Book Review: Sweet Sleep -Nighttime and Naptime Strategies for the Breastfeeding Family

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La Leche League’s 2014 book, Sweet Sleep: Nighttime and Naptime Strategies for the Breastfeeding Family, is a book for families of infants which focuses on attachment-oriented research evidence and strategies for understanding and addressing sleep challenges.  The intent of the book is to provide breastfeeding-friendly infant sleep knowledge, support, and problem-solving and, as I describe below, the authors have succeeded in meeting this aim.  

Writing in a calm, articulate manner, Weissinger, West, and Pitman are appealing to educated and informed parents who are at least somewhat familiar and open to attachment-based parenting approaches to sleep.  Likely the La Leche League publication naturally draws the attention of those already inclined to providing nurturing measures, in general. Although not an academic paper, the level of education required is rather high.  The book’s strengths lie in its use of evidence and research balanced with clear descriptions and case studies that highlight the key points.

It is quite a lengthy book that takes several hours to read, something that may be a challenge for all but the most motivated sleep-deprived parents.  Despite this, the depth and quality of the information and evidence provided make this my new primary recommendation to clients who are keen to read about infant sleep. Unlike other books on infant sleep, this books looks specifically through the lens of breastfeeding. However, it is still appropriate for non-breastfeeding families if shared in a sensitive way to those not currently struggling with breastfeeding or with previous decisions/necessity of weaning.  There is enough valuable information to firmly entrench this as an infant sleep book for professionals to consistently draw from when providing eager parents with detailed information or references scientific evidence.

Reading this book now, as a weaned mother of three children who now sleep well, I was so excited about the evidence they include that supports attachment-based sleep support for families.  In particular, their section on bedsharing (detailing La Leche League’s Safe Sleep Seven principles) is both evidence-based and instinct-focused: you, as a parent, must weigh the information available to you in the context of your own infant, yourself, and your family.

The references and citations are the real strength of this book.  Subtitles and indexing make it fairly easy to navigate the kindle version. The richness of the content makes it likely that families would benefit from a print version, rather than kindle version, in order to mark particular sections and to use the index more freely. I suspect most families who are so inclined will have print versions decorated liberally with sticky notes.



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Let's Talk About Pee.

Mannekin Pis, bronze statue in Brussels, Belgium. Pixabay.

Mannekin Pis, bronze statue in Brussels, Belgium. Pixabay.

After sleep, and perhaps after discipline, potty training is next in line as one of the likely questions you’ve had (or will have!) about raising your wee ones. Aside from it being a rite of passage for our kiddos, moving beyond diapers is also a big leap for us as parents. When our children stop using diapers and start regularly using the toilet:

  1. We cut down on purchases and on garbage (extra garbage tags, anyone?);

  2. We spend less time dressing and undressing, wiping, and washing the kids.

  3. We have more freedom on outings, even if initially we are simply trading diapers for a portable potty seat.

  4. And we can relish in a significant milestone that shows us our little ones, regardless of how many other ways they need our support, are developing and growing up.

Getting to that point of diaper free, however, is not like stepping through a single doorway. Just like with infant sleep, it is a developmental skill that is complex and cannot be rushed without consequences. Below are strategies for approaching toilet learning with kiddos. And, as with all things parenting, we can begin setting the path right from birth.

  1. “R.E.S.P.E.C.T.”. Awareness of and respect for one’s own body (and all its bodily functions!) starts with how others treat us. Telling your little one what you are doing as you do a diaper change is a simple and yet helpful way of reminding us (and teaching our children) that we respect them.

  2. Pay attention to patterns. Whether you approach peeing and pooing from the perspective of Elimination Communication, or whether you have a toddler with longer periods of time between wet diapers, or an approaching enrolment date for kindergarten, being aware of body language, timing, and triggers (how many pee-infused baths have your kiddos had?!) is helpful.

  3. Each in their own time. Although there are general trends on when children are able to use the toilet regularly for peeing, the age at which children are ready varies so widely that these age ranges are usually not helpful. With the exception of identifying medical, neurodevelopmental, and emotional barriers to toilet learning, the age when most kids are toilet trained may not be helpful in appreciating when your child is ready. Paying attention to signs of readiness, instead of age, can be helpful for taking the pressure off and for respecting your own child’s development.

  4. Model the outcome you want. Kids who see how the toilet is used are more likely to imitate its use, even at the age of one. Consider pointing out why you are using the toilet, and perhaps even invite your toddler to flush! But be prepared that modeling your behaviour might transfer over to putting other things in the toilet —a plumber once told me that in one troubled toilet he found an entire mini collection of playskool people. Pens are surprisingly effective at causing all sorts of back ups (this from personal experience —oh what chaos one little pen can cause). And no one wants their toothbrush to make its way into the bowl. Take it in stride. And keep a plunger nearby!

