Cribsheet

by Emily Oster

  On the other hand, a ten- or eleven-month-old should be able to go through the night without eating, and sleep training babies at that age tends to focus on both their falling asleep on their own and staying asleep through the night.

  Put simply, the goal of sleep training is not (despite what some would say) to deprive your child of basic needs like food and diaper changes. It is to encourage their going to sleep independently once those needs are met.

  A NOTE ON NAPS

  For the most part, the sleep books also suggest that you can use whatever system you are using at night during the day. This includes a version of “cry it out.”

  There is, however, no research I can identify that specifically focuses on daytime sleep training. There is no particular reason to think that crying during the day would be more or less harmful than crying at night, so on this dimension it is not clear if the lack of specific research is an issue. What is more complicated is the question of whether daytime sleep training will work.

  Daytime sleep is more complicated than nighttime sleep. It comes together later (as we talked about in the baby-organization chapter), and it is dropped sooner. Even infants who sleep very well at night have more variable daytime sleeping schedules. All this is to say that sleep training is likely to be more hit-or-miss for naps than at bedtime.

  SO, WHAT DID YOU DO?

  When Penelope was a baby, we lived in Chicago, and we had a wonderful pediatrician, Dr. Li, who happened to be part of the Weissbluth practice. We never saw Weissbluth himself, but the practice in general was supportive of sleep training. And we did sleep train Penelope, working roughly out of the Healthy Sleep Habits, Happy Child playbook.

  However, I will say we didn’t do the greatest job with consistency. We started with a form of Graduated Extinction—crying with checking—which definitely improved things, but didn’t fully work. We had months of on-and-off days of crying, and endless discussions of how long the checking intervals should be, who should do the checking, and so on.

  Finally, at one pediatrician visit, we explained our system to Dr. Li, who told us, nicely but firmly, that we should probably cut it out with the checks. When we did this, the sleep training finally took, and Penelope became (and remains) a good sleeper.

  I wanted to do a better job with sleep training the second time around. With Finn, we would have a plan—one we had written down, agreed upon, and would stick to.

  We used our family task-management software, Asana, for the planning. Jesse created a task—“Finn Sleep Training”—where we could discuss the details back and forth.

  (Why, you ask, do you not use email or—heaven forbid—discuss in person? We like to avoid emails for family tasks since they gunk up our work inboxes and it can be hard to find the thread later. And we, at least, have found that it is much more helpful to have discussions like this, especially when opinions abound and emotions run high, in writing rather than in person. It can be easier to fight it out in writing, so everyone gets to quietly think about what they are saying. Then we can save our in-person discussions for such exciting topics as departmental hiring priorities. Fun!)

  After some back and forth, we agreed on the following system.

  PART 1: BEDTIME/START OF NIGHT

  Finn will go to bed during Penelope’s bedtime, around 6:45.

  We will put his pj’s on and read him a book as part of the bedtime routine.

  He will nurse, and then we’ll put him down in bed.

  We will not return at all before 10:45 p.m.

  PART 2: OVERNIGHT SCHEDULE

  Will feed Finn the first time he cries after 10:45 p.m.

  After the first feeding, do not respond again until at least 2 hours after the end of each feeding.

  Example: If he eats from midnight to 12:30 a.m., then do not respond for another feeding until, at the earliest, 2:30 a.m.

  NOTE: THE LONGEST STRETCH OF SLEEP IS EARLY IN THE NIGHT, SO WEISSBLUTH SAYS WE SHOULD RESPOND MORE FREQUENTLY IN THIS PERIOD THAN AT THE START OF THE NIGHT.

  PART 3: THE MORNING

  Wake-up is between 6:30 and 7:30 a.m.

  If he is awake at 6:30 we get him up.

  If he is not awake he can sleep until as late as 7:30. At that time we wake him up if he is not up already.

  This plan is roughly in the Weissbluth mode. The goal was to encourage Finn to go to sleep on his own at bedtime, but not to deprive him of food. We started this around ten weeks, at which point he was still eating two or three times a night, but we thought he was ready to fall asleep alone at the start of the night.

  I did get a successful do-over on this one. Finn was much easier than Penelope—he cried for perhaps twenty-five minutes the first night, a few minutes on the second, and then very little after that. Just to be clear: He did get up (frequently) later in the night after this first stage. He was seven or eight months old before he actually slept through the night.

  I think part of our success was having a plan written down. You may not want to be quite so formal, and even if you have a plan, there will likely be some deviation from it—that is okay! But knowing at least in rough terms what you are planning, and agreeing with your partner on it, is likely a good idea.

  Part of our success with Finn, we know, was simply because he was an easier baby than Penelope. We were also more experienced parents. Even if you treat your kids exactly the same, they may be different. Some will respond better than others.

