Helping your child to learn to self-soothe and raising a child with good sleep habits is one of the best gifts you can give your child. Infant sleep issues that are not corrected can continue through childhood and beyond. To me this is one of the most important chapters in this book!

In this chapter I will be describing my approach to encouraging healthy sleep habits. Finding the right method for you and your family can be confusing. There are at least four levels of quality evidence most parents use when trying to find a sleep approach that works for them. The first is advice from family and friends, the second is advice from a trusted advisor, the third is by following national guidelines, and the fourth is turning to the internet where you might find unfiltered or unverifiable sources.

My approach has evolved over the past 25 years and comes from three of the above approaches. The first is from personal experience as a nurse and mom, the second is from trusted advisors such as Dr. Ron Fischler and Dr. Jeffrey Siegel and other physicians I have worked with over the years and continue to work with, and finally, advice adopted from national guidelines from the American Academy of Pediatrics.

I thought that it would be fun to see a typical 24-hour day of a 1-month-old taken from Parents Magazine:

16.5 hours sleeping = 69% of the time.

3 hours eating = 13% of time.

1 hour wetting, stooling, and being changed = 4% of the time.

2 hours crying = 8% of the time.

2 hours staring into space = 8% of the time.

Special concerns - SIDS

SIDS is one of the greatest fears for most parents. So, I will start this chapter by talking about SIDS.

Barton Schmitt explains in his book, Your Child’s Health, how the “Back to Sleep” campaign came to be in the United States and how it came to be recommended by the American Academy of Pediatrics (AAP).

In the 1980s, research studies done in Europe, Australia, and New Zealand showed a 20–67% decrease in SIDS with a supine (back lying) position.

The prone or stomach position had a 3–9 times greater risk of SIDS. The side-lying position had a 2 times greater risk than the supine position. It was a better option than the stomach, yet it was still not as good as the back.

In 1992, the AAP recommended back-lying or side-lying due to 6–7,000 deaths from SIDS per year. They recommended that all healthy infants be positioned for sleep on their backs or side rather than the traditional tummy or prone position.

This recommendation was based on the findings from numerous studies completed abroad, which again indicated that babies who slept on their stomachs were at higher risk of dying from SIDS.

Two years later, in 1994, the AAP, along with the National Institute of Child Health and Human Development and other health experts, joined efforts to spread the word that back- or side-sleeping was best for babies.

As a result, thousands of US babies’ lives were saved.

In Seattle alone, from 1992–1995, there was a 30–50% drop in the incidence of SIDS when people followed this advice.

In 1996, the AAP officially changed its position to recommend back- over side-lying.

As the data suggested, the back-lying position for sleep poses a lower risk of SIDS than side-lying and is therefore preferred.

A theory or possible reason the tummy position might increase SIDS is that, when a baby is on their stomach, this puts pressure on the child’s jawbone. As a result, the airway in the back of the mouth becomes narrower. In addition, if the child sleeps on a soft surface, the nose and mouth may sink into the mattress, so the baby is breathing from a small pocket of stale air.

In my classes, I also bring up CPR classes. One of the first things they teach you is to place the person on their back and tilt the head back, to establish the best airway. I also tell parents to think of the airway as a straw. When you kink a straw, you are not going to get the same flow as you do when that straw is straight. So, when your baby is on their back that straw/airway is straight, and your baby has the most wide-open airway possible. This is also a good reason not to let your little one sleep slouched in a swing or infant car seat.

The original reason for the US and Canada to recommend the prone position in the 1950s was fear of aspiration if a child spits up or vomits.

Yet the AAP says they may recommend a tummy or side-lying position if there is a significant medical condition that would mandate this.

Discuss sleep positions with your doctor if there are any medical conditions (such as severe reflux). Now, if you recall, my babies had severe reflux to the point of causing apnea and my pediatricians still recommended my babies were put to sleep on their backs. We just put a wedge under the mattress to add a slight incline to the head of the bed.

SIDS prevention recommendations

Some additional recommendations from the American Academy of Pediatrics include:

Do not let infants sleep on sofas, soft mattresses like the parents’ mattress, or any other soft surface. Keep pillows, quilts, comforters, and stuffed toys out of a child’s crib.

Avoid devices designed to maintain sleep positions. They have not been shown to reduce the risk of SIDS. They can entrap a baby and act as a pillow on each side of the face.

Avoid overheating a baby with excessive nightclothes, like hats, or elevated room temperature. If possible, a ceiling fan should be used.

In general, the temperature should be comfortable for you.

Instead, place your infant down to sleep on a firm, flat mattress and use a fitted sheet.

Never allow cigarette smoking around your baby.

If possible, breastfeed your baby.

Make sure your infant receives immunizations. Immunizing your infant decreases the risk of SIDS by 50%.

Notify your doctor if you see a change in behavior or signs of an illness.

A sleep space that is separate but close to a parent is ideal (more on this later in the chapter).

