Chad Perlyn, MD (Host): Welcome to the For Peds Sake Podcast, a Nicklaus Children's Hospital podcast, that is all about putting children at the heart of healthcare. I'm your host, Dr. Chad Perlyn, a pediatric plastic surgeon here at Nicklaus Children's and also a father of two boys. And I am so excited to welcome you to today's episode.

Today, we are joined by Dr. Lauren Chiriboga, a pediatrician here at Nicklaus Children's Pediatric Care Center, to talk about something that is so important to every parent out there, sleep training. Dr. Chiriboga, thank you so much for joining us.

Lauren Chiriboga, MD: Thank you, Dr. Perlyn. It's a pleasure to be here. I'm so happy to be here.

Host: Yeah, we're excited to have you. And I think it's really important that our audience knows that not only did I introduce you as one of our absolutely amazing pediatricians, but maybe even more important for this discussion today, you're also a mom. What's that like being a pediatrician and a mom?

Lauren Chiriboga, MD: I am a mom, yes. So, I have a little boy, Noah. He's two and a half. And I get asked that quite a lot because I can see my child in a sort of different way, right, when he's sick and everying. And so, it's probably not as complicated as people might think it is. It's beautiful being able to see little kids who are just older than my son, because then I say, "Oh my gosh, you know, it's coming my way when I see a four year old or something like that." But it's wonderful. It's been a great ride.

Host: Amazing. One of the things that I love so much about working with so many amazing pediatric healthcare providers here at Nicklaus Children's is that so many are parents as well or aunts or uncles, and they understand pediatric healthcare, both from the professional standpoint, but also from the family standpoint.

And when you put those together, I think we're able to deliver really world class care and we're excited to share it today. So, let's jump right in. Let's talk about this thing called sleep training. Everybody knows, of course, about potty training, but let's talk about sleep training. This has blown up. We see it on social media. We read a lot about it in the papers, lots of books are about it now. It's been around a long time, but there seems really a lot of discussion. Tell us, what is sleep training?

Lauren Chiriboga, MD: You're right. It is a very explored topic nowadays. I mean, I think most things with parenting now with the internet can be really hashed out. And so, you start to get like team sleep training, team potty training, all of these things. And it can be very confusing for parents to just Google what is sleep training. And so, thank you for having me on here to try and dispel some myths perhaps and just talk about it.

You mentioned potty training. I compare sleep training to potty training a lot, because sleep training is a way to cultivate a sense of independence in sleep for young children. So, kind of similarly to how potty training provides kids with independence in the bathroom, meaning, 'Hey, I can go to the bathroom by myself," sleep training provides that same independence for kids as it relates to their sleep, meaning that it eliminates any kind of crutches that a child may use to fall asleep, like having to be rocked by mom or dad, needing a bottle. Parents, I mean, you know what crutches I'm talking about. So, sleep training aims to allow kids to learn how to put themselves to sleep. And so, it's a really important thing to do, because you're teaching them something similar to potty training that is going to be a lifelong skill.

Host: And just to set the context for our listeners, when we're talking about sleep training, we're really talking about infants and young children at this point, correct?

Lauren Chiriboga, MD: That's right. Absolutely. Sleep training can be done as early as four months old, as long as your child is otherwise healthy and is cleared by your pediatrician to be sleep trained and can continue throughout infancy, so that's before a year old, and through toddlerhood, which it's a lot easier to sleep train an infant than a toddler. But yes, we're talking about the little kids.

Host: Okay. So, let's talk about what are some of the methods that are out there around sleep training?

Lauren Chiriboga, MD: There's a lot of different methods now. But if you go back to the old school days, maybe how our grandparents and great grandparents did it, the most popular method is called cry it out. And it sounds scary, because it is kind of scary, you know, as a mom, I can certainly understand why that sounds scary. Cry it out is also called the extinction method, and it's called that because we're looking to extinguish the behavior of crying when we're put ting them down to sleep. And that is the most traditional method. It basically involves just putting your child down in the crib or in their sleeping area after you have established that all of his or her needs have been met. And then, you walk away and you let the child cry until they are able to put themselves to sleep, which for every child might take a different amount of time. This is not an easy thing for people to do. And thus, other forms of sleep training have arisen that kind of soften the load.

So, there's the Ferber method, which is called graduated extinction. And this is like the extinction method, except that you go in and check in at predetermined intervals. And so, it's a lot gentler for the parents, really. And then, there are various other methods, like the camping out method, where you're using increasing intervals of distance over a few weeks to, and, you know, eventually you would leave the child in their room. There's so many, but the most, most common ones are the cry it out method and the Ferber method.

