Module 5: ToddlerCalm sleep

This module is designed to cover all the background information and knowledge you will need in order to support parents with toddler sleep. It will take you from a scientific basis through an understanding of what is normal for toddlers. Then we will discuss some common sleep problems that do occur in toddlers, followed by all the possible methods that can be used to improve toddler sleep, and their benefits and limitations, from mainstream to mindful and gentle.

The Science of Toddler Sleep

Introduction to sleep science

Introduction to sleep science

Baby and child sleep is a hot topic. It is talked about all the time by parents that you meet, by the media and by health care professionals. Everyone who talks about infants and toddlers, talks about sleep. There is also now a wealth of research on infant sleep, particularly in the area of safety and related to SIDS but also in regard to how sleep actually occurs and how it affects health and wellbeing. From these studies we know quite a lot about the psychology of sleep.

Research by Armstrong, Quinn and Dadds studied the sleeping habits of over 3000 children in Australia from birth to 38 month. Their findings included the following information: 

  • almost one-third of all parents of babies and small children consider their child’s sleep ‘problematic’
  • Only 16% of six month olds regularly sleep through the night, meaning that 84 per cent do not
  • Once children reach the age of 18 months, they require more parental help in order to get them to sleep than they previously needed
  • They found that the majority of children do not regularly sleep through the night until they reach their second birthday
  • They established that there is a wide range of normal childhood sleep behaviour 
  • Daytime sleep becomes less regular with increasing age
  • Frequent night waking that disturbs parents is common from 4-12 months (12.7% disturb their parents 3 or more times every night).

Armstrong, K. L., Quinn, R. A., Dadds, M. R., (1994) ‘The sleep patterns of normal children’


Mothers of 118 infants, who took part in a follow-up study of normal babies, completed a sleep questionnaire at 3, 6, 9 and 12 months. Regular night waking was a common characteristic throughout the first year:

Baby's age      % Babies waking at night

3 months          46%

6 months          39%

9 months          58%

12 months        55%

When talking to parents/care givers make sure that you get them thinking about why night time awakenings may increase and how it differs from societal expectation. Some ideas are; 

  • Separation anxiety
  • Developmental spurts, psychological changes (there is a lot going on for toddlers)
  • Child starting nursery/mother returning to work
  • New sibling/imminent arrival of new sibling
  • Teething


Often parents worry about their child needing parental help to get to sleep, but research has shown us that at least 50% of all one-year olds need parental input in order to help them settle to sleep. 

Goodlin-Jones, B. L. et al., ‘Night waking, sleep-wake organisation, and self-soothing in the first year of life’ (2001) 


Worrying research shows us that 31% of 25-38 month old children were disciplined (mostly smacking) to get them to settle. 27% of parents let their children cry themselves to sleep. 

Scher, A., ‘A longitudinal study of night waking in the first year’ (1991) 1

The biology of sleep

The biology of sleep

Sleep is a fairly complex chemically controlled process. It can (and regularly is) influenced by external factors, but when stripped back, the basic building blocks of sleep are chemical ones. The brainstem (reptilian brain) along with a section of the hypothalamus, is responsible for what is known as 'homeostasis' or basic life support function. It is responsible for all the things that keep us alive; breathing, temperature regulation, eating, and you guessed it, sleeping. The hypothalamus contains neurons which help to promote sleep by inhibiting activity in areas of the brainstem that maintain wakefulness. When the alerting areas of the brain are most active, they send arousal signals to the cerebral cortex (the outer layer of the brain that is responsible for learning, thinking, and organising information), while at the same time inhibiting activity in other areas of the brain that are responsible for promoting sleep, resulting in a period of stable wakefulness. When the sleep-promoting areas of the brain are most active they inhibit activity in areas of the brain responsible for promoting wakefulness, resulting in a period of sleep. 

Circadian rhythms

The neurons and chemicals make us feel sleepy or awake and do so over a period of 24 hours. This recurring 24 hour sleep/wake cycle is known as a circadian rhythm. The word 'circadian' derives from the Latin phrase 'circa dies', which translates to mean 'around a day'.The circadian biological clock is controlled by a part of the brain called the Suprachiasmatic Nucleus (SCN), a group of cells in the hypothalamus that respond to light and dark signals. The SCN is situated at the back of the eyes, close to the optic nerve. From the optic nerve of the eye, light travels to the SCN, signaling the internal clock that it is time to be awake. The SCN signals to other parts of the brain, the most significant being the pineal gland, that control hormones, body temperature and other functions that play a role in making us feel sleepy or awake. The pineal gland responds to the presence of light by inhibiting the production of melatonin.

What is Melatonin?

Melatonin is a natural hormone that is produced by pineal (pic-knee-uhl) gland. This is located just above the middle of the brain. During the day the pineal is completely inactive but starts to work when the sun goes down & darkness occurs. It is 'turned on' by the SCN and begins to actively produce melatonin, which is then released into the blood. Once melatonin levels in the blood rise, we begin to feel less alert and sleepy. Melatonin levels usually remain elevated in the blood for about 12 hours - all through the night - and fall in the morning when they are barely detectable.

Sleep Cycles and Circadian Rhythms in Infants

To understand toddler sleep it is important to start at the beginning. A newborn baby is not born with circadian rhythms and it takes a while for them to develop these, although while in utero, melatonin does pass into the body via the umbilical cord and the mother's body and babies exhibit similar sleep/wake patterns to their mother (Torres-Farfan etc al, 2006). Further research indicates that circadian rhythms are not well established until babies are around four months of age. This is the age from which you may start to notice a child’s sleep patterns showing some response between night-time and daytime.

Mirmiran, M., Maas, Y. G., Ariagno, R. L., (2003) ’Development of fetal and neonatal sleep and circadian rhythms’

Understanding Sleep Cycles

Stage 1 - a drowsy state or very light sleep - your eyes are usually closed but it's easy to wake you up

Stage 2 - early sleep, muscles relax - You are in light sleep. Your heart rate slows and your body temperature drops. Your body is getting ready for deep sleep

Stage 3 - deep sleep, heart rate slows, body temperature drops - This is the deep sleep stage. It's harder to rouse you during this stage, and if someone woke you up, you would feel disoriented for a few minutes. 

During the deep stages of NREM sleep, the body repairs and regrows tissues, builds bone and muscle, and strengthens the immune system.

REM - body immobile and brain highly active - Your heart rate and breathing quickens. This is the stage of sleep that you can experience intense dreams, since your brain is more active. 

Baby's sleep cycles are also much shorter than an adults and their sleep is much lighter, therefore babies are much more easily awakened than adults - 50% of a newborns sleep is spent in REM  in comparison to 20% of a adult. In evolutionary terms, this is incredibly beneficial for babies. An average adult sleep cycle lasts for approximately 90-120 minutes (starting in phase 1 and ending in REM sleep) at the end of this cycle the adult will either awaken or go back to sleep for another cycle.

A baby's sleep however is very different; their sleep cycles last on average 45-60 minutes. When a newborn first falls asleep they enter a state known as “active sleep” or REM (fluttering eyelids, rapid irregular breathing, body jerks and vocalizations). Babies in active sleep are easily woken and remain in this stage of sleep for about 20 minutes. The final 20 minutes a baby passes into "quiet sleep" or NREM (no eyelid fluttering/movement/noise), this stage of sleep is deeper and babies are less likely to awake in this sleep cycle (including being less likely to wake to a lack of oxygen, Parslow, 2003). At the end of this sleep cycle a baby may wake if something alerts them (this can be anything from a wet nappy, feeling cold or feeling hungry to feeling insecure or lonely when not close to their caregiver) or start a new sleep cycle. This makes perfect sense in evolutionary terms to keep a newborn safe, it would have kept them alert to any potential predators or harm and more recently it is believed to help protect a baby from SIDS. 

REM sleep is said to be especially important to the developing brain in babies and young children, researching hypothesise that the increased neutral stimulation that happens during this is stage is necessary in order to create new neural connections in the developing brain. As a baby grows their sleep cycles become longer and they spend less time in active sleep. 

  • Newborn = 50% REM sleep 
  • 3-6 Months = 40% REM sleep 
  • 6-12 Months = 35% REM sleep 
  • 1-2 Years = 30% REM sleep
  • 2-3 Years = 28% REM sleep 
  • 3-5 Years = 25% REM sleep
  •  5-13 Years = 20% REM sleep 
  • Teenager = 25% REM sleep 
  • Adult = 20% REM Sleep 

A child's sleep cycle does not reach the average length of an adult sleep cycle until they are school age (approx 4-5 years). This is also when most people see an improvement in their child's sleep and "sleeping through the night" (without needing parental input) usually becomes more frequent. Some research has indicated that 50% of pre-school children wake regularly at night.

Blair, P. S., Humphreys, J. S., Gringras, P., Taheri, S., Scott, N., Emond, A., Henderson, J., Fleming, P. J., (2012) ‘Childhood sleep duration and associated demographic characteristics in an english cohort’ 

Now that we understand the biology of sleep a little better, we will look at how research shows that sleep is impacted by external factors.

Sleep and maternal mood and attachment

Sleep and maternal mood

Many parents report that bedtime can be stressful and affect their overall mood, and many professionals have noted that depressed mothers seem to have more difficulty with their infants' sleep. Here we will explore some studies that have been carried out to determine whether infant sleep and maternal mood can affect each other.

Can maternal mood issues impact sleep?

In 2014 research found that life stress in the mothers (in the study) was statistically significant and negatively related to pre-school child’s sleep duration.

Caldwell, B. A., Redeker, N. S., ‘Maternal stress and psychological status and sleep in minority preschool children’ (6 Jan 2014) 

In 2012, the lead researcher. Dr Douglas Teti, commented ‘We found that mothers with high depressive symptom levels are more likely to excessively worry about their infants at night than mothers with low symptom levels, and that such mothers were more likely to seek out their babies at night and spend more time with their infants than mothers with low symptom levels. This in turn was associated with increased night waking in the infants of depressed mothers, compared to the infants of non-depressed mothers. Especially interesting was that when depressed mothers sought out their infants at night, their infants did not appear to be in need of parental help. There were either sound asleep or perhaps awake, but not distressed. 

Teti, D. M., Crosby, B. ‘Maternal depressive symptoms, dysfunctional cognitions and infant night waking: the role of maternal nighttime behaviour’ (2012) 

Research in 2014 highlighted a link that infants may pick up on their mother’s moods and become more distressed as a result. Lead researcher Dr Sarah Waters commented on the findings, saying ‘Our research shows that infant’s “catch” and embody the physiological residue of their mothers’ stressful experiences… Before infants are verbal and able to express themselves fully, we can overlook how exquisitely attuned they are to the emotional tenor of their caregivers.’ She goes on to say, ‘Your infant may not be able to tell you that you seem stressed or ask you what is wrong, but our work shows that, as soon as she is in your arms, she is picking up on the bodily responses accompanying your emotional state and immediately begins to feel in her own body your own negative emotions.’ This goes part way to demonstrating that our own emotional mood affects the sleep of our babies. 

Waters, S. F., West, T. V., Mendes, W. B., ‘Stress contagion physiological conversation between mothers and infants’ (30 Jan 2014)

Can lack of sleep impact maternal mood?

Research from 2005 linked sleep deprivation with the onset of depression in mothers, with researchers concluding that ‘infant sleep patterns and maternal fatigue are strongly associated with the new onset of depressive symptoms in the postpartum period,’ which indicates that maternal depression can be worsened by the excessive tiredness caused by sleep deprivation. 

Dennis, C. L., Ross, L., ‘Relationships among infant sleep patterns, maternal fatigue, and development of depressive symptomatology’ (2005) 

How does all this affect attachment?

Research by Scher * in 2001 examined the association between a young toddler’s sleep pattern and mother-infant attachment in 94 mother-infant dyads. 

