Safe Sleep and Baby Care

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Sleep Training Methods and Advice

The purpose of sleep training
Generally, the purpose of sleep training is to teach a young child (baby or toddler) how to go to bed and
fall asleep with progressively less caregiver intervention. These interventions could be nursing to sleep,
rocking to sleep, having a pacifier etc., and vary by family and situation. If the intervention is something
that is working for your child and family at this point, there isn’t necessarily a need to change it. The
exception to this is if you are trying to break an unsafe sleep association such as bedsharing, sleeping in
a positioner, sleeping on an incline, or a soft surface such as a snuggle pod or dock a tot.

Before you begin

• Sleep training and night weaning are not synonymous.
o It is important to make sure your child’s doctor has no concerns about reduced night
feedings and your child’s growth if reduced night feedings are part of your sleep training
plan.
o Sleep training techniques can be used to teach greater independence at onset of sleep
at the beginning of the night even if your intention is to still offer feeds during the night
• Whether you start with nighttime or naptime or both is largely preference and depends what
sort of sleep issues you are dealing with
o Most babies seem capable of learning two routines: a nap routine and a nighttime
routine
o Very sleep deprived families may choose to do both nights and naps at the same time in
order to get better rest as soon as possible
o Sometime choosing one or the other is done because one is a problem but the other
isn’t (great night sleep, difficult naptimes) or because the process is likely to put stress
on caregivers and they don’t want to make too many changes at once
• Around three months of age, putting the baby in their safe sleep space drowsy but awake gives
them opportunities to try out and build on self-soothing skills. Try this every so often and see
how your baby responds.
• This document uses the terminology “parents” and “caregivers” but can apply to any caregiver
of a baby or young child. For brevity please consider “parents” to refer to the primary caretakers
of the child.
• Almost all methods result in some crying. Where the methods differ is whether caretakers are
with the infant while they are crying or not. Methods like graduated extinction and extinction
result in less crying overall compared to methods like fading or pick up put down. Some parents
feel that leaving a baby to cry alone is not tolerable for them and choose a method that takes
longer. There will be crying, and more minutes of crying with methods that call for more
parental involvement but the baby will have a caretaker with them during most of this crying. All
methods will improve sleep. Choose a method you can be consistent with.
• Please know that sleep disturbances are common after disruptions in routine such as travel,
illness, moves, etc. You may need to repeat the sleep training multiple times until your child is
an independent school-aged sleeper. When you repeat the training, the process is usually faster.
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Which method is right for my baby?
Newborns to 4 months 4 to 6 month olds 6-18 months Toddlers/ Preschoolers
Appropriate Bed and Nap times
A solid bedtime routine
Sleep hygiene
Delayed response
Shush pat
Soothing ladder
Graduated extinction
Pick up / Put down
Fading
Extinction

Consequences of sleep training

When are children are first little, we worry about responding to their every need and that’s appropriate.
As they get older, we must, as caregivers, both foster independence and set boundaries. If you view
your crying baby as frightened, then the crying around sleep training will be excessively burdensome to
you. Crying is the baby’s way of protesting the change you are making. In the same way they may cry as
a toddler if you don’t give them another cookie, they may cry when you try to set boundaries around
naps and nighttime sleep.

There is evidence that sleep problems that are left alone in infants and young children can carry on into
the school years, become chronic, and can affect functioning of both the child and the family. Behavioral
interventions are effective for around 80% of children and the effects endure for at least 3-6 months
(Mindell et al. Sleep 2006; 29(10): 1263-1276).

What can I do to look after myself during sleep training?

• Get support from your partner, parents, siblings, friends etc.

• If using a let-cry method like Graduated Extinction/ Ferber or Extinction turn off the baby
monitor and go into another area of the house, use noise cancelling headphones or take a
shower etc. until its time for a check
• When trying to teach independent sleep using any method, you may need to spend more time
and energy responding to night wake ups than you did before you started. This is especially true
with methods like fading, pick up/ put down. You should pick a time to start when you will have
more energy for this task. For example, if you work, pick your days off. Also put some thought
into alternative strategies to improve your rest during this time. Nighttime help from your
coparent if you have one, daytime help for naps, letting other projects and activities take a
backseat etc.