  5. Offer it and they will pee. Eventually. Having available a potty or an accessible toilet seat (including this one that is built right into the adult seat) along with an appropriate step stool can encourage children to spontaneously try toileting. Getting a potty long before your child is ready results in it being as natural a part of the bathroom as the toilet itself. For kids who don’t like dramatic change, this may be helpful.

  6. Pomp and Circumstance. For kiddos who love to have their milestones celebrated in style, novelty toilets with their favourite characters on it may help. But more importantly, the positive and genuinely pleased approach you take towards their learning may make a longer term impact (and transfers over into all sorts of achievements and milestones without the need to surround yourself with Paw Patrol paraphernalia). Being interested and excited—without been too interested and excited—may take some trial and error. Knowing your child’s temperament, and what works for them in terms of your reaction to other achievements, can help guide you.

  7. Go with the Flow. Whether your child goes diaper-free or bottomless for three intense days in the winter, or for two months in the summer, there will likely be wet clothes and pee on the floor at some point. Cleaning it up without chastising, and (if you can muster it without it seeming like you are punishing them) recruiting their help in a calm way is important for avoiding shame and embarrassment about a tricky developmental skill that will inevitably have its ups and downs.

  8. Know when to hold’em… know when to walk away. If things are not going so smoothly, it is often a sign that they are not ready. Put the goal of potty training aside for a while, and return to it when there are other cues. If, however, you feel like there is more going on, pursue it with your doctor. Urinary tract infections can sometimes be symptom free and yet will cause all sorts of upsets to the progression of potty training.

  9. Natural Opportunities and Oops’s: At one point in the gradual transition to full toileting with my first born, I found myself at a park ten minutes from home when he had to go pee —and we had not brought a diaper with us. This was the first time in the toilet-learning process that he’d been away from home for toileting and he wasn’t so gung ho about the idea of peeing in the public washroom. I offered a choice: he could either pee in the public toilet or we go home right away for him to pee there and remain at home. Although not initially happy with this choice (it was a beautiful day at the park, but boy oh boy the toilet at home was familiar) he weighed his options and chose to give the public toilet a try. It worked! We got to stay another hour, and he overcame the milestone of using a washroom other than our own. The next week, however, at the same park, we ended up with a surprise wet pair of pants. Sometimes natural opportunities (or genuine forced choices) help us make progress. But it’s not always linear.

  10. Dry Nights. If dry diapers at night seem like a distant dream, and you feel like it ought to have happened already, consider constipation. If children are backed up (even if they are pooping every day), it can cause night wetting. If you feel this may be a factor, an x-ray can confirm it, and strategies can be put in place to get things flowing better. Once the bowels are emptying easily and fully, there is less pressure on the bladder and ureter, and more ‘room’ for developmentally-appropriate night dryness. Resolving constipation will also set the stage for smooth transition to toileting for bowel movements too.

When Hurdles Get In the Way

There are a number of situations that delay toileting or that prevent independent toileting. Mobility issues, neurodevelopmental and social-emotional challenges, frequent UTIs, and cognitive delays can impact a child’s ability to progress towards independent toileting. Whether these hurdles are resolved over time (e.g. cognitive development or resolving UTIs) or whether these hurdles remain, respecting a child’s developmental, emotional, and physical abilities is crucial. By appreciating what the challenge is, we as parents may work towards remaining calm about the goal, the timeline, and the barriers.

This patience and acceptance includes when the child is ready and willing emotionally and yet is unable to achieve this milestone, and vice versa —when the child appears physically able but is not emotionally ready.

Signs Your Child May Be Ready for More Progress to Toileting:

  1. Their diaper remains dry for a greater length of time;

  2. They pause activity and take a pee posture (or expresses to you verbally that they are peeing in their diaper) that lets you know they are peeing willfully;

  3. They show an interest in the toilet, especially if it involves imitating you. (However, imitating can happen long before a child is ready physically.) Encourage this imitation, even if it doesn’t ‘yield results’. Toilet habits are a nice thing to develop, if led by your child, even before toilet use is consistent.

Should I Use Rewards to Encourage Toileting?

