Is your Baby Sleeping Through the Night Yet? 

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I'm going to start charging anybody who asks the parents of one of my patients "is your baby sleeping through the night yet?  The answer to the question, while it seems polite enough, often leads to a judgment of how we're doing as a new parent.  We have enough judges. Plus, the answer is almost always "no" and physiologically, that's the right answer. Most children don't sleep through the night because they are built that way. 

The "let them cry it out, is the nursery ready, put that baby down you're spoiling him" culture can also undermine our parenting efforts.  Our culture encourages independence from a very young age and says that normal babies were never meant to be held all the time, and were meant to sleep all by themselves. 

Biologically, anthropologically, psychologically ...our newborns weren't meant to sleep alone.  They were born to be held.  Newborn infants are not supposed to be sleeping through the night.

Normal Sleep

Let's understand normal sleep.  Probably the two most important stages of sleep are stage 4 sleep and REM (rapid eye movement) sleep.

 In stage 4, you are completely unresponsive, with a disconnection between sensory information coming in and your ability to receive it.  You can't hear people taking to you, you don't know your bladder is full, you don't smell smoke, and you can't tell if tigers are around.   This is the prevalent sleep stage of the first part of the night, and the more tired you are, the longer you spend in stage 4 sleep.  You have a really hard time being awakened or awakening from stage 4 sleep. Kids with disorders of stage 4 sleep will have sleepwalking, sometimes bedwetting, or night terrors.

In REM sleep, you have a complete loss of muscle tone.  That's a good thing, since you dream in REM sleep, and if you acted out your dreams you could really hurt somebody or yourself.  REM sleep happens towards the last part of the night.  You can wake up easily from REM sleep.  Kids with disorders of REM sleep have nightmares.

The stages of sleep, and there are more than just stage 4 and REM, are things we go through each night, but we go through them in cycles.  Every 90 minutes of so we actually wake up, check out our surroundings and go back to sleep if everything feels safe.  Awakening about 5-8 times a night is normal.

So, as sleep has developed, one of the major issues surrounding it is safety. We could comfortably enter stage 4 sleep because other people were around us to keep us safe, and at least one person was probably in lighter stages of sleeping so that they could warn us if tigers were around.  That sense of connection is really important to us now even though we aren't really worried about predators.  We were designed to be social sleepers.

Normal babies

We spend so much time dreaming of what our children will be and very little time realizing what they are.

Let's say, for the sake of argument, that human evolution is like a football field.  Human beings as a genus start at the far end of the field, and we as a species show up at about the opposite 10 yard line.  At about the one inch line ( and that's generous) we as an industrial society show up.  Why am I rambling about this?  Because we have to understand that the way we do things is a new idea...but the babies we bring into this world don't know about the way we do things.  They are programmed to do things that human babies have been doing for thousands of years.

And human babies are really vulnerable.  If you've ever seen what baby elephants or horses can do at birth, you know that they can walk shortly after birth, and are running soon afterwards.  Why can't humans do that? Well, if we waited until the brain was mature enough for our kids to walk, the baby's head would be too big to come out safely. We don't need to run to stay safe.  Our gestation period is designed to make sure that our kids arrive in the world with their future intact-- our kids arrive in the world when it's safest for the brain to come out.

Our children arrive in the world as the most neurologically immature primate of them all, and remain the most dependent on a caregiver for the longest period of time.  Our kids can't keep themselves warm, get food, walk, speak, or reason.  They can't manipulate us and they can't consciously choose to make you look like a bad parent.

What do we know about their sleep patterns?  Well, they need to be near a caregiver-- mostly mom.  It makes sense if you think about it.  This immature baby, with little in the way of self-preservation skills, needs to hang out with the source of food and warmth, with the person who is most likely to wake up to meet the needs that they express in the middle of the night.  There are beautiful videos of moms and babies who are almost totally in sync in terms of sleep cycles, showing them waking at about the same time several times during the night, with mom responding to the baby and the baby, who rarely cries, getting their multiple needs met. There is also good evidence that shows that children sleeping near mom have less time in stage III and IV sleep. 

Normal babies sleep during the day and are up at night, at least for the first several (6-8) weeks.  That is normal and expected and nothing we can do to change that.  That means that parents need to sleep when the baby is sleeping to avoid all the great things that go along with sleep deprivation.  Older infants get up at night, but less often, and it is normal for one year olds to not be sleeping through the night.  Of course, if I did my job earlier, you now understand that nobody sleeps through the night.  Interesting tidbit: one study showed that about 80% of parents of one year olds identify their children as having "sleep problems."  Eighty percent?  Maybe we have an expectation for our children that is not based on human physiology and is therefore not realistic. Our current culture doesn't help us set realistic expectations for normal.

How 'bout this idea that we have to teach our kids to "soothe" themselves?  I would argue that a several month old child is still not able to feed themselves, find food, or do any other thing that it would take to live independently.  The process of self-soothing would seem to require more than the basic survival skills babies have. They are speaking up because they need something.  If they need something, even if it just to feel safe, why shouldn't we help them? Do we really need to teach a 2 month old independence?  Why should they do it by themselves?   Because we are taught that self-soothing is normal and important.  It is.  Not in this age group.