Host: Got it. And we'll make sure that we put some great links at the end of the show notes so parents can have the right resources to be able to find some of these methods. Let's talk for a minute about myths, because there is a lot of information about sleep training that's available to parents. There's also a lot of misinformation. I remember as a kid, I think my mom saying to one of my siblings, "Just let him cry. It'll make him tougher when he grows up." Myth? Real? Does this build grit in our kids? Does it build resilience? Talk about what we know and what we don't know about sleep training truths.

Lauren Chiriboga, MD: Absolutely. That is such a good thing to address, because these myths often serve as the barrier between doing this and not doing this some parents, right? We as parents contextualize crying a lot. So, we look at our child and they're crying and we say, "Oh my goodness. There are tears coming out of Sally's face. That means that Sally must be sad or frustrated or something like that." When crying, really, in a young child is just a stress response. It's a way for them to relieve stress and it's actually a way for them to soothe themselves.

It's important that we as parents put crying in the appropriate context, meaning if my child is six months old and I put him down to sleep and he's crying until he falls asleep, he's not crying because he's sad. He's not crying because he is feeling a certain way, feeling abandoned, which is our biggest fear with this as parents, right? He's crying because he is learning how to soothe himself. it's a way for him to do something until he is able to fall asleep independently. So, that's a very, very important distinction.

This crying is not harmful to the baby as long as they are mature enough to handle this. So, that's why four months is that cut off where we say, "If your child is younger than four months, they cannot handle that." So, we rock them to sleep. We survive those nights as you know, as a dad yourself, right? But once they're four months, their brain is mature enough that they actually can handle that form of release of stress.

So, does it make you grittier and stronger? Not necessarily, but it does teach you how to fall asleep independently. Because after a few nights of doing this, you'll see you'll put your child down and they won't cry anymore. They'll just go to sleep. And so, that's kind of what it takes, right? So, it's really important that parents understand that crying in a baby, it's not the same thing as crying for adults or older kids.

Host: I think that's a really interesting point and so important for parents, especially new parents who may be dealing with this, maybe with their first baby to understand. I want to talk about one issue that you raised, which I think is really important, again, for our new parents in particular, but of course, even those who've had multiple kids. Understanding, as you talked about, crying as a form of self-soothing versus knowing when something's wrong. Maybe the baby has reflux or other issues that could be affecting that. Can you just briefly-- I know it's not the exact subject of sleep training, but for sure parents are going to ask this question. We put our baby to sleep, the baby cries and cries. How do I know if something's wrong? What practical advice can you give our families on that?

Lauren Chiriboga, MD: That is such an important question, right? Because we want to be able to put the baby to sleep and then go to our room and say, "Well, at least I know there's nothing wrong." That is where you, as a parent, you have to tag team with your pediatrician, right? Because that answer depends so much on whatever preexisting conditions that the baby may have.

Some babies do have reflux, right? Now, with reflux in particular, reflux is not something that is going to present itself at bedtime magically. So for example, if my baby has reflux throughout the day, my baby will be spitting up throughout the day, in the morning, in the afternoon, all day, because reflux does not know how to tell time, right? If you put your baby down to sleep, and you've just started sleep training, chances are that the baby is crying because of this massive intervention that you've just done, not necessarily because of the reflux at that time. Does that make sense? It's not something that I would use as a fallback. Now, if your baby does have reflux, as long as they're gaining weight, as long as they have been fed sufficiently before bedtime, it is okay to put that baby with reflux to sleep while sleep training. I would not make a special exception for them.

Now, other reasons that babies cry, right? We have to make sure when we put the baby down that they've been recently changed, that their environment is safe, that the temperature is regulated. The ideal temperature for a baby's room is anywhere between 68 and 72 degrees Fahrenheit, very common question that I get. So, we want to make sure that those parameters are in place. If you have an older child, establishing a bedtime routine and having already done that, so bath, book, pajamas, story, bed is really important too. And once those boxes are ticked, you can tell yourself as a parent, "Okay. There's nothing wrong with my child. We've been through it all, diaper, bottle, the whole routine."

Of course, this is all assuming that your baby is not sick. I would not recommend, certainly not initiating, but even proceeding through sleep training while your baby is sick. Signs that your baby are sick are various and numerous, but certainly not if they have a fever, if they're having respiratory symptoms, even a simple cold in a young baby. I would reserve sleep training for a time when your baby is a hundred percent, like, you know, best they've ever been.

Host: Perfect. So now, we're ready to start the sleep training. You went through some of the great tips about routine and the appropriateness of crying. We talked about a little bit about some of the myths. So, what are the benefits? Why should parents do a formal sleep training program for their baby?

