She is gentle and wise and not frightened of rethinking approaches. I recommend her unreservedly.
Tara, mother to Eva and Imari, aged 3 and 7 months
10 top tips for working parents embarking on a sleep plan
1) Keep a detailed diary for 48-72 hours tracking sleep, feeding/eating and activity to give a realistic overview of the issues and patterns of your child's sleep and behaviour - when you're exhausted, frequent night wakings are hard to keep track of
2) Rule out any underlying digestive or health issues affecting your child's comfort levels
3) Tackle the quick wins first: optimise naps, adjust sleep environment, review sleep hygiene and the bedtime routine etc
4) For a more intensive plan, try to clear 2-3 weeks in your diary so that you can keep consistency in your child's familiar home environment
5) Implement change at bedtime on a Friday night or when you have the longest period available with support or off work
6) Review the consistency of your child’s routine if they have different childcarers so that you can keep their body clock well regulated
7) Divide the night or share settling with a partner if you can
8) Think about whether any chores can be outsourced or friends/family can help
9) Changing habits and the way brain processes sleep and associations takes time, so be patient with progress when you’re working gently with your child
10) Get yourself ready for bed and eat dinner early ahead of your child's bedtime if you can so that you can devote the evening to helping them settle and resettle in a new way without getting frustrated (or starving!)
Diagnosing and managing a cow's milk allergy in the first year of life
If a cow’s milk allergy is being explored as a possible cause for your baby’s symptoms, there are now some very clear, updated guidelines for presentation of suspected CMA in the first year of life, as well as how it should be managed by primary clinicians.
Allergies can cause unsettled sleep and more frequent night wakings, as well as skin, gut and respiratory symptoms, so getting to the bottom of the food that is causing problems is likely to unlock better health, wellbeing and sleep for your child.
Here’s a summary of the iMAP fact sheet published for parents:
Food allergy has become more common and happens when a child’s immune system wrongly reacts against some of the proteins in food, thinking they may be harmful. This will then result in either the onset of an immediate allergic reaction or a more delayed onset reaction.
The typical mild-to-moderate symptoms include one or usually more than one of the following:
• Irritability (colic), reflux, vomiting, refusing or disliking being fed, loose or frequent stools, constipation (especially straining to pass even a soft stool), signs of pain in the tummy, a little blood or slime in the stools
• Itching of the skin, redness of the skin, a tendency to ‘rashes’, eczema
• CMA is more likely to be the cause of these symptoms if there is a history of eczema, asthma, hay fever or food allergy in any close family members, but does not have to be present.
There are no skin or blood tests for delayed onset CMA. The only reliable test is to take all the cow’s milk protein out of your diet if you’re exclusively breast feeding or out of the diet of your baby if they're bottle fed by switching to an extensively hydrolysed formula, and then to later reintroduce it in a planned way.
The period of exclusion should be up to 4 weeks (minimum or 2), as this is the time it may take for the symptoms to improve. During the trial, the symptoms will either begin to clearly improve, suggesting the presence of CMA, or there will be no significant change, which usually excludes the diagnosis of allergy.
At the end of the trial, it’s really important to reintroduce the cow’s milk protein. This will then show you whether any clear improvement seen in symptoms during the trial was actually due to CMA and not just your baby improving naturally. If allergy is the cause, the symptoms can be expected to return within a few days of reintroducing the milk protein, but will usually settle well again as the milk-free diet is restarted. If the diagnosis is confirmed, these guidelines are here to ensure that your baby gets appropriate care and the on-going support of a dietician.
Immediate onset of CMA:
• This usually affects older children and often due to other foods, such as egg, peanut, tree nuts or sea food. But it can also occur with cow’s milk and most commonly when cow’s milk-based formulas are used as top-ups or later when weaning with solids and dairy is introduced (yoghurt, cow’s milk, cheese etc).
• Symptoms usually develop within minutes following ingestion, which may be mild, such as reddening of the skin, hives and puffiness around the mouth or eyes or less common is anaphylaxis.
Click here for a link to Allergy UK's resources and the guidelines maps, which you can take with you when seeking a diagnosis or making an initial appointment with your GP.
Top tips to improve your child's sleep hygiene for a calm, positive bedtime
GOOD SLEEP HYGIENE is one of those terms that sleep consultants use all the time. This blog post explains how to achieve this and how you can improve your child’s sleep without resorting to more traditional sleep training programmes.
Many sleep training techniques take time and effort to undertake, and I know many parents often feel overwhelmed and daunted by the probability of getting even less sleep in order to address night time behaviour, so beginning with some simple strategies for bedtime, as well as in the lead-up to bedtime, is a great place to begin.
