Sleep. We all need it. We all want it. Spinoff Parents scientist Dr Jess Berentson-Shaw explains the science behind infant sleep, and what works and what doesn’t.
Content warning: This post talks about Sudden Infant Death Syndrome, also known as Sudden Unexpected Death in Infancy.
When our first baby was about eight weeks old I awoke totally befuddled at around 3am, aware my partner and baby were not back from a much earlier removal from our room due to persistent screaming. I stumbled into the lounge to find that the gentle swinging of the Moses basket had turned into a near 360 degree rotation as the baby screamed and partner looked grim. Lets just say it was pretty painful for us all.
Later, when visiting friends with a newborn, I stepped into their bedroom to peek at the baby. I came out, looked at their ashen faces, and gently suggested ‘perhaps the white noise was a tad loud?’ as the giant speakers next to his basket blasted out static at a level likely to disrupt birds in flight.
Sleep deprivation partnered with a persistently crying baby can do terrible things to a person.
I spent a lot of time thinking if I could just ‘fix’ the baby she would sleep through the night. It took me about three years and another child to figure out I might have been thinking about it all wrong, probably because I did not understand the science of baby sleep. Even scientists can miss the point, when they’re sleep deprived. In fact most of our society thinks about it all wrong. They look at infant sleep as the problem, rather than considering how to better support parents.
Getting our expectations right for the first six months: what is normal?
I am going to discuss baby sleep from 0-six months old, as the first six months is a developmentally distinct time (another post will deal with sleep over six months). Sleep is different in babies over six months.
So here is the honest truth: in the first six months sleep is, for most babies, just not a thing their brains ‘get’. We can’t ‘fix’ that, but we can manage our lives to cope with the reality.
For most young babies their teeny weeny little collection of neurons do not understand sleep. They learn it, but only when they are developmentally ready, and most babies’ brains and bodies are not ready to sleep through in the first six months. Their circadian rhythm (telling night from day) is only built when that part of the brain has the neural connections to do so. They do more Rapid Eye Movement sleep (which plays a role in their brain development), and have shorter cycles, as they need to eat quite frequently. Their brains are also not developed to the point of being able fall back to sleep on their own when they wake.
The lived reality of this can be hell, but it is normal hell.
Like many behaviours, there is variation between babies, which comes down to a complex interplay of biology and environment. So getting a non sleeper and trying to make them a sleeper is going to be almost impossible.
In normal infants the average total sleeping time per 24 hours varied from nine to 19 hours at birth, and from 12 to 21 hours at two months, with wide daily variations in each baby’s total sleeping times.
Only 37% of healthy three-month-old infants regularly sleep eight hours at night without disturbing their parents.
So how many times a night do babies wake? As you can see from the table below, the average wakes in the first couple of months is 1.7 times and about one in the three to six-months period. But there is a wide range within that too, with some waking up to four times (does 5am count as night or day? This was an endless discussion in our house).
Sometimes you are that person to hit the jackpot with a baby who sleeps through, but most parents are not so lucky. My limited experience in the job of parenting tells me it is best to try and manage my children the way they are, not the way I wish they were.
Before anyone jumps in and says “oh but the babies that sleep through must be sleep trained” the science tells us otherwise.
‘Sleep training’ for babies zero to six months is best avoided
If we look at the best science (not all published studies or reports from happy parents can be relied upon, you can read why here), it is clear that sleep training does not work, and can in fact make life for parents, specifically mothers, worse. Sleep training refers here specifically to direct interventions with the baby that attempt to change its behaviour.
Sleep training includes strategies such as: don’t breastfeed your baby to sleep; don’t let the baby get overtired or overstimulated; put the baby down in the cot at the first tired sign; teach the baby to self-settle in the cot; make sure the baby is getting big blocks of sleep instead of catnapping during the day; and use feed-play-sleep cycles. These are also called ‘behavioural interventions’.
What the best research tells us is that behavioural interventions for sleep in the first six months have not been shown to:
- decrease infant crying,
- prevent sleep and behavioural problems in later childhood,or
- or protect against postnatal depression.
Another high quality review of studies says it is possible that in the short term a few minutes extra sleep might be gained (29 minutes), but crying will not be reduced. That needs to be balanced against the potential risks and unintended outcomes. An unintended outcome is when we think an intervention should work, but not only does it not work, but also it makes things worse. Risks may include: ceasing breastfeeding early, worsened maternal anxiety, increased problem crying and potentially even increased risk of Sudden Infant Death if the intervention requires the baby sleeps in a different room.
The big problem for me as a scientist is how parents have been let down with so much bad science. I will be honest here; the plethora of contradictory and often bad sleep advice, sometimes pushed by those with a financial interest, is a shit show for new parents.