At 12 months each dyad participated in the Strange Situation procedure; 77% of the 94 babies were securely attached. 55% of the secure and 60% of the ambivalent children were described as night wakers. The frequency of the night waking was similar for the secure and insecure infants. The findings confirm that night waking at the end of the first year is a common developmental phenomenon that is not indicative of attachment.

* Scher, “Attachment and sleep: a study of night waking in 12-month-old infants.” Dev Psychobiol2001 May;38(4):274-85.

Environmental factors

Environmental factors

There are lots of things which can encourage or inhibit the brain producing the necessary chemical processes that we talked about earlier. In this section we will explore a variety of those external factors. 

Artificial Light

Electric lighting is everywhere! It is a brilliant invention BUT it plays a huge part in the way we sleep. For thousands of years, our circadian rhythms were controlled by the rising and setting of the sun, melatonin levels would rise at dusk and cortisol levels would rise at dawn. Now, we are able to trick our bodies that it's daytime during the night, that the sun doesn't set until midnight or that it rises well before it actually does - all because of artificial light! 

The Professor of Sleep Medicine at Harvard Medical School, Charles Czeisler, said ‘There are many reasons why people get insufficient sleep in our 24/7 society. But the participating factor is often unappreciated, technological breakthrough: the electric light…light affects our circadian rhythms more powerfully than any drug. Professor Czeisler found that between the years 1950 and 2000 the use of artificial light increased fourfold and sleeping problems increased correspondingly. On average children are now getting 1.2 hours less sleep at night than they did 100 years ago. He comments ‘Technology has effectively decoupled us from the natural 24-hour day to which our bodies evolved, driving us to go to bed later. And we use caffeine in the morning to rise as early as we ever did, putting the squeeze on sleep.’ 

Czeisler, C. A. ‘Perspective: casting light on sleep deficiency’ (2013) 

Can you reset your circadian rhythm, I hear you ask! The answer is YES! 

A study carried out at the University of Colorado which explored the effects of camping in nature found that even one week without the interuption of electrical lighting can be enough to improve sleep. The researchers found that seven days of camping, with exposure only to the natural light or the sun and moon, and camp fires in the evening, is enough to reset our circadian rhythms to be more in-line with the natural sunrise and sunset. After studying the melatonin levels of the participants, the researchers found that levels began to rise around two hours earlier when camping, compared to when they were at home surrounded by artificial light. 

Wright, K. P. Jr, McHill, A. W., Birks, B. R., Griffin, B. R., Rusterholz, T., Chinoy, E. D., ‘Entrainment of the human circadian clock to natural light-dark cycle’ (2013) 

Red light, blue light

Some people may argue that we have used artificial light long before the electric light was invented, in the form of fire and candles, but there is one significant difference - the colour and intensity of light. The natural colour of fire and candlelight is always orange-red, in comparison to modern natural lighting which is incredibly bright and, probably more importantly, focussed on the blue and white colour spectrum. 

Research that was carried out to look at the impact of different colours of light has found our body’s natural clock system responds differently to artificial light sources, depending on the colour. 

Holzman, D. C., ‘What is in a colour? The unique human health effects of blue light (2010) 

Debra Skene, a scientist from the University of Surrey, who conducted research into the effect of colour wavelengths of light and their impact on melatonin, says ‘We observed peak light sensitivity at a wavelength of around 460 to 480 nanometres - a nice deep blue.’ She goes on, ‘Red light, by contrast, has only a weak impact on melanopsin receptors and is less prone to stimulate wakefulness. So adjusting the relative levels of blue and red light that people are exposed to throughout the day could preserve normal circadian timing even during prolonged exposure to artificial light.’ 

Warman, V. L., Dijk, D. J., Warman, G. R., Arendt, J., Skene, D. J., ‘Phase advancing human circadian rhythms with short wavelength light’ (2003) 

Screen time

As with artificial light, the increasing popularity of electronic screen time. We are exposed for hours each week to televisions, tablets, computers and smart phones - all which omit artificial light which promote brain activity. Research conducted in New Zealand in 2013 found that in the last hour and half before bedtime almost 50 per cent of children watch as much as 30 minutes of television. Unsurprisingly, those children who watched television in the last hour or two before bedtime went to sleep later than those who watched none. 

Louise Foley, lead researcher, commented that ‘Reducing screen time in this pre-sleep window, could be a good strategy for helping kids go to sleep earlier. Professor Christakis, a paediatrician at the University of Washington, when talking about this research, said “There is growing evidence that media use around sleep time is bad for sleep initiation: it is not so much having a bedtime for your children. You have to have a bedtime for their devices.’

Foley, L. S., Maddison, R., Jiang, Y., Marsh, S., Olds, T., Ridley, K., ‘Presleep activities and time of sleep onset in children’ (2013) 

Researched carried out in 2013 found that the more children used electronic media the less sleep they got. The lead researcher, Teija Nuutinen, commented that ‘Media viewing habits should be considered for kids who are tired and struggling to concentrate or who have behaviour problems caused by lack of sleep’ 

Nuutinen, T., Ray, C., Roos, E., ‘Do computer use, TV viewing, and the presence of the media in the bedroom predict school-aged children’s sleep habits in the longitudinal study’ (2013) 

Sleep and diet

Diet

Now we come to diet! How your diet can help and hinder sleep. 

Research from 2012 found that breast milk produced at night contains signifiant levels of melatonin, the sleep hormone. Melatonin isn't the only sleep hormone contained within breastmilk at night; it also contains more tryptophan, another chemical that aids sleep. 

Cohen Engler, A., Hadash, A., Shehadeh, N., Pillar, G., ‘Breastfeeding may improve nocturnal sleep and reduce infantile colic: potential role of breast milk melatonin (2012) 

Ever heard someone saying that eating a banana can help you sleep better? Well here is the theory behind it - bananas contain Tryptophan! Other foods also do, examples of these are; nuts, seeds, tofu, cheese, red meat, chicken, turkey, fish, oats, beans, lentils, and eggs.Tryptophan is an amino-acid and an essential part of the human diet because our bodies are unable to make it, and the only way we can get enough is through our diet (including breastmilk). Tryptophan is an important component in the manufacture of serotonin and melatonin, the hormone of sleep, and for this reason many suggest that foods containing high levels of tryptophan may help us to sleep. Research has found that although increased tryptophan intake augmented feelings of sleepiness it doesn't decrease the amount of night wakings. 

Hartmann, E., ‘Effects of L-tryptophan on sleepiness and on sleep (1982) 

I'm sure it's no surprise to you that E numbers can have a negative impact on sleep. Research conducted at a Children's hospital in Australian in 1994, found that ‘restlessness, and sleep disturbance are associated with the ingestion of tartrazine (E102, a very common food colouring, usually used to colour foods yellow)  in some children’ 

Rowe, K. S., Rowe, K. J., ‘Synthetic food colouring and behaviour: a dose response effect in a double-blind placebo-controlled, repeated-measures study’ (1994) 

Rowe, K. S., Rowe, K. J., ‘Synthetic food colouring and behaviour: a dose response effect in a double-blind placebo-controlled, repeated-measures study’ (1994) echoed the findings in earlier research. It found there was an increase in time taken to go to sleep at night, as well as night awakenings. 

Kaplan, B. J., McNicol, J., Conte, R. A., Moghadam, H. K., ‘Dietry replacement in preschool-aged hyperactive boys’ (1989) 

Daytime naps and napping

The impact of daycare on naps

96% of parents of three and four-year-olds take advantage of funded pre-school; these figures have steadily risen over the last 10 years. Often children are out at pre-school all morning or all afternoon which obviously leaves them less opportunity to take a nap during their day. 

Research that was published in 2013, looking at the impact of daycare on naps of pre-school children, found that lack of naps taken by children once they started pre-school could be negatively affecting not just their sleep but also their learning. Somewhere between 25 and 50 percent of three and four year olds still naturally need to nap during the day. The lead researcher, Laura Kurdziel, commented ‘when they miss a nap, the child cannot recover this benefit sleep with their overnight sleep. It seems that there is an additional benefit of having the sleep occur in close proximity to the learning. Children should not only be given the opportunity, they should be encouraged to sleep by creating an environment which supports sleep.’ 

Kurdziel, L., Duclos, K., Spencer, R., ‘Sleep spindles in midday naps enhance learning in preschool children’ (2013) 

Siestas and later bedtimes

Research carried out in 2006 suggested that the practice of taking a afternoon siesta might be due, in part, to the glucose contained within our lunch, which inhibits neurons in the brain that are responsible for keeping us alert and active. The researchers said: ‘It has been known for a while that people and animals can become sleepy and less active after a meal, but brain signals responsible for poorly understood.  We have pin-pointed how glucose - the sugar in food - can stop the brain cells from producing signals that keep us awake… This may well provide an explanation for after-meal tiredness and why it is difficult to sleep when hungry… This research perhaps sheds light on why our European friends are so fond of their siestas.’ 

Burdakov, D., Jensen. L. T., Alexopoulos, H., Williams, R. H., Fearon, I. M., O’Kelly, I., Gerasimenko, O., Fugger, L., Verkhratsky, A., ‘Tandem-pore K+ channels mediate inhibition of orexin neurons by glucose’, (2006) 

Dr Michael Twery, Director of the National Heart Lung and Blood Institute’s National Centre on Sleep Disorders Research, said: ‘Napping may help deal with the stress of daily living. Another possibility is that it is part of the normal biological rhythms daily living. The biological clock that drive sleep and wakefulness has two cycles each day. and one of them dips usually in the early afternoon. It’s possible that not engaging in napping for some people might disrupt these processes. 

Naska, A., Oikonomou, E., Trichopoulou, A., Psaltopoulou, T., Trichpopoulos, D., ‘Siesta in healthy adults and coronary mortality in the general population’ (2007) 

Research conducted in 2013 found that pre-school aged children from Asian countries tend to have a much later bedtime than those in Europe, the USA and Australia. The earliest bedtimes were found in Australia and NZ, with an average bedtime of 7.43pm. On the other side of the globe bedtimes in India averaged at 10.26pm, almost 3 hours later! Daytime naps, however, were more common in the Asian countries studied, but the total time asleep per 24 hours was roughly the same for all children, no matter where in the world they lived. It was apparent that children from Asian countries were spreading their sleeps throughout the day and night whereas predominately Caucasian countries daytime naps were significantly rarer and more sleep was being taken at night’ 

Mindell, J. A., Sadeh, A., Kwon, R., Goh, D. Y., ‘Cross cultural differences in the sleep of pre-school children’ (2013) 

Later bedtimes are prevalent in many other cultures around the world. Anthropologists Carol Worthman and Melissa Melby described different bedtime habits of two tribes, the !Kung and the Efe. In a article produced in 2002 it states ‘neither Kung nor Efe have bedtimes, so time of falling asleep varies widely with individuals. People stay up as long as something interesting - a conversation, music, dance - is happening and participate; then they go to sleep when they feel like it….Additionally no-one, including children, is told to go to bed, and individuals of any age may nod off amid ongoing social intercourse and fade in and out of sleep during night-time social activities. 

Worthman, C. M., Melby, M. K., ‘Toward a comparative developmental ecology of human sleep’ (2002) 

Research carried out in 2013 studied toddler bedtimes in comparison to melatonin levels and concluded that, for many toddlers, their sleep problems could be caused by parents putting them to bed too early. The study showed that the average timing that melatonin rises in toddlers is around 7.40pm. Researcher Monique LeBourgeois commented on the results ‘Sleeping at the wrong ‘biological clock’ time leads to sleep difficulties, like insomnia, in adults. The study is the first one of its kind to show that a  poor fit between bedtimes selected by the parents of toddlers and the rise in their evening melatonin production increases their likelihood of night-time setting difficulties.’ She added ‘We believe that arming parents with knowledge about the biological clock can help them make optimal choices about their child’s activities before bedtime, at bedtime, and his or her sleeping environment.’ 