Facilitating time to wind down before the bedtime routine starts, establishing a series of predictable soothing cues and positive associations with the bedroom as a peaceful, restful place, using optimal lighting away from bright, social spaces and getting the awake time right, together in sequence, will all help to promote a calmer bedtime and a better quantity and quality of night time sleep, whether your child is 6 months or 3 years old.
Choosing a set bedtime:
An ideal bedtime is between 7-8.30pm, as this is likely when melatonin is rising. Choose a bedtime and routine that is manageable for your family across the week and weekend, so that you can consistently begin at the same time each night and follow the same sequence of calming stages that lead to your child being settled in their cot or bed. Aim for no more than 30-45 mins from start to finish so that the cues for sleep aren't lost, keeping it focussed around the bathroom and bedroom, so that you’re not bringing your child back into a light, social space they associate with play.
Benefits of a bath:
A daily bath is a great way to begin your bedtime routine each night as it’s a wind-down activity at the end of the day when children are starting to get fussy and tired, it signals the beginning of the cues for night time sleep and the drop in core body temperature coming out of the warm water is a key sleep trigger. In hot weather, just run tepid water so that your child doesn’t overheat.
Swapping screen time for calm play:
We know that the blue light emitted from screens interferes with the production of melatonin, so turn TV and screens off after dinner to give your child’s brain time to unwind and recover. Try some calm play strategies instead before you run the bath, like a filling a ‘treasure bag’ with items to pull out and explore, jigsaw puzzles or shape sorters. If time between returning from work/collecting from childcare and bath time is squeezed, even just 5-10 mins of quality parent-led calm play can make a difference to help your child wind down after the excitement of seeing you, as well as giving their love tank a boost before bed.
Keeping the bedroom as a place of refuge and sleep:
Take away anything from in or around your child’s cot or bed that could be distracting or emits a glow, like a mobile, light show or lots of soft toys. If you have another area in the house for play, it really helps to keep most toys out of the bedroom, particularly anything that’s overstimulating, like toys that are big, bright and noisy. Declutter the floor so that everything can be tidied away out of view and out of reach as part of the bedtime routine, as well as for nap time.
If your child is exhausted and crashing out at bedtime, look at increasing daytime sleep or shifting bedtime a little earlier, even just by 10/15 mins to begin with. ‘Crashing’ asleep changes the architecture of the sleep cycle and does not allow a child to experience the gradual shifts in sleep state as they fall asleep. This can be one reason why they wake up after the end of each sleep cycle as they are unfamiliar with the changing sleep state. Conversely, if it’s taking a long time for your child to fall asleep each night, it’s likely that they are just not tired enough and you need to increase sleep pressure by reducing daytime sleep or increasing awake time before bed (particularly if bedtime is earlier than 7pm).
Optimal sleep latency:
The optimal sleep latency (the time it takes your child to fall asleep) is around 15 mins or between 10-20 mins. It’s hard to accurately measure but you can get a sense of whether you child is crashing quickly, falling asleep gently and comfortably in a timely way or conversely struggling to settle, alert and restless. As children drift into sleep, they often move around, toss and turn, move their head from side to side, clear their throat or make murmuring noises. Once deeply asleep, they become very still and quiet and breathing becomes soft and steady.
Nutrition for sleep:
Avoid refined carbs, sugary or caffeinated foods close to bedtime. If your child has an early nursery tea and is hungry when you pick them up, stick to foods with protein and fibre, like egg or peanut butter on wholegrain toast, bananas, oatcakes or natural yoghurt, rather than sweet cereals or treats.
Children’s eyes are more sensitive to light than adults’ so in summertime especially, it can help to start dimming lights/closing blinds and curtains around the house and using a dimmer light in the bathroom too. Really effective blackouts are a worthy investment so that light doesn’t creep around the edges at bedtime (or from sunrise for those early risers). If your child is afraid of the dark, choose a red night light and position it away from the cot and their eye line, as this will inhibit melatonin less.
Benefits of exercise:
Try to do at least 1 activity a day that gets your child’s heart rate up and plan for lots of outside play and fresh air. Bouncing is a great activity for babies not yet on the move, set up an obstacle course in the house if it’s raining or try some baby/toddler yoga or dancing together. Toddlers, especially, have boundless energy and they need to expend it during the day!
My toddler doesn’t want to sleep in their cot any more – are they ready for a bed?
Here’s a really common scenario … Your lovely toddler is between 18 months to 2 years and has been sleeping well but then, seemingly out of the blue, starts to battle going into the cot and doesn't want to go to bed. You hope it’s a one-off but then it happens again the next night, and the next night. They seem well and aren’t in discomfort with teething during the day but they suddenly don’t want to fall asleep without you and get very upset when you leave the room. Then, the more you’re needing to intervene and comfort at bedtime, the more nightly wake-ups are creeping in, settling becomes increasingly challenging and, when you pick them up, it’s an endless battle to get them back into the cot. They may end up coming into your bed during the night or you find putting a mattress on the floor in the room to lie with them makes it more bearable. It seems like they just absolutely hate the cot now and maybe they’re just ready to transition to a bed instead and then it will all settle down. Sound familiar?
