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What is normal, what is not? Parenting is a mammoth task, and brings with it a lot of uncertainty as to what is actually within the norm, and what may need more urgent attention. I shall therefore attempt to sketch a picture of what is considered normal, with initial focus on the first few months of life, which are particularly panic-provoking! This includes a few words on the dreaded “C-word”…Colic. I shall then go through system by system what may go wrong and when to seek help. As a paediatric allergist, I have a particular interest in allergy prevention strategies, hence shall attempt to dispel a few myths and iron out some truths about what we can do to reduce allergies in the offspring. What is normal in the first few months? The first few months of parenthood are particularly tough as you take full responsibility for a precious but needy little baby, and have to function on minimal sleep. My advice: accept all the help you can, don’t set your expectations too high, and don’t expect your baby to fit into a mould! This is “survival time” for all- the enjoyment of parenthood will come! For the first 3-4 months babies’ brains and tummies are still very immature. This time has been dubbed the “fourth trimester.” The baby is not yet able to manipulate you hence it is not really possible to “spoil” a baby during this time. However, routines can be established from an early age and it is useful to try have a baby in some kind of a routine of sleep, feeding and play by 12 weeks or so if possible. The predictability of a routine helps you as well as other caregivers as well as your baby. Remember to be flexible and especially adaptable at times of travel, sickness and immunisations when the routine may be disturbed for a while. The first few months are vital for establishing a bond with your baby and a relationship of trust- the baby needs to know that “warmth and food and cuddles will come my way when I need them.” Remember that it is normal for a baby to cry as it is its only way of communicating. Crying increases from an average of about 1 hour a day at birth to 2-3 hours a day at 6 weeks, then slowly decreases again to about 1-2 hours a day at 3 months. Remember this “crying curve” when you are tearing your hair out at 6 weeks post birth! Gripes and Groans in the first few months The immature gut during the first 3-4 months means that most babies have gripes and groans to varying degrees. “Colic” by definition is excessive crying of more than 3 hours a day, more than 3 days a week, typically from 2-3 weeks until 3-4 months of age. Truly colicky babies by definition are thriving and usually have a pattern of an unsettled period, typically (but not always) in the early evening, when they cry inconsolably and may draw their legs up in discomfort. Although the specific cause of colic is rather mysterious, the general feeling is that it may be caused by an immature gut and immature nervous system (oversensitivity). Colic does not cause long term harm or distress to the baby. Simple measures such as winding the baby carefully, holding them upright with gentle pressure on the tummy, movement, driving, “white noise”, wind drops and probiotic drops may be useful. More potent colic mixtures can be sedating hence should be used sparingly only for “crisis” times once or twice a day after discussion with your clinic sister or doctor. Individual colic “medications” do not have a great success rate, and each one may work in only about a third of patients. Therefore, if they do not make a difference after a week or 2, stop them. Time is the great healer for colic, but this is hard to accept when you have a little baba crying 24/7! Some cases of excessive crying and discomfort may be caused by reflux of acid and milk into the throat, lactose intolerance and cow’s milk protein allergy. Please discuss concerns of with your clinic sister and doctor, especially if there is excessive vomiting, constant crying, inadequate weight gain, severe nappy rash, or chestiness. On that note, most babies vomit as they have an immature valve at the top of their stomachs which lets milk go up again. This is normal. Vomiting, in fact, only peaks at 4 months. However, if the vomiting seems excessively painful, the baby back-arches a lot, refuses to lie on the back, and is extremely miserable after feeds or fusses excessively during feeds, reflux “disease” should be considered and discussed with your healthcare practitioner. Stools During the first few days of life the baby passes meconium, which is a black or dark green stool of “marmite” consistency. After a few days, stools change. Breastfeeding stools are normally mustard yellow with white “seeds” of curdled milk. Breastfed babies have a wide variety of stooling habits. In the first few weeks they tend to pass stool after most feeds. After a few weeks they settle into a pattern which is widely variable: from 7-8 stools per day to one stool per week- this is all within normal limits. Babies on predominantly formula feeds should ideally pass stool at least once a day. Babies often groan and strain and become red in the face when they are passing stools- this is normal unless accompanied by painful crying. If you are concerned about constipation- (if stools are infrequent or unusually hard or painful to pass) please consult your doctor. Sleep Sleep is always an issue in families with young kids. We won’t go into detail here as every child and family is so different. Don’t expect miracles before 6 months- the young baby is programmed to require night feeds which can be normal until 8-9 months of age. Thereafter, demanding a milk feed is usually not a nutritional issue but a comfort “prop” to help them fall asleep again. Teaching a child to self soothe is an important tool to impart on your young one and can be done from about 4 months of age. They may need a comforter such as a special blanket, soft toy or dummy (or a combination of these) to help them fall asleep. Babies are generally reasonably easy for the first 10 days or so then may become more difficult as colic and wind sets in. Their sleep requirements are high (about 16 hours a day in total for the first few weeks), gradually settling into a pattern of approximately 3 naps per day by 3 months of age. If possible, some naps should be more than 40 minutes long to provide restoring sleep. At night time they will continue to wake 3-4 hourly for feeds for the first few weeks; by 3 months there is often a longer “stretch” of sleep during the night of 5-6 hours. Remember that the safest sleep position for your baby is