How do I know that the method I picked is working? When should I see results?

It’s a good idea to keep a log of your sleep interventions and their effect on your child. For example, if
you are starting graduated extinction/ Ferber recording the number of checks required, the length of
the process before sleep each night or total crying time can give you quantitative indicators that the
process is working. If you are being inconsistent in your application of chosen method the log can also
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provide evidence for that. The number one reason sleep training does not work is inconsistency on the
part of parents/ caregivers.

For methods like extinction or graduated extinction, an improvement is typically seen in the first 3-7
nights. For methods that rely more on parental intervention the process seems to take 2-3 weeks (pick
up/ put down, chair method). For techniques like the bedtime routine, sleep hygiene, and providing age
appropriate nap and bedtimes the process is longitudinal. You will likely see some improvement in the
first week after starting these but they may need to be adjusted as your child ages.

Will sleep training harm my baby or our relationship?

Studies of behavioral interventions for sleep disturbances have never shown an adverse effect on
infants. Instead, when infants are sleeping better they are “found to be more secure, predictable, less
irritable, and to cry and fuss less following treatment.” (Mindell et al. Sleep 2006; 29(10): 1263-1276)
Parental mood improves and reported stress levels related to parenting and marriage are reduced.

Explanation of methods
Appropriate Bed and Nap Times
It’s much easier to teach a baby or toddler to sleep when they are being put to bed when they are tired.
Sometimes parents and caregivers keep a child up too late to enjoy spending time with them in the
evenings. Early bedtimes are biologically appropriate for young children. Sometimes night waking or
bedtime difficulties can be a sign your child is ready to drop a nap.

For infants and young toddlers appropriate bedtime will happen in relation to dim light melatonin onset
and should be between 6 and 8 PM.

Last nap of the day should finish before 5 PM to avoid the forbidden zone of sleep, time when body has
already started to prepare for night sleep. A nap in the forbidden zone sends the body false signal that
night sleep is already happening, which is why baby will wake up from their catnap extra vigorous and will
end up overtired.
First nap of the day should be happening after a period of morning activity that clearly separates night
sleep from day naps. If possible, this is the time when you should take your baby outside too.
Observing the baby’s sleep needs instead of following wake and nap schedule charts is the best way to
ensure that your baby is getting healthy amount of sleep.

“Many naps per day help avoid the over-tired state and allows your child to
sleep better,” dr. Weissbluth says. “The normal development of circadian nap
rhythms is that you see a morning nap around 9 a.m., then a mid-day nap
anywhere from 12-2 p.m. (for children under nine-months), followed by a third
late-day nap that disappears after nine months of age.”
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A Solid Bed-time Routine

A bedtime routine is a series of steps in a predictable order that signal its time for bed. Some of these
are required for health (tooth brushing) but the rest are parental/ caregiver preference. Pick things you
enjoy doing and don’t make it too elaborate because you will be doing the routine every day for….a long
time. Its reasonable to have a shorter, less elaborate, nap routine and a longer bedtime routine.

Examples:

• bath, lotion, pajamas, tooth brushing, book, lullaby, bed

• Bath, pajamas, bottle/ breastfeed, tooth brushing, lullaby, bed
• Pajamas, tooth brushing, book, bed
• Pajamas, tooth brushing, lullaby, say good night to every item in the room, bed

You get the idea.

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Young children really thrive with predictability and routine. Your routine should not require any props
that are confined to your residence. That way your routine can be the same when you are travelling or if
your child spends the night with another family member (for example when their sibling is being born).

Sleep Hygiene
Sleep hygiene refers to actions taken during the day that can make it easier or harder to fall asleep. For
adults some examples of good sleep hygiene are: getting up at the same time everyday, no caffeine
after noon, limiting screen time and turning off or muting devices such as smart phones a few hours
before bed, limiting alcohol use before bed, using the bedroom only for sleep and intimacy.

