By Linda J. Smith, MPH, IBCLC, LCCE, FACCE

In recent days, there has been much press and discussion about a new book written by pediatricians that professes to help parents 'train' their new baby to sleep through the night. The scathing criticism of the book by both parents and professionals alike are consistent with what we know about the needs of a newborn baby and their sleep and feeding patterns. Today on Science & Sensibility, Linda Smith, MPH, IBCLC, LCCE, FACCE shares accurate, evidence based information that childbirth educators and other professionals can use to talk to new families about newborns and their sleep and feeding patterns. Linda is one of the authors of La Leche League International's newest book; Sweet Sleep: Nighttime and Naptime Strategies for the Breastfeeding Family.

This book written by Smith along with co-authors Diane Wiessinger, Teresa Pitman and Diana West provides families with information to help the entire family get more sleep and do so safely, while meeting the nutritional and developmental needs of newborns. Preparing families for life with a newborn is one of the challenges we face as educators. The information Linda provides here along with the resources included in this post can help you to be sure that your information is backed by research and appropriate for your new families. - Sharon Muza, Community Manager, Science & Sensibility

How do I address sleep with my childbirth class participants?

New parents are instantly thrust into the reality of life with a baby. As Dr. Helen Ball writes, 'Sleep (or the lack of it) looms large for parents-in-waiting - and it is pointless to pretend that your sleep will not be disrupted by your new bundle of joy. His body clock, which until recently was controlled by your own, is now free-running, and a day-night pattern does not start to emerge until he is around three months old. His stomach is tiny, and he will need frequent feeds all around the clock - he cannot wait eight hours through the night to be fed just because you need to sleep. If you don't feed him, he will cry. If he's cold, he will cry. If he hurts, he will cry. If he misses being in close contact with you, he will cry. He doesn't know that you will come back once you leave his sight. If he feels abandoned, he will cry frantically - it's his only method to attract attention and bring himself to safety. If he cries frantically, it will take a long time for him to calm down and you will have to help him.'

'The experience of sleep, and of being left alone for sleep, is very different for babies than it is for adults. The more quickly you can understand your baby's needs - for comfort, food, reassurance, contact, love - the less disruptive nighttime baby care will become, and the less anxious you will feel. Some of the decisions you make early on about nighttime baby care will affect how you manage sleep disruption and cope with your new baby.' Dr. Helen Ball

What is normal sleep?

• Pregnant women do not sleep in long unbroken stretches, i.e., 'all night.' Neither do postpartum mothers - not for many months, regardless of how they feed their babies.1 Breastfeeding mothers get more sleep than formula-feeding mothers; breastfeeding mothers who bedshare get the most sleep of all new mothers.2,3

• Before birth, babies sleep rather randomly, not necessarily closely synchronized to their mothers' body clock. After birth, babies sleep in short (1 to 1½ hour) cycles and need to be fed approximately hourly because of their very small stomachs.4 They do not even begin to develop day-night sleep patterns for several months, regardless of how they are fed.5

• Frequent feeding day and night is normal, essential for the baby, yet is often called 'inconvenient' for parents. Let's face it - all babies are 'inconvenient.' Most of us didn't get pregnant just to make our lives less complicated. Babies need to be touched - a LOT, day and night, and skin-to-skin.6 Touch is nearly as important to babies' overall development as food.7Breastfeeding is an easy way to assure plenty of touch; so is safe bedsharing.8 Most breastfeeding mothers nurse their babies to sleep and sleep with their babies at least part of the night.9

Safety issues

• SIDS (Sudden Infant Death Syndrome) and suffocation are two distinct and rare risks to infants in the early months. SIDS is a diagnosis of exclusion: there's no obvious reason for a baby's death. Risk factors for SIDS are well- documented, so avoiding these can help parents reduce the already-small risk: (1) smoking;10 baby sleeping prone;11 formula feeding;12 and baby sleeping unattended.13 (details below)

• Suffocation is a more easily-preventable risk to babies than SIDS. The main risks for suffocation (entrapment) are putting the baby to sleep on a sofa with or without an adult,14and/or a drunk/drugged adult sleeping with a baby on any surface.15 'Never bedshare' warnings don't tell tired parents/mothers where they CAN safely feed their babies at night. A new infographic by La Leche League, 'Safe Sleep Seven: Smart Steps to Safer Bedsharing,' lists seven steps that vastly reduce the major SIDS and smothering risks.

