Health & Wellness
Establishing Healthy Sleep Habits in Your Young Infant
Sharon A. Bucher, MD and Charles E. Rapp, MD
Addressing sleeping problems in any child is one of the most challenging and sometimes frustrating aspects of being a parent or a pediatrician. However, establishing good sleep habits early on will help prevent future problems. Most parents hope to turn their infant into a "good sleeper," and although there is no magic solution, there are some strategies that parents find helpful. The following is not meant to be a comprehensive guide to sleep, but may provide a starting place.
When you first take your newborn home from the hospital you will probably be fairly exhausted. We have found it important to sleep when you can, i.e. napping when your child is sleeping. Newborn sleep patterns are unique with a typical newborn sleeping 16-20 hours out of a 24 hour day. This pattern usually will consist of 2-4 hour sleeping periods, punctuated by feeding and brief arousal or "play." Often, parents are frustrated by the fact that babies seem to have their "days and nights mixed up." You can foster nighttime sleeping by keeping baby's room relatively dark, quiet, and making overnight feedings as brief as possible without much stimulating play. Encourage play and interaction during daylight hours. In the first few weeks of life most babies sleep a maximum of only 4-5 hours at a time, mainly because they need to feed frequently. Try to move this longer period of sleep to the nighttime, by waking and feeding your infant at least every three hours during the day.
The sleep environment is important. The room should be smoke-free. The baby should not be overheated (a common problem). Usually this means a room temperature of 65-71 degrees. Generally, if you are comfortable with a certain number of layers, your baby will need just one more layer, such as a "onesie." If your baby is frequently sweaty at night, she's probably too hot. Blackout curtains can be helpful, especially during the summer. To prevent suffocation, the surface of the bed should be relatively firm, without pillows, comforters or stuffed animals. You may find that having your newborn sleep in a bassinet next to your bed is the most convenient.
You probably have noticed that in the hospital the nurses wrapped your baby in a blanket. This is "swaddling" and has been practiced as a technique for calming babies for centuries. While in the womb the baby was comfortable with pressure over its body, and after birth that is still the case. In essence, you're recreating a "womb-like" confinement. Swaddling is also helpful because many babies would otherwise flail and startle, waking themselves up. Many babies that dislike sleeping on their backs will often tolerate the position if swaddled. If you are interested in swaddling, make sure you ask your post-partum nurse for a demonstration before leaving the hospital.
Whether you choose to swaddle, use a light blanket, or just clothing, babies should always sleep on their backs. The "back to sleep" campaign has reduced the risk of SIDS (sudden infant death syndrome) by over 50%. Though incompletely understood, SIDS is a leading cause of death in the first year of life. It's important for all caregivers, including babysitters and grandparents to be familiar with the "back to sleep" recommendation. Rarely, medical problems will necessitate other sleep positions; only your baby's doctor should make this recommendation.
As your baby grows, you may find he shows telltale signs of drowsiness. It's important to put baby down to sleep at the first sign of sleepiness. Delaying the opportunity to sleep will result in more difficulty settling down to sleep—the "overtired" baby. The signs of drowsiness can be subtle and vary with each child. They include rubbing the eyes, pulling the ears, irritability, clumsiness, giddiness, staring into space, and intense sucking.
At 2-4 months of age, we recommend starting to establish a nighttime sleep routine. Even before your baby shows signs of drowsiness, you'll want to begin the regimen. This can include bedtime stories, bathtime, quiet music, or feeding. Following this, put your baby down "drowsy but awake." A little protest from your baby at this time is fine, unless the fussing goes on longer than 10-15 minutes, or is accompanied by screaming at the top of his baby lungs. Our hope is that by going down "drowsy but awake" your baby learns how to fall asleep on his own. Not surprisingly, most sleep problems are related to inappropriate sleep onset associations. For example, a baby that always needs to be rocked or breastfed to sleep will learn that sleep cannot occur without this cue. As tempting as it may be, breastfeeding your six month old to sleep while watching a Seinfeld rerun, is probably not the optimal sleep strategy.
Most babies awaken or nearly awaken 4-6 times per night. Those babies who can "self-soothe" are more likely to get back to sleep on their own. This is the major reason why we recommend a consistent sleep routine, and placing baby down "drowsy but awake." Expect sleep to be quite active, with some occasional moving, even twitching, snuffling, jerking or smiling. You shouldn't necessarily interpret this as hunger. Moreover, by five to six months of age babies are physically able to sleep eight hours straight without needing to feed. They make up for this by more frequent daytime feeding.
If your sleep strategy isn't working you may find yourself looking for help, possibly on the internet or in a book. Undoubtedly, any visit to your local bookstore will reveal a huge number of books on the subject of infant sleep. The bitter irony is that if your baby is an excellent sleeper then the books are probably not necessary and any technique will work, whereas a poor sleeping baby frequently has difficulty with all of the established techniques. The simple fact is that sleep can be very tough, and you should never feel guilty if your baby doesn't sleep.