LeBourgeois, M. K., Carskadon, M. A., Akacem, L. D., Simpkin, C. T., Wright, K. P., Achermann, P., Jenni, O. G., ‘Circadian phase and its relationship to nighttime sleep in toddlers’ (2013) 

Sleep and carrying

Sleep and carrying

Research carried out by Urs Hunziker and Ronald Barr found that babies who were carried during the daytime for one hour more than those in the control group cried 43 per cent less. Between the hours of 4pm to midnight the babies who were carried more cried 51 per cent less, compared to a control group. 

Hunziker, U. A., Barr, R. G., ‘Increased carrying reduces infant crying: a randomised controlled trial’ (1986) 

Research into rituals and rhythms

Bedtime Rituals

Research into the sleep behaviour of 199 toddlers between the ages of 18 and 36 months has shown that the use of a consistent bedtime ritual can improvement multiple aspects of toddler sleep, bedtime behaviour and maternal mood. Bedtime rituals were shown to:

  • Produce improvements in sleep onset and the number and duration of night waking’s.

  • Toddlers were less likely to call out to their parents or get out of their crib/bed during the night.

  • Sleep continuity increased.

  • A significant decrease in the number of mothers who rated their child's sleep as problematic.

  • Maternal mood also significantly improved.

Dr Jodi Mindell, professor of psychology at Saint Joseph's University in Philadelphia stated:

”There is no question that maternal mood and children's sleep impact one another. The better a childsleeps and the easier bedtime is, the better a mother's mood is going to be. In addition, a mom who is not feeling tense, depressed, and fatigued is going to be calmer at bedtime, which will help a child settle down to sleep."

Families were randomly assigned to a routine or control group. The first week of the study served as a baseline, during which the mothers followed their child's usual bedtime weeks. During the following two weeks mothers were instructed to conduct a specific bedtime routine, while the control group continued with their child's normal bedtime procedure. All children included in the study had a small to severe sleep problem, as identified by the mother. Problems included more than three nightly wakings, awakening for longer than 60 minutes per night, or having total daily sleep duration of less than nine hours.

Parents in the intervention group were given a three-step bedtime procedure to follow that included a bath, an application of moisturising lotion and quiet activities (such as cuddling and singing); lights were to be turned out within 30 minutes of the end of the bath. Mothers then proceeded to put the child to sleep as they normally did, by either putting the child to bed while awake or rocking them to sleep. Thus, the only instituted change was the routine.

Source: Mindell JA, Telofski LS, Wiegand B, Kurtz ES. “A nightly bedtime routine: impact on sleep inyoung children and maternal mood.” Sleep. 2009 May;32(5):599-606.

According to Armstrong, Quinn and Dadds, how many parents consider their child to have a sleep problem?

  • Just over half
  • All of them
  • Almost a third
  • None of them

Briefly describe the difference between Adult and Toddler Sleep

Please ensure that you refer to the biology of sleep

Sleep Cycles

  • Stage Two
    early sleep, muscles relax - You are in light sleep. Your heart rate slows and your body temperature drops. Your body is getting ready for deep sleep
  • Stage One
    a drowsy state or very light sleep - your eyes are usually closed but it's easy to wake you up
  • Stage Three
    deep sleep, heart rate slows, body temperature drops - This is the deep sleep stage. It's harder to rouse you during this stage, and if someone woke you up, you would feel disoriented for a few minutes.
  • REM (Rapid Eye Movement)
    body immobile and brain highly active - Your heart rate and breathing quickens. This is the stage of sleep that you can experience intense dreams, since your brain is more active.
  • NREM (Non Rapid Eye Movement)
    the body repairs and regrows tissues, builds bone and muscle, and strengthens the immune system

Name three things that affect the way we sleep and discuss why they affect our sleep

Normal toddler sleep

Research into normal toddler sleep

Normal toddler sleep research

One to Two Years

 Research indicates that a child does not regularly sleep through the night until they reach their second birthday. It also indicates that once children reach the age of 18 months they need more parental help in order to get them to sleep than they previously did. 

Armstrong, L., Quinn, R. A. And Dadds, M. R., ‘The sleep patterns of normal children’ (1994)

Research indicates that 55% of children in their second year of life are still waking regularly during the night

Scher, A., ‘A longitudinal study of night waking in the first year’ (1991) 2

Research shows that at least 50 per cent of all one-year olds need parental input in order to help them to settle to sleep. 

Goodlin-Jones, B. L. et al., ‘Night waking, sleep-wake organisation, and self-soothing in the first year of life’ (2001) 

Three to Five years

Night waking is fairly common, although an increasing percentage are able are able get back to sleep without much parental help & the total duration of night waking is less than 5 minutes. However, research indicates almost a third of children in this age range have been on the receiving end of punishment for their sleeping patterns, with over 1/4 being left to cry themselves to sleep. 

Scher, A., ‘A longitudinal study of night waking in the first year’ (1991) 1

Around the world

Traditional baby sleep patterns

  • From Africa to the Arctic to the Americas, modern-day hunter-gatherers keep their babies in close, physical contact throughout the day, and mothers typically sleep with them at night. Babies frequently fall asleep while breastfeeding and experiencing skin-to-skin contact (Konner 2005).
  • In Bali, babies sleep with their mothers until age 3. During the day, they are carried in slings as their mothers go about their daily work. Babies may fall asleep in the sling, and, if mothers must put their babies down, they are encouraged to give them to someone else to hold (Diener 2000).
  • Among the Beng, village farmers living in the Cote D’Ivoire, babies spend their days on someone’s back; either the mother or a designated baby carrier. Carrying a baby in this way is considered a good way to get babies to fall asleep (Gottlieb 2000).
  • In Japan, family members have traditionally slept in the same room, and many babies sleep in their parents’ beds (Fukumizu et al 2005). Where babies sleep in their own beds, parents often lie with babies until they fall asleep (Moore et al 1957).
  • Mayan babies share their mothers’ beds and may breastfeed during the night until they are 2-3 years old (Morelli et al 1992).
  • Among the Ifaluk of the South Pacific, babies sleep alongside their parents each night. This continues until they are about three years old. During the day, babies may be rocked to sleep (Le 2000).

The history of sleep

History of sleep

Night-waking

From an anthropological and evolutionary perspective, human infants (including toddlers) would have been kept very close to parents at night. It is normal and necessary for them to be within touching distance and to need the reassurance of seeing and touching their parent when they wake during the night. Checking on their own safety at several points during the night is a natural survival instinct which humans cannot simply override.

Two sleeps

Children often wake during the night, sometime parents report that their children will wake in the early hours expecting to get up and play, have some food/drink and not return to sleep for a couple of hours. This, of course, isn't normal to us but it may be how we 'should' sleep! 

Research by Roger Ekirch, professor of History at Virginia Tech found that adults haven't always slept in one eight hour chunk. The existence of our sleeping twice per night was first uncovered by Roger Ekirch. He described this range was about 12 hours long, and began with a sleep of three to four hours, wakefulness of two to three hours, then sleep again until morning.

References are scattered throughout literature, court documents, personal papers, and the ephemera of the past. What is surprising is not that people slept in two sessions, but that the concept was so incredibly common. Two-piece sleeping was the standard, accepted way to sleep. Ekirch says “It’s not just the number of references – it is the way they refer to it, as if it was common knowledge,” 

But just what did people do with these extra twilight hours? Pretty much what you might expect.

Most stayed in their beds and bedrooms, sometimes reading, and often they would use the time to pray. Religious manuals included special prayers to be said in the mid-sleep hours. Others might smoke, talk with co-sleepers, or have sex. Some were more active and would leave to visit with neighbours.

As we know, this practice eventually died out. Ekirch attributes the change to the advent of street lighting and eventually electric indoor light, as well as the popularity of coffee houses. Author Craig Koslofsky offers a further theory in his book Evening’s Empire. With the rise of more street lighting, night stopped being the domain of criminals and sub-classes and became a time for work or socializing. Two sleeps were eventually considered a wasteful way to spend these hours.

No matter why the change happened, shortly after the turn of the 20th century the concept of two sleeps had vanished from common knowledge & it has more recently turned into a sleep problem for a number of toddlers. 

What does the evidence tell us?

So what can we take away from all that scientific understanding and research?

We have given a wide range of evidence in regard to infant (for background) and toddler sleep, both in the form of biological understanding and in terms of research studies across a range of disciplines affecting sleep. Below we take a brief look at what useful, tangible knowledge we can gain from all of that evidence.

Sleep cycles & circadian rhythms

The fact that we sleep in cycles of lighter and deeper sleep helps us to understand that there are times in the night when humans are more rousable than others. The fact that toddlers sleep cycles are still much shorter than adults' tells us that there is a greater frequency in which toddlers are more likely to wake at night.

By understanding that we don't always wake each time we enter a lighter state of sleep we can can extrapolate that sometimes adults and toddlers are able to move from one sleep cycle to the next with little or no difficulty. We can also realise that even as adults we don't always transition from one sleep cycle to another. Sometimes an external (light change in the room, noises) or internal stimulus (full bladder, thirst, discomfort) can cause even adults to wake during the night. 

Adults are usually quite accustomed to dealing with whatever woke them (if they know) and then settling themselves back to sleep. Toddlers are both not yet, and not consistently, competent in understanding what woke them, nor can they always have the maturity of emotional control and neocortext development necessary to calm the reptilian brain that is necessary for "self-settling". Sometimes they may be naturally calm enough to settle back to sleep but if awake at night, toddlers are likely to need reassurance from a parent to feel safe and calm enough to sleep.

From history and anthropology we can understand that children are programmed to take their safety cues from their parents and to be extra vigilant at night. If a child can see their parent is calm, they are more likely to be able to calm themselves and sleep.

Melatonin production & environment

Enviromental factors such as artificial light & the colour and intensity of light have a huge impact on the melatonin production. If melatonin production is restricted by the things that are all around us then there is no wonder that we have problems falling and/or staying asleep. Parents may not have considered that a very bright bedtime routine is negatively impacting their toddlers bedtime or that the blue night light that they leave on all through the night is causing their toddler to startle when they move from one sleep cycle to the next. If we can share this information with parents then it will help them to consider it when thinking about their toddlers sleep. 

Attachment and mood

The studies that we explored in Sleep and Maternal Mood showed us that maternal mood and child sleep tend to go hand-in-hand. Low maternal mood often resulted in difficult infant sleep and difficult infant sleep often resulted in low maternal mood. 

Diet

When we looked at how diet can impact a toddlers sleep we discussed foods which can encourage the chemical processes in the brain which get us to sleep and also the foods which can inhibit that process. Often foods (and medicines) that contain these ingredients inhibit that process are marketed to children. As an example we looked a E102 which is very common and used to colour foods yellow) which was found to cause restlessness and sleep disturbance. 

We found that foods containing tryptophan (an amino-acid) was a important component in the manufacture of the hormone of sleep and that including such foods in our toddlers diet can help to promote the chemical process that results in sleep. 

Parental expectations vs reality

In the introduction to the science of sleep we described some basic statistics on infant and toddler sleep. One of the most interesting and significant points within those statistics is understanding the combination of the percentage of parents who consider their child to have a "Sleep problem" versus the percentage of reported children who wake. What this basically tells us is that wakefulness in babies and toddlers is very common and therefore is "normal" sleep behaviour, and it is the parents that struggle with their child's normal behaviour. This is similar to the situation that we see when we look at toddler behaviour. Parents often think that their child has a behaviour problem when really they are displaying normal exploration or emotion venting behaviour.

At ToddlerCalm one of the key elements of sleep work with parents lies in normalising infant and toddler sleep behaviour.