on the back. The “back to sleep” campaign in the UK has seen the rate of cot deaths halve over only a few years. If the family is really not coping with the interrupted nights, or if there is a sudden change in sleep pattern, it is worth having the child looked at to make sure there is not a physical ailment disrupting the sleep. The routine and feeding pattern should be examined to make sure the daytime sleep and feed requirements are being met. There are a variety of forms of sleep training available, from controlled checking to gentle gradual separation techniques- please discuss with your clinic sister or doctor before embarking on these. If a child is unwell or going through a stage of separation anxiety, it is not a good time to sleep train. Remember that “this too shall pass” and that most children- even the worst initial sleepers- sleep very well by the age of 5 or 6 years. Feeds Initial feeds should be 3-4 hourly during the day, and on demand at night. Some babies only manage 2 hours in between feeds initially- this should stretch once they are able to drink more at one time. Breastfeeding is ideal for babies for several reasons including cost, convenience, allergy prevention and to boost their immune systems. The clinic sisters have vast experience with breastfeeding, please consult them for advice if you are battling. However, not all mothers manage to breast feeds or have insufficient milk- nothing to feel guilty about. There is a vast choice of formula milks and the approximate volume that a baby needs for the first few months is 150 mL milk per kg per day (divide this volume into the number of feeds per day). For example, a 4 kg baby on formula milk who feeds 3 hourly needs approximately 150 x 4= 600 mL per day; ie approximately 75 mL per feed every 3 hours. (8 feeds per day) Some babies need less milk, some need more- the best way to judge is by their weight gain. For this reason we plot babies’ weights on the growth chart regularly to make sure they are not falling off the growth curve. Babies lose weight during the first few days of life- loss of up to 10% of their birth weight is normal. The baby should regain its birth weight by 2 weeks of age. After that, for the first 3 months or so weight gain should be between 150-350 grams per week. After 3 months it slows down somewhat. Solids can be introduced any time from 4 months (17 weeks) onwards. Throughout the first year of life milk is the most important component of the infant’s diet, and even on 3 solids meals a day, during the first year the infant requires at least 450-600 ml milk per 24 hours. After the age of one, milk can be cut down gradually to 300-500 mL per day- overfeeding with milk after a year of age will interfere with an appetite for solids and may lead to problems such as anaemia. From about 14 months or so many toddlers notoriously go through a fussy eating stage-their growth curve naturally slows down and the world around them is SO much more interesting than food! It is therefore important to try and introduce a great variety of foods to the toddler before the fussy stage begins. Developmental Milestones Every baby develops at a slightly different pace, but generally the sequence of development is similar. Stimulation of a baby’s development will be covered by my colleagues. As soon as the baby starts fussing and seems fed up, stop with the stimulating process so that they can calm down in preparation for the next nap. Below are basic milestones typical at different ages. Remember each child develops at a different pace, and individual babies may be advanced in a certain area e.g, grabbing and mouthing yet a bit slower in other areas e.g. sitting/crawling. If your child is lagging behind significantly please consult the paediatrician: the sooner delays are picked up, the quicker we can intervene to find a diagnosis and treatment. Developmental milestones Age Gross Motor Skills Fine Motor Skills Hearing and Language Development Visual Development Personal/Social Birth Very little head control Hands are closed and grasp reflex present Startles to loud noises -Eyes close in response to bright light -Best distance of vision is about 30 cm away -Black and white vision Cries 6 weeks Moderate amount of head control -Can make tight fists -Places hands in mouth -Responds to sounds by calming, startling or crying -Starts making cooing sounds May follow slow moving objects through 90 degrees Begins to smile in response to familiar face or voice 3 months -Very little head lag -Can lift upper body and head when lying on tummy -Leg kicking and stretching -Standing reflex develops (pushes down on a surface with legs when held up) -Hands held loosely -Inspects hands and grasps objects that are place within hands -Can bring hands together -Recognises and responds to parents -Coos and gurgles -Blows bubbles Follows objects moving up to 180 degrees in the field of vision -Smiles spontaneously -Develops facial expressions to show basic emotions -Recognises mother’s face and scent 6 months -Supports head well -Can support upper body with hands when lying on stomach -Sits with support -Can roll over -Reaches for and grasps objects -Places objects in mouth -Transfers objects from hand to hand -Responds vocally when spoken to -Uses sounds such as squealing or laughter to express emotions -Uses repetitive monosyllabic sounds like bababa Can move eyes in all directions Recognises toys 9 months -Sits without support -Crawls on stomach and then on hands and knees -Starts to pull body into a standing position -Can pick up, shake and drop small objects -Grasps food and places in mouth -Holds a bottle Begins to point Starts imitating sounds -Stranger anxiety- Knows and trusts a limited number of caregivers -Recognises own name 12 months -Cruises around furniture -Starts to walk (walking may take up to 18 months) -Begins to throw objects -Good pincer grip -Holds 2 objects and bangs together -Still mouths a lot -Speaks 2-3 words -Makes sounds at toys Picks up tiny things from the ground -Searches for hidden or fallen toys (0bject permanence) -Waves goodbye, - points -Shakes head 15 months -Walks steadily -Starts to climb Stacks 2- 3 blocks Speaks 3-4 words -Has temper tantrums when frustrated -Becomes attached to a soft toy or other object 18 months -Walks steadily. -Runs -throws ball underhand -kicks -Scribbles -Stacks 3-4 blocks -Speaks 6-8 words -May have some 2 word phrases As above -Starts to use fork and spoon -“reads” picture books on his own 24 months -Runs -Jumps with 2 feet -Walks down stairs one foot at a time -stacks 6 blocks -scribbles -may still use both left and