What is normal anyway? 

The average newborn sleeps between 11 to 17 hours a day. When a baby is first born, sleep typically has no pattern. However, after 2 to 4 weeks, most newborns will begin developing a rhythm or pattern to their sleep. Most newborns seem to sleep closer to 16-17 hours a day. 

When fully matured, we refer to these patterns as circadian rhythms. Circadian rhythms are controlled by hormones secreted from the pineal gland in response to sunlight. Researchers have identified two stages of newborns, rapid eye movement (REM) and non-rapid eye movement (NREM) sleep.  This differs from babies three months and up (and adults), who have 4 identified sleep cycles: NREM1, NREM2, NREM3, and REM.   

REM sleep is sometimes called active sleep because newborns often make noise, suckle, smile/frown, or even cry out. This can sometimes be mistaken for the baby waking up! Whereas NREM sleep is sometimes called quiet sleep because the baby is often still. Newborns spend much more time in REM sleep compared to infants and adults. The amount of time spent in this “active” or REM sleep decreases gradually in the first 12 weeks of life. 

When babies start to connect their REM and NREM sleep cycles they are able to stay asleep for longer periods of time. This process is referred to as sleep consolidation. Most babies will consolidate their sleep cycles at night before daytime naps. 

So what does all this mean? 

1. Babies learn how to sleep. With age and help their sleep becomes more “organized” meaning they develop a sleep or circadian rhythm. This rhythm is affected by light, environment, and age. 
2. Babies seem awake during active sleep but are actually in an important stage of sleep! It is important for caregivers to observe their individual babies so they can learn what active sleep looks like and not wake them during this stage of sleep. In the beginning, try waiting a few moments when your baby cries to see if they are truly awake and need you or just in active sleep. If your baby is awake they will likely escalate in their crying versus if they are in active sleep they may continue at the same level of activity or fall back into a deep sleep. 

A note on preterm babies 

Premature babies spend more time sleeping (90%) than full-term (70%) babies. So expect your little ones to spend more time sleeping if they are not yet term. Additionally, preterm babies spend more time in active sleep than quiet sleep, so do your best to observe their sleep and get to know what active sleep looks like so as not to wake your little one whilst they are actually sleeping. 

Days & Nights all mixed up! 

One of the most common newborn sleep concerns is that they are asleep all day and up all night, the so-called day-night reversal. Sleep hormones are controlled by the pineal gland. This gland is located in your brain and responds to light. Newborns spend a lot of time inside away from sunlight. To help babies’ circadian rhythm adjust it is helpful to expose them to light during the day. A walk in the morning and just before the last afternoon can be especially helpful in getting babies’ rhythm on the correct course. You also will want to make sure your baby is not sleeping more than 2 hours during the day. Make sure at bedtime the lights are dim and playing/noise is kept to a minimum. 

Step One: Setting the Scene 

The first part of setting up a sleep environment for your baby is ensuring safety. Most parents choose bassinets for their babies (check out our blog on evidence-based bassinet choices). Babies should always be put to sleep on their backs on a flat, firm surface free of any objects. This includes bumpers, pillows, nests such as dock-a-dots, and blankets, which are all suffocation risks. 

When considering where to put your baby, the American Academy of Pediatrics (AAP) recommends room-sharing for the first six months. The AAP also strongly recommends against sharing a bed with your baby due to the risk of suffocation and Sudden Infant Death Syndrome (SIDS). 

A smoke-free environment is extremely important for your baby as there is a strong association between parental smoking and SIDS. If you or anyone else smokes, minimize your baby’s exposure to second hand-smoke by showering and changing clothes before being around your baby. Also, consider reaching out to your provider if you or anyone else are considering quitting smoking and need guidance! 

Avoid hats at night on your baby, they are also a suffocation risk. You do not have to want your baby to overnight. The general rule of thumb is your baby needs only one more layer than you do to sleep at night. If you keep the temperature of your baby’s sleep environment between 68 and 72 degrees Fahrenheit, that is usually a long PJ with a swaddle. 

Remember how we were talking about the importance of light in setting your baby’s rhythm? This is why it is so important to keep the room dark at night. Use a dim light to feed and perform diaper changes. Make sure you have black-out curtains and no light in sneaking into your baby’s sleep environment. 

Step two: Falling Sleep, the famous 5 S’s

Babies need help falling asleep for the first several months. That is normal and should be encouraged. I recommend, Dr. Harvey Karp’s famous method for soothing babies “the five S’s”. They are: 

1. Swaddle 
2. Side position 
3. Shushing
4. Swinging 
5. Sucking 

For more information on how to do the five S’s and why they are important to sleep see:

 https://www.happiestbaby.com/blogs/baby/the-5-s-s-for-soothing-babies?utm_source=google&utm_campaign=&gclid=Cj0KCQjw7KqZBhCBARIsAI-fTKL3QcRIPTGYT7DaIWSR8NemNpbGw64VxT9CbG-Rs5gvTRYST92sBdkaAto9EALw_wcB#how-the-5-s’s-lead-to-sleep

There is NO way to “spoil” a baby in these early months. It is an urban myth that rocking, swinging, and holding your baby will spoil them so that they cannot sleep alone. Newborns need help learning to fall asleep and evidence shows have an improved ability to organize their sleep when assisted early. You may want to try starting to put your baby down drowsy but still awake to allow them to practice the skin of falling asleep on their own. 