Normal toddler sleep quiz

Please select which of these statements are true or false.

  • Other cultures think about toddler sleep differently from us
  • It is normal across the world for parents to struggle with their toddler's sleep
  • Co-sleeping and bed sharing is a western fad from Attachment Parenting
  • Most mammals sleep in two distinct periods during the night with a period of wakefulness
  • From an evolutionary perspective, toddlers are designed to be wakeful at night for survival
  • It is parents, and not toddlers, that have a sleep problem in most cases

How normal is it for children to wake in their 2nd year?

According to Scher, how many children regularly wake through the night in their second year? 

  • 55%
  • 25%
  • 33%
  • 79%

Key element of sleep work at ToddlerCalm

At ToddlerCalm one of the key elements of sleep work with parents lies in infant and toddler sleep behaviour.

Common sleep problems

Introduction to sleep problems

Introduction to sleep problems

We have talked about how many parents assume their child has a sleep problem even when they are faced with normal infant and toddler sleep, due to a distorted parental expectation. However, sometimes toddlers, like adults do have real sleep problems.

Sleep disorders can commonly be divided into the following two broad categories: 

Parasomnias - These are unusual experiences or behaviors that occur during sleep; they include nightmare disorder (which occurs during rapid eye movement [REM] sleep), sleep terror disorder (known commonly as night terrors in toddlers) and sleepwalking, both of which occur during stage 4 sleep .

Dyssomnias – These are characterised by abnormalities in the amount, quality, or timing of sleep; they include primary insomnia and hypersomnia, narcolepsy, breathing-related sleep disorder (i.e. sleep apnoea), and circadian rhythm sleep disorder.

Primary insomnia is the general term for difficulty in initiating or maintaining sleep. Because sleep requirements vary from individual to individual, insomnia is considered clinically significant when a patient perceives the loss of sleep as a problem. Insomnia may be further characterised as either acute (transient) or chronic in adults.

In this section we will look at the most common disorders affecting toddler sleep. These do not include those associated with primary insomnia because, as we have established, this is actually normal for toddlers biologically.

Nightmare disorder

Nightmares

Nightmares are quite common in young children. They often begin between the ages of 18 months and three years. 

Nightmares aren't usually a sign of emotional disturbance. They may happen if your child is anxious about something or has been frightened by a TV programme or story. After a nightmare, your child will need comfort and reassurance. 

Research that was conducted at the University of Tel Aviv in 2012 found that children who experienced nightmares had difficulty separating fantasy from reality; something that is heightened the younger the child is. Professor Sadeh, the lead researchers, said, "We send children mixed signals by telling them that monsters aren't real while we tell them stories about the tooth fairy…simply telling a child that their fear isn't realistic doesn't solve the problem." 

He suggests that we use the imagination of the child in order to reduce their fears: for example, help the child to write a letter to the monster asking for a truce and read them bedtime stories about monsters and nightmares that turn out not to be scary after all. Professor Sadeh found that allowing the child to transfer their fear and worry onto a stuffed toy, which they then care for and help not to be so afraid, can help significantly, too. 

Zisenwine, T., Kaplan, M., Kushnir, J., Sadeh, A., “Nighttime fears and fantasy-reality differentiation in pre-school children’ Child Psychiatry & Human Development (2012) 

Nightmare sleep disorder

Nightmare disorder, also known as 'dream anxiety disorder', is a sleep disorder characterised by frequent nightmares. The nightmares, which often portray the individual in a situation that jeopardises their life or personal safety, usually occur during the REM stages of sleep. Though such nightmares occur within many people, those with nightmare disorder experience them with a greater frequency.

Children are more apt to experience nightmares than teenagers and adults.Young children normally have nightmares once or twice a week and will usually not develop a nightmare disorder unless they are under  psychological stress.

Health professionals are reluctant to prescribe medication for this disorder though it is possible. The first method of management should always be a reduction in the stress of the child either by changing their circumstances or by using relaxation techniques (mindfulness, meditation, yoga, massage, alpha music etc).

Sleep terror disorder

Sleep terror disorder (aka Night terrors)

Sleep terrors (also referred to as night terrors or pavor nocturnus) are a specific sleep disruption most remarkable for their intensity and anxiety-inducing nature. Several precipitating factors have been suggested, but no consistent structural or biochemical abnormality has been identified to account for all cases of sleep terrors.

Signs and symptoms

Symptoms of sleep terrors include the following:

  • Sudden arousal from non–rapid eye movement (NREM) sleep, usually occurring in the first third of the night
  • Associated autonomic and behavioral manifestations of fear, including crying, screaming, or thrashing
  • Agitation (more commonly seen in adults)
  • Significant autonomic hyperactivity, including tachycardia, tachypnea, and diaphoresis
  • No or minimal response to external stimuli during the event
  • Upon wakening: Confusion, disorientation, and amnesia regarding the event

There are no specific physical findings or signs found on routine physical examination when the individual is awake.

Night terrors most commonly occur in children between the ages of two and five, but they can occur much earlier (cases have been reported in 6mth old babies). Boys are more commonly affected than girls. Night terrors are more likely to occur during times of stress or fatigue. They can be extremely distressing for the parent, but are generally self-limiting and there is not a great deal that you do when your toddler experiences one aside from trying to alleviate any known stress from the child's environment and to check that the child is getting enough sleep. During a night terror it might seem as if the child is awake and hallucinating, but actually they are very much asleep. It is important to distinguish night terrors from nightmares; the two are very different as seen in the table below:

The difference

Nightmares and night terrors are very different. Night terrors are relatively rare, affecting around just 3 per cent of children. Research by consultant psychiatrist Professor Bryan Lask, carried out at Great Ormond Street Hospital in London, may provide hope for parents of children suffering from night terrors. Professor Lask suggests that parents make a note of the time that their child’s night terrors occur for five nights in a row. If there is a pattern to the child’s night terrors, he suggests waking the child around ten to fifteen minutes before the night terror usually starts and keeping them awake for five minutes before allowing them to return to sleep. The process should be repeated each evening until the terrors are extinguished, which in his research was less than a week for all cases. 

Lask, B., ‘Novel and non-toxic treatment for night terrors’ BMJ, (1988) 

Some parents report a reduction in night terrors using a process of scheduled awakenings first introduced by Psychiatrist Bryan Lask at Great Ormond Street Hospital in 1988. The parents first keep a diary of the times that night terrors occur over several nights and then if a pattern emerges they wake the child 10 to 15 minutes before the night terrors usually occur and keep them awake for 5 minutes before allowing them to go back to sleep again.

Source = Lask “Novel and non-toxic treatment for night terrors”. BMJ. 1988 Sep 3;297(6648):592.

Sleep walking

Sleep walking (Somnambulism)

Sleepwalking is when someone walks or carries out complex activities while not fully awake. It is a fairly common sleep problem that occurs in NREM sleep.

It usually occurs during a period of deep sleep. This is at its' height during the early part of the night, so it tends to occur in the first few hours after falling asleep.

Sleepwalking can start at any age, but is more common in children. It’s thought that at least 20% of children will sleepwalk at least once. Most will grow out of it by the time they reach puberty, but it can sometimes persist into adult life.

Treatment and support

There's no specific treatment for sleepwalking, but it generally helps to try to get enough sleep and have a regular and relaxing routine before bedtime.

Often parents simply need reassurance that this is normal for many children and is generally not a problem. There is a handout that can be given to parents who are struggling with this, signposting them to appropriate prevention and management techniques.

Breathing-related sleep disorder

Sleep apnoea and snoring

Sleep apnoea affects between 0.7 and 1.8 per cent of all children under sixteen. An article in the British Medical Journal (BMJ) describes sleep apnoea as ‘a disorder of breathing during sleep that is characterised by prolonged partial upper airway obstruction and/or intermittent complete obstruction that adversely affects ventilations during sleep and disrupts normal sleep patterns’ 

Powell, S., Kubba, H., O’Brien, C., Tremlett, M., ‘Paediatric obstructive sleep apnoea’ (2010) 

Important

This isn't information that we commonly share in every workshop or with every parent but it is worth bearing in mind. It is essential when supporting parents that they realise that most toddler behaviour is normal and not "hyperactivity". If parents are struggling with their toddler's normal behaviour they might want to grasp at this as a "cure". However, with parents who have genuine concerns about sleep and hyperactivity, this is information that could be shared. 

Nocturnal enuresis

Nocturnal enuresis (aka Bed-wetting)

Bedwetting is incredibly common and a natural part of childhood in most cases. It is perfectly normal for children to sleep in nappies at night until they are at school, sometimes right up to seven years, so really isn't a sleep "problem". However it is a common difficulty with toddlers that parents may be anxious about when they come to a ToddlerCalm sleep workshop.

Estimates of the incidence of bedwetting indicate that around 10 percent of 2 year olds will be reliably dry at night, rising to 20 per cent at age 3, 55 percent at age 4 and around 80 per cent at age 5. Around a 1/4 of all reception children will still wet the bed with some regularity and is slightly more common in boys than girls. 

Fergusson, D. M., Horwood, L. J., Shannon, F. T., ‘Factors related to the age of attainment of nocturnal bladder control: an 8-year longitudinal study’ (1986) 

Bedwetting is only really a problem if it begins to bother the children or parents. Only rarely will this be considered a problem in children under five years old. Many families first seek treatment when the bedwetting affects a child's social life (for example, preventing sleepovers).

Medical treatments aren't usually recommended for children under five (although exceptions can be made if a child finds bedwetting particularly upsetting).

There's usually no obvious reason why children wet the bed and it's not your child's fault. In many cases, the problem runs in families.

Bedwetting could be caused by your child:

  • producing more urine than their bladder can cope with 
  • having an overactive bladder, meaning it can only hold a small amount of urine 
  • being a very deep sleeper so they don't react to the signals telling their brain their bladder is full 

Constipation is frequently associated with bedwetting, especially in children who don't wet themselves every night. In these cases, bedwetting may happen during the night when the child has not had a poo during the day. Sometimes, treating constipation is all that's needed to treat bedwetting. Untreated constipation makes any treatment of bedwetting much harder.

Occasionally, bedwetting can be triggered by emotional distress, such as being bullied or moving to a new school.

In rare cases, bedwetting may be the symptom of an underlying health condition, such as type 1 diabetes.

Treatment and support

Often parents simply need reassurance that this is normal for many children and is generally not a problem. There is a handout that can be given to parents who are struggling with this, signposting them to appropriate prevention and management techniques as well as other support.

Common sleep problems test

Match up the sleep problem with its description

  • Nightmare sleep disorder
    a sleep disorder that is often characterised by frequent nightmares. The nightmares usually occur during the REM stages of sleep and are often caused by psychological stress.
  • Night terrors
    usually occurs in the first third of the night with sudden arousal from NREM sleep. It is often see the person crying, screaming and thrashing. Upon wakening there is usually confusion, disorientation and amnesia regarding the event.
  • Sleep walking
    is when someone walks or carries out complex activities while not fully awake. It is fairly common that occurs in NREM sleep.
  • Sleep apnea
    a disorder of breathing during sleep that is characterised by prolonged partial upper airway obstruction and/or intermittent complete obstruction that adversely affects ventilations during sleep and disrupts normal sleep patterns
  • Nocturnal enuresis
    also known as bedwetting. It is incredibly common and perfectly normal for children to sleep in nappies at night until they are in school, sometime right up to seven years.

Sleep training

Introduction to sleep training

Sleep Training 

Sleep training describes any approach you may take to help your baby learn to settle herself to sleep. When we are talking to parents we need to be fully aware of the different information that is readily available to them, methods they may have used or may be thinking about using. There are lots of sleep training methods around, some are marketed as 'gentle' while others aren't. 

You will have already explored the 'experts' and many have a specific approach that they advocate or reinvent. 

