Let me introduce myself. I’m Julia Fensom, a baby-friendly accredited midwife, a previous SCBU (special care baby unit) nurse, mother of four, aged four and under (the youngest is currently 2 years old), a karate teacher and now author of the book; “With sleep, I can do anything. The first year – A manual”.
It was suggested to me that I should write a parenting book by various friends and colleagues because of the amount of ‘stuff’ that I have going on and the fact that I manage to fit it all in whilst still appearing to be a sane and rational person. However, what started as a joke turned into a serious thought as I started to realise that it could be a lot of fun to write a book with tips, tricks and advice, so that’s what I did.
As part of the research for my book I decided to try and join as many parenting and ‘mum’ forums as I could so I could look at my target audience and see what their main issues were, and the one that is at the top of every list, was sleep! Which was helpful as it’s what I know most about. Unfortunately, a rather unsettling pattern started to present itself. It appears that very few healthcare givers and as a result, parents, know anything about infant sleep. It seems to be considered ‘normal’ for young babies to sleep badly throughout the day and then wake frequently at night. There are of course those who embrace this, but for those who need their sleep, their ability to function starts to unravel and normally by the time they hit seven months after giving birth, they are at their wits’ end!
This is what I want to change. I am on a journey to educate as many people as I can, both healthcare professionals and parents, about the importance of infant sleep, and I believe that as a profession, both midwives and health visitors especially should be taught about sleep during their training so we can offer true, informative advice.
Let me start with a scenario:
Bessie is five months old. She is exclusively breastfed and she feeds every two hours. She falls asleep in her mother’s arms only to wake after 35-45 minutes during the day. By evening she is inconsolable and after a lot of ‘cluster feeding’ she eventually falls asleep. Once asleep, however, she wakes frequently and is fed back to sleep and wakes at around 5 am. Both Mum and Bessie are now exhausted, but every time Mum asks anyone for help, she gets patted on the back and told “It’s normal”, or “Enjoy it whilst you can, it won’t last forever!” Not particularly helpful to a sleep-deprived mum.
I’m sure this scenario is readily recognisable for many of you and you very well may think, well yes, that is normal! But in truth, it is only ‘normal’ in so far that it is common. This is not actually how a baby should sleep, and bad sleep can cause problems for everyone, whatever their stage in life.
How does poor sleep affect us?
Matthew Walker, the scientist and author of “Why we sleep” explains how just one night of poor sleep can affect adult brains in the following ways:
✖️Memory is impaired.
✖️There is an increased production of the toxin protein beta amyloid, which is then not eliminated during deep sleep.
✖️Reproductive systems are affected – men have lower testosterone.
✖️Immune systems are dramatically affected – after just one night of 4-5 hours of sleep you have a 70% reduction of immune cells. After just ONE night!
✖️Cardiovascular systems are impaired – it is during deep sleep that your heart rate and blood pressure go down and your whole cardiovascular system is rebooted. The risk of heart attacks and strokes rises by up to twice as much.
✖️Declines in brain function and body impairments after 16 hours of wakefulness. That’s a “normal” day if you wake at 7am and go to bed at 11pm. After 19 or 20 hours awake, you would be at the same level of impairment as someone who was legally drunk behind the wheel of a car. We then need about eight hours of sleep, after 16 hours of wakefulness, to repair this damage.
“Wakefulness is, essentially, low-level brain damage” according to Matthew Walker.
This is what happens to an adult brain, and yet imagine what it does to a developing brain that is having to digest, absorb and learn EVERYTHING from scratch!
In order to understand the above scenario and why it shouldn’t be ‘normal’, I would like to address the concept of awake times, sleep cycles and then sleep associations which culminate in this very common scenario.
Awake Times And Sleep Windows
The term awake time refers to the amount of time that a baby can stay awake without getting overtired. Awake times can change quite rapidly and are often the cause of what are known as ‘sleep regressions’ which is when the baby’s sleep pattern suddenly deteriorates. This is normally because parents haven’t adjusted their babies’ awake times to their new age of development.
A newborn should sleep between 16-20 hours a day on average. So that means they have a maximum awake time of two hours before showing signs of overtiredness.
The time when newborns are next ready to go to sleep is known as their sleep window. If they miss it, they then go into overtired mode. A baby that has had the appropriate amount of awake time and is in their sleep window should settle to sleep very easily. Even from newborn.
A mistake that is very commonly made with newborns is the following: they feed, they play for a little bit, they make cute gurgling noises that make everyone turn warm and fuzzy. Then suddenly, they start fussing, crying and complaining. If you were to look at your watch at this time you would see that baby has been awake for at least an hour and is in their sleep window so should just be put down to sleep. Simple! But since their only method of communication is to cry, they cry!
But what often happens now is that instead of being put down to sleep they are then fed again! And no surprise, baby falls asleep at the breast. Not only have they not had a very substantial feed, they are starting to develop a feed-to-sleep association.
But let’s say, they haven’t been fed at this point but they are picked up and rocked and cradled and shushed to sleep, so they eventually fall asleep in someone’s arms. Similarly, they will now be developing a rocking-to-sleep association. Both of these may not cause much issue before four months but as they get older, this parent-infant sleep dependence becomes problematic.