There is evidence that pacifiers reduce the risk of SIDS, even if it falls out after the baby is asleep. You may want to use a pacifier during nap time and bedtime but try to limit use to these times of day and night. Do not attach the pacifier to your baby’s clothes or around their neck when sleeping, it is dangerous. If you are breastfeeding, wait until your milk supply is established before introducing the pacifier. Check out our blog on paci for more info on use, introduction, and selection. 

Step Three:  How to Help Your Baby Learn To Stay Asleep 

Sleep is really important for proper growth and development and is mostly a learned skill. The most important aspect of teaching your baby to develop a healthy sleep rhythm is a consistent routine. Evidence shows that establishing a consistent bedtime routine results in less nighttime waking and sleep problems. I encourage families to start the day they bring their baby home. 

So what does a bedtime routine look like for a newborn? You can give your baby a little bath, cuddle, say a prayer or massage, then diaper, PJs, and put them down for sleep. I will talk more about massage later. The important thing is to be consistent. If you are a patient of our’s please reference your baby’s individualized sleep plan. 

Another evidence-based intervention for helping your baby develop a healthy sleep rhythm is light modification. Exposing your baby to light during the day and maintaining a dark environment at night has been shown to lead to longer sleep. This means covering up or eliminating all lights such as night lights, lights on baby cameras, and other electronics in the room such as humidifiers, etc. 

Sound has been shown to improve sleep. Either a quiet or white noise is ideal for a baby’s sleep environment. If you choose white noise, pick a sound that is one frequency as changes in frequency are actually stimulating to babies. For example, jet engines are often single-frequency sounds versus ocean sounds are variable. Additionally, music therapy during awake periods can improve sleep, feeding, and heart rate stability, especially for premature babies. 

Try to separate feeding from falling asleep so that your baby does not start to rely on feeding to fall asleep, which can become a very powerful (and difficult to break) sleep association. The separation can be brief at this stage, like just a diaper change. 

Special push for the massage and skin-to-skin 

I especially like to recommend infant massage as part of a family’s sleep routine for multiple reasons. Evidence demonstrates that massage increases baby-parent bonding, and results in longer sleep with fewer nighttime awakenings. Moreover, studies have shown decreased sleep latency (the time it takes your baby to fall asleep) as well as crying. There is evidence that it also increases heart stability, suggesting less stress in your baby. Lastly, there is some data to suggest that massage may aid weight gain in the premature population and decrease the length of NICU stay. 

Not only are there benefits for babies from massage but also for mothers. Studies have shown improvement in motor night wakings and sleep quality. Mothers who incorporated massage into the sleep routine also noted improved perception of the weight’s mood and bedtime ease. 

I also highly recommend skin-to-skin for newborns. There is a large body of evidence that demonstrates huge benefits for neonates (see our blog on neonatal skin-to-skin for more information). Benefits include improved growth, breastfeeding success, bonding, and lower cortisol (the stress hormone) in parents and infants. Infants who have skin-to-skin also have fever awakenings from sleep and improved sleep organization. 

References

1. Rachel Y. Moon, Rebecca F. Carlin, Ivan Hand, THE TASK FORCE ON SUDDEN INFANT DEATH SYNDROME and THE COMMITTEE ON FETUS AND NEWBORN; Evidence Base for 2022 Updated Recommendations for a Safe Infant Sleeping Environment to Reduce the Risk of Sleep-Related Infant Deaths. Pediatrics July 2022; 150 (1): e2022057991. 10.1542/peds.2022-057991
2. https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
3. Wielek, T., Del Giudice, R., Lang, A., Wislowska, M., Ott, P., & Schabus, M. (2019). On the development of sleep states in the first weeks of life. PLoS One, 14(10), e0224521.https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0224521
4. Field, Tiffany, et al. “Mothers massaging their newborns with lotion versus no lotion enhances mothers’ and newborns’ sleep.” Infant behavior and development 45 (2016): 31-37.
5. Mindell, Jodi A., et al. “Massage-based bedtime routine: impact on sleep and mood in infants and mothers.” Sleep medicine 41 (2018): 51-57.
6. Ferber, Sari Goldstein, and Imad R. Makhoul. “The effect of skin-to-skin contact (kangaroo care) shortly after birth on the neurobehavioral responses of the term newborn: a randomized, controlled trial.” Pediatrics 113.4 (2004): 858-865.
7. Baley, Jill, et al. “Skin-to-skin care for term and preterm infants in the neonatal ICU.” Pediatrics 136.3 (2015): 596-599.
8. Mindell, Jodi A., and Ariel A. Williamson. “Benefits of a bedtime routine in young children: Sleep, development, and beyond.” Sleep medicine reviews 40 (2018): 93-108.