Healthy Sleep Habits, Happy Child
25
‘Let Cry’ Sleep Solutions: Graduated Extinction & Extinction (Sleep Solutions #3)
May 3, 2021

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Healthy Sleep Habits, Happy Child

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Introduction

A Healthy Child Needs a Healthy Brain, A Healthy Brain Needs Healthy Sleep

If you have not already done so, please read Blog Posts 1 through 5 that describe how sleep is important and beneficial. I will post specific information for parents and children based on my book, “Healthy Sleep Habits, Happy Child.” Please do not be put off by my book’s length. This is a reference book. Read only the topic of interest to you.

Blog 25‘Let Cry’ Sleep Solutions: Graduated Extinction & Extinction (Sleep Solutions #3)

SLEEP PROBLEMS:
PREVENTION VERSUS TREATMENT

All the items listed below in “WHAT A PARENT CAN DO” contribute to the prevention of sleep problems developing in the first place; the earlier you start, the more likely your success. Also, all of the items listed below in “WHAT A PARENT CAN DO” also contribute to the treatment of sleep problems, but they might not be sufficient. Specific family circumstances (Blog Posts 14 and 17) and individual differences in babies (Blog Post 20) might make this difficult to accomplish and a sleep problem (difficulty falling asleep or staying asleep) might develop in your child. 

Two safe and effective treatment strategies that do not involve letting your child cry are ‘Fading’ and ‘Check and Console’ (Blog post 19). 

Two safe (Blog Post 24) and effective treatment strategies that do involve letting your child cry are ‘Graduated Extinction’ and ‘Extinction’.

Because of differences in specific family circumstances and individual differences among babies, it is difficult to give specific advice regarding which method best suits a particular family. Nevertheless, here are some general observations that might help you:

  • If there is moderate or severe marital distress or perhaps if either one or both parents have symptoms of anxiety or depression, consider starting with ‘Fading’ or ‘Check and Console’.
  • If there is mild marital distress or perhaps only one parent has symptoms of anxiety or depression, consider starting with ‘Graduated Extinction’.
  • If there is minimal marital distress and neither parent has symptoms of anxiety or depression, consider starting with ‘Extinction’.

GRADUATED EXTINCTION

Graduated extinction means that after a bedtime routine including soothing, at sleep onset and in the middle of the night, you let your baby fuss or cry for a predetermined brief period, say five minutes. It may be a little less or more. Then you pick up your baby, talk to him, feed him if hungry, and do whatever is necessary to calm him down. You might either calm him to a drowsy state or to a deep sleep state and then you put him down and possibly leave the room. On a given night, you might keep the interval constant, say five minutes, or progressively increase the delay interval by, say five minutes, with each episode. Or, on a given night, keep the interval constant, but on each subsequent night, progressively increase the delay interval. During one of these delays, your child learns to fall asleep unassisted because he is learning self-soothing skills.

EXTINCTION

Extinction (you are extinguishing the habit expectation that crying out always brings parental attention) means that after a bedtime routine that includes soothing, at sleep onset and in the middle of the night, except for feeding, changing, and any suspicion of medical distress, you let your baby fuss or cry without time limit until the morning.

  • Extinction with a cap: Some parents put a cap on the number of minutes of ignoring their child, so they know they are not committing to endless fussing and crying, for example 45 minutes. Too brief a cap might allow your child to learn to cry to the time of the cap for the reward of parental soothing.
  • Extinction with parental presence: Some parents remain in the room until their child falls asleep. 

Your child learns to fall asleep unassisted because he is learning self-soothing skills.

CAUTION

Neither Graduated Extinction nor Extinction will work if:

  • Parents are inconsistent, for example, “just once” take the child back to their bed for nursing.
  • The bedtime is too late.
  • Naps are not going well.

(To be continued.)

