Richard Jacobs: Hello. This is Richard Jacobs with the future tech and future tech health podcasts. I have Carey Chronis. He’s a respected practicing pediatrician in Ventura, California. It goes Dr. Carrie’s baby care on FAAP, city Ventura. And we’re going to be talking about infants and how they sleep and how to make sure that they’re getting the proper sleep they need. So, Dr. Chronis, thanks for coming. How are you doing?

Carey Chronis: Very well? Thank you for having me. This is a really wonderful opportunity. I appreciate being able to speak on this important topic.

Richard Jacobs: Yeah. I hear and I’m sure everyone hears, everyone talks about the parents and the impact on their sleep, but obviously, the most important impact is on the infant sleep. So what got you into noticing or caring about how infants sleep?

Carey Chronis:  Well, a lot of it depends from the parents because the parents are concerned that they’re not getting much sleep because they’re struggling with how to deal with their child in the middle of the night and what to do and always feeling the need to attend to them and to fix the problem and really not knowing how to go about that. So in essence, fixing one problem fixes both. You create a situation where the child or the infant is sleeping much better and the parents are sleeping much better and the goal is for everyone to have a great long term sleep routine.

Richard Jacobs: So what are some of the issues that are causing them to wake up so many times? Is that just a natural thing and you have to just deal with it or there are other ways to have your infant sleep for longer periods of time?

Carey Chronis: Well, it is a natural thing to a certain extent. No one sleeps all night long. We wake up, we look around, we go back to sleep. The key to understanding this is at what points do we not need to attend to it, to an infant and at what point do we help them to learn to work it out themselves and to fall into a nice sleep pattern and the age I really start to push that is at the four-month mark. First off, I don’t think parents realize how much sleep an infant really needs on the first day. I tell them that the infant sleeps more than their average teenager that you’re looking at ideally 14-15 hours a night and then a few naps during the day time. So it’s really a lot of sleep that children require and early on breastfeeding every two to three hours during the daytime and a child can go up to five hours at night. If you have an ideal world, they will go to sleep about 6:37 PM, they’d wake up about midnight for feeding. They wake up again at 3:00 AM for feeding and then by morning when the sun comes up, they’re up again for a feeding. Usually at that point every 90 minutes, so they naturally want to take another nap. So you’ll get a few naps in during the day time and then 24 hours go by and you start all over again.

Richard Jacobs:  Yeah I have noticed. My kids when they were younger, you’re right, they would sleep all the time, say multiple naps and then when they got to be I think three or four they would go to like one nap a day and then as they get like six or seven, then they’d stop napping and they would be awake and just sleep in one slab at night. It took a while for them to transition through their stages.

Carey Chronis: Certainly every child is different. I think my parents just reminded me multiple times that I just did not want to take a nap to no matter what. But you know, encouraging naps as long as possible is really your best bet. But really it all comes back to set the stage early and the stage I like to set that it is at the four-month mark. And, the reason for the four months mark is, infants have not developed what we call object permanence. And by that I mean you took an object, one of their toys, rattles or something and hid it under a blanket. They don’t realize where it went. So the infants at four months of age are not going to go reaching underneath that blanket to try to locate that item. And if you decide to transition, if you have the opportunity to put them in their own room and you transition them into their own room at four months when they wake up in the middle of the night, they don’t actively stop and say, oh, mom and dad are in the other room. They just don’t have that ability. If they see you, they know you, they’re all excited to see you. But the moment you disappear from the room, you’re gone. And then setting this sleep stage at this point is really your easiest time to transition because, by five to seven months of age, that object permanence will kick in. They will know that rattle is under the blanket. They will know you’re in the other room and if you get them used to a good sleep cycle, a good sleeping situation in their own room at that stage, you have a much better chance of keeping that fleet pattern in a good progressive manner long-term. Now, so the question to ask oneself at the four-month mark is, do I want my child in my bedroom at two years of age? And if the answer is no, then four months is your easiest time to transition them into the other room. Not to say that you can’t do it sooner or later, but it’s much more difficult four months is your best time.

