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Posts from the ‘Sleep’ Category
I apologize for my long absence from the blog. It’s been a busy couple of months. We finally bought a house, and with the help of many friends, got moved to our new home. Then the projects began – and continue. Summer school term wrapped up, and I’m prepping for fall term to begin in a couple of weeks. My book is coming along slowly what with all of the above. The blog has been completely neglected.
But I need to get back here. It’s like running and yoga for me; once I get out of the habit of lacing up my shoes or rolling out my mat or actually hitting “publish” on a blog post, these things I love seem to get a bit harder to do. So today, I thought I’d share my latest installment of Things I’ve Learned About Traveling with Children. (Follow the links to previous installments on traveling with babies and toddlers).
Last week, Cee and I traveled together to Kentucky, where I grew up. It was a last-minute trip, tickets booked just days before our flight. Husband was working and couldn’t leave on such short notice. The reason for our trip was bittersweet. A dear friend died unexpectedly, and we went to mourn her loss and celebrate her life. Despite the sadness, it was a special trip with Cee. It was her first visit to Kentucky, so she met (and vice versa) lots of old friends, many of whom now have kids of their own. (I no longer have immediate family in Kentucky, so we don’t visit there often.) Together, we explored the little house where I grew up, touched the grave of my father, and splashed in the creek where I spent the summers. My mom and my brother also came, so it was full reunion of family and friends.
Something else made this trip special: Cee was an absolute joy as a travel companion. Until this trip, travel always felt like a scary limbo – so long as we were in airports or on planes, until we had a bed and a home base, I carried the knowledge that everything might fall apart at any moment. There could be a poop explosion on the plane or projectile vomit upon landing. My bare boobs might fly out of my shirt as my nursing baby squirmed, the two of us wedged in the middle seat between two strange men.There could be two hours of inconsolable crying on a fully booked red eye from Oregon to New York. I say this because all of these things have happened over the last few years of traveling with Cee. We’re experienced travelers, we know the tricks, and we roll with the punches when things get messy. And they usually do, so I don’t much look forward to traveling.
But now… Cee is potty trained, so no poop explosions (although she did wear a pull-up while we were flying, just in case). She can now tell me when she feels nauseous, so we had plenty of time to get out the little complimentary motion sickness bag. And she’s weaned, so no need to lift my shirt. She sleeps when she’s tired, avoiding that dangerous over-tired state. Cee is two, but when people ask how old she is, I now feel the need to add that she’ll be three in November. Especially after this trip, she doesn’t feel like a toddler anymore. Read more
I’ve been thinking about bedsharing and sleep safety for the last few months. I have devoted an entire chapter of my book to this topic. Not only is it an important question for parents, but it’s an issue with so much complexity — wrinkles and folds of factors like breastfeeding, bonding, instinct, culture, and just plain reality.
I think it is vitally important to understand the relationship between bedsharing behavior and risk of SIDS and accidental deaths. But our ability to tease apart every factor that might impact sleep safety is imperfect; there will always be factors that aren’t quantified in these studies, not to mention the fact that case control studies have some inherent limitations. You’ve probably heard about the study published this week by Carpenter et al. in BMJ. It combines 5 historic case control data sets from Europe, the U.K., and Australasia to specifically look at the risk of bedsharing in breastfed babies in nonsmoking households. It concludes that bedsharing poses an increased risk of SIDS, even in these ideal situations. I think it’s an important study, but it also has some limitations and doesn’t answer all of our questions with certainty. In fact, no study will probably ever do that. (You can read some critiques of the Carpenter study here and here.)
But even if we accept that bedsharing increases a baby’s risk of dying unexpectedly during sleep, we still have to answer the bigger question of how we translate this information to families living in the real, difficult world of infant sleep. Many families value bedsharing as a cultural practice; others choose it because it feels right. Still others bedshare because it is the only way that anyone gets any sleep at night, and we all know that sleep deprivation carries some risk, too, as does falling asleep on a couch with your baby. This is the reality.
