now just as there was a trap for young players with tired babies being difficult to get to sleep, so the same trap exists once sleep has been achieved.

The baby who is getting enough sleep, sleeps deeply. They sleep through telephones ringing, doors banging, T V, radio, conversations, vacuuming and moving around in their room.

For babies who are not getting enough sleep it is the reverse. As they become more overtired they are more easily awoken. A telephone ringing, a door creaking, your footsteps. Sometimes you could swear to yourself that just the sound of your breathing wakes them. Because they are overtired they wake easily and begin to cry at once.

It is not fair for the world to do this. Where is justice? Where is common sense? Logic suggests that the overtired baby should sleep deeply but unfortunately the reverse is the case.

Once you understand the above concept then the method of solving the problem becomes obvious. If the child is restless because of fatigue then everything else has to be put into second place to increase the hours of sleep which the child achieves. Once the baby has caught up on its sleep, it will achieve a more sound sleep.

The child who is getting adequate sleep is very easy to define. These children are calm, they go to sleep efficiently on their own, they sleep through all normal domestic noises. They return to sleep from their normal waking episodes without your help and almost always without you knowing they have been awake.

The tired baby is also easy to pick. It takes a long time for them to achieve sleep. They waken easily to normal domestic noises. They waken for their normal waking periods within a block of sleep and are unable to achieve sleep alone, so they cry.

The moral of the story is to make sure that the baby is getting adequate sleep to perform the learned skill of sleep achievement. In the next chapter on sleep I describe sleep training and give guidelines on the amount of sleep that children usually need.

REWARDING BEHAVIOUR.

This is slightly complex section but it is important to understand. As soon as you understand it you will realise why it is important.

As the mother of the child it is important to understand your status. You the mother are wonderful. You are the most wonderful person in the world. Your smell, your touch, your milk, the sound of your voice, your warmth. To a baby these things, each and every one are attractive, pleasant and reassuring. As a mother, and also as a father, it is a joy to feel our child's security in our arms. This is how life is. These contacts provide some of life's great pleasures and contentments.

Contact with mother or father is a reward. Now there is a time and a place for rewards. 12 midnight, 2 am, 4 am and 5 am are not the times for these rewards. These are times when as soon as possible after our child's birth we want and need to be asleep.

From the baby's point of view any behaviour pattern which is rewarded by parental contact is worth the effort. So if crying or kicking does the trick, so be it

The first point that I am making is that any contact with you is a reward even if it does not include a feed. It is to your advantage not to reward behaviour that you do not want to see reproduced. If you are happy that the baby is well fed, clean and dry, in good health and is not in an uncomfortable or dangerous position in the bed, then leave them alone. If you know that the baby is only one hour into a three hour sleep and they start to cry a little do not attend. Your attending is a reward to crying and will slowly increase the frequency with which that behaviour is exhibited. This is not being unloving but the reverse. Do you love your baby enough to allow him or her to learn the skill of sleep achievement alone?

Now the final point is a little more difficult to grasp but is easily proven by scientists. If you reward behaviour occasionally eg one time in three, this is a stronger reward than if you reward the behaviour every time. Thus if a reward is given occasionally there is an increased chance of the behaviour pattern being repeated more often and for a longer period of time once the reward is finally withdrawn.

What does this mean?

If you have decided that your child needs to learn a sensible sleep pattern and you have stopped attending to crying between feeds, then stick to it. If you find that one time in three or four or five that you attend and give the child comfort then the lesson that is learned by the child is 'If I cry often enough and long enough the reward will come.' The sooner the pattern of rewards are consistent, the sooner the desired sleep pattern will emerge.

Cuddles, feeding, laughing, touching, loving are wonderful. Enjoy them to the full. But they are for wake times. Sleep times are for sleep and only sleep. Love your baby enough to help them learn the skills of sleep. Babies need much more sleep than adults. They need it in blocks of at least three to four hours. By 12 weeks of age many babies can sleep ten or more hours at night in a solid block. If you have not quite achieved these lengths please do not feel inadequate. These times are given as a guide and not as absolutes. Use them as a target to aim for at your baby and your circumstances allow.

I hope that once you have mastered the ideas raised in this chapter it will give you confidence. Understanding why you are helping your baby to learn the skills of sleep will greatly increase your chances of success.