The variety of expert opinions on sleep is staggering. In Solving Your Child's Sleep Problems, Richard Ferber, MD, suggests a technique termed "progressive waiting" where you will put baby down, and accept crying for a period of time before attending to baby. You will gradually extend that period of time until baby will learn to fall asleep by herself. Sometimes, this can be difficult for parents who find it hard to listen to their baby cry. An even more controversial, but also popular book, Babywise, by Gary Ezzo, describes a method of "parent directed feeding" where a parent responds to baby's cues within certain, fairly strict limits. This begins very early on, even in the first few weeks of life, hence the controversial nature of the book. Marc Weissbluth, MD, in Healthy Sleep Habits, Happy Child, makes the excellent point that many babies are put to bed too late, take too few naps, and this interferes with good sleep patterns.
If it's difficult for you to consider letting your child "cry it out" you might consider another group of books which can be described as the "no cry technique." These books, including The Sleep Lady Book and the popular No Cry Solution have at their root, the idea that a baby can be gently weaned of poor sleep habits, without the necessity of crying. In one strategy, a parent might attend to a baby the first night by picking the baby up, then the next night by standing at the cribside and verbally reassuring baby, the next night standing in the doorway, then the hallway, and then eventually not even needing to reassure a baby who awakens.
We have found the "Lull-A-Baby Sleep Plan" by Cathryn Tobin, MD, to be particularly helpful for many parents, because it's straightforward, dovetails with American Academy of Pediatrics recommendations and doesn't require parents to deal with long crying bouts. Many tips in this article, particularly placing baby down, "drowsy but awake" come from this source.
A different approach is that of William Sears, MD, a proponent of "the family bed." Dr. Sears argues that co-sleeping with your baby is helpful for bonding and sleeping. The challenge faced by many parents using this system is how to eventually get the infant out of the parents' bed and into his own. In general, we've found it easier for babies to relearn sleep habits if they're less than 4-6 months old.
As with many other issues in infant sleep, co-sleeping is controversial. It does work for many families, but there are risks. If you choose to co-sleep, please adhere to these recommendations: Babies should always sleep on their backs. You should not co-sleep if you're on medication that makes you tired, or if you've been drinking alcohol. There's too much risk of rolling onto your baby in these situations. Make sure there is no gap between the mattress and wall or headboard where baby could get stuck. Watch out for dangling curtain draw cords, which could pose a risk. Lastly, if you're still using your waterbed or bean-bag chair (circa 1974?) these are not appropriate for co-sleeping.
It's important to note that many babies will fuss or cry a little on going down or when awakening overnight. It's okay for a baby to do this for up to 10-15 minutes. However, screaming at the top of his lungs is unlikely to resolve with a few minutes, and in these situations we recommend attending to your baby.
Many parents may not be aware that recent studies seem to show that pacifier use reduces the risk of SIDS. Furthermore, after breastfeeding is established (usually at 1-2 weeks age), pacifier use is unlikely to interfere with breastfeeding. However, if you use a pacifier when baby is going to sleep and it falls out, we do not recommend replacing it frequently overnight. This is a hassle for you, and habit forming for baby, essentially a negative sleep associaition.
Nevertheless, there are times when you do need to give your baby more nighttime attention, even if there's a risk for a negative sleep associaition. Examples of such issues are colds, discomfort during hot summer nights, ear infections, or traveling. However, as soon as this situation has resolved, you should quickly help baby settle back into her previous nighttime sleep pattern.
Lastly, each baby is distinctly different, and responds differently to various approaches. Some babies are just plain tough. Dr. Rapp notes, "We did basically the same sleep stuff with both our kids. Our sixteen month-old son is an excellent sleeper, while our four year old daughter still has trouble." There are few truly "wrong" ways to go about sleep training. That being said, the strategy of forming a nighttime routine and placing your baby down "drowsy but awake" is a reasonable starting place. If that's not working, you'll want to speak with your pediatrician. And if one approach isn't helping and you've given it a good try, feel free to try another. Don't get too discouraged, at some point your baby will be sleeping through the night.
Sharon Bucher, MD completed her pediatric residency at Children's Hospital of Buffalo, NY. She joined Evergreen Pediatrics in 1984. Sharon lives in Battle Ground with her husband and daughter.
Charlie Rapp, MD completed his pediatric residency at Children's Hospital-Los Angeles, and came onboard with Evergreen Pediatrics in 2001. He lives in Hazel Dell with his wife and two children. Charlie is also a Clinical Instructor at the University of Washington School of Medicine.
Founded in 1978, Evergreen Pediatrics is a nine-pediatrician, comprehensive, independent practice, dedicated to the care of infants, children and adolescents. All physicians are board certified, and staff members of Legacy Salmon Creek Hospital and Southwest Washington Medical Center. More information is available at evergreenpediatric.com