Richard Jacobs:  So do you focus on the four months plus mark or do you also help parents that are having problems in the first four months where there are no real gauge strategies right.

Carey Chronis: For the first four months, my recommendation is generally to calm your child, attend to your child’s needs and don’t let a trial faster cry for a long period of time. For me, for the first four months, the child is in complete control. If they are thirsty or hungry or whatever you attend to them. Trying to keep eating at least two hours apart and holding and comforting but not worrying so much about setting a pattern of having them sleep a long period of time. If they need your attention, you attend to it, if they don’t, you let that lie calmly. It’s really at the four-month mark that I start to work on setting that pattern that should feed long term. And again, if the child has their own room to be put into four months is the best time, the easiest time I should say, I discourage monitors. If a baby is fussing at four months, there’s really no reason to go rushing into the room. If they’re screaming their head off, it’s good to go in and just make sure things are okay. Is your child jammed up against something? Is something wrong? Does the diaper need changing? There’s something that needs to be attended to and if everything is okay, it’s really okay to give your child a few pats and leave the room. At that point, It’s really up to the parent’s discretion. Feeding should not be an option after four months of age. It’s really the time to stop nighttime feeding. And I really discouraged mom from being the pacifier and if they’re screaming, there are multiple methods, some say simply leave them alone. If everything is fine and things look good, let them cry and just walk away. Others will feel the need to, they just can’t do that. So they will feel the need to want to calm their child. Ideally, they should not pick up their child at that point. And if they do feeding should simply be off limits and bringing them back into your own room should be off limits too. So choosing the strategy for calming is really up to the parents, in my mind but not feeding them and not bringing them back into the parent’s room is really what I’m after starting at four months.

Richard Jacobs:  When you said feeding them if you have a breastfed baby versus a formula fed, is there a big difference? Because I would say breastfeeding, it goes through their digestive system a lot faster and they would need to eat more personally, regardless of their age.

Carey Chronis:  At four, they really don’t need to be eating in the middle of the night whether breastfed or bottle fed. The only difference that I address is in the middle of the night mom might want to pump once or twice to maintain milk supply so she can breastfeed long term and not every mom is going to dry out because they’re not breastfeeding in the middle of the night. But it certainly is a possibility, and the way to help reduce that chance is to simply pump in the middle of the night.

Richard Jacobs: Right. What does through the night mean? Does through the night mean that, five hours for a kid of that age, that through the night or is it eight or is it longer?

Carey Chronis: It’s longer. You’re still going to put your child to sleep at about the same time, which is about seven o’clock ideally. And that can vary from family to family and the situation, but typically seven o’clock and then that will be enough until five or six in the morning. And again, no one sleeps all night long. So I do expect that child to wake up periodically, look around, maybe make some noises and then ideally, to him or herself. Because what you really want is, a child who learns to suit themselves, put themselves back to sleep when they wake up and not relying on food or outside stimuli to put themselves back to sleep. So the goal is to eventually have a child who is older, who’s good at getting themselves to sleep and the time to start working on that is the four-month mark.

Richard Jacobs:  So a four months old and go 10 to 12 hours without food?

Carey Chronis:  Or longer. Yes. Simply, there’s no reason why one needs to eat. Just like an adult, you have your last meal at night, you really don’t need to be eating until the sun comes up. That’s not to say they wouldn’t eat if you feed them. I think all of us would have a bite to eat if we woke them up and tried to feed them in the middle of the night. From a physiologic standpoint, there really is no reason why they need food in the middle of the night. And the longer you wait to stop that nighttime time feeding, the harder it will be to accomplish that. And then we run into further problems besides sleep issues, as the teeth start coming in and food is against the teeth, it can lead to cavity issues and a whole bunch of other things that we’d like to avoid. So, the goal is to set the stage long before that becomes an issue.