I generally take an “Alfie Kohn” approach to rewards (see his book Unconditional Parenting for his perspective on rewards and punishment): rewards usually coerce compliance rather than support the development of a skill. Although a well-timed encouraging gesture can tip “almost ready kids” solidly into the “totally potty-trained” category, rewards tend to assume that all the pieces are in place for success, and that all the child needs is a sticker or toy or chocolate to achieve the milestone. This is not usually the case. Kids are built to want to develop new skills. If they are resistant to developing a new skill then perhaps (a) they are not ready yet and a reward will frustrate, rather than motivate, or (b) they are relying a lot on this skill being your priority rather than a priority that comes from within. Occasionally, a reward to sweeten the deal can be helpful in cases where there is a lot of fear —the extra motivation to overcome that fear might help. But in my view, we ought to use rewards sparingly.

All in Good Time

Generally, as with most developmental skills, if we as parents provide the environment (nurturing, supportive, with opportunities for development, and access to the right tools -e.g. a potty!) children will develop new skills when they are developmentally ready, including toileting. If the timing is right, this happens smoothly, albeit gradually and with set backs along the way. And although there may be pressure to speed things up and rush the process, we can remind ourselves that, just as with learning to walk, most kids will get where they need to go when they are ready.

Resources

Alfie Kohn, Unconditional Parenting

Built-In Potty Seat, amazon.ca

Mannekin Pis, bronze statue in Brussels, Belgium. Credit: Pixabay.

Mannekin Pis, bronze statue in Brussels, Belgium. Credit: Pixabay.

Normal Sleep from 6 to 12 months

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For those concerned about their infant's short naps and night waking, a new study led by Dr. Pennestri at McGill adds to our knowledge that:
-Interrupted sleep in infancy is normal. 
-Consolidated sleep happens gradually over time. 
-Interrupted sleep is not correlated with developmental issues (contrary to some previous studies).

Pennestri’s study coincides well with a much older study (Scher, 1991) that showed an increase likelihood of regular night waking at 9 months of age: although 40% of babes were waking up regularly at 6 months of age, this increased to 60% at the 9 month mark, dropping only slightly to 55% by 12 months of age. These studies explain what many parents have experienced at this age and explains why a significant number of my clients call me by the 10 month mark, concerned and exhausted! This bump in the road might be explained by the enormous social and emotional changes that are happening at this age.

What does this mean for you and your little one? 
1. Biologically normal night waking can be approached through perspective changes, self care, and environmental adjustments to help nudge children gradually towards longer sleep periods. 
2. Listen to your instincts about whether there may be an underlying issue (colic, reflux, environmental and food sensitivities) --these can all be sleuthed out and addressed to bring sleep more in line with your child's natural sleep needs.
3. Lean in to what is normal for babies and soak this intense, amazing, draining, and exciting time in as a season of parenting that can feel tiring, but does not need to feel terrible.
4. Call for support! Even if your baby is sleeping "normally", it can be helpful to have someone support your efforts through evidence, reflection, suggestions, and guidance. Sometimes the best intervention is through understanding.

Because there are significant (and often challenging) changes to infant sleep between 6 and 12 months, expect further articles of the research on “what is normal” for this age range soon! And even though it is hard to “rest” assured, most babes are shifting towards more regular and longer sleep periods by the one year mark. Better sleep is ahead!

Resources:

The McGill study, by Dr. Pennestri et. al., is in the December 2018 issue of Pediatrics. and is reported in McGill.ca, November 2018. Parents shouldn’t worry if their infant doesn’t sleep through the night by 6-12 months of age

Scher (1991). A longitudinal study of night waking in the first year. Child: Care, Health, and Development, 17 (295-302).


Photo Source: Pixababy yc0407206360

Photo Source: Pixababy yc0407206360

Even With Older Children, Attachment and Connection Support Sleep

A photo from quite a few years back of a relaxed and joyful part of our bedtime routine —hanging out together. Sleep is important. And so is connection. The two can work together. (It is recommended that children under two not bed share next to a sibling.)

A photo from quite a few years back of a relaxed and joyful part of our bedtime routine —hanging out together. Sleep is important. And so is connection. The two can work together. (It is recommended that children under two not bed share next to a sibling.)

There was a time before kids when I was not as attachment-focused in my sleep approach. And if I am completely honest with myself, there have been times even after becoming a mother where I have struggled with attachment-based approaches to supporting sleep. Shifting my perspectives and expectations this much has been a process.

But now, with my youngest at age 4, and with my two older boys, I’ve hit my stride (without perfection, but with calm intention) when it comes to supporting their sleep most nights.

Tonight’s bedtime routine (with all it’s imperfections, and bumps) feels like a story worth telling, in that it reflects how profoundly I’ve shifted my priorities around night time parenting. I don’t dismiss the importance of sleep (enough of it, and of good quality). But I do know that more often than not the best way for our kids to get good sleep is to meet (and exceed) the need with an open heart and a calm, unhurried state of mind.

