Baby Behavior in the News: Safety of Infant Sleep Machines

If you’ve been a long time reader or have had the chance to browse through our previous posts, you know that we've posted a lot on infant sleep over the years. We know from experience that one of the hardest parts of being a new parent is adjusting to the lack of sleep that comes with caring for such a tiny baby. In the past, we've explained why babies don’t sleep through the night (see Baby Behavior Basics Part 1), how babies sleep at different ages and the difference between falling asleep and staying asleep  (see The Science of Infant Sleep Part 1, Part 2, and Part 3), and we’ve provided tips for sleep deprived parents (see Dealing Realistically with Postpartum Sleep Deprivation Part I and Part 2.

As we’ve discussed infant sleep and parental fatigue, both in person at speaking engagements and with readers of this blog,  we’ve gotten a lot of questions about the use of noise machines to help babies sleep better.  While we understand the concept (white noise is repetitive stimulation, which we know calms babies), there are a few reasons we’ve been careful not to recommend use of these machines for babies. First, we know that babies, especially young babies, need to wake often (see Baby Behavior Basics Part 1) and second, we didn’t know much about the safety of these machines for use with babies.  So, when a recently published study about the safety of infant sleep machines showed up in the news, it caught our eye.

The authors evaluated 14 machines that are widely available in the US and Canada. Each machine played a range of 1 to 10 different sounds, including nature noises (for example, wind, water, birds, etc) white noise, mechanical sounds (traffic, trains, etc) and heartbeat sounds. During the measurements, the authors tried to recreate the experience of using these machines in real life. They used a microphone set-up to mimic an infant’s ear and measured the sound level at 3 different distances,  30 cm (~11.8 inches) similar to crib rail placement), 100 cm (~ 3 feet) to replicate placement on a table near the crib, and 200 cm (~6.5 feet) to represent a machine placed across the room.

Not surprisingly, the closer the machine was to the microphone, the louder the measurement. At the crib rail and bedside table positions, all 14 machines exceeded the recommended levels for hospital nurseries. Three of the machines were so loud that they would be considered dangerous for adults when exposed for 8 hours (like overnight, for example). Even when placed across the room, 13 of the 14 measured louder than recommended.

Like usual, the authors state that more research is needed. They did not collect information about how these machines are usually used in real life, so this study does not provide information about where parents usually place the machines, how long they typically stay on, or which volume setting is used most (they measured at the loudest setting).  However, they point out that all of these machines are easily available for purchase with very little instruction for use or safety information and that there is clear evidence that inappropriate noise exposure can change infants’ heart rates, disrupt sleep quality and duration, and even lead to hearing loss.

The authors suggest that policy makers require more oversight for these machines, including limits on volume levels, better labeling and instructions for use, and requiring automatic timers to shut the machines off and prevent overuse.  For parents who are using these machines, they recommend placing the machine as far away from the baby as possible, setting the volume as low as possible, and limiting use by using automatic time shut-off or turning the machine off once the baby falls asleep. 

Reference: Hugh, Sarah C et al. Infant Sleep Machines and Hazardous Sleep Pressure Levels. Pediatrics Volume 133, Number 4, April 2014. 

Happy New Year!

Happy New Year! We'd like to welcome you back to our blog! We took some time off for the holidays, but now we are back. For those of you new to our blog, welcome! We would like to start the new year off with a little tutorial about how our blog works and where you can find "The Basics" of Baby Behavior, which is a great series of posts to start with if you are new, or if you haven't been around here in a while. You can begin with our overviews on your baby's cues, crying, and sleep patterns.

Everything else we've posted is available to you and there are a few ways you can find what you are looking for.

• On the left side, in the section titled Blog Archive, you can find links to every blog we've posted (the titles of each blog are listed with the most recent at the top).
• If you have a specific topic you are interested in, you can use the keyword links, in the Labels section, to find related entries.
• If you just want to browse full entries, you can use the older posts link at the bottom right of the page. This link will take you through the posts, beginning with the most recent.

We hope that you find the information we've provided useful. If you don't find what you are looking for or if you have any questions, please send us a comment. We love to answer our readers' questions and are always accepting new ideas for future posts!

Our Top 5 "Sleep" Blogs!

Infant sleep is by far the most popular topic on our blog. So, we decided to find out which sleep posts were the most popular (highest number of page views). Here is what we found:

#5: The Science of Infant Sleep Part II: Big Changes in Sleep Patterns (6 to 16 weeks)

In this post we talk about the big changes in sleep patterns that occur between 6 and 16 weeks of age. Babies’ sleep starts to get more predictable and parents may be giving a sigh of relief that the 1^st 6-weeks are over! The biggest change is that babies start falling into deep sleep instead of light sleep around 4-months of age. They also start sleeping for longer periods.

#4: Three Newborn Behaviors That Can Mislead Parents

One of the behaviors that can mislead parents is that some babies wake up every time you try to put them down for a nap after a feeding. This post explains why that happens.

#3: Why We Don’t Like “Sleep Training” for Babies: Part 1

In this post, we explore the topic of sleep training and explain why we don’t agree with the concept. We encourage parents to understand normal infant sleep patterns and talk about why babies need to wake up at night for their own health and safety.