Richard Jacobs:  So what is the goal and what’s the past? Does it take a whole month or multiple months or sooner getting the kids to sleep through the night without feeding or what does this process look like?

Carey Chronis: At four months, it’s actually much easier than parents think. I think they often get anxious about the prospect of it and hold off trying to do this because they think it’s going to be a difficult task, but then when they actually go ahead and do it. The parents, at least in my office who come in and are good about setting a stage at four months of age are surprised at how simple it was to get their child to sleep all night long and they’re usually the ones who are bragging to their friends, that a year of age when their child is sleeping wonderfully and the other parents are struggling to try to set a routine with them at a time, which is much more difficult than had they done it previously. So rarely do I have a parent who has difficulty with setting the sleeping stage at four months of age as long as they stick with it. Now, having said that, there are times when parents want to go backward and I really try to discourage them. It’s natural when a child is sick. Well, for instance, you have a child who apparently has done a wonderful job setting the limit, getting their child to sleep through the night, starting at four months of age and not feeding them, they’re not going in. They’re really happy with how their child is sleeping. And then at six or seven months of age, the child gets a cold or they go on vacation somewhere or something happens where the sleep is disrupted and the first thing parents think is, they want to bring the child into their own room or have them sleep with them. And now they’ve created a problem because they’ve now created a new expectation that the child tries to hold on to and it becomes very difficult to go back to good sleeping arrangements. So I really try to get parents to stick with the routine despite what the situation is whenever possible. And if they have to deviate from that routine because they’re on vacation and they don’t have a separate place for the child or whatever the moment they are back in a stable situation is to simply go back to that routine and just deal with the fact that it might be a little difficult for a few days until we get back to where we were again.

Richard Jacobs:  Do you have any significant amount of parents that don’t have their child sleep in a crib but sleep in the bed with them for the first four months?

Carey Chronis: I do have quite a few parents who do that. It is certainly discouraged by the American Academy of Pediatrics because you have a higher chance of the child being on their belly and suffocating or being rolled on or being injured. I’m also aware that it’s a very cultural system. Cultures are much more likely to wants to co-sleep than others and well, I go out of my way to make clear what the risks are. I also make clear that regardless of what their sleeping situation is, they really should transition their child to their own bed or their own room at four months of age. And to elaborate on that, there are many situations where parents simply don’t have a separate room for their child at the four-month stage, that’s just not an option. They have a one-bedroom place and they have the ability to put a crib in the corner or some other place and it’s at the four-month mark that no matter where they’re sleeping, I really encourage them to at least put them in their own bed and not to attend to them and try to calm them if possible in the middle of the night. And also not feed them in the middle of the night. So well, at four months they may not have the luxury of putting their child in their own bedroom. They can at least not have the child in their own bed and have them in their own crib. So we can establish a good sleeping habit because otherwise they’re back at the situation or do you want your child in your bed at two years of age? And if that answer is no, then four months is still your easiest time to make that transition.

Richard Jacobs:  Yeah what’s the leeway on that? So does five months getting a lot harder or six months or a year or how long the window is?

Carey Chronis:  Well, the window is when object permanence kicks in and that can be anywhere from four and a half to six and a half months typically. It varies from child to child. So, that’s really the barrier that one is confronting. And because parents are reluctant to want to put their child in their own bed or own room or some parents are trying to get that to happen as early as possible, makes the likelihood of it happening much higher. So four months, again, since they don’t need to be eating in the middle of the night and object permanence hasn’t kicked in is just a convenient time to make that transition.

Richard Jacobs: Are there any other developmental cues that either helps the process to make it more difficult?