• Prenatal smoking is very bad for babies and increases risk of SIDS at least five-fold. Smoking is a significant hazard to babies if the mother smokes during pregnancy, and smoking in the household (and everywhere) continues to be a risk to the baby after the baby is born. Smokers exhale carbon monoxide for many hours after each cigarette,16 and secondhand smoke is harmful to babies.17 Smoking is a well-known risk to adults, too.

• Every health authority in the world recommends exclusive breastfeeding for the first six months starting in the first hours after giving birth, then continued breastfeeding while adding family foods till the child is at least two years old.18 Formula-fed babies are less arousable from sleep than breastfed babies;19 have more than double the risk of (SIDS);12 and have many other health problems.20 If families need help with breastfeeding, contact WomensHealth.gov or La Leche League International or the federal government Women, Infants and Children program (WIC).

• Unattended babies (sleeping out of sight and sound of a competent adult) are at higher risk of SIDS and entrapment/smothering accidents. People are better monitors than electronic devices. Babies should always sleep face-up, in a safe container, and within sight and sound of a competent adult for all sleeps, naps and nights - unless they are safely tied on someone's body or safely in someone's arms or sleeping next to their sober, nonsmoking, breastfeeding mother on a safe surface. Baby should be lightly clothed (not overheated. One study reported swaddling as an independent risk factor for SIDS. 21).

• Recommend that parents baby-proof the family bed, even if they think they won't ever bedshare. Sleep happens, and exhaustion overrules common sense. No thick covers, no toys, no pets, firm clean flat mattress. Most breastfeeding mothers sleep with their babies at least part of the night, and breastfeeding mothers have the lowest rates of SIDS and other sleep-related accidents.12 Accidental bedsharing is riskier than planned bedsharing.22 A side-car attached to the bed can be a good option - baby is close enough for touching and feeding, yet separate enough to avoid rollovers and exhaled breath of smokers. A safe crib for the baby in the bedroom is safer than baby sleeping unattended in another room.

• Adults should never lie down with a baby on a sofa or in a recliner, even 'just for a minute' - the threat of suffocation, entrapment or dropping the baby is high especially when (not if) the adults falls asleep.23 If a sofa or recliner is the only option for sleep, the adult can lean back and tie the baby securely onto their chest with a scarf, shawl or soft carrier so their arms aren't holding the baby when the adult dozes off.

• Wearing a baby many hours a day in a soft-tie-on carrier or sling is a great way for everyone to nap, and helps baby's motor development besides. Baby's face should be fully visible and her head should be close enough to kiss. This babywearing guide has information on how to safely wear an infant.

The 4 big questions

1. When will the baby sleep through (longer) the night?

Probably not for many months. Welcome to parenthood! (Sorry, biology rules!)

Babies are growing faster in the early months than they ever will, and need food and comfort very often for normal physical, emotional, and psychological development. A famous scientist described the first 9 months of a baby's 'outside' life as the period of external gestation.24 The best way to get enough sleep is for parents to plan to safely bedshare with their breastfed baby, and take naps with the baby. (see the Safe Sleep Seven and Sweet Sleep 25 for more information.)

Beware of 'sleep training' programs, books and advice, which have a long sad history.26 New strong evidence of baby's biological and emotional needs suggests that babies remain highly stressed even when the parents think sleep training 'worked,' with serious long-term negative consequences for the baby. Babies cry because they need to be touched held, fed, rocked, and nurtured, and simply cannot meet their own needs for any of those comforts.