right hands to draw -Names at least 6 body parts -Uses 2-3 word sentences -Half of speech understandable -Starts to learn some colours Adult visual acuity -Asks “why?” -Begins to show interest in playing with other children but finds it difficult to share. Play is often in parallel -Helps with dressing -Uses fork and spoon 30 months -Jumps easily -Balances on one foot for a few seconds -Walks down stairs with alternating legs -Draws vertical line and circle -Pencil grip starts to develop -Handedness becomes evidence -Able to name some colours and shapes -2-4 word sentences -Able to recite name -Able to brush teeth with assistance -Washes and dries own hands 36 months -Hops on one leg -Rides a tricycle -Copies a circle -Shows definite handedness -3-4 word sentences -Able to follow 2-3 word commands -Starts to play with other children -can name a friend -Able to help with dressing Dr Claudia Gray, Paediatrician and Allergologist, Vincent Pallotti Hospital and Red Cross Children’s Hospital, Cape Town

Whoever it was who coined the phrase “sleep like a baby” has obviously never had one! Many parents may wonder why their child seems to have such difficulty with sleep issues, when other children seem to sleep like angels. Environmental change The arrival of a sibling, can cause your toddler to become excessively weepy and clingy, especially at bedtime. Moving into a new home, starting or changing playschool, a change of teacher or caregiver may also cause a problem. The death of a parent, grandparent, or loved caregiver, as well as divorce, may also cause sleep disturbances. Acknowledge his loss with him, and allow him time to grieve with lots of extra hugs and kisses. If you have returned to work, expect your toddler to be a bit unsettled. Give him time to get used to his new routine. Holidays, or houseguests can disrupt the routine your child has come to know and expect. Try to keep your routine the same as always, even if you are not at home – toddlers need to know what is coming next, and become very confused when things change. Medical and health issues Any medical issues need to be addressed, and if you or your child have been hospitalised owing to illness or surgery, it will obviously very traumatic for all concerned – expect your routine to take at least 10 days to settle once you are home. If your child is ill or teething expect your nights to be a bit wobbly – medicate if necessary. Certain medication can cause side-effects such as insomnia and hallucinations– so be informed before administering any new medication to your child. Always check ingredients of medicine with your pharmacist. Worm infestation can also cause restless nights as some worms’ eggs are active at night in the anal area, causing irritation and itchiness. De-worm the whole family, including your animals, and check out playschool staff as well. Speak to your healthcare provider about the correct age-appropriate dosages. Anaemia can cause behavioural problems and frequent night waking, so speak to your clinic sister or pharmacist about a good iron supplement. Muscle cramps and growing pains can cause restless sleep – ask you pharmacist to recommend a magnesium supplement and give it to him at bedtime. Inappropriate stimulation Exposure to too much of the wrong sensory stimulation, for example excessive and inappropriate TV watching in the late afternoon and evening, can over-stimulate your child’s nervous system, impairing his ability to shut down and go to sleep. Rather play some gentle classical music, and keep the TV switched off. Hyperactivity or sensory overload: Neurotransmitters are the little chemical messengers which are released at each and every nerve ending as it transmits a message to and from the brain. The balance of stimulating and calming chemicals enables the sensory system to work efficiently in regulating basic automatic functions of sleeping, feeding, heart rate and breathing. In some children, usually owing to genetic factors, the concentration of the neurotransmitters is faulty, and they give irregular and inconsistent messages to the brain. This can manifest in over-active behaviour. We know too, that disturbed sleep patterns can lead to high levels of these chemicals, which cause the brain (nervous system) to be in a more aroused (alert and wakeful) and irritable state. This is largely due to stimulatory chemicals being released when the body is fatigued, and of course, sensory overload. So, the more tired the child is, the more likely he is to be hyperactive and irritable. Nightmares Nightmares are part of normal sleep, and are not associated with any specific emotional problems. Nightmares occur when we dream during the REM or light cycle of sleep. If your toddler has a nightmare it is likely that he has been dreaming of normal anxieties and fears, such as falling off a building, or not being able to breathe. In most instances, he may simply call out, but continue to sleep. Older toddlers (approximately four years of age) are more prone to nightmares as their imagination can become overwhelming at this stage. If you can hear that he is getting increasingly distressed, then go to him, wake him up and console and calm him. If your child has many nightmares, keep a dim night light on in his room – he will be comforted by this. Nightmares are usually a passing phase and have no lasting effect on your child. Night terrors Night terrors are different to nightmares in that your child wakes up (usually screaming). He looks terrified and anxious, his heart is pounding, his chest heaving, and he is utterly inconsolable. Night terrors are not bad dreams, and actually occur when he is sleeping deeply. There is not much you can do for your child while he is having a night terror other than holding him tightly and reassuring him that you are there. You may have to wake him up in order for him to recognise you before he will calm down. Most night terrors subside after a few minutes. However, research has shown that night terrors are common in children with abnormal sleep schedules. If your child is experiencing night terrors, try to encourage a daytime nap, move his bedtime earlier and avoid excessive stimulation and sensory overload during the day, particularly before bedtime. Sleepwalking Sleepwalking is unusual in toddlers, although research has shown that sleepwalking is more common if there is a family history. Some children open and close doors or dress and undress. There is no treatment, other than ensuring the environment is safe, then gently taking him back to bed, and tucking him in. Sleeptalking Some toddlers will mutter and mumble in their sleep – usually simple phrases like “No more!” or “Go away!” as if they were remembering an event that may have occurred during the day. Try to limit over-stimulation, particularly before bedtime. If your child sounds particularly anxious, take note of what is happening in his world during the day, and if necessary, make some changes. Head banging and body rocking About 5–10 per cent of children, usually boys, will bang or roll their heads before falling asleep. In most children this is a normal part of development, and should stop by the time they are four years old. This rhythmic behaviour is often due to sensory overload caused by over-stimulation and overtiredness. By moving their bodies rhythmically, the sensory system is calmed, and the children feel calmer and more grounded. Avoid overtiredness and over-stimulation by encouraging a day nap or some regular quiet time, and move bedtime earlier. Encourage your child to participate in more intensive movement and heavy work during the day (pushing a loaded toy/ wheelbarrow) and lots of outdoor play. Very rarely, head banging and body rocking are associated with underlying neurological diseases. Your paediatrician will be able to diagnose these uncommon conditions if they are present, so if you are worried, please seek medical help. Teeth grinding: Teeth grinding during sleep is quite common amongst toddlers, and should improve with age. It has no effect on the quality of sleep, and can occur in any stage of sleep. Snoring: Research has shown time and time again that children (and indeed adults too) who snore are not getting the best quality sleep. In children this can result in increased incidence of bedwetting, daytime drowsiness, mood changes, hyperactivity, headaches and impaired performance. If your toddler has two or more of the symptoms below and is a difficult sleeper please consult your paediatrician for further advice. snoring difficult breathing (or stopping breathing) during sleep restless sleep chronic runny nose mouth breathing when awake frequent colds or middle ear infections sweating when asleep poor appetite difficulty in swallowing excessive day-time sleepiness excessive hyperactivity (not age appropriate). Structure and routine, early to bed and teaching him healthy sleep habits will result in a happier family and a better behaved and more well- adjusted toddler. Suggested further reading: Sleep Sense: Faure,M& Richardson, A: Metz Press: 2007 Toddler Sense: Richardson, A: Metz Press: 2011 (new edition) Baby Sense: Richardson, A; Faure, M: Metz Press: 2010 (new edition) By Sr Ann Richardson Sr Ann Richardson is the author of Toddler Sense and also co-authored Baby Sense and Sleep Sense. She is a qualified nurse and midwife and has worked in the midwifery and paediatric fields for 30 years. For more information from Sr Ann Richardson go to www.toddlersense.com or email her at info@toddlersense.co.za

Most sleep deprived parents will be ready to try anything to get a good night’s sleep. Most likely you are holding onto the hope that you can change your little ones unhealthy sleep habits without resorting to letting him cry.The good news is that sleep training does not have to mean leaving your baby to cry for hours on end on his own. All methods of sleep training entail some fussing and crying. You are teaching your baby a new skill and breaking old expectations. While some crying is unavoidable the ‘crying it out’ method is not advisable, as it can make your baby feel abandoned and emotionally insecure. The goal of sleep training is not only to teach your baby to sleep through the night but: To teach your baby to fall asleep independently and to put himself back to sleep should he wake during the night. Because babies pass through light sleep states every 45 minutes at night (up to an hour in toddlers), it is not possible to prevent your baby stirring at night (due to sleep cycles) but it is possible for you to teach your baby to go back to sleep without your assistance. This means that you will give him a chance to see if he can put himself to sleep (or back to sleep). You do not leave your baby on his own for long periods of time and by portraying a message of consistency and confidence your baby will feel secure not abandoned. When controlled crying for sleep training is done in the correct manner to meet your child’s needs on all levels, especially his emotional needs, there should be no negative effects whatsoever – in fact a well-rested child with well-rested parents plays an important part of creating a loving and secure home. Have the courage to be firm, without guilt or fear that your baby will resent or love you less. Before you start: Decide on an appropriate time to begin Rule out medical causes of night waking Ensure your baby’s diet is adequate for his age, with sufficient milk and age appropriate solid food Your baby’s sleep zone must support sleep and be a consistent and calming environment. Encourage a comfort object (dummy, soft toy) A consistent bedtime routine is an excellent way of preparing your baby for sleep. If you are both working, arrange for a day’s leave on either end of your weekend, to allow consistent time to change the unhealthy sleep habits. Try to rest during the day as it essential that you are rested for the night ahead. If you are not prepared, you will be more likely to give up or be inconsistent out of sheer exhaustion. If possible, take shifts with your partner to allow you to have some undisturbed sleep somewhere along the line to recharge! If you have other children or demands, try to elicit help and support from other care-givers for the first few days, so that you can invest sufficient time and energy into the programme. Reassure your other children that you will make it up to them later – don’t forget to do this! Earmark a reward for yourself at the end of it all Confidence It is important to communicate confidence and calm to your baby when you begin. He needs to see an emotion that makes him feel secure that you are comfortable with what you are doing. Consistency It is no good to start with sleep training at bedtime only to relent later out of desperation and give your baby his ‘crutch’ (such as feeding to sleep). The message that your baby receives in this case is that he must cry long and hard to have the old method reintroduced. Any inconsistencies will simply prolong the process of sleep training. Collaboration Sleep training is an act of teamwork between you, your partner and your baby. It is completely essential that you all work together and do not undermine the process for each other. Doing it If your child has