Perhaps some nights an open heart and a calm, unhurried mind are a struggle. On those nights it’s a challenge to dig deep and meet the need. It becomes a war against our intentions, which often comes out looking like a battle against our kids: them resisting sleep, and us trying to overpower their resistance.

But tonight there was no strong arm, no temptation to coerce, and no resistance. Instead, the evening started with rather feeble efforts on my part to start the routine, and ended with a sense of such connection that I am smitten.

At the usual bedtime, as I do on nights when I am distracted and trying to get work done, I was verbally guiding my two older kiddos (6 and 9) to bed. But as with so many pieces of parenting, you’ve got to walk the walk….and actually walk with them upstairs! Instead, I was giving instructions about shutting down screen time while tapping on my laptop, and listing off bedtime steps without modelling them myself. Hardly “leading by example”.

Now I do know that my children are capable of walking up stairs independently. Of brushing their teeth independently. Of getting dressed independently. Of climbing into bed and crawling under the covers independently. But I have learned well both through research and through parenting experience, that the ability to do something independently is not the only factor in accomplishing a task. Not by a long shot. Coming alongside, and “doing with” are powerful strategies for connecting and accomplishing.

So instead of escalating the volume of my voice, getting sharper and snappier and frustrated, I paused, and heeded the call from my spouse to please come upstairs and help usher them to bed (we both play integral parts in the bedtime wind-down) —tonight things weren’t going all that smoothly. There seemed to be a frenetic energy in the upstairs loft (full moon?!). A lot was happening that had very little to do with bedtime. There were push ups and jumping jacks, karate punches and kicks into cushions, building of forts, requests to make elaborate paper plate faces to tape to these “punching bags” (yes that sounds terrific; yes, it will have to wait till tomorrow), and a lot (a lot) of talking.

But step by step, slowly and calmly, we made our way to their beds where story time was pulled off the roster but gratitude questions and a review of their day remained intact. By now it was very late and despite having more work to take care of, I lay with them a while, and I closed my kindle (did I say screens shouldn’t be part of bedtime? Direction not perfection!), and just lay there as my middle child told me elaborate explanations of how things work. He chatted while holding my hand. His volume was louder than usual, and we kept having to remind him that his little brother was sleeping. He talked with excitement and enthusiasm and while he talked he played with my hair. And then, interrupting his story, he requested that I get the detangling brush….so that he could brush the knots out of my hair.

Now the old me —before I became a mother, or before we got to a point where I was getting enough sleep most nights to make flexibility and patience easy— would have said no, it’s bed time, good night. But tonight I paused, considered how comfortable and content he was: he was getting one-on-one time with me as he peered at the full moon out his window and lazily shared contemplative explanations of zombies and werewolves.

Here was a kiddo whose one-on-one time often gets squeezed out between the needs of his younger brother and the activities of his older brother. The kiddo who sometimes stops talking out of frustration that no one is listening, or that he’s been interrupted again. Here he was chatting to me, connecting with me. So I did what I felt compelled to do: I got the comb, I brought it up, and he combed my hair while talking, while solving dilemmas of his day, while unwinding for sleep.

When all the knots were out I said good night, gave the boys kisses, and left. They both fell asleep without another peep.

There is something liberating about approaching night time this way. For all the conflict, or upset, or missed opportunities to connect during the day, night time has fewer distractions. Night time is a chance to put a cherry on top of the day, no matter how bad the day has been. Night time could be (and often is!) a stressful, exhausting ritual of resistance when we as parents can be maxed out. But by “finishing strong”, and finishing with connection, I’ve made up for some of the less-than-ideal parts of today.

Whatever needs he had not had filled during the day seemed topped up well by my spending this time with him as he lay in bed. And his need for sleep is fulfilled too: maybe not as early as ideal, but certainly as smoothly as I could ever wish for.

Snug as kittens: even older kiddos need to feel relaxed and to unwind with parental support sometimes.

Snug as kittens: even older kiddos need to feel relaxed and to unwind with parental support sometimes.

Reflections on Parenting

I recently took some time to reflect on what my priorities are in supporting parents with infants and young children. I wanted to hone in on what message I am really trying to share with families, regardless of whether we connect about infant sleep, development, or parenting. Whether family life is going along tickity-boo, or whether things feel like they are falling apart at the seams, these thoughts are ones I turn to to help me have perspective, and to have trust in the process.

This work is important to me. And I’m honoured to get to come along with you on your parenting journey as your OT when you reach out to me for support.

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