Sleeping Like a BabyThe How, When, Where and Why

of Newborn Sleep Janelle Durham, MSW, CD, ICCEDirector of Education, Great Starts

janelle@greatstarts.org, 206-789-0883

Presentation for Washington La Leche League Conference, 2006

Images found by googling “sleeping like a baby”

Overview of Presentation

Physiology: What’s Normal for a Newborn

What We Know About Sleep Safety

Where Babies Sleep

Modern Advice: Any Consensus??

Most early sleep studies were based on bottle-fed, solitary sleepers, with little night-time contact from their parents.

So, much of our “scientific” knowledge base is skewed to this model, and much of our advice focuses on independent

sleep, and “self-soothing.”

Physiology: What’s Normal?

Every author has a theory for how much sleep to expect

Quarles, 2003

Normal Sleep Patterns VaryDepending On:

AgeFeeding Method

Sleeping LocationTemperament

Age

Newborns: Total Sleep – 12-18 hours/daySeveral periods, lasting minutes to 4 hrs each

6 months: 14 – 15 hours/day2 naps, 2-3 stretches at night (up to 5 hrs long)

Toddlers: 12 – 14 hours/day1 – 2 naps. 1/3 still have night wakings

(Note: regular daily naps appear to help with night-time sleeping issues)

Frequency of Night – Waking

Newborns – 100%

Six-month-olds – 20-30%

Up to four years: one in three continues to awaken during the night and require intervention by a parent

to return to sleep.

Sometimes, even children who had been sleeping through the night start

waking again:

Pain from teethingDiscomfort from colds, illnesses

Practicing new skills in their sleepSeparation anxiety, nightmares

Why Can’t Babies Sleep More Like Adults?

How adults really sleep:

Bedtime routine

Fall into deep sleep for about 90 minutes

20 minutes REM – light sleep

Cycle repeats.

Several REMs/waking per night

How do Babies Sleep?

Parents soothe till baby nods off

Begins in REM sleep: limbs flexed, startles, twitches, sucks, grimaces

After 20 minutes, muscles relax (limp limbs), breathing regular / shallow.

40 minutes deep sleep, then 20 light. Cycle continues.

What percentage of sleep is REM for each age?

Premature babies: 90% REMBabies 50% REM

Toddlers 30% REMAdults 20% REM

Why is REM sleep important, and why do babies do so much of it?

Babies are born with only 25% of adult brain volume – increases to 70% in first 2 years

During REM, blood flow to brain doubles, the body produces certain nerve proteins which

are the building blocks for brain growth

Brain may use REM to process info acquired while awake, storing what is useful, discarding

what is not

Cycles compared by age:

Newborn: Starts in REM, then one hour cycles,

40 minutes deep sleep, 20 light

6 month old to adult: Starts in deep,then 70 – 110 minute cycles

60 – 90 minutes deep, 10 – 20 light

Hard for an adult to be in synch with newborn!

Sleep Varies Based on Feeding Method:

Breastmilk is low in protein and fat, and high in lactose, so is digested quickly, so babies need

to eat frequently.

One study showed that although length of sleep did not vary based on whether baby was

formula or breastfed, breastfed babies were more easily aroused. (Horne, 2004)

Sleep Varies Based on Sleeping Location:

Bedsharers woke twice as often, breastfed twice as often (avg. 1.5 hours between feeds),

taking in three times more milk.

Bedsharers cry less: .5 hrs per night vs. 2.5 hrs/night for solitary sleepers

Bedsharers get more total sleep

Studies by Mosko and McKenna

Sleep Pattern Varies by Parenting Style

Dr. Spock-style: minimal night-time contact and feedingLLL style: breastfeeding, frequent contact, co-sleeping.

Maximum sleep bout: Spock 6.5 hours at 2 months, > 8 hours by 2 years

LLL-style: 5 hours at 2 months; >five hours by 2 years

Total sleep time (average). Spock-style: 13-14 hours a day.

LLL-style: 15 hours a day at 2 months; 12.5 hours at 4 months; 11 hours a day by two years of age. (Elias, et al,1986)

Sleep Patterns Vary by Temperament

Some kids: Early to bed, early to rise

Some: Have a hard time letting go of the day, then sleep hard all night

Some: Restless all day and night

Risk of SIDS in 1992 was 1.2 /1000

Back to Sleep, and other SIDS reduction education, began in 1994.

In 2001, SIDS rate .56/1000, decrease of 53% over 10 years.