Pediatricians face this reality in their clinics every day, when they talk with parents of new babies about sleep. In my book, one of the questions I explore is how pediatricians handle this conversation, given that their professional organization, the American Academy of Pediatrics, recommends against bedsharing. Several months ago, I sent some questions to one of my favorite pediatrician bloggers, Dr. Melissa Arca of Confessions of a Dr. Mom. She had initially agreed to a Q&A, but then she didn’t respond with her answers. It was the height of the busy flu season, and I figured that she was just busy. Then, this week, she surprised me with her responses. She had been thinking about bedsharing given the news of this recent study, and she was inspired to restart this conversation. We’ve cross-posted our Q&A on both our blogs. Check out her post for more about her initial hesitancy to address these questions, and please feel free to share your experiences in the comments below.
Alice: How did sleep look for your two children?
Melissa: My first child was a challenge to say the least. He is the one who made me question the safety of bed-sharing in the first place. For the first 6 months of his life, sleep was virtually non-existent (or at least that’s the way it felt to me) because he needed my arms and constant soothing throughout the night. But I was terrified to bedshare. I was literally at the end of my sleep deprivation rope. I had tried everything. And instead of listening to my instincts, I was fighting them. Because I was scared.
I never envisioned myself as a bedsharing parent. As a pediatrician, I was adamantly against it. But it was exactly what my baby needed and we struggled and limped along until I finally realized that.
My second child was a breeze and that’s no lie. She was always (and still is) an “easy sleeper”. She needed her space and showed clear signs of being tired. When she was tired, that was it. I didn’t need to bedshare with her. She slept in her own bassinet next to our bed during her first few months of life before being transitioned to her own room.
They could not have been more different in the sleep department. Same parents. Same environment. Different children.
Alice: As a pediatrician, how did you feel about bedsharing before having children? Did becoming a mother change that?
Melissa: I didn’t think it was safe. At all. I had read the studies and the official recommendations. Back to sleep, crib and/or bassinet in the same room with no hazards such as loose bedding, pillows, etc.
I never thought in a million years I would have become a bedsharing parent. But kids don’t have our same agendas. Read more
Sleep deprivation is an inevitable part of having a baby, and surely that’s been true throughout the history of our species. But we also live in a culture that seems to take some amount of pride in getting by on little sleep. We think of sleep as time wasted, as lost productivity. We forget – or ignore – the biological necessity of sleep.
Becoming a parent only further stretches our already-too-thin sleep allotments. Newborn babies wake frequently to feed or for comfort during the night. We try to “sleep when the baby sleeps” and piece it together to come up with a reasonable amount, but it often doesn’t feel sufficient. And now more than ever, new parents are really isolated as they make this transition; they don’t have much in the way of backup resources to help with the 24/7 job of caring for a baby.
This month, the theme of our Carnival of Evidence-Based Parenting is Transition to Parenthood. (See the bottom of this post for links to other Carnival posts and here for summaries of them all.) Sleep deprivation is a universal part of that transition. What does the sleep deprivation of early parenthood really look like? How does it affect us? And what can we do to mitigate it?
Just How Bad Is It?
For many moms, sleep debt actually begins in pregnancy, when sleep needs may increase but discomfort and frequent trips to the bathroom interfere with a full night’s sleep. But by far, the biggest change happens in the immediate postpartum period. One study found that in the first week of the baby’s life (compared with late pregnancy), moms got 1.5 hours less sleep, fragmented into three times more sleep episodes per day. The early postpartum period is also characterized by lots of day-to-day variability in sleep. Sleeping with a new baby means unpredictability, with little to no control over whether tonight will be a good night or a bad one.
Mothers usually get the majority of our sympathy when it comes to postpartum sleep deprivation, but the research shows that fathers’ sleep takes a hit, too. A study of 72 San Francisco couples welcoming their first baby compared sleep in the last month of pregnancy to sleep in the first month postpartum (around 20 days of life). Across this time span, mothers lost an average of 41 minutes of nighttime sleep, while dads lost just 18 minutes. Moms, however, gained 30 minutes per day in daytime napping; dads didn’t get a nap bump at all. In fact, in this study, dads actually slept less than moms – both in late pregnancy and in the postpartum period. Moms still had it harder; they were waking more during the night and had more sleep fragmentation than dads (and it’s quite possible that moms need more sleep, what with recovery from childbirth and the demands of breastfeeding). But regardless, in this and other studies, moms and dads both reported a similar level of fatigue during the day.