For babies and young children having a predictable routine for morning wake up, naps and bedtime is an
important component of sleep hygiene. If you choose to use screen time with your toddler or
preschooler, limiting in it in the hours just before bed can be helpful. Another component of sleep
hygiene is providing a dark quiet space for sleep that is a comfortable temperature.

Very young babies have not yet developed circadian rhythms, but you can help them, and any child
struggling with sleep, by exposing them to bright natural light in the morning, and keeping the lights
dimmer during the evening/ at night. Very young babies generally can sleep almost anywhere and
through anything in their unpredictable way of having multiple naps. This is a window of freedom and
portability where you can enjoy more social time with adults. By the time they are 2-3 months old, most
babies seem to do better if their naps and night sleep predictably occur in a dark quiet room.

Delayed Response
This is NOT extinction or let-cry. Delayed response refers to waiting a few moments when your baby
stirs or fusses in their sleep space. Very young babies exhibit active sleep and may even cry out in their
sleep. Using delayed response, a caregiver will not pick up the baby at the first peep as this can lead to a
waking problem, but will instead observe the baby over the next few moments. Sometimes the baby will
fall back asleep. Sometimes they will start to cry, at which point pick them up and attend to their needs.

Delayed response can start at birth. Delayed response works for older children as well.

The Soothing Ladder

This is a method of starting with the least intervention possible and escalating until the baby falls asleep.
It works well in the middle of the night for young babies. Start at the bottom of the ladder and spend
around 30 seconds on each rung before moving up. For a baby under 4 months the ladder looks like this:

7. Feeding them
6. Picking up to gently rock until soothed but still awake
5. Jiggling baby in the bed
4. Your touch, patting on the back, rubbing head or tummy, hand over top of
the head, and so forth
3. Replacing the pacifier
2. The sound of your voice, talking, singing, shushing
1. Your presence in the room

You can devise other ladders for older children.

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Shush Pat
The shush pat is said to be a way to help babies learn to fall asleep independently. Instead of rocking or
feeding your baby to a deep sleep and then putting them down, you put them in their safe space and
gently pat them while making long shuuuuuusssshhhhh sounds like waves at the beach. You do this until
they fall asleep. This method works best with very young babies as older babies may find this distracting.

Pick up/ Put Down

In this method you place your soothed and drowsy but awake baby in their crib or play yard. At this
point you can remain in the room or leave depending on your preference. If the baby begins to cry you
wait for a few moments to determine if they are fussing or need intervention. If they cry you go to them
and pick them up to soothe them until they are quiet at which point you put them back down. You
repeat this process until they fall asleep.

The pick up put down method works the best between 4-8 months. It is labor intensive and it can take a
long time for the baby to fall asleep or for you to see results. It is a good method for parents who feel
conflicted about letting their baby cry. Some babies do not do well with this method and seem to find
parental presence distracting.

Fading/ Gradual withdrawal/ Chair Method/ Sleep lady shuffle

These methods refer to gradually reducing the time spend on a prop that was helping your baby fall
asleep. Such props could include rocking, nursing. The idea is to do the activity a little less every night
until you aren’t doing it at all.

The chair method/ sleep lady shuffle is a fading method for parental presence at bedtime. Using this
method you place a chair next to the crib or play yard, soothe your baby until drowsy but awake and put
them down. You sit in the chair until they are asleep. Every night you move the chair closer to the door
until you are out of the room. This process is supposed to take 1-2 weeks. One downside is that since
they are present for the crying, it can be difficult for parents to remain consistent.

Scheduled Awakenings
This method helps to consolidate nighttime sleep for a young child that has typical night wakings. A
parent will wake the child from sleep 15-20 minutes before their habitual night waking time and then
soothe them back to sleep using whatever method the child is used to, such as rocking or nursing. Then
by increasing the time between scheduled wakings, these can be faded out.