The authors of both the systematic reviews I mention above highlighted just how much bias there is the published research on the issue of sleep training. There is too much reliance on historical notions of baby sleep.
But all is not lost. If we accept that babies don’t sleep all that much in the first six months, there are evidence-based actions we can do to make life easier.
Dealing with excessive crying
I have had a few conversations lately with new parents who say their babies wake a few times, but because they don’t cry a lot it is manageable. For me, it was often the excessive crying that really sent me over the edge. The research shows that sleep interventions often fail to consider why babies are crying excessively.
One of the causes of excessive crying in young babies, is feeding problems. Feeding problems in this context does not mean reflux problems like GORD (which is probably over diagnosed and over prescribed for), but rather things like “attachment and positioning, functional lactose overload, oral motor dysfunction, types of tongue tie (you can read more about the research and over diagnosis of tongue tie here), and sensory processing problems”.
Unfortunately, research has found that midwives, Plunket nurses, and GPs may be unaware they have knowledge deficits in this area. A good lactation consultant may know this stuff, and a good GP too, but it is hard for individual parents to know whether a clinician is up on the latest research. You can always just ask!
But this gap is a policy one, the suite of policies we have to research infant and new parenting issues, train skilled professionals, and provide the right kind of support to new parents is kind of weak. It is a policy failing that has a lot to do with who counts in policy development and why (hint it is not parents, especially not mothers).
What about maternal (and parental) wellbeing?
The other big issue that needs to be addressed before considering sleep training is parental mental health. It is just so much harder to deal with a waking baby, let alone a waking crying baby, if depression or anxiety is part of your pre- and postnatal experience. The Spinoff Parents has done an excellent job of highlighting the issue. You are not alone and there are very effective treatments out there and support groups.
Baby blues are normal in the short term. But a loss of enjoyment of life and of the things that used to make you happy is not OK. Thoughts about ending your life need to be talked about with a professional: your midwife, if you still have one, or your GP. If anyone dismisses these feelings and thoughts, you are talking to someone who is not good at their job, and you need to talk to someone else.
The painstaking art and science of supporting a woman and her baby
Interestingly, a new multidisciplinary approach has been developed in Australia by researchers frustrated with the poor science. Oddly for us in New Zealand, they call it the Possums Sleep Intervention.
The approach draws on the evidence of what works from adult sleep interventions: things like mindfulness and relaxation, healthy social activities for parents with baby in tow (i.e. going out and have that coffee, because it’s good for your mental wellbeing to socialise), the right exposure to light and daytime noises, addressing feeding or other problems (which have a massive impact on crying and sleep), cue-based care, ten hours of physical contact a day (does not need to be with the mother), babies sleeping in the same place night and day, and sleeping in the same room as a baby for the first six months. There is as yet no randomised controlled trial in this approach. A basic evaluation has been done, which looked positive, but this is not sufficient to say categorically it works.
However, as an alternative to the models that show no evidence of working and potential harm (for example, sleep training) it has promise.
Based on this, I would say that if you were struggling with a crying baby, and considering spending money on a ‘fix’ (and given we don’t have a programme in New Zealand based on the multidisciplinary research), then the following may help:
- Try not to worry if you baby does not sleep much in the day.
- Dedicate time to doing some things you enjoy (and bring the baby along if they are a cat napper).
- Ask someone to hold the baby for hours at a time when you are over it.
- See a lactation consultant (if you are breastfeeding & struggling).
- Breastfeed your baby to sleep if that is what works for your family.
- Sleep in the same room as the baby, or put the baby in a pepipod or wahakura in your bed if you want to bed share (I will talk about bedsharing soon).
- Help the baby develop their circadian rhythms (i.e. tell the difference between night and day) using light and noise cues.
- Spend a lovely hour or two crying in the office of a clinical psychologist who will affirm how hard it is, tell you that you are doing great, and check in to see whether you need some more mental health support.
It is about your well being as much as your baby’s in the early days and months.
Good grief it is hard. So very hard, when you are knee deep in a screaming baby and sleep deprivation and life has to go on and everyone else knows best. A lot of people believe they can sell you a miracle cure and that is not OK. There is no miracle fix – young babies learn to sleep in their own time: The science is clear on that. What there is, is realistic support, good research based advice for underlying issues, and love and support for you and your mental well being.
Kia kaha to those who are struggling in this space. It will pass – it just does not feel like it right now. In the meantime know there are people out there who care and there are safe non-judgemental informative spaces for you to be supported in your parenting. The Spinoff Parents is one of them.
This post has been edited to include a definition of sleep behaviours and links from a later draft.
Dr Jess Berentson-Shaw is a researcher and public communicator. She consults on effective evidence-based policy, and helps people and organisations engage the power of good storytelling to change minds. Follow Dr Jess on Facebook.
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