Consider offering a pacifier at bedtime once breastfeeding is established.

If swaddling an infant, it should be snug above the shoulders and loose at the hips, and always lay the baby on their back. It should not be done past three months of age due to the risk of the baby rolling over and breaking out of the swaddle and then having a blanket in the bed over the baby’s face. It should not be so tight that the baby can’t take a deep breath.

Avoid relying on products or home monitors that claim to reduce the risk of SIDS because most have not been tested for effectiveness and safety (more on this in a moment).

Encourage teaching of “Back to Sleep” guidelines for all secondary caregivers.

No bumpers in the crib.

I recommend reversing the direction in which you lay the baby in the crib every week. Babies tend to turn, even if slightly, toward the side where they can see people and toward the light.

This helps strengthen neck muscles on both sides and also helps prevent flat spots and neck torsion.

It is also important to give your baby time on his/her tummy during the day to allow them to push up with their arms and build upper body strength and neck support. Tummy time also helps prevent the development of flat spots on the head.

Since your baby probably won’t like being on his/her tummy, you may need to entertain him/her while he/she is doing tummy time. Choose times when he/she is playful and alert, then get down to his/her level and try these diversions: make silly faces and sounds, play peek-a-boo, or sing. Stop when they get fussy. If your baby falls asleep, this is not productive tummy time. Before a baby is able to lie flat, you may use a bolster roll to help prop the upper body.

Mattresses

There are also now new, breathable mattresses. Again, these cannot be counted on to prevent SIDS and I would not put my baby to sleep on their tummy thinking they were safe due to the breathable mattress, but it is one more thing you could do to decrease the risk.

SafeSleep mattress is one brand of breathable mattress with an open box spring and not a fiber filling. It has an air-permeable mesh surface with no sheets and fits a standard crib. This mattress can be found at safesleeptech.com

This is just one of many types of breathable mattresses available.

Swaddling

SIDS and swaddling, Arizona Parenting Magazine, December 2006, p. 39

Swaddling decreases the startle response in infants, and it often allows babies to sleep longer through the night and will often allow them to stay on their back or side. It is important that the swaddle is not too tight. The baby needs to be able to breathe easily. He or she needs to be able to take a deep breath and expand the chest. So, make sure the swaddle isn’t so tight that it prevents the chest from moving up and down. Doctors also warn against swaddling in warm blankets as this could be a risk for SIDS. There is a higher incidence of SIDS in winter months and the peak age is between two and four months. In Australia, India, and Asia, infants are commonly swaddled until four months and incidence of SIDS is almost nonexistent. Solona babywear sells breathable, lightweight muslin wraps that are great for swaddling. A sleep suit like the Merlin Sleep Suit may help if your baby is rolling onto their stomach but cannot roll back to their back and waking themselves up crying or getting stuck on their stomach. Now AAP is opposed to weighed sleep suits or sleep wear that holds babies in one place. I need to make clear that when your baby is strong enough to roll in a weighted sleep suit or the Merlin sleep suit it is time for them to come out of it, as these could cause your baby to be stuck on their stomach. So, if your baby is strong enough to roll in the Magic Sleepsuit, it is time to take them out of it. It might be a nice transition, however, when your baby is breaking out of a swaddle but not ready to roll back and forth yet. This may keep your little one on their back longer.

Average hours of sleep

North Scottsdale Pediatrics website https://www.nspeds.com

As most of you already know, newborns sleep a lot during the first month of life.

Your child may sleep anywhere from 12–20 hours per day with an average of 16 hours. The duration of this sleep is variable: from 15 minutes to 5 hours.

Most newborns wake up 1–3 times during the night in the first 3 months of life.

The majority of infants can be expected to sleep through the night by 4–6 months of age. Although there are a few babies that may not acquire this skill until closer to a year. The most important skill to teach young babies is to self-soothe and put themselves back to sleep when they wake. More to come on this.

“Sleeping through the night”

The definition of sleeping through the night by age:

6–8 hours by 4 months

8–10 hours by 6 months

Just like adults there are some of us that can get by on fewer hours of sleep and those of us who need extra hours. Your baby may also need more or less than the average.

Many parents think that the reason babies wake up is because their baby is hungry. This may be part of the problem in the first two months, but there is much more to it. Infants wake up several times during the night because they have an immature sleeping pattern.

Now, the saying “sleeping though the night” is a bit misleading. All babies, and adults for that matter, wake during the night. However, we are unaware of this, as we can fall back to sleep on our own. The goal for us as parents is to not have to do anything to help our little ones fall back to sleep. We want to help them learn to self-soothe and fall back to sleep on their own.

Sleep patterns

By the 8th month of pregnancy, the baby’s sleep periods consist of two distinct sleep patterns: REM sleep and non-REM sleep.

Two general patterns exist:

REM sleep (Rapid Eye Movement)

This is an active sleep pattern. Babies may have restless movements, irregular breathing, brief awakenings, and twitching. Infants may go........

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