(9.6/1000 African-American)

Sleep Safety

Recommendations SIDS Alliance, AAP, etc

- Back is best

- In your room, near where you sleep

- Crib meets safety standards (No adult beds, sofas)

- No soft surfaces: waterbeds, sheepskins, pillows

- No soft coverings: blankets, pillows, soft bumpers

or soft toys – Use wearable blanket

- Pacifier when put down to sleep*

- Don’t overheat – a leading risk factor

AAP/ASIDS add: - Avoid exposure to tobacco smoke – the more exposure, the higher the risk of SIDS.

American SIDS Institute adds- Breastfeed your baby- Avoid exposing baby to infections- Consider home monitoring systems - only for very high risk infants (AAP says no proven benefit even for high risk)

Pacifier Recommendations- Begin at one month, after breastfeeding is well-established. - Continue through first year.- Give at each sleep period – if it falls out, don’t replace it- Don’t coat with any sugary substance- Don’t use string or devices to attach to baby

When a committed adult caregiver, sleeps in the same room but not in the same bed with their infant the chance of the infant dying from SIDS is reduced by 50%.

(Blair, et al 1999; Mitchell & Scragg, 1995; Carpenter et al, Lancet)

Controversy over Co-Sleeping Safety

Prohibitions from CPSC: “Don’t sleep with your baby or put the baby down to sleep in an adult bed. . .The only safe place for babies to sleep is a crib that meets current safety standards and has a tight-fitting mattress.” Ann Brown, Commissioner, Consumer Product Safety Commission, September 29, 1999

CPSC described an 8 year survey of 515 deaths that occurred in adult beds for children under 2 years.

One fourth of deaths – overlyingby adult.

Three fourths – entrapment in bed structure leading to suffocation or strangulation.

The CPSC statement and the report on deaths that occurred in adult beds, led some to ask: how many deaths occurred in cribs?

CPSC data for 18 years, 1980 – 97

Of known infant suffocation deaths:

139 in adult beds (25%)

428 in a crib (75%)

If 25% of deaths occurred in adult beds, and 75% in cribs, then we need

to know what percentage of babies sleep in each location to understand

the relative risk.

PRAMS data from CDC: 68% of US babies co-sleep at least

some of the time.

Kimmel (2002) in Mothering:

Interpolates from PRAMS data from CDC: At any given time, ~ 44% are co-sleeping

This, combined with previous rates shows:Bedsharing less than half as risky (42 %)

Crib sleeping had a relative risk of 2.37 compared with sleeping in an adult bed.

“ Almost all SIDS deaths associated with parental bedsharing occurred in conjunction with a history of parental drug use and occurred in association with the prone sleep position or sleep surfaces such as a couch or waterbed.” (Gessner)

When a Baby Does Die in an adult bed, is it because they were in an adult bed?

Most SIDS deaths associated with parental bedsharing occurred in situations with multiple risk factors: parental drug use, prone sleep position, sleep surfaces such as a couch or waterbed or pillow, tobacco exposure, co-sleeping with other children, maternal exhaustion, alcohol use, or leaving baby unattended on adult bed.

Decreasing SIDS Risk for BedsharingAlll the usual SIDS recommendations still apply! Plus: - Avoid smoking – significantly increases risk- Avoid drug, and alcohol use- Keep other children, pets, out of bed- Avoid beds or furniture set-up which could lead to entrapment: Best to take mattress out of frame, put on floor in center of the room

Additional Recommendations for decreasing SIDS Risk for Bedsharing

- McKenna suggests that if baby is formula-fed, it may be better to roomshare than to bedshare- Lahr, et al recommend that bedsharing be discouraged for infants under 3 months of age (though they cite benefits for infants over 3 months)

Possible protective factors of co-sleeping

Breastfeeding mothers arouse 30% more frequently when bedsharing. Usually awoke before baby. This might increase the chances that mothers could more quickly detect and intervene against a life threatening event.

Babies have immature nervous systems. The bedsharing adult may help cue the baby to regulate temperature, breathing, and arousal patterns.

Where Are Babies Sleeping? And Who Decides?

McKenna

Where do babies sleep?

Meredith Small cites one study of 186 non-industrial societies. None of them have their babies sleep alone in the first year.

In another study of 172 societies, all infants do some co-sleeping at night.

Where Are U.S. Babies Sleeping?

Bedsharing rates:Several studies: About 50% say sometimes

Oregon PRAMS, 1999: 19% never bedshare, 39% sometimes, 16% almost always, 27% always

Bedsharing was three times more common amongst breastfeeding families.

90% in Hispanic homes, 70% in African-American

Does Bedsharing cause psychological harm?