Though it can seem like the best resolution when cot battles and nightly wake-ups are just too exhausting, the issue is more likely to spiral, rather than resolve, and it probably isn’t the cot that’s the problem. Inevitably, you will still have a child that’s increasingly attached to your proximity and comfort to fall asleep and will battle bedtime in their new bed but now, they are also freely hopping out of their bed and coming out of their room into yours during the night.
So my advice is to hold off jumping into a big transition that your child may not be ready for, because most children at this age don’t have the maturity and reasoning to cope without physical boundaries out of their cot. They can be too overwhelmed by having so much control over their sleep environment and the increasing reward for delay tactics and getting out of bed with more cuddles, being tucked in, extra drinks, coming into your bed etc, as you try anything to coax them back to sleep again, is a hard cycle to break.
The best course of action is to review all the factors that are affecting your child’s sleep and try to understand why they are behaving in the way that they are and how best to support them through this unsettled phase, whilst re-establishing your boundaries around sleep times, so that they can happily sleep in their cots again. Then you can make the transition to a bed when they’re really ready and when you’ve prepared them for change. I usually recommend waiting until toddlers are nearer 2.5 years, as these extra months make so much difference as to how well they will cope with having ‘invisible’ boundaries. This is often the age too where the nap phases out as children begin to consolidate all of their sleep at night time.
Toddlers notoriously struggle with significant change – whether it’s adjusting to new childcare or a new baby sibling, parents returning to work, weaning from breastfeeding, a long period of illness, travel, sleeping away from home or holiday periods like Christmas when they’re out of their normal routine. This is frequently the trigger for unsettled sleep and those phases when young children feel the separation from primary caregivers more keenly, particularly because they're at an age where they may not yet grasp the reliability of them coming back. So do think back to when the issues began to see if it fits with a pattern of change for your child. Readiness to sleep for this age group is also often further exacerbated by too much daytime sleep or not enough, inconsistency with routine, too much stimulation in the lead up to bed or the bedtime routine taking too long so that the cues for sleep are lost.
Here are 10 steps you can take:
1. Review the length of your child’s nap and the timing of bedtime so that they are ready to sleep when you say goodnight. It’s very normal for toddlers and young children to chat away, play with a special comforter and process their day for a little bit as they unwind to sleep, so taking up to 10/15 mins to fully settle is ideal.
2. If your child is exhausted and crashing out at bedtime, look at increasing daytime sleep or shifting bedtime a little earlier, even just by 15 mins to begin with. Conversely, if it’s taking a long time for your child to fall asleep each night, it’s likely that they are just not tired enough and you need to reduce daytime sleep or increase awake time before bed.
3. Choose a method to help settle your child in their cot when they are awake, and wean them off your support to fall asleep. If you want to work in gentle steps you can phase out physical contact and increase your distance gradually but the key is ensuring that all the conditions are right for your child to sleep and that you are consistent with your approach at bedtime, during the night and nap time. If your child goes into the cot when they are awake enough to know where they are, they can fully experience what it feels like to move through the phases into a deep sleep. Then, when they rouse in light sleep during the night, they’re in the same place that they fell asleep and they will be more receptive to being resettled in the cot too.
4. The bedtime routine is most effective when it’s a series of stages you repeat at the same time, in the same way every night, so that it’s predictable and conducive to sleep. Keep it calm and focussed around the bathroom and bedroom, so that you’re not bringing your toddler back into a light, social space they associate with play. Declutter their bedroom and make sure it is a place of refuge, calm and sleep.
5. Turn off screens and electronics at least an hour before bedtime and avoid sugary foods and refined carbs before bed. If your child has an early nursery tea and is hungry when you pick them up, stick to foods with protein and fibre, like egg or peanut butter on wholegrain toast, bananas, oatcakes or natural yoghurt, rather than sweet cereals or snacks.
6. Time your bedtime routine so that it is no more than 30 mins from going in the bath to lights out and saying goodnight, so that your child gets the full effect of the drop in core body temperature, which is a key trigger for sleep, and there’s less room for manoeuvre with the sleep cues happening in quicker succession.
7. If your toddler has worked out how to vault over the bars of their cot, then transitioning to a bed may be more urgent for their safety, but often simple changes like dressing them in a sleeping bag again (or even wearing one with a zip back to front if they’ve learnt how to wriggle out of one with poppers) or removing furniture around the cot that aids the escape may help, so that you can delay the transition until they are emotionally ready. If you need the cot for a younger sibling, see if you can borrow a spare one from friends or family, or well worth buying a cheap second hand one instead so that your baby can transition at the right time but your toddler's not rushed out of their cot.