#2: Science of Infant Sleep Part I: The First 6 Weeks

Here we introduce how babies sleep during the 1^st 6-weeks and the 2 types of sleep. We talk about dreaming and brain development and how to help newborns sleep a little better.

And the top infant sleep post…with almost 3 times the number of page views than the second place post is…

#1: Why Do Some Babies Hate Being Drowsy?

Our most popular post addresses the baby who gets very fussy and upset every time he or she is drowsy. You may know one of these babies! We explain why this happens and provide tips for dealing with a baby who hates being drowsy.

What is your favorite post? What post has been the most helpful to you?

Bottles at Bedtime for Older Babies and Childhood Obesity

It’s possible that putting your baby to sleep with a bottle could have long term effects on your child’s health, according to a recent study.

Over 8,000 children who were part of the US Early Childhood Longitudinal Study were included in a recent study about feeding and obesity risk. Researchers, from Brigham Young University in Utah, found that putting an older baby to bed with a bottle could increase his or her chance of childhood obesity by 36 percent. How can this happen? Researchers hypothesized that when older babies are fed a bottle at bedtime on a regular basis or as part of their bedtime routine, babies become used to this and will take the bottle whether they are hungry or not. It can become a pattern. The problem is that this can discourage babies from being able to self-regulate their intake and result in their taking bottles at bed and naptime out of habit rather than when they need the calories. If babies eat more calories than they need every day, they gain too much weight.This pattern of needing to eat before sleep may continue into childhood or adulthood.

Research Meets Reality

We know that many families give bottles at bedtime and understand why you do. Nine percent of breast fed babies and 40% of formula fed babies were “put to bed with a bottle” at 9-months of age according to this study. However, it is unclear whether that means that these babies were given a bottle at bedtime by the parent or given a bottle to self-feed in the crib. It’s also not specified in this study whether or not these babies were put to bed with a bottle of breast milk or formula and breastfeeding to sleep is not mentioned at all. Therefore, we think these study findings need to be interpreted with caution since the question asked the parents in this study was vague.

But, the study findings are straightforward, bottles at bedtime increase older babies' risk of becoming obese. So, what are you supposed to do if bedtime bottles are already a habit?

Helpful Tips if You Do Put Your Baby to Bed with a Bottle

The problem is not the bedtime feeding itself but the excess calories. You want your older baby to learn to eat when he is hungry, not out of habit after he has had enough to eat during the day. The researchers recommended including feeding before bed only if the baby is showing hunger cues and to stop feeding when baby shows fullness cues. They also recommend not forcing your baby to finish the bottle so that he will sleep longer. Overfeeding past the baby’s fullness cues can also cause the baby to override his own body’s hunger cues making it easy for your baby to gain too much weight. 

Alternatives to the Bottle at Bedtime

If you do decide to stop giving a bottle at bedtime, we know that you may be worried that changing your feeding pattern will negatively affect your baby’s sleep. You will need some new tools to help your baby get used to sleeping without a bottle! A consistent bedtime routine will help your baby get to sleep and stay asleep more easily. Babies need help to relax and rest at the end of the day. Bedtime routines can be used to help your baby get so sleepy and calm that she can get the rest she needs. For examples of how to start or change a routine, click here. It’s also helpful to wait until you see signs that your baby is tired before starting your routine; that way she will fall asleep more easily.

AAP Recommendations on Weaning

You may be wondering when your baby should be off of the bottle completely. The American Academy of Pediatrics (AAP) recommends weaning your baby from the bottle before 18 months of age. This is important not only to prevent tooth decay but also to limit the amount of milk your child is drinking. It’s probably a good idea then to start weaning your baby off the bottle as soon as they are eating enough solid food at dinner time so that they don’t need milk at bedtime for nutritional purposes. For most babies, that's around 1-year of age.

We hope that we have provided you with enough information to be able to make an informed decision about feeding at bedtime. We know that this is a challenging topic and hope that the alternative tools we provided above are helpful if you do decide to change your bedtime feeding practices.

References

Gibbs BG, Forste R. Socioeconomic status, infant feeding practices and early childhood obesity. Pediatr Obes. 2013 Apr 2. [Epub ahead of print]

AAP Statement on weaning from the bottle

Quick Tip: Don't Move Bedtime Up too Soon

If you've been reading this blog, you know that babies typically start to concentrate one longer stretch of sleep during the night time hours sometime between 3 and 4 months of age. Of course, parents are more than ready to get a little more sleep by then and it is easy for them to believe that babies should always sleep for 4 to 5 hours once they can "achieve" that first concentrated stretch. Parents who have been putting their babies to bed at 11 pm or midnight in order to sleep until 4 or 5 am, might think they can now move the bedtime up closer to 7 or 8 pm, enjoy some time together, and get two or even three long stretches of sleep each night. Well....you might want to wait on that.

When your baby first starts concentrating a long stretch during the night time hours, you might find that you only get one longer stretch. If you put your baby to bed at 8, she might give you that long stretch until midnight or 1 a.m. then, wake up again at 3, 4:30, and 7 am! You're not doing anything wrong, your baby just isn't ready to have several long stretches of sleep yet. To avoid some frustration, you might want to wait to move up your baby's bedtime until she becomes more consistent with combining shorter periods of waking with longer stretches of sleep. For lots of babies, that happens when they are around 6 months old. It will happen...no really...it will. In the meantime, remember to get some help at home. More sleep is just a few weeks away.