McKenna, 2005 cites studies indicating:- Children who never co-slept are rated by parents as harder to control, less happy, less able to be alone, more fearful, and have more tantrums.- Teachers say co-sleepers better behaved, more social- Adults who co-slept as babies/children have higher self-esteem, less guilt and anxiety, less discomfort with physical affection, higher life satisfaction.

- No difference: sleep disturbance, social competence

Impact of Old Advice on Sleep Habits

For the past few generations, parents have been taught to train their children to sleep alone, and to self-soothe. But, according to the 2000 National Sleep Foundation Survey, of adults whose parents probably followed this advice, 62% report difficulties falling or staying asleep, 60% of kids under 18 complain to their parents about being tired during the day, and 15% of kids admit to falling asleep in school

Modern “Advice from the Experts”Common Consensus on Ways to Help Your Baby to Sleep

This list is taken from Quarles, 2003

1. Help baby learn the difference between day and night (daytime is light, noisy, interactive; nighttime is dark, quiet, and dull)

2. Having a stable, but not rigid, daily schedule helps regulate baby’s biological rhythms

3. Consistent environment: the more consistent you can make the sounds, smells, and sights she experiences when she wakens, the more easily she will settle back to sleep.

4. Bedtime routines: Having a consistent method for putting baby to sleep, and for responding to night-time wakeups will help baby go to sleep well.

5. No sleeping with a bottle.Everyone acknowledges that nursing and bottle-feeding help babies fall asleep more easily. Opinions vary on whether it’s OK to put baby to sleep by feeding, or whether it’s better to feed till drowsy, then remove the bottle or breast and settle to sleep.All say no bottles overnight, because it can promote tooth decay and ear infections

6. Feeding/Attention Upon Early Awakening. Authors agree that giving babies something they enjoy upon waking may encourage them to wake earlier to get more of what they enjoy.Authors vary on their recommendations about how to discourage early waking.

7. Need to feed? After 6 months, babies no longer have a nutritional need for night feeds. Night feeds are usually for comfort, not hunger.

8. Swaddling can comfort a newborn. As they get older, they may resist swaddling.

9. Transitional object: having a favorite blanket or toy may help baby settle down.

10. Temperature: babies sleep best when it’s 65 to 70 degrees

11. Dirty diapers rarely disturb baby’s sleep. If it’s poopy, change it to avoid diaper rash. If just wet, leave it alone.

12. Even the best sleepers will have periods of time when they do not sleep well. Especially around developmental milestones.

13. For premature babies, use their “adjusted age” (based on original due date) to determine reasonable expectations

14. Problems do not disappear on their own. If baby is having a hard time sleeping, it’s unlikely to get better if you just keep doing what you’ve been doing.

15. Keeping a sleep diary of what you’ve done and how baby slept may help you to see patterns that are easy to miss.

16. Feeding solids before bedtime will not help baby to sleep longer.

17. Teething: most experts say teething is not painful enough to wake babies.

18. Medical issues: don’t try to fix a sleep problem when baby is sick.

More Advice on Soothing Baby to Sleep(From Karp, Pantley, Sears, and More)

Watch for baby’s tired cues:- losing interest in people and toys; - yawning, rubbing eyes and ears, turning head from side to side, looking glazed; - asking to nurse or snuggling; - becoming hyperactive;- clenching fists, fussing, crying.

Bedtime routines: Environmental Cues

As it gets later, turn down the light, turn down the heat, turn down the noise.Give a bath if desired.Change into pajamas.Go to the room where baby sleeps.

Swaddle baby.

Feed till drowsy, remove breast or bottle.

Either: Snuggle baby and soothe; when they enter light sleep, keep soothing till in deep sleep (may take 20 minutes)

Or: lie them down where they will sleep (on their side first to avoid startle position, then roll to back). Pat back till they fall asleep

Dealing with Night-time Awakenings – Under 4 months

If baby is just making sleep noises (grunts, whimpers, cries), leave him alone, or gently pat to see if he falls back asleep.

If he’s really awake, tend to his needs (feed if needed/desired), then help him re-settle. Don’t leave him to cry, as babies are harder to settle back down from crying.

Don’t turn on the lights and play… keep things low key at night.

Dealing with Night-time Awakenings – Over 4 – 6 months

Once baby’s sleep cycles start to lengthen, around 4-6 months, he may be ready for a change in night-time responses (if what you’re doing is working for you, don’t feel like you have to change!)