Sleeping Arrangements

The choice of where our children sleep affects (and there is research to show all of this): breastfeeding duration, feeding frequency, infant sleep position, arousal patterns, temperature, carbon dioxide levels, crying, heart rate, parental emotional expectations. 

Babies who have more skin to skin contact with their parents show better oxygen delivery, less frequent crying, higher temperatures, better weight gain, better digestion and less physiologic markers of infant stress.  (It's why kids who are held more have less colic.) So, based on that, it makes sense that more contact with mom and dad makes for a more physiologically sound child.

Sleeping Alone

This is what we are supposed to do.  Kids should learn to sleep by themselves to become more independent, less dependant on mom and dad, able to handle situations better when confrontation happens in the future.  In general, kids who sleep by themselves are better humans. Right?  Does that even make sense?

Interestingly, and really tragically, we (and now I mean me as a doc) said over and over again that sleeping alone was where kids needed to be.  And we as parents did that.  We put our kids on their stomach.  They were sleeping alone, getting really deep levels of sleep that they were never built to handle, got high levels of carbon dioxide around them, and some died. 

The great majority of deaths of infants occurred while they were sleeping alone.  We never asked "is it safe for children to sleep alone?"  We got our answer-- it's safe if they are on their back, on a hard mattress, without any environmental smoke exposure, and if there are no other soft fluffy things in the crib.  We learned that answer the hard way: 92% of the infant deaths in a the 1999 Consumer Product and Safety Commission data base occurred while infants slept alone outside of adult supervision.

Studies recently published show that kids who were never in their parents bed tend to be harder to control, more fearful than children who were permitted to bedshare, more dependent on their parents, and dealt less well with stress.  I am not advocating for all children to bedshare nor would I.  We always need to look at the risks and benefits- and the result will be different for every family.

Co- sleeping

Co-sleeping needs to be defined.  It means being close to your baby as they sleep. I say this because we often associate co-sleeping with sleeping with a baby in bed.  And when we say "never put a baby in bed with you" many will chose an alternative such as a couch or recliner which is often more dangerous. If you do choose to co-sleep, there are safe ways to do it, and some groups that should reconsider that decision. Again, we need to weigh the benefits and risks.  If you choose to co-sleep, we should do it safely.

Safely co-sleeping: (these are going to look a lot like the recommendations for SIDS prevention)

I think these recommendations are interesting.  If you were sleeping on a hard mattress, without a pillow or blankets, near someone, you might not get very deep levels of sleep.  The SIDS prevention recommendations (which include keeping the baby in the parents' room and not alone in a different room) are the same- the interventions are to prevent deep sleep.  If we don't want deep sleep, what are we trying to do?  We are trying to keep the baby arousable.  The baby needs to be able to respond to changing environmental conditions. We are avoiding deep sleep.

How come my friend's baby sleeps through the night?

I don't know.  I don't even know what that means. When I ask about what that means, I get a great variety of answers.  Some people think 6 hours of sleep at night is "through the night" other people want to sleep like they did before they had kids.

I would guess that many of the kids aren't sleeping through the night (some do, and that may be just fine), but that the implications of admitting that your kid isn't sleeping are too hard to admit.  We equate "good sleepers" with good kids, and "bad sleepers" with bad kids.  Our culture allows us to derive moral implications from normal baby behaviors. And of course, parents of good sleepers are good parents.  We would all benefit from trying to eliminate these perceptions.  I don't think they help anyone.

Plus, feeding choice plays a role here.  Formula fed kids sleep differently than breastfed kids.  Formula fed kids sleep for longer stretches of time and therefore have less contact with their parents at night.  Formula fed children are much more likely to be sleeping alone. 

The sleep training techniques that have been sold in the US have never been shown to be associated with anything good for infants but they have been associated with risks, like more anxious children and behavior disturbances in the long term. There is no emotional, social or intellectual benefit to the kids, nor has it ever been shown to help us develop into healthy adult sleepers.  They might help the family sleep in the short term.  We need to balance the short term with the long term.  I know that's very hard to do when you are sleep-deprived.

We have to decide what we want from our kids sleeping through the night. Do we want to seen as good parents?  If you think that you are, why ask for external validation? Embrace it and enjoy your family.  Do we, as parents, want to sleep? Of course we do. Then, to sleep well, we need to be comfortable with the choices we make to help our child sleep. If you try sleep training and it doesn't feel right, then don't do it. Other families may have different experiences and feel comfortable with that choice. Great, as long as we are doing sleep training knowing that the SIDS prevention guidelines want the children nearby and not alone.

We need to have a realistic expectations of normal sleep behavior of little children.  And we really need to reset our cultural expectations of that sleep behavior. If the answer to "is your baby sleeping through the night" is "no" maybe the response could be an offer of support to the tired parents.

Normal newborns and breastfeeding

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Jenny Thomas, MD, MPH, IBCLC, FAAP, FABM