A new perspective on sleep and sleep training
Researcher • Author • Speaker • Parent Advocate & Coach
Improving sleep with mom and baby in mind: Strategies for clinicians
Developmentally-focused, Systems-based Approaches
Presented at the Postpartum Support International Conference
Portland, OR • June 28, 2019
Macall Gordon, M.A. (Antioch University, Seattle; Certified Pediatric Sleep Consultant)
Jen Varela (Certified Pediatric Sleep Consultant, San Diego, CA)
Kim West, LCSW-C (Sleep Lady Solutions)
Sleep research and advice suggests that infant sleep is largely a behavioral event, consisting primarily of episodes of desired and undesired behaviors and parental actions that either reinforce or extinguish those behaviors.
Sleep is so much more than just behavior.
A baby's sleep behavior represents a complex interplay of a variety of factors that can impact whether their sleep is problematic or not.
There are a variety of forces that affect an infant's ability to sustain sleep. Clinicians are often in a unique position to assess the moving parts and make appropriate referrals. Here are some of the non-behavioral factors that can directly influence sleep.
Infant Variables
Normative sleep development
Sleep develops as the brain develops. The ability to go to sleep and go back to sleep directly depends on the brain's ability to manage those transitions.
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Windows of “awake time” start small and grow slowly across the first three years. In the first six months, infants may only be able to stay awake for 60- or 90-minutes before needing a nap.
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Exceeding the child’s awake window can result in a “second wind” which can make ALL sleep more difficult.
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Frequent “regression periods” are normal sleep disruptors as new skills emerge and brain development surges (Chugani, 1998; Sadurni, Pérez Burriel, & Plooij, 2010; Schore, 2003).
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The 4-month sleep regression can cause even previously good sleepers to wake frequently at night. Trying to sleep train now can result in more tears and less progress than if parents can hold of until the developmental dust settles.
Self-soothing skills and sleep regulation also take time to develop and depend on physiological and neurological capacities to come online.
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The ability to self-soothe once upset depends on a toolbox of cognitive and motor skills that are limited at young ages.
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The amount of distress an infant can manage without help is highly dependent on age and temperament (Kopp, 1989).
Sleep is so much more than just behavior
PHYSIOLOGICAL ISSUES
A variety of physiological issues can directly impact the ability to sleep. An uncomfortable baby won't be able to sleep well and will have a reduced capacity to self-regulate. Here are some common physical sleep disruptors:
Silent reflux
Can cause pain that keeps babies awake and uncomfortable without visible “spitting up.”
Symptoms:
Persistent fussiness/crying
Intense crying on being laid flat (especially after feeding)
Back arching during nursing
Sleeps best on an incline
Nurses/feeds best when drowsy
Doesn’t sleep well anywhere (in arms, carrier, seat)
Action: Refer to pediatrician for a diagnosis and possible medication.
Obstructed breathing/apnea (rare in infants):
Symptoms:
Snoring, mouth breathing (not associated with cold)
Sweaty head upon awakening
Very restless sleep
Action: Refer to pediatrician for possible referral to a pediatric sleep specialist.
Feeding issues
Early in infancy, feeding or digestive issues can have a dramatic impact on sleep. If you suspect difficulty with feeding, or persistent fussiness that seems to be related to tummy issues,
Action: Referral to lactation consultant and/or check in with the pediatrician.
Low ferritin stores
Also uncommon, but can low ferritin stores can cause disrupted sleep architecture and, in older children, symptoms of Restless Legs Syndrome (Peirano et al., 2010).
Action: Refer to pediatrician for possible blood test.
Intense/Sensitive Temperament
Related strongly to depressive symptoms via fatigue, but also due to the violation of expectations and challenges to self-efficacy and self-concept.
Relevant traits seen in infants:
Low sensory threshold - Can’t buffer out sound/activity. Easily overstimulated. Light sleeper.
Intensity/Reactivity – Cries vigorously; difficult to soothe.
Alertness - Very aware, often has subtle or no sleepy signals.
Persistence - Does not easily give up. Doesn’t respond to distraction.
