Kinga Molitorisz

The benefits of sleep training techniques and their use by age

Sleep training techniques refer to various methods and strategies used to help infants and young children develop healthy sleep patterns. These techniques have evolved over time, with key figures contributing to the science of sleep, and having an impact on their use in the field of sleep. There are many sleep training techniques that are used by sleep practitioners, and during my course, I have had the chance to learn about them. I have read about their usage in various books written by professionals who have been researching sleep, sleep techniques and their recommendations for particular sleep situations. Before we can go into the techniques, let’s discuss the concept of sleep training, and various opinions on it’s effectiveness and impact on children. Subsequently I will choose the techniques that I am most at ease with and describe them, along with their intended target age group.

            Sleep training aims to enable babies to sleep for multiple hours during the night without assistance. In the event that they wake up, they acquire the ability to self soothe and return to sleep. When a baby is sleep trained, they can sleep for 9-12 hours at night. By sleeping well, they will feel better throughout the day and their parents can also enhance their overall quality of life. Babies will still require naps during the day, but tired parents (especially mums) can enjoy a more restful sleep. In just a few days, babies can learn to sleep on their own using certain sleep training methods. The process may take longer for others, especially those who use gentler methods that minimize crying. There is no right or wrong way to sleep train. Success requires consistency and patience.

Before we look at sleep training techniques we need to consider the child’s overall health and development. We look at the child’s general health, if they have any sleep disorders, anxieties and stress. We also look at sleep hygiene, which involves the child’s routines especially bedtime routine. We look at the routines consistency and if they benefit the child. Is the routine consistent and at appropriate times or needs to be changed. We also aim at establish positive sleep associations for children who have been nursed to sleep or have fallen asleep with the TV on or in a different room from where they sleep.

Babies between 0-3 months don’t have their circadian rhythms established yet, so we cannot sleep train children at this young age. They fall straight into active sleep and they cry, grunt, move their limbs. They sleep between 16-18 hours. Starting at about two months old, it’s a good idea to try to put them down drowsy but awake whenever you can, just to get them (and you) used to it, even if they fuss a bit. We can start introducing routines that will help babies establish the difference between day and night. This will help regulate their body clock. Sleep hygiene is also important and the baby’s sleep environment needs to be looked at. Regulating sleep can be achieved through daytime activities, feeding, and bedtime/nap time routines.

            Dr Harvey Karp recommends the 5S’s to calm babies and get them to sleep:

1. Swaddling: helps going to sleep as it resembles the tightness in the womb. Newborns have a falling reflex (Moro reflex). Babies instinctively throw up their arms when they feel like falling. This reflex makes them startle and awake. Restricting arm movement helps and reduces startles and arousals by up to 90%. Swaddling can be used until baby learns to roll over at about 5-6 months of age. Parents need to make sure they don’t swaddle too tight as this can cause breathing issues and hip displacement.
2. Side/Stomach: is the babies feel-good position. Soothes the screaming newborn and shuts off the Moro-reflex, however this should not be the babies sleeping position as to prevent SIDS babies should always sleep on their back
3. Shhhhing: is babies favourite soothing sound. The louder the baby cries the louder the shhhing has to be to calm them.
4. Swaying or swinging is a movement that is rhythmic monotonous, jiggly. Must be vigorous at first to help the baby stop screaming, and then it can be reduced to a gentler motion to keep babies calm.
5. Sucking: triggers the calming reflex and releases natural chemicals in his brain, which lead to relaxation. According to Karp the all-time number one sucking toy is a mother’s nipple.

The first two S’s start the calming process by shutting off the Moro-reflex and the 3^rd and 4^th break into the crying cycle by triggering the calming reflex and soothing the baby’s  nervous system. The 5^th S keeps the calming reflex turned on and allows the baby to relax.

Babies aren’t ready for sleep training until they’re 4-6 months old. Before then, they haven’t developed the circadian rhythms that will help them sleep through the night. At this age, they’re able to pick up skills like sleeping independently, and they haven’t gotten too used to you rocking them to sleep.