There’s some good news to come out of this research, however. It seems that experienced moms are better at handling sleep in the postpartum period. Despite juggling more responsibility at home, studies show that moms who had given birth at least once before tended to get more sleep at all stages of pregnancy and in the postpartum period. Their sleep was also more efficient, meaning that of the time they spend in bed, they spend most of it sleeping rather than tossing and turning – or laying awake listening to the grunts and sighs of new baby sleep. Somehow, experienced moms seem to prioritize sleep more, or they’re just so tired that they crash hard at every opportunity.
How does sleep deprivation affect new parents?
We know a lot about the effects of sleep deprivation but actually very little about the specific type of crap sleep experienced by new parents. Most sleep deprivation studies have been conducted in residential labs, where participants (often young, probably resilient, undergrads) are generally paid to live for a few nights or maybe weeks so that their sleep habits can be controlled and monitored. In a review paper entitled “Sleep Disruption and Decline in Marital Satisfaction Across the Transition to Parenthood,” Gonzaga professor Anna Marie Medina and colleagues make an important point: Lab study participants know that they’ll be subjected to sleep deprivation for a finite amount of time, and they know they can even drop out if it becomes too much for them.
“Understanding that one can end a study, and being certain of the temporal parameters of potential sleep deprivation, imbues the experience of sleep loss with a level of controllability that new parents seldom have. That is, (most) new parents realize they cannot opt out of the sleep disruption experience, and they have no certainty about when they may have an opportunity for sufficient sleep. The stress literature has suggested that such uncontrollability could amplify the mood and physiological consequences of sleep deprivation.”
In other words, most of what we know about the effects of lost sleep may be even worse in new parents. On that happy note, there are a few major areas of concern… Read more
Nothing can prepare you for the changes in your sleep when you welcome a newborn baby into your family. Experienced parents will issue dire warnings and tell you to sleep while you can during the last few weeks of pregnancy. (And you will think, yeah right, there’s a large boulder resting on my bladder, and sometimes it kicks for good measure.)
But then the baby arrives, and your world changes forever. Sleep disruption is one of the most immediate and dramatic changes associated with parenthood. It isn’t just that you’re getting less sleep; it’s that your sleep is suddenly dependent on this baby sleeping. And even though newborns sleep a lot – as much as 16-18 hours per day – it feels disorganized and unpredictable.
The thing is, babies, even brand new ones, actually do have organized sleep, it just isn’t organized like yours. But under the surface, baby is working towards being more like you in his sleep. During the first few months, you have no choice but to go with the flow and sleep when the baby sleeps (something I was never good at), but it can help to understand the inherent patterns in your baby’s sleep/wake cycles so that they become more predictable. Your goal is to work with your baby’s biology, find some time for your own sleep, and support your baby in his natural development towards more mature sleep patterns.
In the research for my book, I’ve buried myself in research papers on infant sleep, trying to glean some knowledge that can be helpful to parents in these first few months of baby’s life. Here’s what I’ve come up with so far:
1. Understand newborn sleep cycles. Newborn sleep alternates between active and quiet sleep (akin to REM and non-REM sleep in adults). During the first few months of life, infants usually begin each sleep period in active sleep. Then, after about 25 minutes, they’ll transition to a cycle of quiet sleep, also about 25 minutes long. During active sleep, babies will twitch and flail their limbs, grunt and sigh, and maybe even cry a little. Their eyes move beneath translucent closed lids and may even open from time to time. In quiet sleep, babies breathe slowly and rhythmically, and their bodies are still 1,2.
Why care about the biology of sleep? Because it can help you in these practical ways:
- Babies wake easily from active sleep, so if your baby falls asleep in your arms, wait until you see signs of that deeper, quiet sleep before you try to move him.
- Around the 45-50 minutes mark, baby will be finishing up that first active/quiet sleep cycle of 45-50 minutes. Transitioning from one cycle to the next can be tricky for a new baby, so if he wakes during this time (particularly if it’s after just one cycle), see if he wants your help returning to sleep before assuming that he’s ready to eat or play.