8. Do recognise phases when your child is feeling more insecure so make time for special 'talking time' and lots of cuddles and touch during the day when they are happy and content (not just when they’re upset), so that they’re less likely to seek physical contact at night. Play games like hide and seek to help your child understand that you do come back. Incorporate lots of physical and outside play into the day, as well as time for mental stimulation with puzzle-solving and activities that require focus, like finding hidden toys, building a tower etc.
9. From the age of 2 is a good point to introduce a system like a sun clock or timed lamp so that your child knows when morning has started and when to call for you to get them up – toddlers love the responsibility and it’s really key to have this established first as, once they’re sleeping in a bed, 5am can feel like morning. Do set it for a realistic time initially based on their average wake-up and then you can gradually shift it later by 5 mins at a time. With a Gro Clock, make sure you use the setting to turn off the blue glow so that it remains dark in the room overnight.
10. If your child has a good daily bedtime routine that’s predictable and conducive to sleep, they can fall asleep happily in their cot, you’ve taken time to prepare them well so it’s not a sudden change (being mindful that sleeping in something new may be unsettling to begin with as they’ve been in their cots for majority of their lives) and you’ve taken steps to maintain your boundaries around sleep, then it should be a smooth transition.
Does your child's room really need to be that dark?
Having finally found some brilliant black-out blinds that actually serve their purpose and block out all light, I was dismayed last night, as I put my boys to bed, to find they had totally blown out of place with Storm Doris and our drafty old windows!
I have spent many hours over the past few years attempting to make my children's rooms pitch black with various triple-layer systems and copious duct tape (and my husband looking on with bemusement) so, perhaps, my desire to block out every chink of light is a little obsessive .... But, there are many reasons why darkness is best for young children to sleep.
My first tip, before you embark on any sleep training techniques, is to make the bedroom where your baby or toddler sleeps as dark as possible, so that they can't see you or make out things in the room and light doesn't seep through or around curtains and blinds - whether it's at night-time, early in the morning or for naps during the day. It won't magically fix their sleep issues, of course, if they still need lots of input from you to fall asleep or the timings of their routine aren't quite right for their age but, it can certainly help with settling and resettling in the cot, especially if you're working on gentle techniques to put your baby down more awake. If your child sleeps in your bedroom, it also means that they can't see you in bed, which is often one of the problems that arise when they discover standing up in the cot. Equally, as the early morning hours are becoming brighter now, there's less chance that they will think 5.30am is an acceptable wake-up time.
In the early weeks and months, newborns have an incredibly high sleep drive and different sleep phases and schedules to us. Rather than taking cues from light or darkness, they are guided by hunger, waking to feed and sleeping when sated, and don't develop their internal clocks until around 8-10 weeks. At around 3 months begins a stage of rapid development, with sleep requirements reducing, awake time during the day increasing, circadian rhythms developing and babies becoming biologically ready to sleep for longer periods and more responsive to routines. This means that you have a stronger influence on when sleep occurs and can help create the right sleep environment to enable your baby to fall asleep, and fall back to sleep, more easily.
Sunlight triggers the brain to release cortisol, which makes us feel alert, and this is why exposure to light in the morning synchronises our bodies with the 24-hour day. In darkness, our eyes send messages to the brain to secrete melatonin, which makes us feel drowsy. Children need melatonin to fall asleep but also to stay asleep for longer overnight, and being in control of the light that comes into the room, rather than going by sunlight, can make a big difference to sleep patterns, especially in the summer months. Similarly, night lights, monitors that glow or light shows will inhibit melatonin secretion, so these are best avoided. However, if you have a toddler or older child who requests a night light in the room, choose a red one.
Sleep pressure is at it's highest point in the day at bedtime, especially following the sequence of cues of a regular bedtime routine, like winding down with a bath and massage, into night clothes and milk. However, during the day, it can be harder for babies to transition from social play in a bright space to 'nap-time', especially as their awake time increases. Equally, if your baby continually wakes after 30-45 mins, it really helps to have a dark room so that there is a cue to return to sleep and your baby or toddler will be more responsive to being resettled than if they awake in light and think you've come in to get them up and interact.
Parents are often concerned that, by being stricter about darkness at home around sleep times they will be creating the proverbial 'rod for their own back', and ask how to manage naps on the go, holidays and staying away from home. These are occasions when babies and toddlers are most likely to be disturbed by noise/light or unsettled by a change of environment so, the darker, the better. Travel blackout blinds and breathable snooze shades are fairly inexpensive, easily portable and hassle-free, so well worth investing in to create the best environment for sleep, wherever you are. Then, as children get older, they stop needing to nap during the day, they sleep more deeply and need less night-time sleep, so blackouts become less essential.