developed a habit whereby he is dependent on you for sleep, he will protest within minutes (probably even seconds!) of you leaving the room. This is where the hard bit comes in. Accept that your baby is going to cry, however, you are going to control how long he is going to cry for and you are going to be there for him every step of the way. There are two methods of handling this – neither one is better than the other – do what feels right for you at the time. One thing though, remember to be consistent and stick to one method for at least a week. Staying with your baby If you are anxious about separating from your baby, and if you feel uneasy about leaving your baby on his own whilst he is learning to put himself to sleep, you may want to stay with him for the process. All sleep coaching is hard work and may be very emotionally draining, so if you feel angry and frustrated when your baby cries and feel that you might physically harm your baby out of tiredness and frustration, then this is not the sleep coaching method for you. Leaving your baby for short periods of time This method allows you to pick up your baby when he is crying and comfort him until he is calm, but it differs from the first method in that you actually leave the room for short periods of time from the beginning, before returning to pick him up to calm him once more. If you feel that you could possibly harm your baby physically (out of sheer exhaustion and frustration) this may the method of choice for you as you are able to step away from the situation for very short periods of time in order to catch your breath and re-focus on the goal in sight. Changing unhealthy sleep habits is exhausting and the key to its success is to focus on the goal at the end of it all. Accept that you will be tired and frustrated at times, but try not to get bogged down in the immediate drama of the moment, and rather look at your long term goal. The process of falling asleep unassisted is a skill that needs practice, so bear in mind that success comes only after a period of practice, so don’t give up! By Sr Ann Richardson Sr Ann Richardson is the author of Toddler Sense and also co-authored Baby Sense and Sleep Sense. She is a qualified nurse and midwife and has worked in the midwifery and paediatric fields for 30 years. For more information from Sr Ann Richardson go to www.toddlersense.com or email her at info@toddlersense.co.za

In the early days many babies have difficulty dealing with the world outside the womb, and can easily become over stimulated which may result in fussy and colicky behaviour.Your baby needs you to watch for signs of overstimulation and fussing and to calm his environment if need be. To establish a sense-able rhythm in the first few weeks, remember that your baby will most likely not be able to stay awake happily for longer than 40 – 60 minutes before needing to go back to sleep again. Remember to tune in to his signals and offer the appropriate solution. Over-tired signals: Irritability Looking away from you Squirming with frantic movements Arching his back and neck Frowning Hiccups and colour changes around the mouth Gagging and spitting up Crying Solution: Calm his environment and reduce stimulation Hold him firmly and avoid chopping and changing positions Swaddle him tightly with his hands near his face Say “sshh” quietly and rock him gently in your arms, or push him in his pram Let him suck on his or your finger or a dummy Persevere with one strategy for about 2 minutes before trying another By Sr Ann Richardson Sr Ann Richardson is the author of Toddler Sense and also co-authored Baby Sense and Sleep Sense. She is a qualified nurse and midwife and has worked in the midwifery and paediatric fields for 30 years. For more information from Sr Ann Richardson go to www.toddlersense.com or email her at info@toddlersense.co.za

Nothing can prepare us for the exhaustion that sets in soon after our baby’s birth. The first week, we tolerate and cope with the lack of sleep, but ten nights of broken sleep down the line, most parents are feeling exhausted and the focus becomes on the big question: “When will my baby sleep through the night?” Sr Ann Richardson’s, co-author of Baby Sense and Sleep Sense, gives advice on establishing good sleep habits from the beginning. What to expect In the early days, most babies wake two to four hourly for feeds at night, especially breastfed babies. This gradually reduces and within a few weeks (usually at around 6 weeks of age) your newborn should start to stretch for one long stretch of five or more hours at night. This is usually the late evening feed (around 10 pm). Don’t be tempted to wake your baby up to feed at this time in the hope that it will do away with the 2 am feed, it won’t work! By the time your baby is around 3 months of age, she should be able to go for up to 8 hours at night without needing a feed. In time your baby will drop most night feeds but many babies only start sleeping through the night when they are on a full solids diet. So for three to six months one night feed may well be the reality - this feed is usually at around 2 or 3 am. Day-Night reversal There are many other issues that may concern us with our newborn’s sleep. One common concern with newborns is whether they have their day and night muddled up. In the dark world of the womb, little differentiates day from night, with the exception of how much mom is moving. And since movement is lulling, babies may in fact sleep more during the day and be more wakeful when mom goes to bed. Once they are born it is important that babies begin to differentiate day and night. Since newborns sleep almost constantly between feeds they will not be wakeful either day or night in the early days, however we want to encourage our babies to feed more frequently during the day and begin to stretch feeds at night. The way to do this is to feed on demand in the early days, but if she is tending to sleep her days away, and wakes frequently in the night for feeds, wake her to feed three to four hourly during the day. If your baby is gaining weight and is a healthy baby without concerns for her growth, leave her to wake you at night. By doing this, within a few weeks your baby should be waking frequently for feeds during the day and sleeping for at least one longer stretch at night. Too sleepy to feed well Another cause for concern in the early days is the baby who is too sleepy to feed well. If your baby is not waking himself for feeds at all during the day or night and sleeps through feeds, you may want to have your clinic sister check him for jaundice or lethargy due to low sugar