Reference:
Heraghty JL et al. The physiology of sleep in infants. Arch Dis Child. 2008; 93: 982-985.

Reader Questions: Sleep Review

Over the last few weeks, many readers have sent in questions about infant sleep, several focusing on how older babies sleep.  So, today we will review some information about normal sleep at different ages. Then we will share some tips for tired parents and links to past posts about infant sleep.

Sleep Duration

All babies are different, but there are some general patterns of infant sleep duration at each age. The following is an excerpt from a past post we wrote about infant sleep. (Click here for the full post)

• Newborns (birth to 6 weeks) wake frequently and erratically. Parents of newborns must be realistic, prepared, and ready to ask for help!
• By 2 months, most babies are sleeping longer stretches, but waking 2-3 times during the night.
• By 4 months, many babies start to sleep more like their parents, falling asleep into a deeper sleep and sleeping for 4-5 hours at once. Unfortunately, teething and changing routines can increase waking intermittently around this time.
• By 6 months, some babies sleep for 6 hours while others are still waking more frequently, though not every night. There are so many changes typically occurring at 6 months, new skills, new activities, new travels, new teeth...older babies sleep well for a few nights, then wake again. It is no wonder that "sleep training" is so popular among parents of babies around this age. 
• About 80% of babies sleep through most nights by 1 year of age.

Remember that sleeping through the night by research definition is about 6 hours of continuous sleep!

Why Babies Wake Up During the Night

Young babies wake up for 3 important reasons:

• To eat frequently
• They dream a lot (which helps their brains grow and develop) and wake easier when dreaming
• Waking often helps them stay comfortable and safe

These reasons are described in more detail in one of our very first posts! Click here to read more about why it is important for young babies to wake up.

Older babies who are healthy and growing well may still waking at night. If your older baby wakes frequently at night, check the following:

• Lights from TVs or video games flickering on the wall (steady nightlights are usually ok)
• Caffeine in the breastfeeding mother's diet
• Changes in daily routine or no consistent routine
• Baby is overstimulated or overtired
• Too much sleep during the day
• The need to practice new motor skills
• Noise, but only if it is sudden and quite loud (babies quickly get used to familiar noises)

For more information about the developmental reasons older babies wake, read our previous posts  Baby Behavior Mysteries: A 9 month old resists his crib and  provides Tips for dealing with a waking 9 month old.

Tips to Deal with an Older Waking Baby

The following is another excerpt from a past post (Click here for the full post) that offered alternatives to try in place of sleep training. Using these tips can help everyone get a little more sleep.

• Establish routines!  Repeated activities and experiences are calming to babies and help them establish body rhythms that are closer to those of their parents. Bedtime routines allow babies time to shift naturally from a drowsy state into sleep. Babies will differ in how much time they need to become ready for sleep; many take at least 20 minutes. Believe it or not, you'll miss the bedtime routines when your children outgrow them.
• Reduce or eliminate caffeine for breastfeeding mothers (don't worry, you'll get to have that morning mocha again). Babies' bodies take a lot longer to get rid of caffeine than we do. Remember there is caffeine in tea, sodas, energy drinks, and other products. Read labels.
• Make sure that baby isn't overstimulated close to bed time (this is easy to do if parents typically get home late from work). Watch for indications that your baby is drowsy and start your bedtime routine right away. If you wait too long, you might end with a screaming, overtired baby who will be less likely to sleep than a baby put to bed earlier.
• Make sure that baby spends plenty of time awake during the day. Give babies plenty of chance to be active, moving, and practicing their new skills during the day.
• Include a special bedtime toy in your bedtime ritual, something that is safe to leave with baby as he drifts into sleep.
• Don't end your routine with baby being completely asleep. When babies are put down when they are very drowsy but before they are asleep, they may be better at putting themselves back to sleep if they wake in the night. This doesn't work with babies who hate feeling drowsy and resist sleeping at all costs! I had one of those! The trick is that the baby must be very drowsy or very accustomed to this as an end to the night time routine.
• Recognize that most babies make noise when drifting to sleep or they are dreaming, don't assume that intermittent noises mean your baby needs you immediately. Give your older baby a few moments to fall asleep or get back to sleep on his own.

Additional posts about infant sleep:

Back to Basics Part 1: Reasons Why Babies Don't Sleep Through the Night

The Science of Infant Sleep Part I: The First 6 Weeks

The Science of Infant Sleep Part II: Big Changes in Sleep Patterns (6 to 16 weeks)

The Science of Infant Sleep Part III. Relationships that Influence Babies' Sleep

The Science of Infant Sleep Part IV: Falling Asleep versus Staying Asleep

What the Recent Research on "Cry it Out" Doesn't Tell Us

Reader question about older baby sleeping independently

Why We Don't Like "Sleep Training" for Babies: Part I

Why We Don't Like "Sleep Training" for Babies: Part II

We hope this review of infant sleep was helpful in answering some of your sleep questions. If not, let us know and we will do our best to provide the most up-to-date, evidence-based information!