Check and Console/ Feber/ Graduated Extinction/ progressive waiting/ interval method
In this method, you place your soothed baby in their crib and leave. If they begin to cry you start the
clock. You re-enter the room to reassure them verbally and possibly with a pat for a minute or so and
then leave again. You do not pick the baby up and you keep your intervention small so that you don’t
reinforce attention-seeking behavior. You can use set intervals or increase the amount of time before
you respond again with each interval as suggested by Dr. Ferber. Using his method, when the intervals
get to 15-30 minutes, you hold the interval steady and continue to check on the baby if they are crying
until they fall asleep while you are out of the room. If they stop crying, restart the clock for that interval.
For night wakings, you repeat this process starting at the first interval for that night.

There is nothing magical or scientific about the intervals that Ferber proposed. You could create your
own schedule, just keep it consistent.
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Some babies seem to get more upset with checks than with extinction. It seems the older the baby is the
more likely checks will make them more upset but this is anecdotal.

Extinction
In the classic extinction method, a soothed and drowsy baby or child is put to bed after the routine, the
parent leaves the room and closes the door. The child is left until the morning.

In practice, extinction can be modified. Many 7 month olds continue to have a feeding in the middle of
the night. Extinction could be used for sleep onset but the infant responded to at the time of their
nighttime feed, for example. Some parents will decide on a stop for crying at the beginning of the night.
So for example, they will respond after 20 minutes of crying, re-soothe, and then place the infant in bed
and leave. This isn’t really extinction or graduated extinction but is effective after self-soothing habits
and skills are in place.

You should respond to your child if you have suspicion that you child is hurt, ill or in danger.

Methods for Older Children (3+)

What can you do if you are struggling with an older child that won’t settle down and go to bed at the
beginning of the night or one that struggles with night waking? Nightmares? The advice above for sleep
hygiene and picking an appropriate bedtime applies.

Here is some advice about sleep hygiene for school-aged children:

(https://www.healthyfamiliesbc.ca/home/articles/good-sleep-
habits-10-tips-children)
Establish routines
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1. Keep regular sleep and wake times
Help your child go to bed and get up around the same time every day. Keep wake-up times on school
days and weekends to within two hours of each other. This can help get your child’s body clock get into a
regular rhythm. In the mornings, he should get out of bed when he wakes up, rather than trying to go
back to sleep.
2. Avoid daytime naps for older kids
If your child is five years or older, avoid daytime naps. Daytime naps longer than 20 minutes can make it
harder for children over five to get to sleep at night, to get into deep sleep, and to wake up in the
morning.
3. Relax before bed
A regular bedtime routine of bath, teeth brushing, story and bed help younger children relax and feel
ready for sleep. Older children might like to wind down by reading a book or listening to gentle music.
Turning off electronics an hour before bed will also help your child relax and fall asleep.
4. Wind down at night
If your child has a busy morning routine, encourage her to use some wind-down time at night to
complete morning tasks, such as getting clothes ready for the next day, making lunch, or getting her
school bag ready.
Check your child’s sleep environment
5. Make sure your child feels safe at night
If your child feels scared about going to bed or being in the dark, you can praise and reward him
whenever he’s brave. Avoiding scary TV shows, movies, computer games or books can help too. Some
children with bedtime fears feel better when they have a night light.
6. Check noise and light in your child’s bedroom
A dark, quiet, private space is important for good sleep. You can check whether your child’s bedroom is
too light or noisy. It’ll probably help to turn off electronic stimulation in your child’s bedroom at least
one hour before bedtime. This includes loud music, mobile phones, computer screens and TV.
Encourage good health and nutrition
7. Eat the right amount at the right time
Make sure your child has a satisfying evening meal at a reasonable time. Feeling hungry or too full
before bed can make the body more alert or uncomfortable. This can make it harder to fall asleep and
have good quality sleep.
8. Get plenty of natural light in the day
Encourage your child to get as much natural light as possible during the day, especially in the morning.
This will help her body produce melatonin at the right times in her sleep cycle. A healthy breakfast also
helps to kick-start the body clock.
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9. Avoid caffeine
Encourage your child to avoid caffeine – in energy drinks, coffee, tea, chocolate and cola – or avoid
offering them in the late afternoon and evening.
10. Do some exercise
Physical activity and exercise help children to sleep longer and better. But if your child is having trouble
getting to sleep, discourage active play and sports late at night. The stimulation and increase in body
temperature can make it harder to go to sleep.
Other ideas
If worries and anxieties affect your child’s sleep, you could work on the problem together during the
day. You could talk about it with your child or he could try writing anxious thoughts in a journal.
Sleep problems
Up to 40% of children and teenagers have sleep problems.
Lack of sleep affects children and adults in different ways, and can have a negative effect on behaviour,
emotions, attention, social relationships and school or work performance.