Be aware that, although you may not agree with these methods, some parents may have already used these on their children and it may be very emotive when discussing the various methods. 

It's important to be aware that although we do discuss different sleep training techniques along with the pros & cons of each during our classes we never advocate any sleep training method. We want to allow parents to make an informed choice and without all the information they are unable to do that.

If a parent attends your workshop or consultation and then goes on to use a method of sleep training that does not mean you have failed or done something incorrectly, it indicates you have provided all the relevant information for that family to make their own informed choice. 

Controlled Crying

Controlled crying vs Crying it out

We have purposefully not included "Cry it out" (also known as extinction, it involves leaving a baby or toddler to cry completely alone without parental input) in this section as it is NOT a valid form of sleep training. Leaving a human being to cry indefinitely is abuse and should not be condoned. Although we do not advocate leaving children to cry at all, it must be recognised that controlled crying does differ from cry it out by the nature of some parental input.

What is controlled crying?

Controlled crying is a form of sleep training, where you allow your baby to cry for short, specified periods of time before going in to offer comfort. IN some cases the interval time increases between each parental response.

This approach involves putting your baby to bed awake, and you leaving the room for a short period, returning if the baby is crying, but leaving again for progressively longer periods until the baby falls asleep. 

The use of controlled crying can be traced back over 100 years, and was a method first popularised in the mid 1980s by an American Dr Richard Ferber (American mums refer to Ferberizing their babies when they do controlled crying).

What do we know about Controlled Crying? 

The Australian Association of Infant Mental Health (AAIMHI) states "Controlled crying is not consistent with what infants need for their optimal emotional and psychological health, and may have unintended negative consequences. There have been no studies, such as sleep laboratory studies, to our knowledge, that assess the physiological stress levels of infants who undergo controlled crying, or its emotional or psychological impact on the developing child."

What are the disadvantages of controlled crying? 

Babies miss out on stimulating touch

Babies may not receive as much nutrition

Increased cortisol levels* and possible neurological damage

Increased pulse, blood pressure and temperature

Vomiting

Potential for an increased SIDS risk - this is yet unproven only because it is unresearched** 

Learned helplessness phenomenon

Potential effects on breastfeeding

Potential effects on secure attachment

CC & CIO as a young baby = more fussy & harder to settle by 10mths of age (1)

Although the stress of the experience wears off for parents when the babies stop crying (usually night 3 or 4) research has shown that the experience still remains stressful for the baby who still secrete cortisol long after he stops crying (2) 

(1) Stifter and Spinrad, The Effect of Excessive Crying on the Development of Emotion Regulation, Infancy, 2002.

(2) Middlemiss, W. Granger, D.A. Goldberg, W.A. Nathans, L. (2012) ‘Asynchrony of Mother-Infant Hypothalamic-Pituitary-Adrenal-Axis Activity Following Extinction of Infant Crying Responses Induced During the Transition to Sleep’. Early Human Development, 88 (4), 227-232 - It is very important that you are able to explain this study. On Days 1-3 the cortisol levels in both mother and child were raised, on day 3-4 the child stopped crying, this resulted in the mothers cortisol levels returning to normal however the child's cortisol levels remain elevated. Think about what this tells us about how the child was feeling vs how the child was behaving. 

* When a baby continuously secretes cortisol as an infant it can have an effect on their stress response in later life (they may either over or under produce cortisol when stressed as an adult; either of these is undesirable too much cortisol can lead to anxiety and depression; too little can lead to ambivalence and emotional detachment).

** Encouraging babies to sleep for periods longer than is biologically normal and creating unusually deep sleep means it is harder for a baby to arouse which is thought to be linked to SIDS. Research also shows babies who sleep in their own room are at higher risk of SIDS, most sleep training takes place in the nursery.

Why is this information not more commonly known?

We’re sure you’ve noticed today how emotive this topic is. It is highly uncomfortable to learn that you may have damaged your child in some way by following sleep advice in the quest to ‘do the right thing’ for your baby. In short it is too uncomfortable for society to bring these feelings up. Sleep training is so common in our society and there are too many people with too many uncomfortable feelings.

Michel Odent calls this ‘cul-de-sac epidemiology’ I.e. research that is buried away because it is too uncomfortable for society to deal with.

Why else? Because baby sleep is big business, think about how many baby sleep books you have seen? How many baby trainers and ‘experts’ make their living from ‘naughty non sleeping babies’? How many products are designed to encourage babies to sleep through the night? Nobody makes money from normal baby sleep.

Other forms of sleep training

Other forms of sleep training

In this section we will look briefly at some of the other methods often used by sleep trainers or in mainstream sleep texts to get babies to sleep longer. Each of these have their own pros and cons which are worth investigating.

Gradual retreat

This is usually marketed as a more 'gentle' approach to sleep training. Gradual retreat involves the caregiver doing their bedtime routine as normal; including any cuddling, rocking or feeding. Then just as the child becomes drowsy, put them down into their cot to fall asleep by themselves. The parent/care giver must then sit down next to the cot and wait for the child to fall asleep. If the child protests, cries or tries to engage then the parent/care giver must 'remain boring' reminding baby it is time to go to sleep, using 'key words' that are repeated (e.g. its bedtime, time to sleep). Each night the parent will do this from a progressively further distance from their toddler, eventually being outside there room.

Room restriction

Putting  stair gate or equivalent on your toddler's room so that they cannot leave their room during the night or in the early morning before you are awake. Some parent do this for safety and respond immediately to their child if called. However others use this as a tool to prevent having to respond.

Pick up/Put down 

This particular sleep training method was made popular by Tracey Hogg (The Baby Whisperer). It has been marketed as the more gentle of sleep training techniques and it is suggested that this should only be carried out with a baby older than 3 months. 

If baby cries when he/she is first put him/her down,  hand a on his/her chest gently and reassure baby with a 'Shhhh' or key phrase like ‘It's sleepy time'. 

If this doesn't soothe baby, pick them up and repeat the key phrase.

When baby stops crying, but is still awake, put them back down in their cot. If they start crying on the way down, put them in anyway.

If baby is still crying, pick them up again. This process is to be repeated until signs that baby is settling are clear (for example, his/her cries are getting weaker).

When this settling behaviour if clear, don’t pick baby up anymore. Leave him/her in their cot, place a hand on them and say the phrase.

Then the care giver is to leave the room.

If the baby starts crying again, the process is to be repeated as many times as needed until baby falls asleep.

The hope is that the baby will eventually associate the key phrase or 'shhhh' with going to sleep.

Big kid room

Parents/care givers often put lots of enphasis on a new 'big kid room'. This usually has a new bed, new decoration, new accessories, new bedding etc. The parents/care givers tell the child that they are a big boy/girl now and they sleep in their big kid room, alone, with all their new, wonderful things. Parents often have spent a lot of money on this renovation. 

Return to room

  • The first time the child gets up, remind them that it’s bedtime, lead them back to bed, give them a kiss and a cuddle, and leave the bedroom.
  • The second time, do the same but use a firmer voice and make the kiss and cuddle brief.
  • The third and any subsequent times, say nothing at all as you lead them back to bed, tuck them in, and leave the room. This is the hard part as it’s very tempting to give a cuddle. Remember that a gentle, consistent approach will convince your child that you’re there for them, but that you insist they sleep in their own bed.

Sleep trainer Clocks

The most common example of these are Gro-Clocks but there are various others on the market, as well as Do It Yourself variations. 

These are designed to tell the child when they are allowed to get up and, more importantly, disturb their parents. The instructions are; you must stay in your bed/bedroom when the star is showing and must only get up/leave your bedroom once the sun comes up (on the display screen). 

Reward/Sticker Chart 

Children are given an requirement (go straight to bed, not get up through the night or too early, stay in their room) and if they complete this they are given a sticker or reward. 

A letter from a sleep trained baby

 Dear Mummy,

I am confused…

I am used to falling asleep in your soft, warm arms.

Each night I lay snuggled close to you; close enough to hear your heartbeat, close enough to smell your sweet fragrance. I gaze at your beautiful face as I gently drift off to sleep, safe and secure in your loving embrace. When I awaken with a growling stomach, cold feet or because I need a cuddle, you attend to me quickly and before long I am sound asleep once again.

But this last week has been different.

Each night this week has gone like this.

You tucked me up into my cot and kissed me goodnight, turned out the light and left.

At first I was confused, wondering where you’d gone.

Soon I became scared, and called for you.

I called and called for you mummy, but you wouldn’t come!

I was so sad, mummy. I wanted you so badly. I’ve never felt feelings that strong before.

Where did you go?

Eventually you came back!

Oh, how happy and relieved I was that you came back! I thought you had left me forever!

I reached up to you but you wouldn’t pick me up.

You wouldn’t even look me in the eye.

 You lay me back down with those soft warm arms, said “shhh, its night time now” and left again.

This happened again, over and over.

 I screamed for you & after a while, longer each time, you would return but you wouldn’t hold me.

After I had screamed a while, I had to stop. My throat hurt so badly. My head was pounding and my tiny tummy was growling. My heart hurt the most, though. I just couldn’t understand why you wouldn’t come.

After what felt like a lifetime of nights like this, I gave up.

You don’t come when I scream, and when you do finally come you won’t even look me in the eye, let alone hold my shaking, sobbing little body.

The screaming hurt too much to carry on for very long.

I just don’t understand, mummy. In the daytime when I fall and bump my head, you pick me up and kiss it better.

If I am hungry, you feed me. If I crawl over to you for a cuddle, you read my mind and scoop me up, covering my tiny face with kisses and telling me how special I am and how much you love me. If I need you, you respond to me straight away.

 But at night time, when it’s dark and quiet and my night-light casts strange shadows on my wall, you disappear.

I can see that you’re tired; mummy, but I love you so much. I just want to be near to you, that’s all.

Now, at night time, I am quiet. But I still miss you.

All my love,

Your Darling Baby xxx

 

Use and printing with kind permission from Imogen O’Reilly

 

 

Sleep training quiz

Please select whether the following statements are true or false

  • Controlled crying raises the level of cortisol in toddlers, leading to potential issues in later life
  • Controlled crying causes mental health issues
  • Some sleep training methods are gentle and harmless
  • Crying it out is a valid method of sleep training
  • Crying it out is irresponsible and dangerous
  • There are pros and cons to all forms of sleep training
  • Parents need to be informed of the pros and cons of sleep training so they can make a proper choice
  • Parents may still choose to use sleep training methods after attending a ToddlerCalm class
  • We should discourage sleep training wherever possible
  • Parents who sleep train clearly don't value their child's needs

ToddlerCalm sleep strategies

Introduction to ToddlerCalm sleep

ToddlerCalm sleep solutions

At ToddlerCalm we look to work with parents to help them find their own strategies to manage their toddler's sleep. We inform and they choose, so we do not condemn sleep training methods or advise on "gentle" sleep tools. We don't advise at all. This may seem like we have nothing to offer parents to help them solve the very thing they came to us to solve. This isn't the case either.

What we do next is we help parents to take the information with which they have been presented by us, both in regard to sleep science and in regard to general toddler brain development, and we walk them through applying it in a way that becomes a strategy to manage life with their toddler.

There are three "strategies" we can give to parents for them to use to do this, which we will look at in more detail. They are:

  • Using a CRUCIAL strategy for sleep
  • Helping your toddler CALM for sleep
  • The ToddlerCalm SNORE ritual

Previously in ToddlerCalm the crucial acronym was adapted loosely for sleep as it is with any "behaviour" issue and the only additional sleep "solution" given to parents was known as the three-step bedtime ritual. This consisted of the followings headings:

  1. Expectations: Understanding that most sleep that is considered problematic is actually normal.
  2. Cues: Using smell and sound to condition "sleepiness"
  3. Comforters: Offering a transitional object or mother substitute

Following further research and because as a community of consultants we have agreed that the "ritual" was not substantial enough to be all that we offer to parents as sleep support, the leadership team has developed both the CALM acronym that is now being used across BabyCalm and ToddlerCalm and the SNORE acronym which will be used in both BabyCalm and ToddlerCalm for sleep.