Six months of age is generally agreed to be a good time to start sleep training, although you can begin as early as four months or as late as nine months. Nine months can be better for some babies since they no longer need to eat during the night at this age.

It can be difficult to know when babies are ready for sleep training. However, if a baby starts to fall asleep on their own at night (even if they wake up throughout the night), they’re most likely ready. Just as there’s no exact right age to begin sleep training, there is also the option not to sleep train. Babies will eventually learn to sleep on their own. The benefits of sleep training are significant for both babies and parents, with no evidence of negative long-term effects

When infants are unable to sleep well, it is distressing to both the baby and the parents. Children may develop paediatric insomnia, and parents are at higher risk of depression, stress, and poor health. In contrast, when babies get more sleep, their parents feel better, and so do their babies. Babies who get more restful sleep have fewer developmental and behavioural issues, and have a happier temperament overall.

When thinking about approaches over the years I have come across parents that firmly believed that the Cry it Out method was the easiest way for them to teach their child to sleep. But this method didn’t turn out to work with other children who were anxious and because their parents imposed this method on them up until today they have problems with their sleep. When it comes to using methods I personally wouldn’t use the CIO method but I tend to agree with/ use the Controlled crying/Ferber method if a baby is securely attached and there is no anxiety issues.

Dr. Richard Ferber is a leading figure in sleep training techniques, known for his book “Solve Your Child’s Sleep Problems.” He introduced the Ferber method, which has been in use for more than thirty years and has helped thousands of babies learn how to sleep independently. We’ll walk through how the Ferber method works and how to do it, with some clever tips that will help babies fall asleep independently sooner. 

The Ferber method, which is also known as “graduated extinction” is a type of sleep training created by paediatric sleep expert Dr. Richard Ferber. With this method, parents will allow their child to fall asleep independently, but return to comfort them at timed intervals. The Ferber(2013) method teaches babies how to fall asleep on their own and to return to sleep when they wake up during the night.

Some parents who use Cry it out(as an alternative sleep training method) choose not to return  to their baby’s room, even if the baby cries for a long time. Due to periodic check-ins on the baby when he/she is crying, the Ferber method is considered a gentler option.

During the check-ins, the parent, will visit their baby at intervals that gradually increase until the baby falls asleep. The check-in times increase on subsequent nights. Ferber refers to it as the “progressive waiting approach.”

Parents have the option to soothe their baby either verbally or through gentle rubs or pats. It’s best not to pick them up or feed them, and visits should last no more than a minute or two. Although sleep training may be emotionally challenging, the Ferber method has simple and straightforward steps. These are the steps:

1. After your bedtime routine, put your baby into her crib. She should be drowsy but awake.
2. Tell your baby goodnight and leave the room.
3. If your baby cries, wait for a set amount of time (more on how long below), then go back in to briefly comfort her by talking in a soothing voice or gently patting her. Don’t pick her up or feed her. 
4. Leave the room and repeat as needed if your baby continues to cry, going back in to reassure her at specific timed intervals.

Around 5 or 6 months is a common time for babies to be ready for sleep training, which includes methods like Ferber.  At that point in their development, they have the ability to self-soothe. Both day and night sleep can benefit from this technique. Sleeping without nursing through the night is possible for them now that they are old enough.  But if parents have any questions or doubts about their baby’s development, they should talk to their GP. 

It is not mandatory to start sleep training as soon as a baby reaches the 5 or 6 month mark. For some parents, holding off until their baby is a little older is more comfortable. This is also achievable keeping in mind that the older the baby gets, the harder it might be for them to learn to fall asleep on their own instead of being rocked, fed or soothed by their parent.