Readers' Questions: Drowsy Babies

Over the last few weeks, we’ve received several comments in response to our post “Why do some babies hatebeing drowsy?” from parents who have noticed that their babies seem to resist falling asleep or wake easily right after drifting off. Today, we’d like to address 2 of these comments.

Reader #1: My problem with my 2 month old is she not only fights off sleep, she will wake herself up by forcing her head up and going from side to side or making her body jump, even if she has completely fallen asleep.

This baby seems very active! When she is moving that much while sleeping she is most likely in active sleep. At 2 months old, she is still goes into active sleep first, which means that immediately after drifting off she starts dreaming. When babies are dreaming, they may move around a lot. It is normal for them to twitch and move their bodies and they may even make sounds or sucking noises. Although this may seem strange, dreaming is an important part of brain growth and development.

Because their brains are so active while dreaming, they can also wake easily while in active sleep. All babies (and adults) cycle through active sleep, quiet sleep, and waking throughout the night. Therefore, she may wake again when another round of active sleep comes around. If the baby is uncomfortable for any reason  she might wake up during this light sleep.

So, what can you do?  First, if she falls asleep in your arms, wait until you see signs of deep sleep before putting her down. When in deep sleep, she will be less sensitive to the position change and may stay asleep longer. Second, keep her as comfortable as possible! Make sure she is dressed appropriately (temperature and comfort level), has a clean diaper, and that anything else that might make her uncomfortable is taken care of. Remember, 2-month olds only sleep for about 2-4 hours at a time, so it is normal for them to wake during the night.

With such an active baby it’s also important to keep her sleep environment safe. With so much movement she could move herself right off of a bed or couch. Follow the AAP safe sleep recommendations here.

Reader #2: Please give me some help. My 14 week old son fight his sleep. What can we do, I am too tired. Somebody help. Thanks.

Waking up with young babies is hard. Adults are used to sleeping for long stretches and it can be frustrating that babies don’t sleep that way.  Having a baby who gets irritable when drowsy can make waking even more difficult because it may be harder to get the baby back to sleep during the night.

Like we explained in the original post, some babies have a hard time winding down after they’ve spent time interacting with the people around them. At 14 weeks, the reader’s baby is learning so much and it may take longer for his brain to transition from playing and learning to resting. The tips we listed in the original post can help. When this baby is getting tired, the parents can help him transition to sleep easier by minimizing stimulation (turning off the TV, keeping the noise to a minimum, etc), making sure he is comfortable (clean diaper, dressed comfortably, etc), and following a bedtime routine. Doing 3 or 4 things the same order every time the baby is going to sleep can help his brain calm down enough to sleep.

We also suggest that this reader ask for help from friends or family. Caring for a young baby is not easy and her comment shows how tired she is. Whenever you are feeling overwhelmed, ask for help! Asking someone to come over just few an hour or two so you can rest can make a big difference.

Here are a few more posts readers with similar questions might find useful:

The Science of Infant Sleep Part II: Big Changes in Sleep Patterns (6 to 16 weeks)

The Science of Infant Sleep Part IV: Falling Asleep versus Staying Asleep

Tips for Nap Time

Tips from the Trenches: Surviving Sleep Deprivation

Does "Back to Sleep" Delay Babies' Rolling Over?

By Jennifer Goldbronn, RD, MAS

The Back to Sleep Campaign, now known as the Safe to Sleep Campaign, educates parents about ways to decrease SIDS risk, including putting babies on their backs to sleep.

There has been some controversy in the past that this campaign has actually decreased the total time babies spend on their tummies not just during sleep but while they are awake.  There was some concern that less time on the tummy would delay some motor skills such as rolling over, sitting up or crawling. What followed was a campaign to promote “tummy time” during awake time.

Studies then followed looking at whether or not specific developmental milestones were delayed since inception of the Back to Sleep Campaign.

Some studies found slight delays but results were still within developmental norms.  Other studies showed that the age of rolling tummy to back was older and that babies were reversing which milestone they hit first, rolling back to front first instead of front to back. For information on the age at which babies roll over, click here.

Thus, a new study aimed to see if there really was a difference in the developmental milestone (rolling over) before the Back to Sleep Campaign compared to now, 20 years later. Current data were compared to the AIMS (Alberta Infant Motor Skills) data set, a measure of normal infant motor abilities, collected 20 years ago. The current data set used the same assessment guidelines and age ranges as the AIMS data set, and the proportion of infants passing each of four items (immature and mature front to back rolling and immature and mature back to front rolling) by 36 weeks of age was assessed.

What did they find? Infants in both groups achieved the milestone of rolling over at almost the same age. The order with which the infants reached the four milestones (passing each item) was the same in both the pre-campaign and post-campaign groups. The age at which 50% of infants could perform each milestone was also the same in both groups.

The results of this study show no significant effect of the Back to Sleep Campaign messaging on infants’ ability to reach the "rolling over" milestone. The authors of the current study will continue to assess the effects of the Back to Sleep Campaign on other motor skills such as crawling, sitting and walking. Stay tuned for the results!

For more information about making tummy time easier for your baby, click here.

We also clarified some common misconceptions about tummy time in this subsequent post.