Lauren Chiriboga, MD: There are many benefits to sleep training. The primary idea and the primary benefit being independence as it relates to sleep. So, you had likened it to potty training earlier. So, the benefit of potty training is we remove a massive crutch and that crutch is the diaper, right? We remove that diaper from the situation and now the baby can go anywhere and not have to sit in their number two at a restaurant, right? And so, we've removed that massive crutch. In this situation, we are removing the massive crutch of an external soothing factor, whether that be rocking to sleep, a bottle at bedtime, whatever it may be. in removing that crutch, that means that baby does not have to depend on mom or dad anymore to go to sleep.

Babies sleep an inordinate amount during the day. Depending on their age, they should be sleeping upwards of 16 hours for some really, really young babies. In the sleep training range, it's more about 10 to 14 hours per day. Those babies need that sleep. So if they're waking up in the middle of the night and they need you, mom or dad, to come and put them to sleep. And parents who are struggling with this know, sometimes that's an hours long process to get the baby back to sleep, they're losing out on that sleep as well. Another benefit is just uninterrupted sleep. So, the goal of sleep training is that your baby, after being sleep trained, wakes up, it's 2am, they look around and they say, "Okay, this is my room. I am safe here. I know how to do this. I know how to put myself back to sleep." they roll over, and they go back to sleep. So, good for baby because baby gets the sleep they need. Great for mom and dad because mom and dad, you know, don't have to wake up and do this whole song and dance, right? And it promotes independence and well-being for your child and the huge part of life that is sleep.

Host: Amazing. So to summarize for our parents, there is this thing called sleep training, which we talked about, like potty training, a formal process where you want to have consistency and a routine. I think listening to you, that was really. It sounds like there's a couple of different methods and families should maybe talk to their pediatrician about what the pediatrician recommends. Is that the best starting point?

Lauren Chiriboga, MD: Yes, definitely. And I think managing the expectations as well when you're speaking with your pediatrician is important, because you mentioned consistency. Consistency is key to this process. If the baby is getting mixed messages, "Oh, if I cry and dad is around, he'll pick me up. But if I cry and only mom is home, then I'm going to keep crying..." You know, this happens a lot when there's a disconnect between the parents or or the caregivers. So whatever method you as a parent and your partner, you know, other caregiver can come to an agreement about is the correct method.

So, a lot of parents don't like cry it out because it's kind of like a hardcore method. You know, you may be listening to your child's cry for an hour tonight. Not everyone is comfortable with that and that is okay. And so if you and your partner are not on board with that, perhaps it's not the method for you. It is very parent-focused as well. So, review with your pediatrician what methods exist. What can we as a couple or as a family, what can we tolerate and agree to do to do what is best for the family?

Host: And it's okay to change methods, right? You start one a period of time, see if it's working. And if it's not, it's okay to change, right?

Lauren Chiriboga, MD: Absolutely. Yes. And the goal here is to do something that works for the whole family as well. You know, we put the baby first. But at the same time, you know, if mom is totally against this and thinks that it's not something she's comfortable with, that is okay. Then, we compromise. And that's why other methods of sleep training exist.

Host: Perfect. Final moments. Anything you'd like to share with our families on this subject?

Lauren Chiriboga, MD: So when I speak to parents, what I never want to sound like is very prescriptive as a pediatrician. You should sleep to train your child and go home and do it. It's something so difficult to do. And what I never want to happen is for a parent to say, "Well, easy for her to say," right? I share with my patients, parents, my experience with sleep training. My husband and I, we did not want to do cry it out because for us it was too much. I did not want to listen to my son cry for 60 minutes. Yeah, we tried and it just wasn't fun. And so, we did the Ferber method, which is a method that's kind of like cry it out light. You know, you let them cry, but you go in after 10 minutes and reassert your presence and so on and so forth.

I guess it's just important for me to convey that I understand as a parent the frustration that this time can evoke in parents and in families. But at the same time, I try to advocate so hard for sleep training because I've seen what it can do. And in my case, after doing the Ferber method for a few upwards of a week or so, my child became an independent sleeper since he was six months old. We put him in the crib and he'd go to sleep. I was able to see the benefits of it myself.

And so, yeah, for anyone out there who thinks that you're the only one struggling with this, you're certainly not. There are so many people who are going through this ordeal with you. And trust your pediatrician and trust their guidance.

Host: I love how you talked about your own experience. As a surgeon, people often ask me, "What would you do if it was your child?" And for you to be able to say that for your patients and share that on the podcast, what you did do for your child and the experience you went through is really wonderful. Lauren, thank you so much. It was a pleasure to talk to you.

Lauren Chiriboga, MD: Thank you.

Host: This concludes this episode of the For Peds Sake podcast. We hope you learned some helpful tips from Dr. Chiriboga. Make sure to stay tuned for our next episode. And in the meantime, be sure to follow us on all social media channels. You can find Nicklaus Children's Hospital on Instagram, Facebook, TikTok and YouTube. See you next time, and good luck with the sleep training.