ToddlerCalm's CRUCIAL™ strategy for sleep

CRUCIAL for sleep

Here we revisit the CRUCIAL strategy that we use across the ToddlerCalm programme and apply it directly to sleep. Remember that the idea of ToddlerCalm solutions is to give parents a toolkit that they can use in any situation with their toddler so that they feel empowered to manage new challenges without the need for "experts".

Control

It is easy to give our toddlers some control under the heading of sleep in small ways such as what pyjamas they wear, what stories they have, the bedsheets they use and such. However there are some bigger ways that we can give control back to our toddlers around sleep even though many of us find these a little trickier for fear of creating bad habits or creating bigger sleep problems. Examples of this might be allowing our toddlers to choose where they sleep (i.e. in their bed or yours), when they go to sleep or whether they actually do want to have a nap. Individual parents will have their own preferences and boundaries as to what control they are willing to relinquish.

It is also worth noting that toddlers may be taking back control at bed time or during the night because they don't have enough in other areas of their lives so parents can think more broadly in order to help the sleep situation.

Rhythm

This is such a huge area in relation to sleep that we will go on to talk about it in more detail later in this section. In brief, in the way that toddlers normally respond well to predictability, having a rhythm to bedtime will make it go smoother. When this rhythm becomes a ritual (is always the same every day) toddlers will be conditioned into winding down and their brains will start to predict sleep. There are many ways you can create an effective bedtime rhythm/ritual which we will discuss in detail and will link this concept with some other areas of the toolkit too.

Understanding

Parents will have been given a better understanding of toddler sleep and hopefully will therefore have changed what were probably completely unrealistic expectations of their toddler's sleep.  It is important that they are motivated to understand their own toddler better and make choices about what is right with this understanding.

Communication

From the toddler

Toddlers who cry out for their parents or do not want them to leave are communicating. They are potentially telling their parents any number of things: they are feeling insecure, they are feeling scared, they are over-tired, hungry or thirsty, they cannot get to sleep on their own, they are sad or they need to connect. It is important for parents to consider what their toddler is trying to communicate.

From the parent

It can be tempting for parents, when initiating or maintaining sleep is a problem, to try and reason with their toddler or explain to them why their behaviour is a problem. "I really need you to go to sleep now because I have work to do" OR "Please go back to sleep, you need to sleep otherwise you might get sick" OR "Why don't you want to sleep? you are so tired".

It is important to remember how the language and reason part of the brain (neocortex) is far less well developed in toddlers and that this is pointless. Any communication needs to be at the toddlers level and parents may also consider whether their communication is helping the toddler to sleep. Activating that part of the brain, may actually inhibit their ability to fall asleep.

Individual

Parents often come to us thinking their toddler has a sleep problem because their toddler isn't sleeping the way someone else's toddler does or how the latest book they read says they should. It is essential that parents understand that their toddler is an individual with unique needs and personality traits. Comparing toddlers is not helpful to parents or their toddlers. The sleep behaviour is only a problem if it is unmanageable for the parents or more importantly if it is negatively affecting the child.

Advocacy

It is important to understand that your toddler has needs 24/7 and that your responsiveness to those needs doesn't need to be different at night. By meeting your toddler's needs you are advocating for them, realising that they are important enough to respond to, even when it's hard. Some of the most important times to remember advocacy in relation to sleep is when others tell us we, or our toddlers, "should" be doing something differently.

Love

For your toddler

Parents need to be reminded that no matter how difficult their toddler is at bedtime, at night or early in the morning, they are not behaving this way to upset them. They are simply not capable of doing that. It is the difficulty in sleeping that the parent dislikes or finds impossible to manage, not the toddler themselves.

It is also worth discussing with them the fact that a toddler whose needs are met, has a secure attachment to their parents and feels loved unconditionally are often more calm, more settled and will therefore find it easier to sleep (eventually).

For yourself

Parents need to have the capacity to meet their toddlers needs. If parents are utterly exhausted and at the end of their tether, it is almost impossible for them to give what they need to, to their toddler. Remind parents that making time to catch up on rest, have time for themselves and manage their own emotions in whatever way works for them is not an afterthought. It is essential and should be a priority. 

A working CRUCIAL example for sleep

A CRUCIAL sleep example

Your toddler takes hours to put to bed and wakes at least once every night and you are understandably exhausted!

Control

Help your child to have control by allowing them at least the small chores such as choosing their pyjamas, choosing a favourite toy to sleep with, choosing whether to leave the light on or off. If you are comfortable with it, consider allowing bigger choices around sleep such as where and when they choose to sleep.

Rhythm

Create a rhythm with your toddler that indicates that bedtime is coming. Make this the same every day so it becomes a ritual that conditions the brain into sleep mode. By using other tools in our ToddlerCalm toolkit we can make this ritual a calm and sleepy experience.

Understanding

Consider that previous expectations you had about your toddler's sleep may have been unrealistic. Around half of all toddlers still wake regularly at 2 years of age; in fact it is not really until the age of 4 that a toddler’s sleep becomes as reliable/similar to that of an adult. Understand also that your child might be scared alone/of the shadow on their wall/may be ready to start the day at 5am even though you are exhausted and need them to sleep, perhaps this understanding may help you to make a change in your behaviour rather than your toddlers?

Communication

As with understanding, sleep problems can be a sign that your child is trying to communicate something to you, they may be feeling insecure, they may be feeling scared, they may be telling you they need to be closer to you. Understanding what need they are trying to communicate can be really helpful.

Individual

As with understanding there are so many reasons why toddlers find it hard to get to sleep/wake in the night/rise early – here we would suggest forgetting what your friends’ toddlers do and focus only on your toddler and remember sleep is only a problem if it is a problem for you, not just because the last book you read or somebody told you so.

Advocacy

If your toddler doesn’t sleep well in their bedroom, but sleeps really well in your room consider avoiding the creation of a problem by waiting until they are ready - regardless of what some family member told you was normal.  Similarly if your toddler sleeps well with a dummy, but your neightbour told you they were too big for it now so you’ve decided it’s time they give it up, consider whether this is really in your toddler's interest at this time.

Love

As always remember it is the sleep behaviour you dislike, not your toddler. They are not doing it to deliberately annoy you. In fact when a toddler feels safe and secure and unconditionally loved their sleep is often more settled.

Remember that in order to effectively parent your toddler and ensure that you meet their needs, you need to take good care of yourself. Making sure you get time off, time to catch up on sleep or relaxation is important in these early years.

Helping your toddler CALM for sleep

Helping your toddler CALM for sleep

Similarly to crucial, we have seen and used CALM before in the general TodlderCalm section. In this section we will more specifically apply it to helping toddlers to sleep a little better and longer. Using these tools can calm a toddlers' brain and body in preparation for better sleep.

Connection

Toddlers who have unresolved feelings will be unlikely to sleep. Ensuring that you are connecting with your toddler effectively in the daytime and "containing" their feelings for them when necessary will allow your toddler to be more calm at bedtime.

There are many suggestions of ways that parents can connect with their toddlers in the main section on CALM. Some that are most relevant to reconnecting at bedtime are: sharing stories together and sharing familiar songs together (in this case maybe having a few lullabies that are "family" ones).

Whilst carrying or using slings is a fantastic way of connecting with your toddler and of calming to sleep, some parents find it difficult to transfer their toddlers from carrier to bed and therefore do not find it a useful tool for bedtime. This is not always the case so shouldn't be ruled out. This can be a good tool for naps for those parents that are happy for their toddlers to nap in a sling.

Atmosphere (aka sleep environment)

Clearly the atmosphere in which we expect a toddler to go to, and stay asleep is essential. It is important that the toddler feel completely safe in the sleep environment and that they perceive it as a positive place for them to be. In this vein we can see how using "go to your room" as a punishment or even as "thinking about your behaviour" space could be detrimental to your toddler feeling calm enough to sleep. Instead, it is a good idea to play, cuddle, read and enjoy being in the child’s room together as much as possible during daylight hours to build a positive association.

Remember that toddlers are more "sensory" than we are so when looking at their environment consider how sights, sounds, smells and tactile elements could positively contribute to a sense of calm - this is covered in the SNORE ritual in detail.

Lastly, if your toddler is clearly unhappy with their sleep environment, consider changing it. You can move the furniture round, change the decor, move the toddler to a different room or conisder co-sleeping (sharing a room with your toddler) for the time being.

Loving touch

Cuddles and back rubbing

Using loving touch to calm toddlers is a natural part of parenting. This doesn't change at bedtime or at night. Giving toddlers cuddles before they go to sleep, or rubbing their backs or cuddling them to sleep has been demonised by some people who call themselves sleep experts under the assumption that parents would be "making a rod for their back". Cuddling our toddlers is a completely natural way to help our toddlers soothe to sleep. They will not always need us to do this for them but whilst they do parents can feel confident that they are not doing any harm by meeting their toddler's needs.

Furthermore it is anthropologically normal for young children to want to continuously touch their caregiver during the night. This is the least safe time of any 24-hour period for babies and toddlers (in the wild) and so being very close ensures their safety.

Breastfeeding

For mums that have continued breastfeeding past 12 months it is important for them to understand that the breastfeeding relationship provides their toddler with so much more than optimum nutrition, and this is a good thing. I hear of many mothers being told that their toddler should not be feeding at night because "they don't need milk during the night anymore". What well-meaning advisers mean is that toddlers are getting sufficient nutrition in the day. This may be true, or may not, depending on the toddler. However, the additional nutrition (that is cleverly tailored to their every need), is still highly beneficial to the toddler and this notion assumes that breastfeeding is ONLY about nutrition. This is untrue.

Many "parenting experts" and parents themselves can be often heard to say "oh they are just feeding for comfort" in a manner that suggests that this is pointless and something that should be discouraged. Parents need to understand that comforting a toddler through loving touch is as nurturing and as necessary as nutrition, and breastfeeding is the most natural way to do this (and what we were designed to do).

Massage

A continuation of infant massage, or even learning to massage your toddler without having done any infant massage, is a wonderful tool in offering a sense of calm to your toddler, both in times of difficulty and as part of a wonderfully calming bedtime ritual. This can be done over pyjamas or ideally skin-to-skin with some natural oil. To a certain extent, specific strokes are unimportant. The important factor is nurturing, loving touch.

Movement

Rocking to sleep

Parents often use movement to soothe babies and then this becomes something they are used to, so we find ourselves rocking a heavy toddler to sleep, whether in a chair or (more painfully) in our arms. This is another classic example of something that "people" will tell parents is a bad habit to form with their toddler. At ToddlerCalm we disagree. If this is a method that works to calm your toddler to sleep and you are happy to do it, then carry on doing it until it no longer works for one of you. At some point in the future your toddler will no longer need you to do this but for now, meeting that need will assist in their development and their ability to become independent.

Exercise and movement

A toddler who has had a good amount of exercise and movement during the course of the day will find it easier to settle to sleep at night. In addition, movements such as toddler yoga can help a toddler to be generally more able to relax, making other efforts to calm them more effective. This is obviously a more preventative calming technique, rather than something used at bedtime.