Reference

Darrah J, Bartlett DJ. Infant rolling abilities- the same or different 20 years after the back to sleep campaign? Early Hum Dev. (2012) [Epub ahead of print]

Dealing Realistically with Postpartum Sleep Deprivation Part 2.

In our last post, we shared information about why young babies need to wake at night. Of course, if your baby is awake, that means that you are awake too (yes, research studies have actually been done to tell us that). Rather than being frustrated and stressed trying to find ways to get your young baby to sleep longer, we want to encourage you to look at the problem differently and look for ways to cope with having to wake up so much. Since adults’ sleep cycles (including both dreaming and non-dreaming sleep) are about 90 minutes long, new parents have reported feeling more rested when they are able to get 90-minute blocks of uninterrupted sleep several times per day. Focusing on getting these “chunks” of rest may make those first few weeks a little easier. Even if the baby is not cooperating and still feeding every two hours, parents can take turns and trusted friends and family can help make sure the baby is cared for between feedings. So "sleep when the baby sleeps" really is great advice. Right? Well, ok, we know it isn't always that simple.

Barriers to Sleep

Here's some more research that won't surprise you: many parents don’t “sleep while the baby sleeps” even if they try. Parents have a hard time finding time to sleep, falling asleep, returning to sleep, and staying asleep even though they are exhausted. If you are dealing with any of the following problems, you may be wondering what you can do to get more sleep.  

Hormone Shifts

Hormone shifts in the first days and weeks after delivery can leave moms feeling hot, cold, exhausted, wired, and moody 24-hours a day. These hormone shifts typically last only a short time and you should start to feel better and be more able to rest after the first couple of weeks. Talk to your doctor if you have any concerns.

Worry

First-time moms are more likely than experienced moms to suffer from sleep disturbances (including difficulty in falling and staying asleep) because of higher stress levels. First-time moms are more likely to be nervous and unsure about baby care. New dads worry too. You might find yourself wide awake wondering if you're a good parent. You might even stay awake worrying about getting enough sleep! Talk to your experienced friends and get tips to build your confidence, read this blog, share your concerns with your doctor, partner, and supportive friends and family. When you talk about your feelings, you might find a new perspective and learn that many parents feel the same way.You may find that it helps to follow a short routine and listen to soft music every time that you lay down to rest so those worrisome thoughts don't get a chance to get going. 

Other Responsibilities

Another common reason that parents said they couldn't get to sleep (when they had the chance) was that they worried about keeping up with household chores and other responsibilities. Some parents reported that they didn't even try to sleep because they were too busy with visitors and housecleaning. I know it is easy for someone like me to say “just let the chores go.” There can be many reasons why that can be very hard to do. But if you can’t let things go, you are going to need some help. You may feel that you should be able to handle it all but that's just not realistic; we are not meant to raise our children alone. Remember that whole “it takes a village” thing? It’s true. We have some posts to help you arrange to get some help when you need it. If you are ok with letting things go (and we hope that you are), just make sure the chores get done that are directly related to safety (you don’t want to trip and fall or give yourself food poisoning).

Believe us, we know what it is like to be in that early postpartum fog. We hope that these tips help you to get through it. Remember, more sleep is just a few weeks or months away.

References:
1. McQueen A, Mander R. Tiredness and fatigue in the postnatal period. J Adv Nurs 2003; 42: 463-469.
2. Coo Calcagni S, Bei B, Milgrom J, Trinder J. The relationship between sleep and mood in first-time and experienced mothers. Behav Sleep Med. 2012; 10:167-79
3. Insana SP, Montgomery-Downs HE. Sleep and sleepiness among first-time postpartum parents: A field- and laboratory-based multimethod assessment. Dev Psychobiol. 2012 May 2. doi: 10.1002/dev.21040.
4. Hunter LP, Rychnovsky JD, Yount SM. A selective review of maternal sleep characteristics in the postpartum period. J Obstet Gynecol Neonatal Nurs. 2009;38(1):60-8.

Dealing Realistically with Postpartum Sleep Deprivation Part I

Over the last 3 years, some of our most popular posts have been related to infant sleep and many of our new readers find us when they are searching for reasons why their babies are still waking (particularly at 6 weeks). We know you’re tired; we know babies take a long time to sleep "through the night." To make things worse, there are more news reports every day about the negative effects of losing sleep. What are new parents supposed to do? In today’s post, we’ll talk about the science and realities of sleep deprivation in the first 6 months postpartum and next time, we’ll share some ideas about coping with this inevitable challenge.

The Baby Side of Waking

We’ve already written quite a bit about how babies’ sleep patterns change over time and the reasons why babies need to wake, especially early on. The bottom line is that young babies need to wake to eat frequently enough to grow well and to ensure that they get the care they need (to be warm, clean, etc.). The first 6 weeks are especially brutal because newborns don’t have the hormones in place to know night from day, so they wake (literally) at all hours. Of course, babies differ a great deal in how much sleep they need but many babies take at least 6 months before they are sleeping 6 hours most nights.