Once you have figured out what your baby’s tired cues are, you can navigate their sleep much more easily. As a general rule, after being fed, (changed and burped, etc) they tend to play and it’s when they go from having been happy to suddenly crying or fussing that they are then showing you that they are tired and need to be put down for a nap. As they get older, the amount of time before this happens will increase, but as you are being led by your baby (and not a clock) then you should be able to avoid the sleep regressions as your baby will tell you when they want to sleep.
Sleep cycles are exactly as they sound. They are the way that our brain works through the different stages of sleep, from non-rapid eye-movement (NREM) to rapid eye-movement (REM) and back. In infants, their sleep cycles last approximately 35-45 minutes in the day and up to two hours at night. This doesn’t cause too much of an issue in newborns as up until the age of four months, once asleep, they can move from one sleep cycle to another without fully waking up. However, once they hit four months, the fun begins. They start to wake fully in between sleep cycles. This isn’t a problem if you have a self-settler as they can send themselves back off to sleep, but if you have developed a feed/rock-to-sleep association, then your baby will require you to send them back off to the land of nod every time they wake! Many think that they are waking out of hunger when in fact it is their dependence on their parents to help them back to sleep.
Unfortunately, it seems to be so embedded in our society that to even suggest that a baby should be able to sleep well is controversial! And the phrase ‘sleep training’ incites anger in militant mums everywhere as it leads to visions of babies being left in rooms to scream by themselves. This is not the case. Teaching your baby to be able to sleep shouldn’t be considered a negative thing. There are many methods, some faster than others, that help your baby to learn to settle by themselves and that do not harm the baby in any way. If anything, helping a baby develop a healthy sleep pattern from early on can only benefit both babies and their parents.
The Stress hormone
There was a very interesting article refer recently that stated that even in the traditional “Cry it out” method, the levels of the stress hormone ‘cortisol’, were in fact not any higher than when they experienced anything else new, such as a bath, or an immunisation. And no one is going to stop bathing their baby for fear of causing them stress. What happens is that after a few baths, they learn from their initial stress response that it is no longer to be feared and turn it into a positive response. They haven’t just “given up crying.’
There is also quite a lot of evidence to suggest that a child has a higher level of sustained cortisol when starting daycare than after a few nights of ‘sleep training’. And this study was referring to the very traditional “cry it out” method, which is the most controversial sleep training method. REFER
Ironically, it is the self-same stress hormone that starts to circulate through your baby’s system when they are overtired, which means that they are even less able to sleep well. So, by trying to avoid ‘stressing your baby’ by sleep training them for a few nights, you inadvertently create a situation in which they have a higher level of cortisol running through their system on a daily and long term basis.
Back to the scenario
So, now we know a little bit more about sleep and what the baby needs and when, let’s go back to our scenario so we can see what is going on.
As we’ve seen, Bessie has been fed to sleep since birth, so now she is dependent on milk in order to fall asleep.
Because of this, when she naturally wakes after 45 minutes during the day she is unable to get herself back to sleep so has frequent, poor naps where she doesn’t sleep long enough for her brain to go through all the required stages of sleep. As a result, she becomes overtired and starts to get very irritable by evening. In order to calm her down, she is “cluster fed” as her mum assumes she is hungry when she is actually very overtired by this point.
Because she is overtired, she is hard to settle and even when she does eventually fall asleep, she has cortisol running through her system, meaning that her sleep is poor and she wakes early. (Imagine you have an important meeting the next day that you’re stressed about. You might sleep, but you won’t sleep well and you won’t sleep long. It’s the same for babies). Again, because of her sleep associations when she wakes in the night after each sleep cycle, she requires milk in order to fall back asleep, so the cycle continues.
How does feeding fit into this?
Before we look at healthy newborns, let’s look at previously compromised infants. A newborn that leaves SCBU is encouraged to feed roughly 4 hourly (also known as on demand) on discharge and even healthy term babies that develop issues such as low blood sugars or jaundice are told to feed 3 hourly, implying that healthy babies should be able to last longer. It is only because parents (and a lot of healthcare professionals) mistake sleep cues for hunger cues that they think that feeding every two hours is normal. But we have to start looking at both feeding and sleeping together and stop thinking that one can work well without the other.
If we say that a newborn has an awake time of one hour, then it stands to reason that they should eat, stay awake for an hour (inc feed time), and then sleep for 3 (give or take). And as their awake times lengthen, their nap times shorten but their feed times stay roughly at the same intervals. It’s not responsive feeding if you don’t know what you’re responding to or you’re responding to the wrong thing. Milk shouldn’t be the immediate response whenever a baby cries. It is very important to be able to recognise baby’s hungry cues AND tired cues and not get one confused with the other otherwise you end up in a scenario similar to the one above. A baby that sleeps well, will naturally eat 3-4 hourly.
It is essential to understand all the aspects of infant care in order to give appropriate advice and we as midwives and health care professionals are falling short in this area of sleep education. It’s the parents and the babies in our care that are suffering.
This has got to change.
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