“She goes down quickly with a breastfeed at 7pm, but from midnight she is awake every hour or more. Often it takes up to an hour to get her back to sleep … I can’t keep going like this!”
This baby is waking excessively at night. The difference between developmentally normal and excessive night waking is discussed in a previous article, Hey, baby! Why are you awake so much of the night? A pattern of waking about every two hours at night but with everyone returning back to sleep quickly after a breastfeed (or bottle-feed) is developmentally normal in the first year of life,1-5 and typically doesn’t result in less parental sleep overall.6, 7
In this case, you’ve taken the family’s sleep history, excluding other causes of disrupted nights. The baby’s circadian clock is not well aligned with her parents’ circadian clocks, and you’ve offered evidence-based parent education, including about:
- Infants’ highly biologically variable sleep needs;
- The importance of rich environmental experience (referred to here as “sensory nourishment”) during the day, to keep baby dialled down and to optimise development;
- The two biological sleep regulators, the circadian clock and the sleep-wake homeostat, which controls sleep pressure;
- The one or two weeks it takes to reset disrupted baby sleep patterns.
Now, you are ready to create a management plan together. This approach is known as the Possums Baby and Toddler Sleep Program (adapted in the UK as Sleep Baby and You),8 9 with four evaluations showing positive results to date.10-13 Here are some words you might use to help parents reset their baby’s circadian clock.
Regular get-up time
- “Although you might have heard that a regular bedtime is necessary for your baby’s healthy sleep, that’s not actually what the sleep science tells us. The circadian clock is set by a regular get-up time. I wonder if you could tell me what you think the earliest manageable get-up time might be for your family?”
- “Is there any chance that the parent waking up for feeds in the night could have a little sleep-in, while another loving adult starts the day with the baby – usually after the baby has had a wake-up feed? Is that something that could work in your context?”
- “Some families are night owls, and don’t mind if their baby goes down very late at night, as long as they don’t have to get up before 7.30am or 8am or later! Other families are happy to start the day at 5am but prefer earlier bedtimes at night. You can set your baby’s circadian clock to suit your family.”
- “Remember that it takes one or two weeks to reset disrupted sleep patterns. If baby is starting the day at 7am and you would like her to start the day at 6am, you would get her up a little bit earlier each day over the next week or two, until you’ve reached 6am.”
Day-time naps are under the control of sleep pressure
Day-time naps are discussed in a previous article, Hey, baby! Why can’t I put you down for day-time naps? In summary, the days are easiest if the primary carer offers the baby rich and changing sensory nourishment by being outside the home as much as possible, because the interior of our homes are low in sensory opportunities.
The carer can trust that, in the context of diverse environmental experiences and plenty of milk (if under six months), the baby will take the sleep she needs. You’ve reminded the primary carer that it is important not to focus on trying to get baby to sleep or trying to keep the baby asleep during the day, but to create an enjoyable day outside the house, expecting baby to fit in. There is no reason to worry about concepts such as overstimulation or overtiredness, which are not evidence based.
Offer milk frequently and flexibly
Milk (if under six months, and if breastfed over six months) is best offered frequently and flexibly during the day and evening, in response to the baby’s communications or cues. Formula-feeding parents are advised to use the approach known as paced bottle-feeding. It is biologically normal for babies to go to sleep with breastfeeds (or bottle-feeds), and this does not create bad habits.
- “You might have heard that breastfeeding your baby to sleep sets up bad sleep habits, and that your baby is waking frequently because she is looking for the breast. Actually, your baby isn’t waking excessively because of the breastfeeding, but because she has a disrupted circadian clock.”
- “It’s true your baby has learnt that when she does wake up, the breast is the loveliest way to go back to sleep again – but that’s not a bad habit, that’s a gift you’ve given her! When you want this to change, you’ll teach her something new in the night. But in the meantime, breastfeeding back to sleep (or using the bottle) is the easiest way to make a baby’s normal night-waking manageable for you as parents.”
Evening bedtime is under the control of sleep pressure
- “Although you might have heard that you should have your baby down to sleep early at night, even 6pm or 7pm, if we look internationally, we see that babies are going to sleep much closer to the parents’ bedtime in other countries. If a baby who has a lower sleep need goes down at 7pm, that little one might start rousing very frequently from 1 or 2am because her sleep pressure is no longer very high and her metabolism is ready to start the day.”