  Finally, a big part of our success on our second round was having Penelope there.

  The great fear during sleep training is that the next time you go see your baby, they will hate you. Your only hope for real success is if you can convince yourself that this is good for your family, and will help you and your baby be better rested. And if you can remember that it will not cause long-term harm.

  Of course, this is all hard to remember in the moment. When we were going through this with Finn the first night, he was crying and we were finishing putting Penelope to bed. I was anxious—no matter how convinced you are of the plan, it is very hard to listen to your baby cry. Penelope looked at me—very seriously—and told me, “Mom, whatever you do, you can’t go in. He needs to learn to sleep on his own. We have to help him do that.”

  In the presence of a child who was sleep trained and obviously does not hate you, it is hard to hold on to your fear.

  The Bottom Line

  “Cry it out” methods are effective at encouraging nighttime sleep.

  There is evidence that using these methods improves outcomes for parents, including less depression and better general mental health.

  There is no evidence of long- or short-term harm to infants; if anything, there may be some evidence of short-term benefits.

  There is evidence of success for a wide variety of specific methods, and little to distinguish between them.

  The most important thing is consistency: choose a method you can stick with, and stick with it.

  12

  Beyond the Boobs: Introducing Solid Food

  Gideon Lack is a researcher at King’s College London. He studies allergies in kids, especially allergies to peanuts. At some point, perhaps through discussions with colleagues in Israel, Dr. Lack got the impression that peanut allergies were much less common among children in Israel than in the UK. So in 2008 he published a paper testing this theory. Using a questionnaire, covering about five thousand children in each location and focusing on Jewish children in both Israel and the UK, he found that school-age children in the UK were about ten times more likely to be allergic to peanuts than children in Israel.1 Almost 2 percent of the children in the UK were allergic, versus just 0.2 percent of the Israeli children.

  In the paper reporting these findings, Dr.
Lack and his colleagues went beyond just showing the prevalence differences. They actually speculated as to why the differences existed: specifically, early peanut exposure. Children in Israel are more commonly exposed to peanuts early in life—there is a popular peanut-based early childhood snack called Bamba—and the researchers argued that this exposure may be the cause of lower incidence of peanut allergies in Israeli children.

  The careful reader will know this type of claim is exactly the kind of thing that drives me crazy. A huge number of things differ between Israel and the UK! These issues are by no means fully addressed by using only Jewish children in the UK. An obvious difference is diagnosis rate—what if even mild peanut allergies are diagnosed in the UK, and only severe ones in Israel? Since the data is based only on a questionnaire, we have no way to verify the allergy or how bad it is.

  Gideon Lack might have stopped there, and we’d be left with a vaguely interesting fact and some unsatisfying speculation about why, but he didn’t. He pursued this idea using a much more convincing method: a randomized controlled trial.

  In the years following their initial findings, Lack and his colleagues recruited a cohort of about seven hundred babies between four and eleven months old and randomized them into a peanut exposure group and a non-exposure group. Parents of children in the exposure group were told to expose their kids to a dose of peanuts—about 6 grams a week—in the form of either the Israeli snack Bamba or regular peanut butter. Parents of children in the other group were told to avoid peanuts.

  The researchers selected a group of children who were more likely to have peanut allergies than the general population—this was important to make sure they could draw strong conclusions even with a relatively small sample size—and they also divided the sample into children who had no sensitivity to peanuts at baseline and those who showed some sensitivity. This let them look at these effects overall, and in children who were more prone to allergy. The kids were, of course, closely monitored for any adverse reactions.

  The researchers finally published their findings in 2015 in the New England Journal of Medicine.2 The results—I put them in a graph on this page—are striking. Children who were exposed to peanuts were far less likely to be allergic to them at the age of five than children who were not. In the group that didn’t get peanuts, 17 percent of children were allergic to peanuts at age five. (Remember, this figure is higher than it would be in the general population because of the way the researchers selected their sample.) However, only 3 percent of the children who were given peanuts were allergic.

  Since the study was randomized, there was no reason other than the peanut exposure that allergy rates would be different. And these differences showed up in both the high- and low-allergy-risk groups.

  This is a striking finding, to say the least. It suggests that exposing children to peanuts early helps them avoid peanut allergies. The finding is especially notable as it suggests that the standard advice parents were given about peanuts up to this point was entirely wrong. (With Penelope, we were told to wait until she was a year old to introduce peanuts.) This advice was given especially to people whose children were at higher risk for allergy.3

  It is not an exaggeration to say this advice has made things worse and, indeed, may be largely responsible for the increase in peanut allergies over the past twenty years. The fact that your kid has to bring SunButter to school? That may well be the fault of bad public health advice.