Some authors say that after 4 months, an infant who continues to wake may be becoming a “trained night cryer”

Cold turkey: stop responding at night-time

Cry-It-Out: ignore child’s cries for progressively longer intervals till they “learn to self-soothe”

Scheduled awakenings: wake child at scheduled times, shortly before anticipated awakenings. Gradually lengthen intervals between wake-ups

Continue to respond to baby’s needs, as you have done since they were born

Some Options Parents Have Tried

What’s a parent to do:How do you know how to respond

Seek out advice: from other parents, from books and so on. Keep the ideas you like, ignore anything that doesn’t feel right to you! Remember what you know about the physiology of infant sleep, and realistic expectations!

Pay attention to your baby: Before you try any interventions, keep a sleep diary. What is actually happening? What is baby telling you about what does / doesn’t work for him?

Evaluate the situation: Do you have a sleep problem? Don’t listen to outsiders on this one: it

doesn’t matter what your friends, neighbors, or mother-in-law thinks. It matters how you feel!

If it’s working for you, your partner, and your baby, then NO, you don’t have a sleep problem.

If, however, you, your partner, or your baby are miserable, stressed out, sleep-deprived, frequently ill, or just tired of the situation, then take steps to fix the problem!

Paul Fleiss says that the real problem with newborn sleep is unrealistic expectations from the parents. “Babies are not adults, and there is nothing you can do to turn them into adults overnight. Let your baby be a baby and both you and the baby will be much happier.”

Establish good bedtime rituals, to start teaching healthy habits, but don’t worry about night wakings – they’re normal.

In the end, once parents are aware of baby’s health and safety needs, each parent needs to do whatever works for their family to allow them to do their life’s work, stay healthy, stay happy, and stay connected as a family!

Bibliography: • Barnard K. Beginning Rhythms: The Emerging Process of Sleep Wake Behavior and Self-

Regulation. Seattle: NCAST-AVENUW.• Elias, Nicholson, Bora, Johnston. “Sleep-wake patterns of breastfed infants in the first two years

of life”, Pediatrics 77 (1986)• Karp, H. (2003) Happiest Baby on the Block. Bantam.• Kimmel, Tina. How the Stats Really Stack Up: Cosleeping Is Twice As Safe

Mothering, Issue 114 September/October 2002 • Lahr, et al: Bedsharing and Maternal Smoking… (includes review of all the available studies on

bedsharing and SIDS!)• www.cademedia.com/archives/cdc/mchepi2005/ppt/F5_Lahr7.ppt#403,36,Recommendations • Liedloff, J. (1986). Continuum Concept. Addison Wesley.• McKenna, James and Thomas McDade. “Why babies should never sleep alone: A review of the

co-sleeping controversy in relation to SIDS,bedsharing and breast feeding.”PAEDIATRIC RESPIRATORY REVIEWS (2005) 6, 134–152

• Mosko, McKenna, et al. (1996). “Infant Sleep Architecture During Bedsharing, and Possible Implications for SIDS.” Sleep 19:9.

• Pantley, E. (2003). The No-Cry Sleep Solution: Gentle Ways to Help your Baby Sleep Through the Night. McGraw-Hill

• Quarles, Michael. Amazing Baby Sleep Secrets. 2003 * • Sears, W. & Sears, M. (2003) The Baby Book. Boston: Little, Brown.• Small, M. (1999) Our Babies, Ourselves: How Biology and Culture Shape the Way We Parent.

Anchor.• Pacifiers can help reduce the risk of SIDS: http://firstcandle.org/research/pacifiers_guidelines.pdf • AAP recommendations for SIDS reduction:

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;116/5/1245#SEC15 • CPSC Press Release: “CPSC Warns Against Placing Babies in Adult Beds; Study finds 64

deaths each year from suffocation and strangulation” September 29, 1999

Note about Quarles, 2003:* Quarles summarizes advice from 14 sources. I have clustered them into parent-led, middle of the

road, and responsive parenting, but please note that I have not read all of these books, and this categorization is based only on snapshot summaries of them:

Parent-led / scheduled / “self-soothing”• Cutherbertson and Schevill, Helping Your Child Sleep Through the Night• Ezzo, On Becoming Babywise• Ferber, Solve your child’s sleep problems• Mindell, Sleeping through the Night• Weissbluth, Healthy Sleep Habits, Happy Child

Middle of the Road, with a Parent-Led Leaning• American Academy of Pediatrics, Guide to Your Child’s Sleep• Hogg, Baby Whisperer• Hull, Sleep Tight Video• Spock, Dr. Spock’s Baby & Child Care

Middle of the Road, with a Responsive Leaning• Brazelton, Touchpoints• Karp, Happiest Baby on the Block

Responsive / Attachment / Relationship-Based• Fleiss, Sweet Dreams• Pantley, No-Cry Sleep Solution• Sears, Night-Time Parenting.