2. When will the mom sleep like she did before she got pregnant?

The research definition of 'sleeping through the night' range is inconsistent and arbitrary.27 Parents can make up any definition they want when quizzed about the baby 'sleeping through.' A useful (and vague) response: 'Of course the baby is a good sleeper.'

3. Will parents ever have sex again?

Beds aren't the only places where sex can happen.

4. Will parents ever get the baby out of their bed?

Babies who bedshare get their emotional needs met sooner and more fully than those who sleep separately.28 All babies are inconvenient for a while.

Where can parents get more information?

• La Leche League International's Sweet Sleep: Nighttime and Naptime Strategies for the Breastfeeding Family.
• Dr. Kathy Kendall-Tackett http://www.uppitysciencechick.com/sleep.html
• Dr. Helen Ball
• Dr. James McKenna
• Academy of Breastfeeding Medicine Protocol # 6

What do you talk about with families in order to prepare them for parenting a newborn? How do you find the balance between providing accurate information and not 'frightening' them with the realities of newborn sleep patterns. Have you read this new book? Would you recommend this book to families who are desiring more information about how to provide a safe sleep environment for their breastfeeding newborn? - SM

References

1. Montgomery-Downs HE, Stremler R, Insan SP. Postpartum Sleep in New Mothers and Fathers.Open Sleep Journal. 2013;6(Suppl 1: M11):87-97.
2. Doan T, Gay CL, Kennedy HP, Newman J, Lee KA. Nighttime Breastfeeding Behavior Is Associated with More Nocturnal Sleep among First-Time Mothers at One Month Postpartum. J Clin Sleep Med. 2014;10(3):313-319.
3. Doan T, Gardiner A, Gay CL, Lee KA. Breast-feeding Increases Sleep Duration of New Parents.J Perinat Neonatal Nurs. Jul-Sep 2007;21(3):200-206.
4. Bergman NJ. Neonatal stomach volume and physiology suggest feeding at 1-h intervals. Acta Paediatr. May 10 2013.
5. Rivkees SA. Emergence and influences of circadian rhythmicity in infants. Clin Perinatol. Jun 2004;31(2):217-228, v-vi.
6. Feldman R, Rosenthal Z, Eidelman AI. Maternal-Preterm Skin-to-Skin Contact Enhances Child Physiologic Organization and Cognitive Control Across the First 10 Years of Life. Biol Psychiatry.Jan 1 2014;75(1):56-64.
7. Feldman R, Singer M, Zagoory O. Touch attenuates infants - physiological reactivity to stress.Dev Sci. Mar 2010;13(2):271-278.
8. Hofer MA. Psychobiological Roots of Early Attachment. Current Directions in Psychological Science. April 1, 2006 2006;15(2):84-88.
9. Ward TC. Reasons for Mother-Infant Bed-Sharing: A Systematic Narrative Synthesis of the Literature and Implications for Future Research. Matern Child Health J. Jul 2 2014.
10. Zhang K, Wang X. Maternal smoking and increased risk of sudden infant death syndrome: a meta-analysis. Leg Med (Tokyo). May 2013;15(3):115-121.
11. Dwyer T, Ponsonby AL. Sudden infant death syndrome and prone sleeping position. Ann Epidemiol. Apr 2009;19(4):245-249.
12. Hauck FR, Thompson JMD, Tanabe KO, Moon RY, Vennemann MM. Breastfeeding and Reduced Risk of Sudden Infant Death Syndrome: A Meta-analysis. Pediatrics. June 13, 2011 2011.
13. Moon RY, Fu L. Sudden infant death syndrome: an update. Pediatr Rev. Jul 2012;33(7):314-320.
14. Blair PS, Sidebotham P, Evason-Coombe C, Edmonds M, Heckstall-Smith EM, Fleming P. Hazardous cosleeping environments and risk factors amenable to change: case-control study of SIDS in south west England. Bmj. 2009;339:b3666.
15. Ball HL, Moya E, Fairley L, Westman J, Oddie S, Wright J. Bed- and sofa-sharing practices in a UK biethnic population. Pediatrics. Mar 2012;129(3):e673-681.