Comments

  1. Hi Dr Weissbluth

    We are 13 days into extinction with our daughter- 8 months old. After 45 minutes of crying on the first night, she gradually improved until there was only a few minutes of crying on night 5. However, since then, it’s been more of a roller coaster. She’s had some nights where she’s cried for an hour and others of 15 minutes or 45 minutes. Last night there was no crying but tonight she cried for 58 minutes! This inconsistency is making me doubt myself.

    Her naps total about 2.5 hours a day, and we try put her down when she shows drowsy signs. We put her to bed between 5:30 and 6:30, depending on when she wakes from her final nap.

    There has been an improvement in terms of her night waking- she was waking twice a night for a feed but since we started extinction she has dropped to one feed and has no trouble falling back to sleep after her feed.

    Given that she’s been so inconsistent with her crying, should we give extinction a break? Or is it too early to give it up as we’re only on day 13?

    I appreciate any advice!

  2. Yawning and rubbing her eyes and face. Her wake window before bedtime is usually around 3-3.5 hours after the last nap.

  3. I’ve read Blog posts 9 and 83- thanks for directing me to them. She is definitely showing fatigue signs on the nights with crying. I am going to try and start the bedtime routine earlier while she is happy and soothe her to sleep when she shows the drowsy signs instead of starting the routine when these first appear.

    Thanks again

    1. Please let me know how the next 3-4 nights go so we can fine tune this if needed.
      Sweet Dreams,
      DrW

  4. Hi Dr Weissbluth

    We’ve had a huge improvement over the past 5 nights. We’ve gone through the bedtime routine much earlier than we were and have started soothing our daughter to sleep as soon as she yawns. Her routine now starts around 4:30 pm and she’s in bed between 5 – 5:30pm. Out of the past 5 nights, we’ve had one where she protested then cried for 28 minutes, but on the other 4 nights, she went to sleep with no tears. She even woke up after an hour on several nights but put herself back to sleep with no tears. It’s hard to believe that all she seems to have wanted was an earlier bedtime- we are in shock!

    Thanks again for responding and for your amazing blog.

    1. Hi Crystal,
      I am happy that you had the courage to try a super-early bedtime. Not all parents are able or willing to give it a try. As weeks go by, she will be napping better and then will appear less drowsy in the late afternoon and early evening. At that time, slowly and in small increments, allow the bedtime to become later. Follow her lead and don’t be tempted to rush her. Also, please resist family and friends who might suggest that it is all right for her to stay up later. By the way, today I started to post ‘Fake News’ reels about children’s sleep on Instagram (#marcweissbluth). If you find it worthwhile, please spread the word.
      Sweet Dreams,
      DrW

  5. Thank you for that extra advice- I will look for the signs that she’s ready to go a bit later over the next few weeks.

    Friends and family have been quite surprised to hear how early we’ve been putting her to bed and some have suggested to me that she may wake early as a result- she hasn’t! I just tell them about your book and blog. I’ll have to mention your instagram too. My husband has also had a few days where he’s not seen her because he’s had to work late. However, we know it’s just a short term thing and we’re so happy to have seen her sleep so soundly this week.

    Thanks again

  6. Hi Dr Weissbluth

    We are having similar issues with our 6 month old as Crystal did (still crying after 10 days of ST) and are planning to move her bedtime earlier – from 7pm to 6pm – in hopes that will help.

    My question is around the napping. Is it ok for her to take 3 naps still? Right now she is napping around 9:30, 12:00 and 16:00. The naps are usually 40 mins to 1 hr. We are basing this off her sleep cues (starts to fuss or doesn’t want to play anymore, eye rubbing, face rubbing). She is still waking up at the 30 min mark during naps and in the evening – sometimes she soothes herself back to sleep quickly and sometimes there is crying.

    Any advice would be appreciated.

    Thank you!