- Active sleep is noisy. Parents often mistake the normal vocalizations of active sleep as the baby waking, and in their efforts to soothe the baby, they’ll actually wake him up. If you think your baby is waking up, pause and watch him for a moment. He may just be dancing in his sleep, or he might be waking briefly only to return to sleep on his own.
2. Help your baby find a rhythm. We are adapted to Earth’s 24-hour cycle of light and dark, and our physiological circadian rhythms help us to feel awake during the day and sleepy at night. Newborn babies, on the other hand, sleep just as much during the day as they do at night. It takes them some time to develop rhythms to match our day/night cycle. You can help by sending baby strong environmental and social cues about day and night. Read more
I’m working on the “sleep strategies” chapter of my book. This chapter is about the strategies that we use to help our babies sleep and how these practices correlate to the development of baby’s sleep patterns.
I’m fascinated by cultural variation in nighttime parenting strategies. However, according to some accounts, there’s a simplistic dichotomy in the way parents around the world help their babies sleep. In most of the world, mothers sleep with their babies and breastfeed on demand throughout the night. Sleep is not a problem, because babies simply aren’t expected to sleep through the night. We in the West, however, don’t understand normal infant sleep. We bend over backwards with all sorts of tricks and gadgets to help our newborns sleep, often alone. (I’m looking at you, swings, bouncy seats, strollers, drives in the car, exercise balls, washing machines.) Then, a few months later, we tire of the antics, grow intolerant of night wakings, and turn to sleep training as the answer.
There is definitely some truth to this. It’s something that I’m writing about in greater detail in my book. But we also know that nothing is as simple as it seems, and infant sleep is no exception. I think it’s helpful to know that parents everywhere struggle with their babies’ sleep or lack thereof, and that’s true regardless of sleep customs or cultural expectations (Sadeh et al. 2011). No matter where they’re born, babies have to acclimate to a world that grows dark and quiet at night and bright and busy during the day. We might use different strategies to help our babies sleep, but there are many similarities as well.
I ran across one of these similarities in a paper I read yesterday (Anuntaseree et al. 2008). Thai researchers surveyed parents of three-month-olds born across the country in 2000. They asked the parents how their babies fell asleep, where they slept, how they were fed, and how often they woke during the night. The parents of more than 3700 babies responded to the survey.
Most of these babies – 68% – shared a bed with their parents. The rest slept in a separate bed but in the same room. Putting babies to sleep in a separate room was nearly unheard of. Of 3700 babies, only two slept alone (a whopping 0.05%). About half were exclusively breastfed, and another quarter were fed a combination of breast milk and formula. On average, these three-month-old babies woke their parents 2.7 times per night, but there was of course a lot of variation here. Nearly 50% woke just one or two times per night. The researchers wondered which factors were related to waking more often, and they found significant correlations with these: male gender, more than three naps per day, falling asleep while feeding, exclusive breastfeeding, and the use of a swinging or rocking cradle.
The gender and napping associations are a little odd and not supported by other studies. However, the rest of it isn’t surprising. It is well accepted that breastfed infants wake more often during the night. Human breast milk is more rapidly digestible than formula (Cavell 1981), so breastfed babies need to feed more frequently. It’s also a common finding that feeding to sleep increases waking (or more accurately, waking the mother) during the night.
But I was really interested in learning more about the swinging or rocking cradles mentioned in this paper. It turned out that 88% of babies commonly started their night in such a cradle. Here’s how the paper described it:
“Use of a swinging or rocking cradle for infant sleep is traditionally used in many Asian countries including Thailand. The typical “getting the infant to sleep” situation in Thailand is for parents to use a cradle as a sleeping aid, and then when the infant falls [to] sleep, transfer the infant to the bed. There has been no previous study regarding the effect of this custom on night waking; our study is the first to demonstrate this association.”
I was curious about what a Thai swinging cradle might look like, so of course, I Googled it. The only photos I found showed a pretty extraordinary contraption: Read more
I’m working on the sleep chapters of my book right now. I had originally planned one sleep chapter, but I’m realizing that it’s such a huge topic that it needs to be split into two chapters: one on the question of where baby should sleep and one on sleep strategies and sleep training.
