School of Public Health

From Safe Sleep to Healthy Sleep: A Systemic Perspective on Sleep In the First Year

October 2018
Guest author Macall Gordon is currently a Senior Lecturer in Antioch University’s graduate counseling psychology department teaching research methods and parenting psychology classes. She has also conducted and presented research at international conferences on infant sleep interventions and parenting advice and is a certified Gentle Sleep Coach. She received her M.A. in applied psychology (Infant Mental Health) from Antioch University and her B.S. in Human Biology from Stanford University.


Infant safe sleep and the neurodevelopment of infant sleepSource: Federal SUIDS/SIDS Workgroup Safe Sleep Photo Repository.

Sleep is a major issue for parents of infants and a complex one for the health professionals who work with them. Popular parenting advice ignores the idea that sleep is a developmental process closely tied to brain growth1-3, affected by individual differences in temperament or physiology, and embedded in a system of behavioral, family, and cultural contexts.4,5 Advice for caregivers about how to help infants sleep well and safely intersects these numerous influences.

LESS SLEEP = LESS SLEEP

Parents with an early waking infant will sometimes push bedtime later to encourage sleeping in, but this can backfire.  Overtiredness results in a release of chemicals to help the child stay awake, resulting in even greater difficulty with sleep across the day and nighttime.10

Infant sleep is often portrayed as having a linear progression with fixed and achievable norms,6,7 and a majority of research and popular advice considers infant sleep a purely behavioral event with an emphasis on the trainability of infants.8

The notion that sleep and the ability to self-soothe are skills readily and equally available from birth can put a lot of pressure on parents. They might overestimate how much their baby is capable of and become frustrated or blame themselves when sleep doesn’t proceed smoothly. A broader, more systemic perspective can help clinicians and other health professionals understand and discuss infant sleep with families in order to find an appropriate solution. 

WHAT IS AN INFANT SLEEP PROBLEM?

While parenting advice suggests that there are discrete targets for sleep, there are disagreements even between researchers on what constitutes a sleep problem.2 Many sources imply “sleeping through the night” means “five hours of sleep between midnight and 5am,”9 whereas others suggest 4-month-old infants can be trained to sleep 12 hours without a feed.7

Any advice that implies that most babies sleep through the night by a given age can increase pressure and worry for parents whose baby may be waking in a normative way for their age. Increasingly, experts define “sleep problem” as what parents consider to be problematic.

A DEVELOPMENTAL PERSPECTIVE ON SLEEP

Infants brains are often more active in sleep than they are while awake.10 The growth of neural connections between areas of the brain is intense and rapid in the first year.11  During sleep, an infant’s brain releases growth hormones12, grows and repairs tissues13, and consolidates learning.14 Sleep is necessary to facilitate the brain’s capacity to learn and adapt.15,16

The ability to go to sleep and return to sleep, however, depends on the ability to regulate attention and self-soothe. These skills develop as areas of the brain come “online.” The development line is also not perfectly straight. Across the first year, regression periods precede the onset of new skills.17 Advances in brain development or motor milestones like crawling, pulling to stand18, and walking19 directly impact sleep. Even babies who used to sleep well may suddenly have a burst of fussiness and nightwaking.20

The notion of “self-soothing” is not completely present at birth but develops as infants are able to bring their hand to their mouth or turn their head away. Babies can only manage a certain amount of distress at a time. The “window of tolerance” for distress grows across the first several years. Self-soothing is really only available when distress is at a manageable level.21 Beyond that point, infants need parents help to calm down.

SLEEP DEVELOPMENT ACROSS THE FIRST YEAR

Newborns: Newborns sleep about 14-16 hours a day in 2-4 hour shifts and their sleep is spread out evenly across daytime and nighttime hours (circadian rhythms come online later). They spend about the same amount of time in quiet sleep as they do in active sleep. During these early weeks, they are also easier to wake (may be adaptive for SIDS prevention).2,12,22

2-3 months: At this age, a gland in the brain has developed enough to release melatonin in response to the setting of the sun. This means that infants are able to consolidate their sleep bouts into more of a day/night pattern13 (though they may still wake at night for a feed or help with returning to sleep). At this age, they need about 14-16 hours of sleep, with naps during the day about every 60-90-minutes.

4 months: The 4-month sleep regression results from a large burst of brain growth.24,25 A physical growth spurt may also prompt nightwakings for feeding. Although, this is when most parenting advice indicates it is  time to start sleep training26, it may be difficult to do at this age and may produce less progress than if parents wait until the regression is over and skills are in place. Infants may still nap about every 90-minutes to 2-hours and wake at night for feedings.