    1. A common reason why ST does not work well is a bedtime that is too late. Depending on naps and drowsy signs, think of bedtime as between 5:30-6:00pm, for now. Based on her age, I would not let her start a third nap after 3pm. Thus, she may need extra soothing and distraction in the late afternoon. The extra sleep in the beginning of the night will allow her to wake up better rested which will allow the naps to get longer. Weeks later, the longer naps will permit a later bedtime. But please don’t rush this. Your guide for the bedtime will be her drowsy signs and because of nap variability, the bedtime will vary. Does this help?

  7. Hi Dr Weissbluth,
    Thanks so much for the amazing content you provide, helpful as we try to sleep train our 7 month old. I have a clarification point here for the extinction method. You say “except for feeding, changing, and any suspicion of medical distress” to let the baby cry. How should we know if we need to leave the baby alone or feed them? I read somewhere that your view is that babies perhaps need night feedings up until age 9 months, but I can’t find any more information on this. If my son wakes up 3 times at night (between 6pm bedtime & 8am wakeup) and falls back asleep right away if I feed him, what category does this fall in?

  8. Hi Dr. Weissbluth.

    My Baby is 7 1/2 months old. He is thank Gd a very easy going baby generally. He naps pretty well overall. His last short nap of the day some time between 3-5 pm does not always happen. He sometimes will just cry and not sleep. Each of his first 2 naps of the day range from being an hour-2 hours long generally.

    He nurses some time between 530-6 for the last time before bed time. I have been trying to wean him off of night feedings slowly because he was still waking up well before midnight to nurse. For maybe 2 weeks, I have not been going to nurse him before midnight. He still wakes up and cries before then, sometimes for a long time. Shouldn’t it have taken fast if I did extinction and didn’t even go into him? Shouldn’t he be accustomed to not waking up before midnight?

    I want to get him down slowly to 2 feeds then 1 feed then no feeds. Any advice is appreciated.

    Thank you!

    1. What is his most common sleep schedule: time of naps, duration of naps, beginning of bedtime routine, time of falling asleep, times of nighttime feedings, and wake up times?
      Does he self-soothe for naps and night sleep?
      Do you ever use a supplemental bottle (expressed breast milk or formula)?

  9. He goes in for a nap in the morning between 8:30-9. He generally sleeps until 10/10:30. Depending on when he wakes up from that morning nap, he goes in around 2 hours later (between 12-12:30). Sometimes, he’ll go in closer to 1 if he takes a longer morning nap. Then his afternoon nap is a lot of times only about an hour (again, sometimes it can be 2 hours, but I think usually his morning nap is longer it seems). So I guess his last short nap of the day might be around 3:30, but he doesn’t always fall asleep right away. Sometimes it can be at 4 or later.

    Then if he’s very cranky, I start nursing him before he goes to sleep around 5:30/5:45. I do not nurse him to sleep. He falls asleep for bed time and naps completely unassisted. He doesn’t take a pacifier – he sucks his thumb. He seems to often be tired and fall asleep in the early 6s for the night.

    The time he’ll wake up and cry for a bit at night varies. And sometimes, it’s only a few minutes and then he’ll sleep a few more hours. Sometimes, it’s for a while (the other night was an hour until midnight and then I went in to nurse since it was midnight). There is nothing so specific about his nursing times at night besides that I won’t nurse until midnight at least. The first one might be around midnight, and then 3 hours later, and then he has been waking up in the 5s or at 6 and is still tired, so I nurse him and he goes back to sleep until 7 or until I wake him at 7 something.

    One night he slept until 2 am and nursed only then for the first time. He seems to not be so consistent with his night wakings/feedings.

    I don’t do bottles of any sort.

