In the first of a regular column on infant care, Dr Pam Douglas dispels some myths about sleep.
“The nights aren’t too bad, but he wakes up the minute I put him down during the day. The only way he naps is if someone is holding him. … I can’t keep going like this!”
When a parent says this to me, I hear two things. Firstly, she wants to do the very best for her baby’s development and well-being, and secondly, she is exhausted.
It used to be that a good GP knew to respond to this by directing parents to the ‘sleep training’ or graduated extinction programs available from child and baby health clinics, private businesses in the community or online, and in residential parenting centres.
But in 2021, GPs caring for parents with baby sleep concerns face a stark problem: the research shows that sleep training doesn’t work for most families,1-4 and that sleep training increases parental anxiety.5-7 See below for a list of techniques that DON’T work.
Studies evaluating infant sleep training programs in the first year of life show that sleep training doesn’t reliably achieve the main outcome it claims to offer: decreased frequency of night-waking.1-4 In fact, sleep training advice to make sure baby achieves a certain amount of sleep, including for long blocks during the day (by quiet dim rooms, low stimulation, or, as this mother is doing, holding baby to keep him asleep) risks disruption to the circadian clock and may result in worsened night-waking in a few weeks’ time.
This gives rise to the question: are we seeing widespread excessive infant night waking induced by the dominant sleep training belief that large blocks of baby sleep during the day benefit both parent and baby? What is in fact the best, most evidence-based response we can offer this exhausted mother?
I have six suggestions which are likely to bring her relief.8-10
I suggest you say to her:
- Experimenting with the practical ideas I’m going to share with you now often dramatically improves a parent’s well-being, so try them out and see what you think.8-10 Helping you with your absolutely vital need for rest and self-care is a whole important topic that I’d like to discuss with you when we meet again soon, if you’d be willing.
- Baby sleep needs are incredibly biologically variable. It seems like your baby doesn’t need as much sleep as you’ve been thinking.11-15 You can only tell this by experimenting with a changed approach – by living as if you don’t have to worry about how much sleep your baby is having during the day, and finding other ways to meet your own need for rest. Then in a fortnight, look back and see if the days have been easier and more enjoyable for both of you, or not.
- I’d like to reassure you that low sleep need babies do not have poorer developmental outcomes compared with high sleep need babies.16-19
- Sleep is under the control of two sleep regulators, the circadian clock and rising sleep pressure (or the sleep-wake homeostat). We keep these regulators healthy in babies by enjoying active days outside the home without feeling you need to make baby sleep or keep baby asleep. When the sleep pressure is high enough, your baby will drop off to sleep wherever you are.
- Babies grizzle and cry (or ‘dial up’) when their neurological needs for rich and changing environmental (sensory-motor and social) enrichment aren’t met. The interior environments of our homes are low sensory no matter how many mobiles and toys we have. Babies often dial up inside the house for this reason, but you might have heard that you should interpret this dialling up as a ‘tired cue’ or ‘overtiredness’ and put him to sleep. Instead, experiment with creating a new adventure, stepping outside the house into a new environment whenever you possibly can. Rich sensory nourishment will dial him down while his sleep pressure gradually rises, until sleep comes easily. Create a rich social life outside the home, and take every opportunity for time on a deck or in the backyard, or walking the streets or parks, or even looking out an open window if that’s all that is available, to drench the baby in the complex environmental stimulation of the outdoor world.
- Place your baby down on his back somewhere safe near you when he falls asleep, in the midst of daylight, noise, and activities. If he wakes, he doesn’t need more sleep – even if he wakes grizzling or crying. If I nap during the day, I find that moment of waking quite disorienting and unpleasant – have you ever experienced that too? Babies wake up crying because of an immediate and biological need for the comforting sensory experience of their carer’s arms, not because they need to go back to sleep. As long as his biological needs for plenty of milk or food and rich sensory nourishment are met, he’ll take sleep when he needs it, for as long as he needs it, while you get on with having the most enjoyable, socially and physically active day outside the home that you can possibly create – for you.
‘Sleep training’ approaches that do NOT reliably decrease infant night-waking1-4
- ‘Sleep breeds sleep’
- Adhere to sleep and wake duration estimates
- Watch for ‘tired cues’ (as detailed in lists)
- Put baby down with first ‘tired cue’
- Demonstrate sleep architecture and cycles in diagrams
- Encourage second sleep cycles during day-time naps
- Teach self-settling
- Don’t allow baby to fall asleep in arms or at end of feeds
- Implement feed-play-sleep cycles (dissociate feeds from sleep)
- Practice bed-time routines (build ‘positive sleep associations’)
- Put baby in cot drowsy but awake (dissociate sleep from being held)
- Delay responses to cues, or respond to cues but not as baby intends, or ignore cues
- Avoid ‘overstimulation’
- Avoid ‘overtiredness’
- Place baby in quiet dim room for sleep during day (please note: this contradicts safe sleep guidelines for the first 6-12 months of life)
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 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 Maternal Newborn and Families Research Group MHIQ, Griffith University, and Senior Lecturer with the Primary Care Clinical Unit, University of Queensland.
She is author of The discontented little baby book: all you need to know about feeds, sleep and crying.
References
1. Kempler L, Sharpe L, Miller CB, Bartlett DJ. Do psychosocial sleep interventions improve infant sleep or maternal mood in the postnatal period? A systematic review and meta-analysis of randomised controlled trials. Sleep Medicine Reviews. 2016;29:15-22.
2. Douglas P, Hill PS. Behavioural sleep interventions in the first six months of life do not improve outcomes for mothers or infants: a systematic review. J Dev Behav Pediatr. 2013;34:497–507.
3. Bryanton J, Beck C, Montelpare W. Postnatal parental education for optimizing infant general health and parent-infant relationships. Cochrane Database Syst Rev. 2013(11):CD004068. DOI: 004010.001002/14651858.CD14004068.pub14651854.
4. NHMRC. Report on the evidence: promoting social and emotional development and wellbeing of infants in pregnancy and the first year of life. http://www.nhmrc.gov.au: Australian Government, 2017.
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