I have been focusing on the question of bedsharing for the last several weeks. I have read the major studies associating bedsharing with SIDS and suffocation and studied the professional opinions of those recommending against bedsharing from a public health perspective. I have also read the studies coming from James McKenna, Helen Ball, and others that take a more holistic view of bedsharing. These authors talk about bedsharing as the cultural and physiological norm for human infants, particularly in the context of breastfeeding. They advocate for a more tempered view of bedsharing safety, one that recognizes that all bedsharing situations are not alike and that, though not proven, it is certainly possible that a safe bedsharing environment can exist.
I’m trying to understand both the science and the controversy of this topic. There are the data, and there are the people analyzing it and interpreting it. Reading these papers, I get the feeling that it is difficult to find someone conducting research in this field who isn’t at least a little invested in the outcome. I wonder if these guys ever sit in the same room together and talk it out, because it feels like they are coming from different planets. There’s the epidemiology planet, where numbers rule and nuance is scorned. (And don’t get me wrong – I’m a numbers girl – but I can see the limitations in them here.) Then there’s the anthropology planet, a beautiful land of skin-to-skin, breast milk, and perfect physiological attunement between mother and babe. In my opinion, neither world completely represents the reality facing new parents in today’s world.
I wonder, for example, if the members of the AAP committee, which recommends against bedsharing, have ever cared for a baby who had extreme difficulty sleeping alone. And I wonder if the anthropologists have ever cared for a baby who wanted her own space, perhaps needing a break from all that day-and-night sensory input. I have met both types of babies, and as parents, I think we have to recognize that their needs are not the same.
In the real world, lots of factors determine how different families handle sleep. Infant temperament is one of them. Safety is another. There are also cultural expectations, family dynamics, work schedules, parenting styles, and feeding methods to factor in. Where baby sleeps is a complex parenting decision, one that is exceedingly difficult to study in a quantitative manner.
As I’m writing this chapter, I’m trying to present the science in a balanced way. I also recognize that this parenting decision – and most of them for that matter – can never be reduced to science and statistics. Parenting is about people and their stories. I know that I need to understand those stories as well as the science to write a worthwhile book.
So, I’m hoping you can help me.
Help me understand WHY your babies slept where they did – in your bed or in a crib or some combination of the two. What factors were important in your decision? Did your baby sleep where you had planned, or did you have to adjust your expectations? What worked well about your arrangement, and what didn’t?
I may be interested in including some of your stories in my book, but I’ll send you a direct email if that’s the case. Thank you – as always – for sharing your stories!
Cee was sick about a month ago – sick in a flu-sort of way with fever, cough, stuffy nose, and general misery. We threw our regular sleep routines out the window. There was a lot of back rubbing and singing to help her to sleep and more of the same when she woke burning with fever during the night, needing some reassurance from Mama or Daddy and another dose of ibuprofen.
Once she was better, Cee had a bit of a hard time transitioning back to our regular routine of books, song, and goodnight. She said, “Mama, lie down?” wanting me to stay with her until she fell asleep. I couldn’t get into that habit. I had humored her a few times, and I knew how it went. I would lay down next to her until her breathing slowed and she was still, but I’d still be afraid to budge for another 20 minutes to be sure she was in a deep sleep. By that time, I would either fall asleep myself or at the very least have lost all motivation to do anything productive for the rest of the night. Plus, I hate the sneaking out thing. It makes me feel like I’m not being honest with her. Cee knows how to go to sleep on her own.
Instead, I stayed with her for a few extra minutes. I held her hand and talked quietly about her day, full of friends at daycare, walks outside, time with mommy and daddy, meals, bath, books, and all the regular mundane things we do together. It was a busy day, I told her, and tomorrow would be another busy day. Time to rest, little girl. Night night. I kissed first one hand and then the other and then her forehead, now thankfully cool now since the fever was gone. It was a good bedtime. She fell asleep, and I got to work.
The next night, as I was kissing her goodnight, she said, “Mama, lie down?”
“No,” I said, “I’m not going to lie down with you. I need to go work upstairs.” (She actually accepts this response. It seems to make sense to her.)
She had another idea.
“Mama, talk busy day?”
And so began our new bedtime tradition. It’s Cee’s favorite part of bedtime now, and mine too. She asks for it with anticipation every night. When Husband is home at bedtime, he shares in it as well. We snuggle together in a Cee sandwich and recall the day. Read more