Carey Chronis: I’m not sure with developmental cues per se with help or make it more difficult, but certainly a child who tends to be a little fussier and cries a little bit more. It needs a little more calming, can become more of a challenge for a parent, but I think that when you have that kind of situation, you have to also take a look at the bigger picture and ask yourself, is my child really getting 13, 14, 15 hours of sleep at night? Are they taking three naps during the day? Are they getting two to three hours of sleep during the day plus that sleep at night and make sure that total sleep hygiene, for the lack of a better term, is sufficient. It’s usually the child who isn’t getting enough sleep during the daytime and night combined. That tends to be a little bit more fussy and irritable. That’s not to say that you can’t have medical issues that can make it challenging. You could have a child who has reflux, that’s rather painful and that the underlying condition may need to be addressed or you might have some medical issues with the child that one needs to attend to. So every child is different and you have to take it into context. But the general rule is to set that stage at four months.

Richard Jacobs:  Any other modulators you see on the ability for toddlers sleep through the night or ability to not feed during the night? Any dietary interventions or other items that really, make it more difficult or easy to do?

Carey Chronis: No. Not really, there no other things that will make it easier or more difficult, but oftentimes one will start the rice, cereal or other items at four months of life and keeping a child prior to going to sleep well, not prolong sleep or make them more comfortable. So it really doesn’t matter when one introduces rice cereal, we typically start other foods at six months of age, give or take. And that in itself isn’t going to change the sleep habits either. So really none of these have a great influence. It’s really a matter of a quiet environment that’s at a reasonable temperature and make sure that the child is comfortable on a firm mattress. At that age, pillows and blankets really don’t have much role. There’s really no reason for a stuffed animal or a toy in the bed with them at that point. Usually putting them in a onesie and another layer is sufficient. The general of thumb is if you need two layers to say warm, your child should have three. If you need one layer your child needs two and just making sure that the environment is comfortable and then letting them work it out. Now if a child is really fighting sleep and having difficulty falling asleep, odds are they’re overtired and then the next night you really should consider putting them to bed little bit earlier because you probably waited a little longer than you should have and when we get overly tired, we tend to fight sleep.

Richard Jacobs:  Yeah, no, that’s true. I know I do. My kids are older but they still fight sleep all the time. So yeah, definitely.

Carey Chronis: Also, over the course of the next 18 months, you know, from four months till two years of age, they will try to go backward usually two to four times during that period of time. Meaning that they will try to push the limits and stay up and cry a little bit more and be a little fussier. And the temptation is to give in and to feed them or bring them into your own room and it’s really important. So during those times to be consistent, don’t feed them in the middle of the night, don’t bring them into your room in the middle of the night. And if you’re consistent and you give it a few days, they will go back to the kind of sleep pattern that you’re really after. So it’s usually an incidence of them, like I said, prior to being sick or you traveling somewhere or them just sort of pushing limits or being overtired. That makes us want to go backward. And when those situations arise, it’s really important to just be consistent. And learn to calm them in their own bed and let them get back to sleep. And you will find that almost all we say we’ll go back into a nice sleeping pattern and life is much easier for everyone.

Richard Jacobs:  Got you. Well very good. So what do you see as the future of your work? Where you want to take it now? Or is it just you just want to help as many people as you can with this protocol?

Carey Chronis: Yes. Well, a lot of my focus is on Dr. Carey’s Baby Care. Our Facebook page has I think over 650,000 followers and growing. The drcareys.com website is, the basics are laid out and we’re starting to put more articles on that will flesh out a complete look for expecting parents and so that’s the direction we’re moving with the work of Dr. Carey specifically, so it’s not just sleep, but covering a whole bunch of other issues that that are important during the first year of life and eventually the first five years of life where we plan on taking this.

Richard Jacobs:  Well, very good. And what’s the best way for people to get in touch and the learn more?

Carey Chronis:  They can go to our website drcareys.com or they can find us on Facebook at Dr. Carey’s Baby Care. And they’re welcome to send us notes through messenger on that platform if they wish or contact us however they want. We try to make it convenient for them.

Richard Jacobs:  Okay. Very good. Well, I appreciate you coming on the podcast.

Carey Chronis:  Yeah, thank you very much. It was really nice to talk about this subject. The more parents can get their child to sleep well the happier everyone is, I think.

Richard Jacobs:  Excellent.