Ferber’s 2013 book ‘Solve Your Child’s Sleep Problems’(Ferber) suggests that parents using this method conduct check-ins at the following times:

Day 1

First check-in after: 3 minutes

Second check-in after: 5 minutes

Third check-in after: 10 minutes

Subsequent check-in after: 10 minutes

Day 2

First check-in after: 5 minutes

Second check-in after: 10 minutes

Third check-in after: 12 minutes

Subsequent check-in after: 12 minutes

Day 3

First check-in after: 10 minutes

Second check-in after: 12 minutes

Third check-in after: 15 minutes

Subsequent check-in after: 15 minutes

Day 4

First check-in after: 12 minutes

Second check-in after: 15 minutes

Third check-in after: 17 minutes

Subsequent check-in after: 17 minutes

Day 5

First check-in after: 15 minutes

Second check-in after: 17 minutes

Third check-in after: 20 minutes

Subsequent check-in after: 20 minutes

Day 6

First check-in after: 17 minutes

Second check-in after: 20 minutes

Third check-in after: 25 minutes

Subsequent check-in after: 25 minutes

Day 7

First check-in after: 20 minutes

Second check-in after: 25 minutes

Third check-in after: 30 minutes

Subsequent check-in after: 30 minutes

By having predetermined check-in times, consistency can be maintained and the baby can become more comfortable with soothing themselves. Parents are free to adjust the intervals slightly if they believe it would be more effective. Being consistent with any changes we make is crucial. If we are consistent, sleep training should be a successful.

            Babies respond to sleep training in various ways, and some babies are quicker at adapting  to the new bedtime routine than others. In general,  there will be a decrease in crying over the course of three nights. It is likely that it will cease altogether sometime between nights four and seven.

            Babies may experience some rough nights after sleep training, especially if they are sick, teething, or working on a major developmental milestone. Once they feel better, it should be simple for them to return to their usual routine now that sleep training has been established. Sleep training isn’t exactly enjoyable, but it doesn’t need to be dreadful either.

To be successful in sleep training with the Ferber method (Ferber, 2013), it’s important to keep a few strategies in mind:

1. Deciding on the start time for the sleep training. It’s crucial to schedule sleep training during a calm time for both parents and babies. Waiting until everything is settled down can be beneficial if the baby is sick or teething, or if the parents have a new babysitter or return to work. It’s best not to do sleep training during holidays, as travel will only derail efforts.
2. Wean nighttime feedings. Sleep training can be more challenging for a nursing mother, who responds to the baby’s cries by going to feed him/her.
3. Establishing a bedtime routine. Babies can wind down for the night with soothing activities like bathing, reading books, and cuddling. If feeding is currently at the end of the bedtime routine, parents should try to move it earlier to prevent the baby falling asleep at the breast or bottle. It is important for babies to be both drowsy and awake when they are put into their cot by their parents.
4.  Observing baby’s sleepy cues. Our goal is to place the baby to sleep when they are feeling tired but not overtired. Babies struggle to settle down when they are overtired. It is possible that their sleep is disturbed and wake up multiple times at night.
5.  Using the babies cot for bedtime and naps is important, as if the baby naps in other places they might have a harder time sleeping well in it at night.
6. It is important for both parents to be involved in the sleep training and to reach and agreement on the method of sleep training because they will need to support each other during the process. Having a partner come in may help the baby settle down more easily if the baby associates mum with nursing and comfort.
7. Consistency is essential. Hearing a baby cry can be challenging, and it might even cause some parents to abandon their plans.

            Research has demonstrated that, for babies over six months old, sleep training that involves controlled crying and bedtime fading leads to improved sleep and does not increase levels of cortisol. It is reassuring to know that if it leads to better sleep , a little crying won’t cause any harm to a baby.

            If the baby doesn’t make any progress, and continues to cry excessively, it may be necessary to take a break. Parents have the option to try the Ferber method again a bit later or take a different approach to sleep training. Having a conversation with the baby’s Health Visitor or GP is worth considering. They can assist in determining any underlying causes that could be preventing a baby from sleeping, such as infant acid reflux, teething or an ear infection.  Almost all sleep training methods involve tears. Within a week or two the baby and parents will experience improved sleep.

