Sleeping Like a Baby
The How, When, Where and Why
of Newborn Sleep
Janelle Durham, MSW, CD, ICCE
Director 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??
Physiology: What’s Normal?
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.”
Every author has a theory for how much sleep to expect
Quarles, 2003
Normal Sleep Patterns Vary
Depending On:
Age
Feeding Method
Sleeping Location
Temperament
Age
Newborns: Total Sleep – 12-18 hours/day
Several periods, lasting minutes to 4 hrs each
6 months: 14 – 15 hours/day
2 naps, 2-3 stretches at night (up to 5 hrs long)
Toddlers: 12 – 14 hours/day
1 – 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 teething
Discomfort from colds, illnesses
Practicing new skills in their sleep
Separation 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% REM
Babies 50% REM
Toddlers 30% REM
Adults 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 feeding
LLL 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
Sleep Safety
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)
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 – overlying
by 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.
When a Baby Does Die in an adult bed, is it
because they were 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)
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, cosleeping with other children, maternal
exhaustion, alcohol use, or leaving baby
unattended on adult bed.
Decreasing SIDS Risk for Bedsharing
Alll 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 formulafed, 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”
Some Options Parents Have Tried
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
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 SelfRegulation. 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.