Introduction to ToddlerCalm's SNORE™ ritual

ToddlerCalm's SNORE ritual

The idea of the SNORE ritual is to take parents through realistic things they can actually do to improve their toddler's ability to initiate and maintain sleep. We have established in the science section that having a bedtime ritual can be beneficial to toddler sleep and so have considered the evidence in relation to sleep to create the basis for a ritual that optimises the benefit to sleep. We have come up with this:

S ensory cues

N ight-time expectations

O bjects (transitional)

R esponsive night-time parenting

E xternal factors affecting sleep

Sensory cues

Sensory cues

Cues are essentially a stimulus that parents condition (behaviourism) to induce the response of relaxation or sleepiness. By introducing certain things to situations when the toddler is getting ready for sleep/relaxing, and by repeating this over a sustained period of time, the stimulus itself will eventually be enough to induce relaxation (conditioned response). Adding cues to a bedtime ritual can be powerful sleep triggers. When we understand that toddler's brains are more sensory than ours, we can see that making our sleep cues sensory will be most effective. These are listed in order of usefulness for creating relaxation cues.

Smell

Creating an association between sleep and a certain smell can be highly effective. Using a smell such as lavender or chamomile (known for their relaxing properties) can be achieved in a number of ways: using an aromafan, a balm, a bath additive or essential oils on a muslin all work well. Using a smell such as lavender may also be useful in replacing a toddler's need to smell their mother in order to sleep. At ToddlerCalm we used to demonstrate a battery operated fan that used essential oils, but the ones we used became unavailable and there isn't a similar alternative. There are many oil diffusers on the market though so we feel that leaving it up to parents to discover the right way to add smell into bedtime is probably the way forward.

Sound

Using sound as a cue is also particularly helpful. This is because there are a number of sounds that are inherently helpful in relaxation. 

Alpha music

Studies have shown that music is an effective natural aid to sleep. Alphamusic is music that is set to 60 beats per minute (resting heart rate) and is specifically designed to regulate the alpha waves in the brain, relaxing the mind and body into a state that is referred to as the ‘alpha state’. If played during the whole bedtime ritual, toddlers will become calmer and more ready for sleep. They will also be more likely to transition from one sleep cycle to another during the night, without waking or needing assistance. If this remains a problem, the music can easily be played quietly throughout the night.

There are a number of places parents can find Alpha music but the most obvious one to recommend is that on the ToddlerCalm CD. We are considering getting this updated and improved but that won't happen for a little while. We are also looking at providing the music as a download and developing an app that offers the music as well as information.

Lullabies

Calming songs that your toddler is familiar with are a wonderful sleep cue for toddlers; "We sing this song at bedtime". This doesn't have to be a specific lullaby (I often hear people say "but I don't know any lullabies"). It can be any gentle song that you know, enjoy, and is familiar to you and your toddler.                                                                                                                                                                            

White noise (and other similar sounds)

In simple terms, white noise is a special type of sound signal which is used to mask background sounds. When used to promote healthy sleep, white noise helps to drown out sounds which might otherwise prevent you from either falling asleep or waking up whilst asleep. It is also useful for babies particularly in mimicking the more constant background noise that they would be used to from the womb.

In technical terms white noise can be described as noise whose amplitude is constant throughout the audible frequency range. Genuine white noise can only be generated electronically and sounds similar to TV or radio ‘static’. It is not very pleasant on the ears as it contains a lot of high frequency energy.

Sometimes “white noise” is used as a general description for any type of constant, unchanging background noise. It’s become a colloquial term for a diverse range of sounds including:

  • nature sounds – rain, sea/waves, crickets chirping, jungle etc
  • machinery noises – air conditioning units, washing machine
  • ambient soundscapes – aircraft interior, crackling campfire, crowd noise

Some people prefer to listen to these types of sounds when they’re trying to get to sleep in preference to the harsh tone of pure white noise. Here are some of the ways that a constant calming background noise is helpful as a cue for toddler sleep:

  1. It can be used as part of a bedtime ritual. "I hear this noise and I am ready to sleep"
  2. It buffers disturbing unexpected sounds that may wake a toddler in lighter sleep
  3. It helps to quiet busy thoughts or worries - hence it being used for meditation
  4. Many of the rhythmic versions of background noise promote a calmer body and potentially induce an alpha state in the brain
  5. It acts as a cue to return to sleep if your toddler does wake at night
  6. You can bring white noise anywhere, especially if you can have it on your phone.

BabyCalm currently offers a CD of white noise. As with the ToddlerCalm CD, we are looking to update this to offer a range of background sounds for parents to choose from. Ideally this will be available on CD, on download and via an app. This is all in the early stages of development.

Touch

Touch is the first sense that babies develop in the womb and therefore babies and toddlers are very tactile; they respond strongly to touch. This explains why sometimes the only way your toddler seems to want to sleep is when they are physically touching you. It makes them feel safe. For some families this means bed sharing is a good option (we will talk about this later) but for other families this isn't an option.  There are a number of other ways touch can be used as a sleep cue:

Massage and stroking

Adding massage into your bed-time ritual can be a fantastic way to incorporate touch as a sensory cue for sleep, which is why it is mentioned in more depth in the CALM section. Many parents incorporate touch into their ritual without even considering it. The stroking of hair, the side of the face or hands is often something that parents of toddlers do whilst they wait for them to drift off. This can be very useful but is something that requires the parent to be present so will not assist with night-wakings without parental input. That doesn't make it a bad thing though.

Soft objects

We will talk about comforters later in the section but for now it is important to say that having something soft to touch (a toy, blanket or muslin) can be an excellent sleep cue for toddlers. It also acts as a "mother substitute" but even without that, comforters offer a tangible cue to toddlers' senses that can be maintained through the night and are completely portable.

Sight

The most effective visual cue for toddlers is to be able to see their primary caregiver. From an evolutionary perspective, being able to see them means that protection is close and being able to sense whether they are calm or stressed (from their facial expression) means knowing whether there is danger. For this reason both bed-sharing and co-sleeping are ideal sleep environments for toddlers. However, they are not an option for all families. 

Some toddlers find it useful to have a nightlight in their room to enable them to see at least a little if they wake. This can help them to feel safe. Turning on the night light can also be a cue for them that it is now bedtime. With nightlight it is important to choose carefully as some light can be more detrimental to sleep than others (see below in external factors).

Taste

Taste may seem like an odd one as we don't want to "feed" toddlers right at their bedtime. However, milk is a taste that toddlers have already associated with calming and sleeping from when they were babies. The conditioning is done already. Furthermore milk contains amino acids that are naturally sleep inducing. Offering milk at bedtime is an excellent way of helping a toddler initiate sleep.

For parents who are still able to breastfeed, this is an ideal way to use taste (and many other senses at the same time) to help induce sleep. Breastmilk also contains sleep-inducing hormones, amino acids, and nucleotides, whose concentrations are higher during the night and may actually help toddlers establish their own circadian rhythms  (Sánchez et al, 2009Cohen et al, 2012). It is completely biologically normal for toddlers to continue breastfeeding to sleep through their second year and beyond. Remember toddlers will not need this forever and will naturally wean or can be gently weaned when parents find it isn't working for them any more.

For parents who cannot, or choose not to breastfeed, milk is still a good addition to the bedtime ritual. Cow's milk (remember formula is completely unnecessary past 12 months of age) provides at least some of the sleep inducing qualities and is still a pre-conditioned cue for relaxation. In addition, sucking releases the hormone cholecystokinin (CCK), which results in a sleepy feeling (Uvnäs-Moberg et al, 1993).

Lastly, and importantly...

Remember all cues must always be conditioned first. Parents need to understand that they cannot expect alpha music or lavender to work magic on it's own. You have to build a strong association between the cue and sleepiness. The idea is that the toddler's brain responds as "I hear this, I smell this, I touch this and I sleep". This will not only make bed-time easier but will also assist with night-wakings. When the toddler wakes in the night, it may be possible for them to help themselves into another sleep cycle by only using those cues, instead of needing parental input.

Night-time expectations

Night-time expectations

There are two elements to this section:

Expectations of toddler sleep

When parents come to us their expectations are often wildly different from the realities of normal toddler sleep, but hopefully once you have taken them through the content, they will understand and have more realistic expectations of their toddler at night. It is worth emphasising at this point in the workshop that parents ned to keep reminding themselves of what is normal and natural for their toddler as it is easy when tired to feel like they are "doing it on purpose".

Toddler's expectations during the night

The second element of expectations is both to understand what a toddler expects from their parents during the night (due to how they are treated in the day), and for parents to mould their toddlers' expectations of what happens in their night-time family culture, and as part of that, that parents have a deliberate night-time family culture.

Do parents want children to expect no response from them at night? If so, how does that fit with their parenting goals and how they parent during the day? Are children allowed to come into the parents room/bed? What happens when they wake at night? In the morning?

This is entirely individual to each family - it may be good to facilitate a discussion amongst the group here by using some open questions around the topic. This will empower them to find their own solutions and prevent the "expertise trap" where your own personal practice as a consultant can be held up as the high standard.

Objects (transitional)

Objects (transitional)

Donald Winnicott's transitional objects (as discussed in the psychology section) are also known as comforters. Many parents use them without understanding the full meaning behind them or why and how they work to help toddlers feel more calm and settled. The truth is that your toddler's special toy or blanket is not just their favourite because they think it's soft and cute, it is important to them because it is their link to their primary caregiver. Don't get me wrong, Harlow's experiment with monkeys shows us that touch (softness) is highly important to infants, but this is not the whole story.

A transitional object acts as a "mother substitute" offering comfort, connection and attachment when the parent cannot be there. This may be in their childcare setting but is most commonly during the night.

In fact one of the most important factors in a transitional object being effective is how it smells, and particularly that it smells like the "mother". Have you ever washed your toddler's blanket? - I bet they weren't happy.

If parents are looking to introduce a transitional object they need to realise that conditioning is key. The toddler needs to relate the object to their parent and to feeling calm. Keeping the comforter close by at all times and holding it between you and your toddler during close contact will be effective in creating a strong association and in making the comforter smell right.

At ToddlerCalm we demonstrate an excellent example of a comforter called a Cuski-boo. We demonstrate this particular product because we think it is the best one on the market for various reasons:

  • It is officially approved by the National Health Service - the only comforter in the UK with it's own protocol for use in SCBUs and NICUs.
  • It is made entirely from a special bamboo yarn, organically, sustainably and ethically grown.
  • It is ultra absorbent (retaining scent), antibacterial, eco-friendly and biodegradable.
  • Cuski's unique shape stimulates your child’s imagination - a round shape is the first shape a baby recognises as it mimics the shape of faces
  • The growing of bamboo actually helps our planet
  • It is incredibly soft.

Cuski is the anglicised Welsh term, meaning "to sleep".The company was created to bring comfort to babies and toddlers all over the world. There are a number of other very suitable products that Cuski offer such as their muslin squares (bamboo), their giant muslin square (Giant Swandoodle) which are higher popular with children (and adults) of all ages, their bamboo blankets and Cuski comforters made from bamboo muslin material.


It is important to remember though that toddlers will often choose their own transitional object if one is not conditioned for them. If they have already done this, changing objects is probably not advisable unless the chosen object is really unsuitable. In addition there are many many products out there and different comforters will suit different toddlers. We are not prescriptive and simply show the Cuski-boo as an example for parents. The reason we sellthe products we demonstrate on our website is so that parents do not need to search round for them and so that we can offer clients a discount on retail prices. We are not trying to make lots of money from selling people things.

Responsive night-time parenting

Responsive night-time parenting

Although many parents know that parenting is a 24 hours job, they are programmed by society to believe that after the first few months, their baby/toddler does not need them at all during the night-time hours. Many are repeatedly told by the media and friends and family that doing any kind of active parenting at night will in some way harm their child. This is nonsense. All the psychological research is utterly clear. Babies and children whose parents respond to their needs, wherever possible, develop better independence, are more emotionally resilient and have more optimum brain development. Night-time parenting is as important as daytime parenting (even if it is difficult for parents who are used to being asleep during these hours). So how do we make responding and reassuring at night easier for parents? One way is to keep our toddler closer at night so that they wake less and that when they do wake, we need to wake less to respond.