levels (especially in the first few weeks). It is however very common for a normal, healthy baby to be sleepy for feeds in the early days. To deal with this, wake your baby fully from sleep by changing his nappy before the feed. Then don’t swaddle your baby for the feed, leave him uncovered and even leave his feet out of the babygro to keep him slightly cool and less comfortable. Another trick is to wet a piece of cotton wool and stroke his cheek or feet intermittently to remind him to keep sucking well. Difficulty falling asleep Your baby may develop a problem falling asleep between week two and three. Your previously sleepy baby is now more wakeful and getting him to sleep becomes an issue. This results in an overtired baby, which is one of the most common causes of crying in the first twelve weeks and can contribute to bad sleep habits later on. To help your baby fall asleep, watch how long he is awake. An overtired baby will fight sleep. The young baby under 6 weeks can only cope with an hour of awake time. So watch your clock and get your baby back to bed within an hour of waking. This generally only gives time for a feed and nappy change before your baby goes back down. Preventing habits from developing If your baby starts crying after being put down and you have fed him and know he is comfortable, do not assume winds are the cause of this disruption. It is more likely that he is fighting sleep. In this case picking him up will probably lead to more crying in the end. By fiddling with your baby and burping him, carrying him and fussing over him you could well end up with ‘colic’-like irritability. Instead, when your baby cries, listen to him for 2 - 5 minutes to see if he can settle himself. If he continues to cry, then sit next to your baby’s cot and hold his hands still and ‘shsh’ him with firm, deep pressure on his back. Your baby’s little hands are often flying around and irritating or scratching him. Swaddle him, offer him his hands or a dummy to suck and sit still, holding your baby’s hands until he is settled and falls asleep. In this way without over stimulating your baby, you will calm him and help him fall asleep without setting up habits that will be hard to break, such as rocking your baby to sleep. Night feeds for good sleep habits Finally, to set the stage for good sleep habits and improve your baby’s sleep from one week to the next, keep night feeds strictly business affairs. This means not interacting with your baby at night other than feeding. Don’t wake your baby for feeds – take his lead for waking at night. This allows your baby to establish natural sleep cycles. (your clinic sister will tell you whether this is OK depending on his weight) Don’t smile or talk to your baby at night – keep these happy interactions for day light hours Feed in semi-darkness – use a dimmer or a passage light instead of the bright bedroom light Don’t change your baby’s nappy – buy the best nappy you can afford for night time and leave it on all night unless it is clearly dirty with poo or leaking. The new generation gel nappies are fine to leave on all night as they soak up all the urine and the bottom remains dry In the very early days (the first 6 weeks), do not ‘dummy’ your baby in an attempt to decrease night feeds. Rather feed him when he wakes for feeds at night, if more than two and a half hours have passed since the last feed. Once he is over 6 weeks old, and is healthy and thriving, you can try stretching him with a dummy or some cooled, boiled water should he be requiring frequent night feeding (less than 2 ½ hourly). Nothing can prepare you for the feeling of exhaustion and desperation as sleep deprivation sets in; just know these early nights of frequent wakings are short lived. Enjoy and rejoice in your little one during his awake hours, and cherish every little bit of sleep you can grab! By Ann Richardson

The golden question: “When should my baby sleep through?” is one that needs answering as it determines what is reasonable to expect from your baby. Sleeping through is not just a luxury, it’s a developmental necessity. Both for you and your baby, a good night’s sleep is important. Firstly, it needs to be pointed out that sleeping through constitutes sleeping 10 or more hours at a stretch. This would mean that if your baby’s bedtime is between 6 pm and 7pm (as it should be) that could mean a waking at 4 am to 5 am. Many babies will go back to sleep after this time with a feed or a cuddle. If your toddler wakes for the day at this time, keep interactions muted and take him quietly into your bed with you and see if he will fall back to sleep. Under 6 months of age babies have nutritional needs at night that systematically decrease as the baby gets older. Having said this, some babies sleep do through the night as early as 3 months of age but many of these will experience disruption once again between 4 and 6 months. Most babies should be expected to sleep through the night by seven months old. Like other developmental milestones, sleep has certain norms that obviously are flexible as with any other milestone. The following are the norms for sleep at night: 2 – 6 weeks – one 4 – 5 hour stretch between night feeds and 3 hourly thereafter 6 - 12 weeks - one 6 – 7 hour stretch between night feeds then 3 hourly through the night 3 – 6 months - 10 – 12 hours at night 6 – 12 months - 10 – 12 hours at night 3 – 5 years old 11 hours per night as day sleep is dropped If your baby is ill he will not sleep through and will wake for comfort. If you have a low birth weight, premature or a baby with failure to thrive, he will not sleep through until later than other babies. If your baby learns to self sooth for incidental night wakings, i.e. those without organic causes such as hunger or illness, he will be a good sleeper. Even good sleepers who are sleeping through by 6 months old will occasionally suffer disrupted sleep for a few nights, but after the cause such as teething, hunger or illness is resolved, will return to being good sleepers. Broken sleep is debilitating but if your baby is young, hang in there it won’t be long before you see the light. If your baby is older and is not sleeping through you need to go through the process of elimination to establish why your baby is waking. Thereafter you may need to help your baby learn strategies to fall asleep independently so you can get a good night’s sleep. By Meg Faure