Advice for specific problems:

Refusal to go to bed:

Option 1: child proof the room and shut the door. Should you lock the child in the room? You could get a
latch from the hardware store and install it high on the door frame. Fire regulations in the majority of
jurisdictions prohibit locking people in bedrooms. Also not allowing a toilet trained child access to the
bathroom is inappropriate.

Option 2: Silent return to sleep. Using this method you put the child back in bed every time they come
up. You provide no stimulation. You don’t talk to them, tuck them in, kiss or hug them or even make eye
contact. Eventually they get tired of the game and will go to sleep. This method can be frustrating and
relies on the child being small enough and parent strong enough to carry them to bed upwards of 20
times a night the first time it is used.

Option 3: Tokens. Using this method you give the child two or so tokens that can be turned in for more
soothing/ caregiver attention before bed. Examples, glass of water, hug, short cuddle etc. Sometimes if
the child feels in control they protest less.

Option 4: Reward charts. Using this method you provide a sticker or other small reward for cooperation
at bedtime and possibly a bigger reward like a special outing or time with a parent after a week.

Option 5: Designing the bedtime routine with the child. Give your child some agency in designing their
own bedtime routine. Illustrate a chart together and place it in the room. If they get off track, point
them to their chart.

Option 6: Timer/ clock method. Some parents find it very useful to get an old fashioned face clock and
label it with tasks related to bed or use a timer for each stage. That way they are not enforcing the rules,
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the clock is, and the child has a visual representation of how much time they have to get ready for bed
and when the lights go out.

Night waking:

If a child wakes and calls for you in the night, make sure your response is consistent, loving, and short. If
the child comes into your room, return them to bed.

Some parents find using a time for soothing is helpful both at bedtime and for nighttime wake ups. You
can say you will cuddle for 3 minutes for example, and then stick to it. You can reduce the time until
your intervention is a quick good night tuck in.

Other nighttime sleep disturbances (Night terrors, nightmares, sleep walking)

These sorts of sleep disturbances seem to be more common when your child is overtired or during
periods of disruption. Check your bedtime to make sure its appropriate and optimize hygiene.

During a night terror your child is asleep. These are scary for parents but children have no memory of
the event. Hold them to prevent injury.

If you have a sleepwalker make your house safe. Block stairwells, use baby gates and door alarms to
prevent wandering.

References/ Further Reading

Bathory, Eleanor, Suzy Tomopoulos. Sleep Regulation, Physiology and Development, Sleep Duration and
Patterns, and Sleep Hygiene in Infants, Toddlers and Preschool-Age Children. Curr Probl Pediatr Adolesc
Health Care 2017;47:29-42

Ferber, Richard. Solve your child’s sleep problems: New Revised and Expanded Edition. 2006,
Touchstone.

Healthychildren.org (from the American Academy of Pediatrics)

https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/default.aspx

Mindell, Jodi A, Brett Kuhn, Daniel S. Lewin, Lisa J Meltzer, Avi Sadeh. Behavioral Treatment of Bedtime
Problems and Night Wakings in Infants and Young Children. An Americal Academy of Sleep Medicine
Review. Sleep 2006; 29(10):1263-1276

Weisbluth, Marc. Health sleep habits, happy child. 2015 Ballantine Books