Co-sleeping

Co-sleeping means sleeping in the same room as your toddler, but not necessarily on the same sleep surface. This is very normal in many cultures and there are a number of ways this can be done:

Having your toddler in the same room as you may mean that they sleep better without the parent doing anything extra. This is likely because they will be able to see  you, hear you, smell you and when they wake in the night may be reassured simply by your presence. Also, research suggests that when parents share rooms with their toddlers, their heart rates and brain waves are more settled as they regulate each other.

Bed-sharing

Bed-sharing means sleeping with your toddler (and possibly other children) in your bed. The "family bed" is a common concept in other cultures and actually makes a lot of sense. This set-up allows you to be even more highly responsive to your toddlers' needs during the night and provides a greater sense of security to your toddler. 

It is likely that you will get more sleep in this way. However, many parents in our culture find this to be strange and have some common concerns. We can address these concerns but we must remember that this doesn't work for everyone and it is just one of the possible tools we can offer parents to help them sleep more.

Will they ever be independent?

Many parents have concerns that if they start this they will be unable to, or find it very difficult to, move their child into their own room when they want to; essentially that their toddler will never grow to be independent.

Research reliably shows that independence in a developmental milestone that is reached at a certain age and children that have a safe and trusted emotional base (secure attachment derived from responsive parenting) from which to venture become more independent more quickly.

Parents can be reassured that children will naturally want to separate themselves, a process which usually starts around 3-4 years of age.

What about adult space?

Another concern of parents when thinking about sharing their sleeping space is that they will no longer have space for their adult relationship. This is something that is perpetuated by media coverage of co-sleeping and bed-sharing with a common misconception that "co-sleeping kills relationships".

In truth there is a huge list of things about being a parent that are seriously tough on both parent's sex lives and their relationship as a whole. Between changing roles, changing hormones, changing energy levels and changing bodies (just to cover the main ones), parents often feel that things have fundamentally changed. This can be very difficult but the main thing that parents can do to counter all of it is to keep communicating. Communication is fundamental to strong relationships. Being able to have honest and open conversations about all of the above is essential. So for the good of your toddler, find time for your relationship - to nurture it and be responsive to that too.

As for sex! If parents are both willing, regardless of all the changes and struggles, then it's time to get a bit more creative and take it out of the bedroom. What a great way to re-kindle the fun.

External factors affecting sleep

External factors affecting sleep

This last item in our SNORE ritual is being cautious about external factors that may inhibit sleep for our toddlers. Form the research we can see that there are a number of things that could do this and, if they are a problem for your toddler, there are some relatively simple ways to prevent them affecting sleep negatively.

Diet

The things we eat can have an positive or negative impact on sleep and usually more so our toddlers. 

Lots of food aimed at children contains E numbers which has been found to cause restlessness and sleep disturbance, so if your toddler is having trouble with sleep then it is worth considering if they are being exposed to any E numbers (there are some foods which you may not consider have E numbers but, for example, Infant Paracetamol can have several E numbers contained). 

There also foods which can contribute to more, well rested sleep. You may have heard some people suggesting feeding their toddler a banana each day and it will make them sleep. This is because bananas contain Tryptophan. Tryptophan is an amino-acid and an essential part of the human diet because our bodies are unable to make it, and the only way we can get enough is through our diet (including breastmilk). Tryptophan is an important component in the manufacture of serotonin and melatonin, the hormone of sleep, and for this reason many suggest that foods containing high levels of tryptophan may help us to sleep, although it has not been proven to reduce the amount of night wakings.

Breastmilk, is a useful tool to promote sleep. Breast milk produced at night contains signifiant levels of melatonin, the sleep hormone. 

Screens

Screen-time can have a hugely negative impact on sleep initiation. Some children can happily fall asleep whilst watching a dvd. However others struggle with having screen-time in the two hours prior to bedtime. Research has shown us that those children who watched television in the last hour or two before bedtime went to sleep later than those who watched none so if parents are struggling with bedtime, limiting their toddlers' exposure to screens in the 2 hours before bedtime might be hugely beneficial. 

Light

Artificial light plays havoc with our circadian rhythms, making our bodies think that the day ends much later than what the sun sets and the day starts much earlier than the sun rises.

Night lights can also contribute to disturbed sleep and problematic bedtimes. Research that was carried out to look at the impact of different colours of light has found our body’s natural clock system responds differently to artificial light sources, depending on the colour. More natural, low intensity light (reds, oranges - colours than mimic firelight) aren't inhibiting of melatonin (the sleep hormone) but blue and white lights have been shown to trick our brains to thinking its daytime. 

Remember, if your toddler does not have a sleep problem, there is no need to take these measures. If it ain't broke, don't fix it.

CRUCIAL quiz

Please select whether each statement is true or false.

  • Parents should choose where their toddler sleeps and stick to it
  • Toddlers who have little or no control over their lives may exhibit difficult behaviour around sleep
  • Having a ritual is helpful for toddlers to understand that bedtime is coming up soon
  • It is essential that you have a strict routine for bedtime that conditions your toddler to fall asleep
  • Having an understanding of the neuroscience of sleep will tell parents everything they need to know to make their toddler sleep better
  • Parents will need to take time to relate what they have learnt to their toddler
  • Telling your toddler why they need to go to sleep will help them understand and make them sleep better
  • Toddlers who demand attention at night have a need that they are communicating.
  • The crucial strategy that your friend developed for her toddler will not be suitable for your toddler
  • Comparing your toddler to others of the same age is useful in determining whether their behaviour is normal
  • If you have made a change to your toddlers sleep environment, it is important to stick to the change even if it isn't going well, otherwise they will be confused.
  • Parents must practice self-care so that they can parent responsively at night as well as during the day

CALM quiz

  • Bedtime stories are a great way of connecting with a toddler at bedtime
  • Parents should control which stories and how many stories happen at bedtime to ensure it is not too stimulating
  • It is important to learn proper lullabies as they are know to be calming
  • It is important that a toddler likes and feels calm being in the room in which they sleep
  • Massage is too stimulating at bedtime
  • Loving touch that helps induce sleep can be as simple as touching your toddler's hand
  • Toddlers who move more during the day, sleep better at night
  • Rocking a baby to sleep is not a habit you want to form

SNORE quiz

  • You must use all the senses in order to provide a proper environment for sleep
  • Parents should use whichever sleep cues suit their family
  • Parents need to work out what they are comfortable with at night (their culture) and build their strategy around that
  • It is important toddlers are gently helped to understand those expectations and they are realistic
  • It is important to ensure your toddler's comfort object is a proper one
  • We have a deal with Cuski and must promote their products where possible
  • Responsive parenting is just as important at night as it is during the day
  • At ToddlerCalm we are all very keen on bed-sharing and co-sleeping
  • It is important to be cautious about the light we have in toddler's bedrooms at night, avoiding blue and white light sources where possible.
  • Screentime and TV watching will always cause more difficult sleep

Please identify the difference between co-sleeping and bed-sharing

Looking at ToddlerCalm's sleep toolkit as a whole, please identify the three key factors in promoting better toddler sleep

  • Having a bespoke bedtime ritual that delivers the conditioned response of sleepiness
  • Having a fixed bedtime routine
  • Parents having realistic expectations of their toddler's sleep
  • Parents understand that responding to their toddler will make strong positive brain connections and promote independence
  • Parents learn that bed-sharing and co-sleeping are the ideal night time set-ups
  • Parents must use a combination of sensory stimulus to induce sleep
  • Ensuring that parents eradicate all possible inhibitors of sleep

Sleep safety

Creating a safe place to sleep

Safe toddler sleep

Please note that there is no official guidance regarding safe toddler sleep. It is worth looking at the safe sleeping guidance for infants as some of it apply. As far as we know, this is the only specific guidance for safe toddler sleep:

A safe place to sleep? 

Toddlers can sleep wherever is right for them and their caregivers. Some parents choose to have their toddlers in their own bedrooms, others are happy to have them sleep in the family bedroom/bed. Wherever the toddler sleeps, it must be made a safe environment for them. In this section, we will explore how and where a toddler can safely sleep. 

The Do's and Don'ts

Toddlers can:

  • use a toddler pillow & duvet 
  • take naps in slings (following safe sling use) 
  • sleep in their parents bed 
  • sleep in their own cot/bed 


Toddlers should NOT:

  • sleep with their parents who have been drinking alcohol or taking drugs (illegal or legal) 
  • sleep with their parents if either one of them is a smoker 
  • sleep at the edge of a bed where there is a danger they will fall out during the night
  • sleep with their parents on a sofa or armchair

Sleeping in their own bedroom

Sleeping in their own bedroom

The following things need to be checked and parents/care givers must make sure that the room is safe, after all the child is being left alone and is likely to be awake at some point without supervision. 

1. Furniture and windows

It may seem like their chest of draws or toy storage unit is sturdy enough to stay put, but if  a toddler climbs up on them, his/her weight added to the front can pull the whole thing forward and down on top of him/her. It can be a fatal accident, unfortunately. So parents need to be made aware of this risk and how to rectify it. You can buy such things are furniture straps or simply just get a bracket and screw to the wall (most units are supplied with these now).

Another scary thing that can happen in a toddler’s room, is he/she can climb out of his window should it be left open or unlocked. He/She may have never done it before, but, as you know, toddlers can be unpredictable. 

Also ensure that window blind chords are affixed appropriately. They can become a dangerous addition to a toddlers bedroom should they get stuck in one. Most blinds now come with a safety feature which will allow parent/caregiver a bracket to keep the chord out of the way. 

2. Choking Hazards

Although toddlers stop putting as many things in their mouths than when they were babies, toddlers are still very sensory and like to explore with their mouths. Make sure the room doesn't have  any choking hazards. As a good rule of thumb,  anything that fits into an empty toilet paper roll could be considered as a potential choking hazard.

3. Electricity and wiring

If there are a lot of wires in toddler’s room from the lamp, CD player, humidifier, etc. it may be worth considering concealing the wires using a wire guard. This can limit curiosity about “what happens when I do this?”.

4. Stairs

If your toddler’s room is upstairs, it is important to consider if you ned to make the stairs safe or whether you need to prevent the toddler from roaming freely on other floors. If either of these are necessary, it might be a  good idea to have a stair gate on the top of the stairs. Even if a toddler is able to navigate the stairs with confidence and competence, if they wake in the night and are still half asleep, they may wander out on to the landing and not know they are near the staircase. They may sleep walk. This is more of a parental choice and will be different for each family.

5. Monitoring

Some parents find it comforting to have a monitor (either audio or video) and others find it induces paranoia. Listen to your instincts but understand that unless you really couldn't hear your toddler without it (even this depends on their age) a monitor isn't necessary. As always, if it helps parents feel calmer then great; it can give some parents peace of mind without disturbing their toddler unnecessarily. 

All care givers vary in terms of how they feel about their toddler’s new found freedom. Some of them will be very nervous and others won’t feel the need to have a gate or monitor. How large their house is, the layout of the house, and what is in their toddler’s room may be big factors, as well. 

Sleeping in parents bedroom

As with the previous section "sleeping in their own bedroom", it is important that if a child is left in any room alone, those safety guidelines are followed. 

There are usually two sleep surface options when a child shares a caregivers bedroom:

  1. In their own bed, separate to the master bed 
  2. In the master bed with parents/care givers. 

If they are in their own bed (be that a floor bed, toddler bed, single bed etc), it is important to still follow safety guidelines. 

When must a toddler NOT share a room with their parents? 

There are certain reasons why it would be deemed significantly less safe for parents to room share/bed share with their toddler:

  1. When either parent who sleeps in that room smokes or take drugs
  2. When either parent has been drinking alcohol excessively and are unable to appropriately care for their toddler.