16. van der Vaart H, Postma DS, Timens W, et al. Acute effects of cigarette smoking on inflammation in healthy intermittent smokers. Respir Res. 2005;6:22.
17. Tong EK, England L, Glantz SA. Changing Conclusions on Secondhand Smoke in a Sudden Infant Death Syndrome Review Funded by the Tobacco Industry. Pediatrics. March 1, 2005 2005;115(3):e356-366.
18. American Academy of Pediatrics. Breastfeeding and the Use of Human Milk. Pediatrics. March 1, 2012 2012;129(3):e827-e841.
19. Mosko S, Richard C, McKenna J. Infant arousals during mother-infant bed sharing: implications for infant sleep and sudden infant death syndrome research. Pediatrics. Nov 1997;100(5):841-849.
20. US Department of Health and Human Services. The Surgeon General's Call to Action to Support Breastfeeding. Washington, DC: US Department of Health and Human Services, Office of the Surgeon General,; 2011.
21. Richardson HL, Walker AM, R SCH. Influence of Swaddling Experience on Spontaneous Arousal Patterns and Autonomic Control in Sleeping Infants. J Pediatr. Mar 12 2010.
22. Volpe LE, Ball HL, McKenna JJ. Nighttime parenting strategies and Sleep-related risks to infants. Social Science & Medicine. 2012(0).
23. Kendall-Tackett K, Cong Z, Hale T. Mother-Infant Sleep Locations and Nighttime Feeding Behavior: U.S. Data from the Survey of Mothers' Sleep and Fatigue. Clinical Lactation.2010;1(Fall 2010):27-31.
24. Montagu A. Touching: the Human Significance of the Skin. Third ed. New York: Harper & Row; 1986.
25. La Leche League International, Wiessinger D, West D, Smith LJ, Pittman T. Sweet Sleep: Nighttime and Naptime Strategies for the Breastfeeding Family. New York: Random House - Ballantine Books; 2014.
26. Middlemiss W, Granger DA, Goldberg WA, Nathans L. Asynchrony of mother-infant hypothalamic-pituitary-adrenal axis activity following extinction of infant crying responses induced during the transition to sleep. Early human development. 2012;88(4):227-232.
27. Adams SM, Jones DR, Esmail A, Mitchell EA. What affects the age of first sleeping through the night? J Paediatr Child Health. Mar 2004;40(3):96-101.
28. McKenna JJ, Mosko SS. Sleep and arousal, synchrony and independence, among mothers and infants sleeping apart and together (same bed): an experiment in evolutionary medicine. Acta Paediatr Suppl. Jun 1994;397:94-102.

About Linda J. Smith, MPH, IBCLC, LCCE, FACCE

© Linda J. Smith

Linda J. Smith, MPH, IBCLC, LCCE, FACCE, is a lactation consultant, childbirth educator, author, and internationally-known consultant on breastfeeding and birthing issues. Linda is ILCA's liaison to the World Health Organization's Baby Friendly Hospital Initiative and consultant to INFACT Canada/IBFAN North America. As a La Leche League Leader and Lamaze-certified Childbirth Educator, she provided education and clinical support to diverse families over 40 years in 9 cities in the USA and Canada. Linda has worked in a 3-hospital system in Texas, a public health agency in Virginia, and served as Breastfeeding coordinator for the Ohio Department of Health. Linda was a founder of IBLCE, founder and past board member of ILCA, and is a delegate to the United States Breastfeeding Committee from the American Breastfeeding Institute. Linda holds a Masters Degree in Public Health and is currently an Adjunct Instructor at the Boonshoft School of Medicine at Wright State University in Dayton, Ohio. She owns the Bright Future Lactation Resource Centre, on the Internet at www.BFLRC.com.

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