Just as you get it all right and think you are on the track to having a baby who sleeps through the night, you get one disturbed night of sleep and it sets you back big time! The question is: are there typical times that you should expect nighttime hiccups? Sleep and your newborn baby In the early days, most babies wake two to four hourly for feeds at night, especially breastfed babies. The night wakings gradually reduce and within a few weeks (usually at around 6 weeks of age) your newborn should start to stretch for one long stretch of five or more hours once at night. Usually the first stretch to develop will be from bedtime to around midnight, as your baby drops the late evening feed first. Don’t be tempted to wake your baby up earlier, to feed, in the hope that it will do away with the 2 am feed - they are usually too tired to feed efficiently and this can cause longer-term sleep problems! If you are having sleep problems at this age it is usually one of the following issues: Your newborn may have their day and night muddled up. Newborns can be too sleepy to feed well, fall asleep at the breast and therefore need to feed more frequently At 2-6 weeks, many newborns become more wakeful and hard to settle to sleep, especially during the afternoon and early evening. 4-6 months old From birth your baby will slowly and steadily begin to sleep for longer and longer stretches at night and you will have the satisfaction of the occasional longer period of sleep. But just as your baby pieces it together and is almost ‘sleeping through’, he will start to wake more frequently again. This happens as your little one begins to require extra nutrition at night, the milk feeds that used to sustain him are no longer doing so and you have three choices: Your baby needs nutritional support at night, so feed him when he cries if three or more hours have passed. Don’t be tempted to ‘dummy’ him because it will impact on sleep later if habits develop. In this way your little one will go back to sleep and wake again in 4 hours for another feed. This is a good idea if Your baby is less than 17 weeks You or your baby have confirmed allergies (in which case you should delay introducing a formula or solids) Offer a top up bottle at bedtime or if he wakes shortly after going down Introduce solids Give your baby a top up feed of formula or expressed breast milk in the evening. Treat this as a cluster feed just before bedtime Start looking at introducing solids – look at simple single grain and yellow veggies.8 months old At around 8 months old, your baby will start waking due to separation reasons or plain old habits. At this age your baby is working hard to establish object permanence – the awareness that you exist when he can’t see you. To decrease the effect of this milestone on sleep: Encourage a sleep soother such as the Baby Sense Taglet or dummy that can be used independently. Play separation games during the day – ‘peek a boo’ or hide and seek. Listen to your baby at night before going to him and see if he resettles on his own. If he cries, go to him, give him love and help him settle on his own with a doodoo blanky. Do not be tempted to feed him at night before 2am as this can lead to habits developing. Sleep and your baby 6m - 12m From 6 months, if your baby is on a full solids diet and has learnt to self-sooth, he can be expected to sleep through (10-12 hours without waking for a feed). After 6 months of age obstacles may presents themselves: If your baby is still waking is may be because he has developed a habit and expects to be resettled in the night in the same way as he falls asleep at bedtime. Alternately night wakings can be due to nutritional needs - your baby now needs specific essential fatty acids for brain development. These nutritional essentials are found in the fats in proteins. So now is the time to introduce protein in the form of dairy, meat, beans and chicken to your baby’s diet. At this age, teething can also disrupt sleep for a few nights. If your baby is definitely teething at night – and make this decision during day light hours when you can actually see the tooth. If there is evidence of teething, use teething powders or painkillers as necessary. Remember though that we tend to blame teething far too quickly and the reality is that it is rarely teething that is the problem and if so only for two to four nights as the tooth erupts. Separation anxiety also affects sleep especially around 8-10 months – as your baby develops object permanence, he may become insecure when you are not around. To decrease the effect of this milestone on sleep: Encourage a sleep soother such as the Baby Sense Taglet or dummy that can be used independently. Play separation games during the day – ‘peek a boo’ or hide and seek. Listen to your baby at night before going to him and see if he resettles on his own. If he cries, go to him, give him love and help him settle on his own with a doodoo blanky. Do not be tempted to feed him at night before 2am as this can lead to habits developing. Toddler years Toddlers are notorious poor sleepers. Your toddler will wander at night and come through to your room. In fact more toddlers co-sleep than newborns, according to recent research! Toddlers call for their parents at night due to night fears and boundary issues. To address this, leave a night light on and encourage your toddler to use a comfort object instead of coming to you. If your toddler repeatedly wanders into your bed at night you have three choices: Repeatedly walk him back to his bed – while this will be exhausting initially, your toddler will eventually learn that night wanders brings no joy. Let him climb into your bed and share a bed with him Find the sense-able middle ground – have a mattress under your bed that he can pull out and sleep on at night – this means your bed remains your own but your toddler has access to you at night. By Meg Faure