  In the wake of these peanut findings, the recommendations about exposure have changed completely. Early exposure to peanuts is now the normal recommendation, especially for children at risk for an allergy. The hope is that with wider dissemination and use of these updated recommendations, there will be fewer life-threatening peanut allergies. And we’ll have Gideon Lack to thank. Of course, this does highlight the problems with basing your initial recommendations on little or no evidence.

  Peanut timing is not the only recommendation that you’ll hear about food. The American Academy of Pediatrics (among other sources) has whole websites devoted to transitioning your child to eating solid foods. For the most part, there is little real evidence behind these recommendations.

  The AAP recommendations echo the traditional Western way to introduce your children to food. This begins, between four and six months, with either rice cereal or oatmeal. You feed your child with a spoon. Make sure to take some adorable pictures to send to the grandparents! These will also be helpful at your child’s wedding.

  Then, a few days or a week later, you introduce fruits and vegetables, one variety at a time, every three days. The standard advice is to do veggies first so kids do not learn fruit tastes better. A month or so after that, you introduce meat. All of this is in a pureed form and fed to your baby with a spoon.

  With Penelope we followed this exactly. I made a brief foray into making my own baby food, which I gave up almost immediately. I did invest in the world’s largest supply of Earth’s Best organic baby food. We actually had a special closet devoted to the jars. When Penelope finally aged out of it, we still had whole pallets of chicken and sweet potato “Step 2” jars.

  Eventually, you introduce foods the kid can pick up with their hands. This would include, say, Cheerios and rice puffs. Gradually, around a year or so, you phase out the pureed food. (In case you are wondering, yes, a food pantry will take those jars you have stacked in the closet.)

  There is certainly nothing wrong with these recommendations, per se. They have worked for many people for many years.

  And there is some reasoning behind this approach. Before four months, your baby is unlikely to be able to eat solid food—the skill is fundamentally different from nursing or drinking from a bottle—and there is no reason to give them anything other than breast milk. There is also a concern about filling their stomach with foods that, unlike breast milk and formula, do not give them the appropriate nutrients for their age. This gives you part of the timing recommendation.

  You start with rice cereal because it is flavorless, and you can therefore mix it with breast milk or formula so your kid is more likely to eat it. These cereals are also iron fortified, which is helpful if you’re nursing, since this is an age at which breast milk may no longer provide enough iron.

  The delay between food introductions is to see if any food causes an allergy. If you feed your kid strawberries and eggs and tomatoes and wheat all in a single day and they have an allergic reaction, it will be hard to know what the source is.

  All these arguments are logical, but there isn’t much testing of the specifics. At best, I would therefore describe these recommendations as logic based rather than evidence based.

  For example, there is no evidence for the order of food introductions. If you’d like to start with carrots or prunes rather than rice cereal, I can find no reason in the published evidence not to. Sure, maybe your baby will be more comfortable with rice cereal, but carrots are actually objectively tastier. Finn thought those cereals were a joke. The only rice cereal he ever ate was congee at our favorite Chinese restaurant.

  Similarly, there is some sensibility behind the idea of waiting between food introductions. Nearly all allergies are caused by one of a few foods—milk, eggs, peanuts, and tree nuts—and it’s sensible not to introduce these foods all at the same time. But most people are not allergic to most things. Yes, you can have an allergy to peas, but this is very uncommon. This doesn’t mean there is anything wrong with the every-three-days plan, and based on other evidence that kids need to try a food a few times before they like it, there may be a reason to focus on adding new foods one at a time. On the other hand, if you plan to introduce all the foods to your kid before they are one, you’ll have to speed up at some point.

  This discussion relates to small modifications around the traditional food introduction plan. But some people go further with this and question the very approach of spoon-feeding purees in the first place. An alternative, wh
ich has grown in popularity in recent years, is referred to as “baby-led weaning.” In this practice, instead of introducing pureed foods and feeding the kid with a spoon, you wait until they are old enough to pick up foods on their own and then have them more or less eat what your family eats.

  I used this approach with Finn. I wish I could say it was because I belatedly discovered a large evidence base suggesting it was better. In fact, it was that I could not bear the thought of another closet full of jars. Baby-led weaning involves just giving your child the food you are eating. This seemed great! I was already producing that food. I was all for signing up for an easier approach that preserved my closet space.

  Advocates of baby-led weaning do not typically focus on the lazy-parenting benefits. Instead, they cite benefits to your child: infants learn to regulate the amount of food they eat, leading to less incidence of overweight or obesity; they show acceptance of a wide variety of foods; and you have better family mealtime experiences.

  Evidence backing these claims is, however, limited.4 A main issue is that the kinds of parents who are likely to try this differ from those who use a more traditional feeding structure. They tend to be higher income, better educated, more likely to sit together at family meals, etc. These factors also relate to mealtime experience and diet quality, making it hard to separate out the role of the food introduction system.