  10. I’m wondering why he is still waking up crying before midnight so often if I haven’t gone into him in 1-2 weeks I think – so I’m not encouraging or rewarding his waking up. I don’t want him to cry every night. Does extinction work for eliminating feeding sessions at night? Am I doing the right type of method in theory? I want to get him down to 1 feed eventually and then no feeds…

    1. How certain are you that your breast milk supply is adequate? Are you thirsty much during the day? Have there been any new stressful events in your life? Are you getting enough sleep? Maybe your breast milk supply is not quite adequate near the end of the day and his bedtime feeding is not quite sufficient so he wakes up before midnight. If you try test feeds before midnight, by his sucking pattern (suck-swallow-suck-swallow-suck-swallow) you might determine that he is hungry then, or not (suck-suck-suck-swallow, suck-suck-suck-swallow). What are your thoughts?

  11. He stops nursing on his own, even when I try to offer more. He’ll just push his head away and seems happy and satisfied.

    He also eats some solids during the day – of course not enough that it would be filling him, but I have not reduced nursing times during the day and he also has solids.

    1. If he is hungry, please feed him. If you are not sure that he is hungry, perhaps his care-giver or a lactation consultant might help you decide.

  12. Dr. W,

    Started extinction w/a cap on my 8 week old son last night. I know the book said the first night (for children under 6 months) they usually will cry between 45-55 minutes, so we used a 1 hour cap. My son cried the entire hour and did not seem to be winding down. My question is – what do we do after “the cap” comes around? Soothe him to sleep? Give it up and try again the following night?

    For reference, he had been up for 90 minutes since his last nap and we put him down at 7:15 after he took 5 ounces of breast milk. His naps that day were slightly shorter than normal since we were traveling for Christmas, but other circumstances seemed optimal and I was surprised he outlasted us. We will try again tonight with a longer cap. But I am curious to know what we should plan to do if he outlasts the cap again?

    Thanks for your help!

    1. What is the usual timing and duration of naps and when did you begin soothing to sleep and when did you leave the room at bedtime?

  13. His morning nap is around 9-10am depending on when he wakes up for the day, and lasts 2 hours. After that his routine is that he spends 80-90 minutes of wake time before napping again for 45-60 minutes repeatedly the rest of the day, with the last nap usually starting between 4-5pm.

    The first night I started soothing him about 10 minutes prior to laying him down and did not stay in the room after laying him down – I walked out immediately and left the house while my husband stayed with him outside the room.

    (For reference, night 2 he cried for 1 hour 40 minutes before I went in to soothe him & put him back down, and then he cried for 10 more minutes before falling asleep. After that he was still restless and waking on and off for the next hour before really getting to a deep sleep for the night.)

    1. Please clarify: For the bedtime, what time at night did you begin the soothing to sleep process and what time did you leave the room?

  14. Sorry, night 1 I started soothing at 7:05pm and left the room at 7:15pm. Night 2 we tried earlier due to an earlier last nap of the day – I started soothing at 6:20pm and I left the room at 6:30pm.

    1. OK. His last nap starts between 4-5pm. How does he look and behave between 3-4pm? How long does this nap last? When this nap ends, hoe does he look and behave before 6ish?

  15. Between 3-4 he acts “normal” for his average wake time – alert, happy, content, interactive. That last nap is only 30-40 minutes max.
    Around the 6pm hour I would say he is usually more fussy and overall discontent than other wake times.

    1. Was he born on his due date or early or late?
      “Around the 6pm hour I would say he is usually more fussy and overall discontent than other wake times”. These are fatigue signs, not drowsy signs. He is overtired and in a state of higher neurological arousal which makes it harder for him to fall asleep and stay asleep. Because you innocently were putting him to bed at night too late, there was a lot of crying.
      Please review drowsy signs in my book or on my Blog and then you will understand that his sleep tank is going towards empty around 4-5 pm. Therefore, no nap then. Keep him up. Begin a soothing bedtime routine around 5ish, put him down for the night and leave the room at 5:30pm. There will be less crying because he is at a lower level of neurological arousal. This super early bedtime is temporary until long regular naps develop between 4-6 months of age.
      How do you feel about this?