            Another method I will present is the gradual retreat method. This method can be used for children over 6 months of age, but can be used for children of any age. It can take from 2-6 weeks to see results. It is used with children who have been associating sleep with nursing, rocked to sleep or sleep on the parent.

            The gradual retreat method is based on the idea of a parent distancing themselves from a child little by little until they no longer need their parent or carer to be present for them to fall asleep.  The aim of the technique is to keep moving on to the next degree of physical separation every few days until the parent or carer is out of the room.

According to NHS guidelines, the gradual withdrawal method is suitable for babies six months or older. It can also be used for toddlers if they are having problems falling asleep or staying asleep.

It is also good for babies with health problems like reflux who have a poor association with sleeping. For example, babies with reflux often associate the cot with pain and to do any kind of rapid return type training with babies like that can often be too traumatic. It also suits parents who don’t want to leave their babies to cry. This method is not suitable for parents who want a quick solution and are unable to commit to sitting beside their baby for long periods during the night.

The steps to follow with this method are the following:

1. Place the baby into the cot and remain beside her until she’s gone to sleep. You can give as much eye contact and physical contact as she needs to settle

If the baby is standing in the cot, you can hold her as she stands along with cuddling and patting and so on.

You should speak calmly and reassuringly, but its best not to get her out of the cot or feed again.

This should take approximately two nights

• Once your baby becomes comfortable about falling asleep in the cot, you need to withdraw some of your physical contact. However don’t leave her alone yet.

Instead, remain beside the cot and reduce the contact slightly. Make sure that as she falls asleep, you are not touching her.

This will take approximately two nights.

• Sit on a chair or cushion by your baby’s cot. When your baby cries, go back to her and gently pat or stroke her. Try to avoid eye contact. As soon as your baby stops, very quietly move your cushion or chair slightly further away from her cot and sit down.

Repeat this, moving your chair a little further away from your baby’s cot each night until you are outside the room. Do this in tiny stages, so that your baby has time to get used to the change.

This can take up to two weeks.

When a baby is breastfed, fed to sleep these are the steps to follow:

1. To avoid falling asleep when breastfeeding, unlatch when sucking has slowed down or simply remove the bottle
2. Move the baby to the cot. In this case it is better for a partner to do it so the baby cannot smell the milk
3. Lastly you should stay with the baby, shushing but avoiding eye contact and engagement

Remaining as consistent as possible is very important throughout all sleep training techniques.  Abandoning a technique halfway through can make things worse in the long run. So making sure parents have a very clear picture of how they are going to respond overnight is important. Making sure they pick a period of time when they can commit to this, and when there will be as few distractions as possible is crucial to sleep training. The help of friends and family for support is also a good idea. The gradual retreat method is also mentioned in the Baby sleep book (Dr. William Sears and Martha Sears, 2008).

Dr. William Sears outlines a different approach to sleep training techniques knowns as “attachment parenting.” His focus is on fostering a strong bond between parents and children, promoting co-sleeping, and responding promptly to infant’s needs during the night. This philosophy stresses the importance of nurturing rather than encouraging independent sleep skills. In his book the technique is described as Fading away as the parent carer slowly eases their way out from the child’s room. In the book it is described how to sleep train a child that has just moved from a cot into a bed and is used to falling asleep with the parent present.

            The technique is not to be confused with bedtime fading which is a different sleep technique devised by Pauline Mitelman. This is a ‘no cry’ technique to align the child’s internal clock with the bedtime you want. This technique involves a gradual shift to the desired bedtime over several days. According to studies, the fading technique is an efficient method for overcoming a child’s persistent reluctance to go to bed. Toddlers and older children have been subjected to bedtime fading. It has been used on children who are both typically developing and have developmental disorders.(Kang and Kim, 2021). However, it may not be a suitable choice for every family. To achieve success, it is necessary to dedicate some time to learning the child’s current sleep habits, and to reprogramme the child’s circadian rhythms. It is important to modify any environmental or lifestyle factors that keep the child awake at night. You need to be prepared for short term difficulties, which could include setbacks and daytime fatigue.