- “I’d like to suggest you start to nudge baby’s bedtime back later by 10 or 15 minutes each night over the coming fortnight. You are waiting for the baby’s sleep pressure to climb really high before you try for bedtime. This means engaging the baby with rich sensory nourishment to keep her dialled down – a long playful bath with a parent, a walk in the night air, lots of vigorous play and interaction! Of course, this approach is never meant to be unkind to babies. You know your baby best and you will know when your little one absolutely needs a breastfeed (or bottle-feed or for some babies a quick rock) off to sleep! Watch your baby and experiment with bedtime when you think the sleep pressure is high. When it is high enough, the baby falls asleep easily.”
- “As an adult, I might come home at 7pm in the evening, feeling tired and cranky. My sleep pressure is getting to be quite high. It has been gradually rising since I got up that morning. But I don’t immediately lie down even though I feel as though I could drop off to sleep at 7pm, because that would seriously disrupt my circadian clock and I’d be waking to start the day at 2 or 3am! I wait another couple of hours until my sleep pressure is really very high, and then I lie down and go to sleep. Similarly, with your baby, you’ll know as a parent that her sleep pressure is rising, that she is becoming more fragile and you are having to work harder with sensory nourishment to keep her dialled down. But you don’t need to put baby down straight away even when you know the sleep pressure is getting higher – you continue to focus on sensory nourishment until you think her sleep pressure is so high that it’s time to experiment with a feed to sleep. Sometimes, she has already fallen asleep in your arms!”
The four great nocturnal disruptors
“Believe it or not, we don’t have to burp babies. Babies don’t swallow large amounts of air, even if there are breastfeeding problems, and will relieve themselves of any stomach gas (sometimes very loudly!) in whatever position they are in. Most human cultures don’t burp their babies. The problem is that burping a baby can be disruptive, causing them to rouse when they would otherwise have drowsed easily into sleep.”
- Holding upright
“Believe it or not, there’s no reason to hold babies upright after feeds. You might have heard you have to do this to protect the baby from gut discomfort or pain, or to make them more settled, but actually any reflux that comes up is close to pH neutral, not acidic. Holding your baby upright after a feed rouses the baby and is disruptive in the night.”
- Nappy change
“There’s no need to change baby’s nappy in the night, once she is no longer a newborn, unless there is stool or a significant nappy rash. Just use plenty of barrier cream!”
“Some parents do like to wrap their baby, and you’ll make your own decision about this. But research exploring the effects of swaddling on baby sleep and arousal in the night does not show clear benefit.14 Since babies shouldn’t be wrapped during breastfeeding, the act of wrapping after a feed in the night may rouse the baby and unnecessarily disrupt everyone’s sleep.”
As you draw the consultation to a close, invite the parents to ask questions. Check that they are comfortable with trying out these new strategies. Offer them a link to back-up resources. Then you might conclude with these words:
“We want sleep to be as easy and as no-fuss as possible, so that the nights are manageable for your family and the days as enjoyable as possible. That’s best for you, and also best for your baby’s development. I know this approach seems really different. All you can do is experiment with these strategies for a couple of weeks and see what you think!”
Dr Pamela Douglas is a GP and Medical Director of Possums & Co. www.possumsonline.com, a charity which educates health professionals in the evidence-based Neuroprotective Developmental Care (NDC) or Possums programs, including the Possums Baby and Toddler Sleep Program. If you wish, you can refer to or upskill to become an NDC-accredited practitioner. There are lots of free videos and other resources for parents with babies here, and online parent peer support is available for a nominal fee. Pam is an Associate Professor Adjunct with the School of Nursing and Midwifery, Griffith University; and Senior Lecturer with the Primary Care Clinical Unit, The University of Queensland. She is author of The discontented little baby book: all you need to know about feeds, sleep and crying.
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- Paavonen JE, Saarenpaa-Heikkila O, Morales-Munoz I, Virta M, Hakala N, Polkki P, et al. Normal sleep development in infants: findings from two large birth cohorts. Sleep Medicine. 2020;69:145-154.
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- Ball H, Taylor CE, Thomas V, Douglas PS, Sleep Baby and You Working Group. Development and evaluation of ‘Sleep, Baby & You’ – an approach to supporting parental well-being and responsive infant caregiving. Plos One. 2020;15(8): e0237240.
- Whittingham K, Palmer C, Douglas PS, Creedy DK, Sheffield J. Evaluating the ‘Possums’ health professional training in parent-infant sleep. Infant Mental Health Journal. 2020:doi:10.1002/imhj.21885.
- Ozturk M, Boran P, Ersu R, Peker Y. Possums-based parental education for infant sleep: cued care resulting in sustained breastfeeding. European Journal of Pediatrics. 2021:DOI: 10.1007/s00431-00021-03942-00432.
- Nelson AM. Risks and benefits of swaddling healthy infants: an integrative review. MCN American Journal of Maternal Child Nursing. 2017;42(4):216-225.