6 months: Total sleep per day decreases to about 14.5 hours with about 3.5 of those hours distributed across three daytime naps – by 9 months infants typically take just two naps. Longer bouts of nighttime sleep are possible.27

8 months: Another period of regression happens with the emergence of crawling.28

10 months: Sleep patterns may shift again just as infants learn to pull themselves up into standing position.12,18

12 months: Total sleep is still about 14-15 hours, but infants will sleep longest at night and take 2 naps a day for about 2.5 hours.12 Sleep may regress as they begin to walk.19 (Note: infants do not typically reduce to one nap until closer to 18-months).

PARENTS SHOULDN'T RUSH INTO INFANT SLEEP TRAINING

The vast majority of infant sleep research and advice recommends using various forms of extinction—the “cry-it-out” method—to improve sleep.26  It’s well understood that many parents don’t like to do this.35 In addition, for parents of intense infants, it either results in much more crying or it doesn’t work at all. While advice suggests that parents withhold their assistance and presence at bedtime to encourage self-soothing and sleep, research shows that parents’ emotional availability can actually result in better sleep overall.29 Health care professionals should encourage parents to establish consistent and positive routines30 and use responsive, gradual approaches to reduce how much soothing or help they give their infant at bedtime and at night.31

Advice in sleep books also typically recommends that parents start early with crying-it-outoften as early as 3- to 4-months of age32-34 or even younger6,7 –despite the fact that no research exists on the use of extinction with babies this young. Given the developmental regressions and changes in sleep that occur at approximately 4 months of age, attempting sleep training now may be quite difficult for some babies. For many families, waiting until 6 months to begin working on sleep allows the infant to develop the skills and capacities that sleep training will require and parents may find they have more success in a shorter period of time.

4 EASY WAYS TO ESTABLISH HEALTHY INFANT SLEEP HABITS

The American Academy of Pediatrics (AAP) discourages placing infants to sleep in sitting devices as they may assume positions that pose a risk of airway obstruction or suffocation. The AAP also acknowledges that health care providers may override these recommendations after careful consideration of the risks relative to the infant's individual medical condition (such as extreme lack of sleep).

1) Encourage good, well-timed naps that are appropriate for the infant’s age.  Up to 6 months, these can happen in safe, supervised locations anywhere that works (swing, carrier, bouncy seat).*

2) Establish a predictable sleep routine and an early (7 or 7:30 “in bed”) bedtime. For infants 6 months and up, try to have one step in between nursing or feeding and going into the crib.

3) Create a pattern for returning to sleep. Infants who fall asleep in the same place they wake up have an easier time returning to sleep. If parents are putting their baby in the crib already asleep, they can work on this gradually.

4) Give it time. Parents should choose an approach that makes sense to them and do it consistently, allowing at least 4 or 5 days to see any change. Babies will often strongly resist changes to their routine and so, the first days can be challenging. Parents might see improvement by Day 3; however, a “last ditch” effort called an “extinction burst” can happen on the fourth day, causing parents to think their efforts aren’t working. If they can stay the course, they should see improvement return.

NON-BEHAVIORAL CAUSES OF INFANT SLEEP PROBLEMS

Some infants have persistent difficulties with sleep that resist behavioral remedies. In these cases, health professionals should consider the potential of underlying physiological causes. If any of these are suspected, parents should be referred to their pediatrician.

  • Silent Reflux refers to reflux that does not result in spitting up and therefore can go undetected. Acid reflux is especially uncomfortable for infants lying flat on their backs. These infants may have difficulty sleeping at any time, or anywhere.37 Parents of infants with silent reflux report that the infant may arch their back while nursing or feeding, feed best when drowsy or “nibble nurse.” These infants may also prefer to sleep slightly upright or on their side.
  • Obstructed breathing, such as snoring or mouth breathing (in children who aren’t sick), might indicate enlarged adenoids or tonsils, which makes it difficult to stay asleep.36 Children with breathing problems may also have a persistently sweaty head when they sleep and may be very restless/active during sleep to find a position that clears their airway.
  • Intense or sensitive temperament in infants can  cause sleep difficulties.34,38 Infants with this temperament often have very low sensory threshholds (i.e. higher sensitivity to sensory input – sound, light, textures, etc.) These children resist sleep more strongly and sleep less overall. Temperament is an important contributing factor to infant sleep development and self-soothing abilities, but is rarely considered in parenting research or advice. Parents  may need a slightly different approach to sleep, as well as more support overall in caring for an infant with a spirited temperament.
  • Anemia and low iron stores can also affect sleep in infants39, even after the condition is treated.40

Infant sleep is a “hot button” issue for parents. This is partly due to the broken sleep that comes with early parenting but also because advice tends to imply that early achievement of infants sleeping through the night is a kind of benchmark for parental competence. Many parents feel responsible for any sleep problems their infant has and often think—even when their child is still very young—that they have already “blown it.”

Health professionals can reduce the stress and anxiety around infant sleep by helping parents understand that sleep, like infants, takes time to mature. When parents are able to choose —from a range of effective options— an infant sleep approach that fits their values and their child this allows them to commit to the level of consistency that’s necessary for behavioral change. 


 


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