            This is the detailed guide for this method:

1. Determine the child’s sleep requirements and establish a reasonable goal for their bedtime and morning wake-up time. It is helpful to take a look at the recommended sleep times for children within the child’s age range. Additionally, consider how the child interacts and functions. There are children who require a higher amount of sleep than others. For example a toddler of 18 months old requires in general a total of 11-14 hours of sleep, including naps, but 9-10 hours of sleep is sufficient for some. Others will need 15 hours.

2.Identify the factors that may hinder the child’s ability to fall asleep at the preferred bedtime. Is it too late for the child to take a nap? Is the child confronted with excessive morning light or bright evening light?

3.Determine the time the child is currently accustomed to sleeping and select a new bedtime that is 15-30 minutes later.

4.Ensure that the child is awake (with calming, pre-sleeping activities) until the newly adjusted bedtime comes. The goal is to help the child in developing a new concept that connects bedtime with a smooth transition to sleep.

5. Monitor the child’s response to the new bedtime and make any necessary adjustments. In case the child takes more then 15 minutes to fall asleep, make a change: On the next night, adjust bedtime to be even later(15-30 minutes).

6. After the child has been able to fall asleep within 15 minutes on two consecutive nights with the same bedtime, introduce a slightly earlier bedtime.

7. Male sure to provide the child with important circadian cues throughout this process. Set a goal for the child to wake up at the same time every morning. To adjust the child’s schedule to a more convenient one, it is important to expose the child to morning light at the same time every day. Also, if a child loses some sleep as a consequence, it can accelerate their adaptation to the new schedule. Increasing sleep pressure during the day will result in the child becoming drowsier at night.

8.Make sure to adjust your sleep schedule nightly to gradually decrease your bedtime it reaches the desired sleep time.

The duration of the method depends on the gap you are trying to close. It may only take a few days to if we try to get the child to fall asleep 30 minutes earlier. Training may last up to two weeks if we need to make an adjustment that takes longer then an hour.

            The purpose of the Cry It Out and Ferber Method’s is to keep children quiet during the night. They fail to teach children how to fall asleep, and it is not guaranteed that a child will become physiologically drowsy at bedtime. The objective of bedtime fading is to adjust the brain’s internal timetable. Children are provided with the necessary biological tools to fall asleep quickly, without any crying or protesting.

            Gradual retreat has similarities with the sleep shuffle/chair method devised by Kim West. She is also called ‘The sleep lady’. Parents worldwide have benefited from Kim’s assistance in getting their babies sleep through the night. Kim’s sleep plan is designed to be gentle and focuses on the baby. The method is suitable for babies from six months.

            Here are the steps to follow for this method:

• On the first night, you place the baby in the cot, drowsy but still awake, and sit in a chair beside it, holding their hand, stroking or patting them if necessary, until they fall asleep.
• If the baby becomes distressed, do everything in your power to calm her down and then restart
• Be calm and avoid excitement minimising emotional support
• In the course of the next few nights, the chair gradually moves further away from the bed/cot to the doorway, then outside but still in view
• Eventually you will be able to put her in the cot, say ‘night night’ and leave
• You use the same methods if she wakes up in the night
• Avoid picking up unless very agitated
• You should be waiting 5-10 minutes to allow the baby to calm itself first

The goal is to help the baby fall asleep easily at night, and to help her sleep through the night. This method will suit parents who want a gentle way of sleep training. The method takes time and patience from parents. It requires some commitment over the course of a few weeks, before the benefits can be enjoyed for years to come.

            I am comfortable in recommending this technique to the parents I have been working with as most of them want a gentle sleep training method. This is a straightforward method, but will not suit  parents who are seeking fast results.