If you are still reading because you think I’m going to tell you the “secret” of getting your baby to sleep longer, you’re reading the wrong blog. There isn’t a safe way to make your baby sleep longer until he is ready (remember we are talking about young babies here). This post is about your real challenge – you have a baby that needs to wake up but you have a life, responsibilities… and besides, being sleep deprived makes you feel awful!  

Baby versus Adult Sleep

While both babies and parents move through different types of sleep in "cycles," the cycles differ in some important ways. Both adult and babies' sleep cycles include periodic dreaming (light sleep) and time without dreaming (deep sleep) but they differ in the timing and duration of each of these types of sleep. Babies waking up at all hours can leave parents without the REM (dreaming) sleep they need for normal brain function and the non-REM sleep they need to feel refreshed.

Rethinking the Problem

Your most pressing problem is figuring out how little sleep do you need to get by. This is where understanding about light sleep and deep sleep comes in. You need both types of sleep every day and you need to find ways to get enough of each type in a 24 hour period even if your sleep is interrupted. While everyone is different in how much sleep of each type they need, most adults drift in and out of both types of sleep within a 90-minute period. That means that most adults will get some benefit from having at least 1.5 to 2 hours of sleep at once. If you normally slept 8 hours before the baby came, you’re going to need about 5 of those 90 minute cycles every 24 hours to feel rested. Of course, I don’t have to tell you that it isn’t the same as getting all 8 hours of sleep at once. As a new parent, you know there are lots of things that can get in the way of getting 2 hours of sleep at a time, even if your baby is sleeping that long. Here are some common barriers:

• Inability to fall asleep quickly (especially after waking to care for the baby)
• Hormone changes
• Visitors
• Daily routines and habits
• Household chores
• Returning to work and/or other responsibilities
• Other children
• Stress

Next time, we’ll share some ideas on how to get around these barriers and get more “quality” sleep even if the quantity is still a few weeks or months away.

References

Hunter LP, Rychnovsky JD, Yount SM.A selective review of maternal sleep characteristics in the postpartum period. J Obstet Gynecol Neonatal Nurs. 2009 38:60-8.

Soledad Coo Calcagni, Bei Bei, Jeannette Milgrom & John Trinder. The Relationship Between Sleep and Mood in First-Time and Experienced Mothers, Behavioral Sleep Medicine. 2012 10:3, 167-179.

Reader Question: Nursing Your Young Baby to Sleep

By: Jennifer Goldbronn

Recently, we received a question from a reader about nursing her 11-week-old to sleep. We have been asked many times whether or not babies get “used to” being nursed to sleep and whether or not it affects his or her ability to get back to sleep alone.  Here is one reader’s story:

My baby is 11 weeks old and I nurse him to sleep. He wakes up several times a night and I doubt he's always waking due to hunger. I have read that I may be contributing to his night wakings by nursing him to sleep and thus preventing him from learning how to self soothe (ie when he wakes he's unable to settle himself to sleep and so I have to nurse him).  If I am cultivating a problem I'd like to nip it in the bud sooner rather than later.

Self-Soothing

At 3 months of age, babies are able to self-soothe back to sleep after night wakings only about 0ne-third of the time. By 1 year, infants are able to self-soothe back to sleep about half of the time.  (Burnham 2002) When babies are not able to get back to sleep on their own, they will need a caregiver’s help, whether that be rocking or singing or nursing, to get back to sleep during the night. Babies do get “used to” how they fall asleep, but not at this young of an age. As babies get older parents can create a bedtime routine that does not include nursing as the last step. For this reader, nursing or rocking her young baby to sleep now does not mean she will have to continue this routine forever!

Night Waking

Babies wake for many reasons other than hunger, though they also need to be fed frequently! Babies also wake when they are too hot or cold, lonely (at this age babies need to interact with caregivers often) or just plain uncomfortable. Since young babies enter into light sleep first, they do wake very easily so it’s helpful to wait until they get into deep sleep before you lay them down. Holding or rocking to sleep are examples of ways to soothe your baby until he enters deep sleep. (For more information about light and deep sleep, click here.) It gets easier! By around 4 months of age babies fall into deep sleep first and won’t need as much help from you at bedtime.  Here are some other tips to get a little more sleep when dealing with the inevitable waking of your little one.

More Information

Falling asleep and staying asleep are 2 very different things. Learn the difference between the two in this post. The recommendation to lay your baby down to sleep awake vs. asleep is also discussed in this post.

As we mentioned above, there are many reasons babies wake during the night; you will find a full list of reasons in this post. You can also read about establishing routines in older babies.

Sleep patterns change a lot as babies get older. Learn more about the specifics of sleep patterns of babies 6-16 weeks of age in this post.

Reference

Burnham MM, Goodlin-Jones BL, Gaylor EE, Anders TF. Nighttime sleep-wake patterns and self-soothing from birth to one year of age: a longitudinal intervention study. J Child Psychol Psychiatry. 2002;43:713-25

Reader Question about Older Baby Sleeping Independently

A few days ago, we received the following question from a reader:

How about sleep with older babies? We have an 11 month old, we've never sleep trained, she's never been a great sleeper (we co-sleep). I'd like to move towards independent sleep after she turns a year but I have no idea how to implement... I feel like some of the reasons I shied away from (independent) sleeping when she was an infant aren't such a concern with a young toddler..? So what are your thoughts on sleep training for an older baby?