Helping your baby to sleep through the night is a goal for most parents. Sleep disruption is so distressing for most mothers that the sooner your baby sleeps through the night, the better. The tips below are in no particular order but by implementing them all you should be in for a better night’s sleep soon. Safety Put your baby on his side or back to sleep on a firm mattress without any pillows or duvets to limit the risk of SIDS (Sudden Infant Death Syndrome/ Cot death). Do not use duvets or blankets, rather keep your baby warm with a baby sleeping bag for safety and convenience. Sleep environment For good sleep habits try having your baby in his own room (if possible) by three months, as you will both have more rested sleep in your own rooms. Make sure the room can be darkened for day sleeps and morning lie-ins by putting block out lining on the curtains or blinds. Use soft linen in the cot and for cool nights, warm the room up a little, without over heating your baby. For the slightly older baby (after 4 months) use a sleeping bag to keep your baby warm to prevent the classic 4am night waking due to kicking all the blankets off. Under three months If your baby is very colicky in the evenings and you find bedtime is delayed to late due to fussing and crying, try to limit handling after 4 pm. Swaddle your baby in a 100% cotton, stretchy fabric such as the Baby Sense Cuddlewrap to help calm them and to limit night wakings due to uncontrolled body jerks. Bedtime routine Have a consistent time for bed with a predictable routine leading up to bedtime. Between six and seven in the evening is an appropriate time for babies and toddlers. Start the evening routine with a soothing warm bath followed by a calming massage (for babies not suffering from colic – colicky babies do better having the massage in the morning). After bath, don’t leave your baby’s dimmed room and keep all interactions in the room calming with less handling and stimulation. Evening feed Feed your baby as much as he will take before bedtime. If your breast milk supply seems low in the evenings, offer your baby a supplementary or top-up feed of expressed breast milk or formula milk before bed. Put your baby to bed awake Rouse your baby after the last feed so that he has to fall asleep without the aid of props such as bottle or breast. The way in which your baby falls asleep in the evening will be what he expects in the middle of the night, i.e. bottle, breast, dummy/pacifier, rocking, etc. Handling fussing at bedtime After three months, expect a little fussing as your baby settles himself to sleep. To manage this, without developing habits, leave your baby in his cot but sit with him, with your hand on him and encourage him to fall asleep after a little fussing. Night feeds Never wake your baby at night for a feed, unless your paediatrician has instructed you to do so because your baby is ill or very underweight. Wait for your baby to signal that he is hungry at night. Calm night feeds Keep the middle of the night feeds strictly business affairs – with no stimulation: keep the room dark, using a passage light to see for feeds. Don’t change your baby’s nappy or diaper at night feeds unless it is soiled or your baby has wet through the nappy. Limit the time for burping, your baby will settle best after a night feed if he is resettled quickly. Sleep coaching Sleep coaching starts from around 4 months of age when you can start encouraging your baby to self sooth instead of relying on you to put him all the way to sleep. This is not sleep training or letting your baby. It is gently encouraging him to find his hands, fuss a little while he settles himself or allowing him to access other strategies. Only sleep train your baby after six months and then only after ruling out all other causes for night wakings. To sleep train your baby – give him the opportunity to self-calm by not responding immediately when he cries at night respond once your baby is really crying or within 5 minutes do not lift your baby from the cot, rather sit with him and encourage him to self-calm as hard as it is, sit with your baby for as long as it take for him to resettle. In this way your baby does not feel abandoned but get the message that you are there but he must go to sleep. By Meg Faure

We stumble into first time parenting, with no manual on how to bring up our unique baby and make mistakes as we go along. A year down the line, we look back and say – “Oh wow if only I had not … then Mary would not have allergies” or “If only I had known how to … Joe would sleep better!” Wouldn’t be great if someone could say watch out for these pit falls. Big 5 Bedtime Boo Boo’s – the things you should avoid doing so that your baby’s sleep habits will develop well. Feeding your baby to sleep If you feed your baby to sleep every time you put him down he will begin to associate sleep with feeding and eventually as he approaches 9 months, may need to be fed every time he wakes at night. In the early days, sleepy newborns tend to fall asleep at the comfort of the breast. This is not a concern. Only from 4 months old will your baby begin to form habits and from this age onwards be sure to rouse your baby after the feed so that he goes down in his crib awake but drowsy. Keeping your baby awake all day to help him sleep better at night A real misconception abounds that a tired baby will sleep better at night. In fact nothing could be further from the truth. In reality, if your baby gets overtired during the day he is more likely to wake at night. These babies usually fall asleep very easily but after three hours sleep wake up repeatedly through the night. Be sure to follow the awake time suggested for your baby’s age in Baby Sense and put your baby down when he is needing to go down – regularly through the day. Using the dummy at night to get your baby to resettle without a feed Some babies start to sleep through the night before three months of age but when they are ready for solids begin to wake earlier and earlier each night. Instead of being tempted to pacify him or put him back to sleep with a dummy, rather feed your baby when he wakes if more than 4 hours (for a baby over 4 months old) have passed. Your baby is probably hungry and needs to be fed. If you ‘dummy’ him back to sleep, you will probably be up 45 minutes later when he is reminded of his hunger during his light sleep state. By using a dummy to coax him back to sleep, you will end up with a dummy waking habit at 9 months old. Make your baby fit your lifestyle by putting him to sleep wherever you areTo develop good sleep habits your baby should have a familiar sleep zone – a space where he goes to sleep every night at the same time. If you are going out get a baby sitter or your family (that’s what grannies are for) to help out so that your baby is not falling asleep overtired in an unfamiliar environment. Waking your baby at 10pm in an attempt to avoid the 2am feed The idea that you can influence your baby’s night sleep rhythm by waking him when it suits you sounds like wisdom but in fact most babies are disrupted by this forced waking. Your baby will probably feed very poorly as he is too tired and not hungry enough to feed. He will then go on to wake after midnight anyway as he did not feed well enough at 10pm. But worse than that if you wake your baby up sufficiently that he does feed well, he is probably wide awake and may not resettle easily or may have long term sleep problems as he has not been left to develop good sleep rhythms independently. By Meg Faure