            Older children also have difficulties falling asleep or staying in their bed. Some of them wake up too early. They might be dealing with school related issues or difficulties, anxieties. It is important to find out what is causing sleep issues. There might also be medical issues involved. I have worked with school aged children who won’t sleep in their bed, and suggested the Family meeting/ bedtime pass method. If one member of the family isn’t sleeping well, it can affect everyone in the home. While babies and toddlers may struggle with sleep and bedtime, it’s a different matter when school aged children consistently have trouble. From time to time, everyone experiences bad dreams and off nights. But if a school aged child is constantly struggling to fall asleep, has trouble getting to sleep without waking up, frequently resists bedtime and is clingy at bedtime, it is a good idea to have a family meeting and establish a set of sleep rules.

To make sure that children are aware of its importance we can take a few steps:

1. Arrange a family meeting to work together on the rules. By doing this the child will feel involved in the decision, and less likely to feel they are being punished. They will be more inclined to follow through on it.

2. Begin with a simple decision, such as which is the most optimal time for the child to fall asleep or attempt to fall asleep.

3. Establish boundaries that are significant and meaningful for the family and record them. For example we can have the child promise to not wake up again after the lights go out. We can set up rules about when they are allowed to wake up, for example to go to the bathroom. A parent can make promises such as ‘I will check on you after light out, if you are not noisy’.

4. Include tools that can provide assistance. By using sleep tools like bedtime routine charts, the child can follow them and the family can track if they are being followed.

The bedtime pass was developed by behavioural analyst Dr. Pat Friman. In 1999, Dr. Friman and research partner, Connie Schnoes, published a study they conducted using bedtime pass. It can be used with children that have autism.

The bedtime pass is a free ticket for the child to leave their room or to receive an extra visit from one of the parents at bedtime. A familiar item or toy can be used as a free pass object. Any time the child leaves the room after using the pass, silently guide them back to their bed or room without speaking or eye contact. When the child calls after using the pass, you can choose your response method. You can either ignore the calls or return after a specific length of time to remind that you are near and they can go to sleep.

Multiple studies have shown that the bedtime pass decreases bedtime resistance in children aged 3-10. I believe that the bedtime pass is an effective tool for struggling parents. This is a tool that should be used alongside boundaries, consistency, connection, and love.

These are the methods I am most comfortable recommending, depending on the age and stage of development of the child/children I am working with. There are plenty of other methods and approaches to consider depending on the child’s medical history, background, and problem’s identified. Sometimes a hybrid approach is necessary. The techniques will only be successful if the parents are in agreement and consistent with them. I have had a case where the parents were not in agreement with each other and were not following the plan, but they were expecting results. I have explained to them that in order for their children to follow the rules they need to be consistent as well when it comes to routines and attitude around them. They also need to model good behaviour and healthy sleep habits.

When it comes to other techniques I would personally not recommend the Pick-up put down method, because picking them up and putting them back down will likely result in too much stimulation. Also as mentioned before I am comfortable in recommending the Ferber method but not the Cry It Out as I believe that children need a certain degree comforting and closeness for them to thrive. Sleep training in general has an important influence on parenting strategies and the health of both children and parents. As a positive aspect sleep training can improve sleep patterns. The Ferber method has helped many infants in developing predictable and consolidated sleep patterns, which have resulted in improved sleep quality for both infants and parents. Establishing sleep routines that are consistent, helps parents improve their overall well-being. They can enjoy more uninterrupted sleep and reduce fatigue. Infants can be encouraged to develop independence and self-soothing abilities through certain sleep training methods, which can lead to their emotional and cognitive growth.

Before we make a decision in using them we also need to look consider negative aspects of sleep training methods. Critics claim that infants may experience distress and emotional detachment as a result of sleep training techniques, particularly those that involve prolonged crying. There is still ambiguity about the long term effects of these practices because every child is unique and what works for one child may not work for another. Certain children can experience sleep disruption and stress because some sleep training techniques may not be suitable for them. While sleep training techniques are widely used, there are no significant long-term studies examining how they impact children’s development, specifically in terms of cognitive, emotional, and behavioural outcomes. In the end it is up to the parents to decide if sleep training is necessary or not for their child.

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