Action: Validate that sleep is harder for these infants (i.e. it's not the parent's fault that they aren't sleeping). The baby may need a lot more help with sleep. Offering support and validation for these parents goes a long way.
Parental Variables
expectations
Advice on expectable sleep for infants typically is not consistent with developmental science. Current advice contained in books often gives parent unrealistic notions of what young infants can manage in terms of consolidated sleep. For example, one book suggests that parents can get their 12-week-old infant sleeping 12 hours straight. While this may be achievable for some parents, it's out of reach for many and not advisable for another number.
Existing advice can raise parents' expectations for what’s “normal,” and then cause them to worry that they are not “doing it right” or “have blown it already” when their baby isn't sleeping the way the books say they will.
A majority of sleep books actually recommend starting sleep training by 4-months or earlier (some popular sources suggest starting at 2-months). Such recommendations are not based in research. Todate, no research has been done on using “crying it out” with infants under 6 months (Gordon & Hill, 2007). Advice suggests that if parents don't intervene early, “bad habits” will be difficult—if not impossible—to break. This also has not been researched. While sleep problems will persist without intervention, there is no evidence of the need to start this early.
Mental Health
A variety of maternal mental health variables have been shown to
directly impact infant sleep:
Depression (Warren, Howe, Simmens, & Dahl, 2006)
Anxiety (Petzoldt, Wittchen, Einsle, & Martini, 2016; Ystrom et al., 2017).
Postpartum PTSD (Garthus-Niegel et al., 2018)
Low self-efficacy (Hall, Moynihan, Bhagat, & Wooldridge, 2017).
Childhood trauma/“ghosts in the nursery” (Hairston et al., 2011)
Lack of social support (King & Blunden, 2017).
Level of partner support (Evanson, 2015)
Marital conflict (Kelly & El-Sheikh, 2011; Mannering et al., 2007)
Prenatal mental health (O'Connor et al., 2007)
Unrealistic expectations (Werner & Jenni, 2011)
Strategies for Clinicians
“Easy” sleep skills for babies under 6-months.
Get sleep in any way that works. “Habits” can be easily shifted when the baby has the cognitive and regulatory ability to manage sleep transitions more independently—after 6-months.
Room-share or use a cosleeper to make nursing/feeding and getting back to sleep quick and easy.
Gently experiment with drowsy-but-awake without crying at bedtime. See if the parent can put the baby down still a tiny bit awake. If not, parents shouldn’t worry. They can try again later.
What to do if it’s a “sleep crisis”
(For infants under 6-months when mom is in critical need for sleep.)
1. Partner to the rescue: Have a partner take a block of nighttime.
2. Marshal social support: Anyone who can help and/or give mom some extra sleep.
3. Night nurse/doula: Get some professional support to get a night or two of solid sleep.
Sleep strategies for over 6-months
Fill up the nap bank. Make sure naps are adequate and bedtime is early.
Rule out variables that need referral or alternative approaches (e.g. physiological difficulties and assess temperament.)
Suggest a very gradual approach to scaffold sleep skills. Parents can stay with the child and pick up if too upset. In a stepwise way, reduce the amount of input, or physical proximity.
If parents are truly exhausted, work only on bedtime. Then add middle of the night. Tackle naps last.
How can sleep consultants help?
As a point of entry. Parents come to sleep consultants with problems that may actually be psychologically or physiologically rooted.
As “boots on the ground.” Trained consultants can work in concert with mental health clinicians. Consultants provide ongoing support and modifications as they track progress.
Not all coaches are the same. Check training, credentials, and philosophy/approach.
Not every sleep problem requires a purely behavioral approach. There are many (potentially more influential) variables that may need to be addressed before sleep intervention will succeed. Clinicians can use their systemic approaches to evaluate the needs and capacities of the whole family before offering any advice about "what to do about sleep?"
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Download a pdf of the conference poster here
Resources:
Good Night, Sleep Tight (2nd edition) by Kim West, LCSW (Gradual approach that can be adapted to a variety of family contexts)
Certified "Gentle" Sleep Coaches (most work remotely)
International Association of Child Sleep Consultants (IACSC)