Most parents define independent sleeping as their child sleeping on their own sleep surface in their own room but different parents have varying goals or ideas about at what age this should or will occur. Let’s take a look at a few studies reviewing where babies sleep at 1-year-old. In a 2002 study, 76% of 12-month old babies slept in their own rooms (in a sample of non-co-sleeping infants). (Burnham 2002) A larger study in 2008 reported that about 71% of 1-year-old babies slept in their own rooms. (Hauck 2008)

While there is really no need to “sleep train” babies (in the popular sense of the term), even at 1 year old, we do have several great posts to help parents through this transition time. I’ll share a few key things to keep in mind, along with links to our past posts for you to read.

First, babies love routines, and this reader is changing her baby’s routine by moving her baby into the baby’s own room. Any change in routine takes some adjustment time and has the potential to cause increased night waking. Creating a consistent new bedtime routine that ends in her new sleep environment is the key. For more about the importance of routines, click here.

Next, some of the guidelines have changed related to crib safety. In the following post we answer a reader question about transitioning her baby into her own room to sleep. We share Recommendations for Infant Sleep Settings and Choosing a Safe Sleep Surface in part one of the post. Then in part 2 we share tips to ease the transition of baby into her own room.

Lastly, there are many reasons why we don’t like sleep training, even for older babies, and truth be told, older babies may wake-up at night in their second year of life as well. For more details, click here.

We think it’s most important for parents to weigh the evidence and then do what feels best for their particular baby and family, realizing this may be different from others’ choices. We hope this was helpful! Good luck and we wish all of you with 1-year-olds a very happy first birthday!


References

Burnham MM, Goodlin-Jones BL, Gaylor EE, Anders TF. Nighttime sleep-wake patterns and self-soothing from birth to one year of age: a longitudinal intervention study. J Child Psychol Psychiatry. 2002; 43(6): 713–725.

Hauck FR, Signore C, Fein SB, Raju TN. Infant sleeping arrangements and practices during the first year of life. Pediatrics. 2008 Oct;122 Suppl 2:S113-20.


Note: The original post “Reader Question: "At what age do you transition babies to sleep in their own rooms?"” published on 6/3/11 contained 2 typos. 1) The 2008 study by Hauck et al found that 29% still bed shared, meaning 71% slept in their own rooms. 2) In the text of the post we said the Burnham study was published in 2005, when it actually was published in 2002 (the reference list was correct). We apologize for the confusion.

AAP Recommendations to Reduce the Risk of SIDS: An Overview Part 2

By Jennifer Goldbronn, MAS, RD

Last time, we provided an overview of the first 5 updated and expanded recommendations from the American Academy of Pediatrics to reduce infants’ risk for SIDS and other sleep related deaths. In this post, we continue with the next 6 "level A" recommendations. For the full report, see the link below.

6. Avoid smoke exposure during pregnancy and after birth
“Both maternal smoking during pregnancy and smoke in the infant’s environment after birth are major risk factors for SIDS.”

Important Points:
• This includes second-hand smoke in an infant’s environment, such as the car or home.
• The risk is highest when the infant bed-shares with a smoker.

7. Avoid alcohol and illicit drug use during pregnancy and after birth
“There is an increased risk of SIDS with prenatal and postnatal exposure to alcohol or illicit drug use.”

Infants are at a particularly high risk of SIDS when parents bed-share with infants while under the influence of drugs or alcohol.

8. Breastfeeding is recommended.

Important Points:
• The protective effects of breastfeeding against SIDS increase with the amount of exclusivity. The AAP recommends 6-months of exclusive breastfeeding for all infants if possible.
• Any breastfeeding is more protective than none.

9. Consider offering a pacifier at nap time and bedtime
“Although the mechanism is yet unclear, studies have reported a protective effect of pacifiers on the incidence of SIDS. The protective effect persists throughout the sleep period, even if the pacifier falls out of the infant’s mouth.”

Important Points:
• Use the pacifier when your baby is falling asleep.
• You do not need to put the pacifier back in your baby’s mouth if it falls out.
• Do not force your infant to take a pacifier if he doesn’t want to!
• Do not attach the pacifier to the infant while the infant is sleeping.
• Wait to give pacifiers to breastfeeding infants until breastfeeding is firmly established, or when babies are about 5 to 6 weeks old.

10. Avoid overheating
“Although studies have revealed an increased risk of SIDS with overheating, the definition of overheating in these studies varied. Therefore, it is difficult to provide specific room temperature guidelines for avoiding overheating.”

Important Points:
• Dress your infant comfortably for his environment with no more than one more layer than you would wear.
• Signs of overheating include sweating or the chest being hot to the touch.
• Avoid over bundling and covering the face and head.

11. Do not use home cardiorespiratory monitors as a strategy for reducing the risk of SIDS
“Although cardiorespiratory monitors can be used at home to detect apnea, bradycardia, and, when pulse oximetry is used, decreases in oxyhemoglobin saturation, there is no evidence that use of such devices decreases the incidence of SIDS. They might be of value for selected infants but should not be used routinely.”

For more information, ask your doctor.