  16. He was born 2 weeks past his due date. So he would be 11 weeks now if he had been born on time.

    We can definitely try this the next several nights. How long of a cap would you suggest given the information? Or in this case would we remove the cap? Thank you for the help.

    1. You are welcome. How about a 3-5 night trial of 5:30 bedtime with extinction (with or without a 1 hour cap on crying) at bedtime and in the middle of the night (of course feed him when he is truly hungry and attend to him if you think he is ill)?
      Keep a detailed record of nap times, nap duration, bedtimes, crying episodes, crying duration, and crying intensity (mild, moderate, severe,) for these 3-5 nights. Please be compulsively consistent during this 3-5 night trial.
      Are you ok with this?
      Is your husband on board?
      Does he sleep in your room or in a separate room?
      Let me know how it goes.

  17. We have moved ahead with your suggestion and did the 5:30 bedtime last night and tonight. (This makes night 4 of using extinction at bedtime.) Both nights that we used the earlier bedtime of 5:30pm, he seems super drowsy after our bedtime routine and lays down awake but drowsy with no crying or protest. However, both nights this was followed by only 30 minutes of sleep and then 3 hours of on/off crying. He will lay down and appear to be going to sleep for 2 minutes or so, then wake back up and cry for 2-3 minutes, then lay back down for 2 minutes, and so on, for hours. Both today and yesterday he woke up for the day between 7-7:30am and napped for 5 hours. He does not have reflux, colic or illness. I’m not sure what else to try. Considering his young age, I had hoped for more progress by now and can’t help but feel discouraged.

    Is there any chance we started him too early on this and need to postpone this another month?

    1. Please be patient and stay the course for 2 more nights and then give me a report.
      Please be optimistic because he is demonstrating self-soothing at sleep onset. During those 3 hours of on/off crying, would you describe it as mostly mild, moderate, or intense crying?
      Am I correct that during this time he is being left alone?
      Is the napping for 5 hours his old pattern or is it new?
      Is the wakeup time (7-7:30am) his old pattern or is it new.

  18. The crying during the on/off hours starts out mild, and eventually moves to moderate. I don’t think he ever persists long enough to get past that level since he lays down and rests every couple of minutes.

    The 7-7:30 wake up time is new as of the last week or so. He used to sleep much later (9:30-10am). The 5 hour total nap time each day is normal as far as I know – I only started timing it every day for about the last 2 weeks. Yes he is being left alone in a crib in our bedroom and we leave the room completely. He is in our room at nights since I am not ready for him to move in with his 4 year old brother just yet. We will stay the course and hope for improvement in the next couple of nights. I’m sure if he were sleeping consistently during that 5:30 – 10pm window that would make a world of difference for him. Thanks again for your guidance.

    1. Perhaps white noise machine might help if your child is hearing household noises early in the evening. The continuous sound dampens the signal intensity of intermittent sounds.

  19. Well we seem to have had a breakthrough!
    Last night he went down at 5:30pm and followed his usual routine of waking at 6:00pm and starting intermittent fussing/dozing. However, this time the on & off fussing only lasted 40 minutes, and then he went back to sleep on his own until 11pm with no more wakings. Not only that, but after the 11pm feeding he went back down in his bed with no crying. The rest of the night was a little rough because he got really congested and was struggling to breathe, but up until that point felt like a big victory for us! Definitely enough progress to alleviate my discouragement and keep us going. Thank you for helping us get through this week.

    1. You are welcome. Did extinction coupled with a super early bedtime begin on the night of 12/27 or 12/28? Either way, congratulations, you and your son have accomplished a lot in a very short time!
      Regarding his congestion, if he has fever, weak suck, decreased sociability, difficulty breathing, or really appears ill, please check in with your child’s caregiver to give you advice on how to proceed. If he is only congested but does not otherwise appear ill, please stay the course.

  20. Extinction began on 12/25, paired with super early bedtime on 12/27. We will definitely keep an eye on his congestion as time goes on. Thank you!

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