Resources and References
Full AAP report: SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment
http://pediatrics.aappublications.org/content/early/2011/10/12/peds.2011-2284.full.pdf+html
Consumer Product Safety Commission (crib safety):
http://www.cpsc.gov/info/cribs/index.html.

Poor Infant Sleep does not Increase Later Obesity Risk

By Jennifer Goldbronn, MAS, RD

With childhood obesity rates at epidemic levels in developed countries around the world, there is great interest in identifying successful interventions to decrease obesity risk. Recently, researchers have suggested a potential association between poor sleep and later obesity risk. Today we’ll discuss this potential association and present information from a new study examining the association between improved sleep in infancy and obesity risk at age 6 years.

In a previous post we wrote about a research article linking short sleep duration to increased risk of obesity. (Bell 2010) In this study, the association found was not specific to infants because the authors grouped together kids of all different ages.

Sleep and Obesity: Why the Link?

Despite all of the research about the relationship between sleep and obesity, there is no evidence showing a cause and effect relationship. Researchers have theories for the associations they’ve found, including: (1) if children are sleeping less, their bedtimes may be later allotting them more time to take additional calories in the evening or (2) children may be less physically active because of fatigue from shorter sleep duration. Unfortunately, at this time, these explanations are just speculation and while some studies have shown associations between BMI and chronic short sleep in older children, none have focused on how sleep in infancy may or may not affect later risk for obesity.

The Study

In a recent Australian study, providing education to parents of infants with parent-reported sleep “problems” at 7-8 months resulted in improved infant sleep organization but did not reduce obesity risk at age 6. (Wake et al. 2011) A Sleep “problem” was identified by asking 2 questions: (1) “Over the last 2 weeks, has your baby’s sleep generally been a problem for you? (yes/no)” and (2) if yes, the parent rated the severity of the problem on a 7-point scale with 1-2 mild and 5-7 severe.

The Study Intervention

Nurses were trained to provide a short sleep education to parents at the 8-month well-child check-up. Topics discussed included normal infant sleep patterns and sleep problems and potential causes. Nurses helped parents to identify possible solutions and created an individualized sleep management plan for each family. Mothers were asked to complete a 2-week sleep diary and to choose one of two sleep strategies: “controlled crying” or “camping out.” Mothers also attended 1-2 follow up sessions with the nurse where sleep patterns and improvements were identified and new goals were set.

The controlled crying strategy involved parents responding to their infants’ cries at increasing time intervals to allow the infant to learn to self-soothe. (see note below) Parents choosing the “camping out” strategy were instructed to initially stay with the infant while he or she fell asleep, slowly moving farther away over the following days, until the infant could fall asleep without the parent nearby.

Results of the Intervention

Parents in the intervention group reported fewer infant sleep “problems” at 10 months (56% vs. 68%) and 12 months (39% vs. 55%) compared to control groups. Intervention parents also reported fewer and shorter night-wakings than control parents. However, sleep duration was similar in both groups.

Although the sleep intervention did decrease parent-reported “sleep problems” and night wakings, there was no effect of the intervention on obesity at age 6. Both intervention and control groups’ BMI and waist circumference were similar. After the study was completed, the researchers looked back at the data to see if there was any association between childhood sleep duration and BMI. They found no association between sleep duration at 7, 10, 12 months or 6 years with obesity at age 6.

The Bottom Line:

According to recent data, your baby’s sleep patterns at night will likely not affect his risk of obesity in later childhood. We know (from experience) that some of you may be very tired right now and hoping for a solution to help your baby sleep better. Our best advice: know what to expect from your baby’s sleep patterns by reading our posts about how sleep patterns change with age and learn some ways to get yourself a little more rest.

Remember, you can’t change the rate at which your baby’s body matures and learns to sleep for longer stretches, but you can change how you react to it! Arm yourself with the knowledge and know that this too shall pass.

Note: We are not advocating letting your baby cry! We are simply reporting the methods used by the authors of the referenced study. Also, it is important to note that this intervention was carried out with older infants, ages 8-10 months; most infants this age have the ability to sleep a 6-8 hour stretch at night, but they may wake if they need something or to practice their new found motor skills.
While we do not advocate parents letting their babies cry for long periods, also known as the “cry it out” approach, parents of older babies can encourage them to learn self-soothing skills. For example, putting your baby to sleep in his crib drowsy, but awake may help him learn to soothe himself to sleep. However, keep in mind that, in a separate study, only about half of 12 month olds were able to self-soothe after awakening during the night. The other half needed their parents’ help to get back to sleep. (Burnham et al. 2002)

References
1. Bell J, Zimmerman F. Shortened Nighttime Sleep Duration in Early Life and Subsequent Childhood Obesity. Arch Pediatr Adolesc Med 2010; 164: 84-845.
2. Wake M, Price A, Clifford S, Ukoumunne OC, Hiscock H. Does an Intervention that improves infant sleep also improve overweight at age 6? Follow-up of a randomized trial. Arch Dis Child. 2011;96:526-532.
3. Burnham MM, Goodlin-Jones BL, Gaylor EE, Anders TF. Nighttime sleep-wake patterns and self-soothing from birth to one year of age: a longitudinal intervention study. J Child Psychol Psychiatry. 2002;43(6):713-25.