The Art and Science of Sleep: The First Year

There may be no greater threat to our self-concept as an effective or ineffective parent than how well our child sleeps. I was blessed and tricked by a first child who slept through the night at 7 ½ weeks. I had read one sleep book that made sense to me, followed the recommendations, used a little “cry-it-out” during transitions that temporarily disrupted her sleep, and otherwise had a great sleeper.

Then I had my second child. This girl didn’t follow any of the rules that worked so well for her big sister. I started keeping a tally of every time I woke up – there were nights of 9-10 wake-ups. She improved after instituting an earlier bedtime, but I was still in a state where I would be positively celebratory if I had a 4-hour sleep streak. For 13 months. I was so tired . . . I read more than one sleep book this time; I read EVERYTHING. I consumed every nugget of information online or in print or through advice from other parents. Letting her cry-it-out accomplished nothing but a super stressed out me laying in bed wide awake, and her STILL not sleeping. I am an educated, reasonable, well-resourced woman; I couldn’t figure out this puzzle -- and there is no motivation like utter sleep deprivation.

This experience, however, gave me the gifts of humility and a bottomless non-judgmental compassion for other parents struggling with sleep. Guess what? There is no one right answer. Sorry to ruin the marketing strategy for so many sleep experts writing all those books (which yes, can be very helpful for a majority of cases), but I came to my own scientific conclusion that the best way to get your child to sleep has a frustrating two-word answer: It Depends. Of course it depends on you, and there are always little tricks you can find to increase your chances of success. It depends on your lifestyle – routine is helpful. But for that percentage of children who are terrible sleepers, it may just depend on THEM: their brains, their temperament, their personalities, how they are wired. As some good sleep authors report, the biological basis of sleep involves genetics that can be very hard to fight, and sleep patterns persist across ages and stages into adulthood.

For some encouragement if you are enduring the sleep nightmare I went through for 13 months, I do believe that all of our strategies to encourage good sleep have now paid off because at age 6 now, she has 5 years of great sleep since that blessed first night at 13 months old.

Because this topic is so dense and complicated, I will take on sleep beyond the first year in future blogs (as I am currently living an experience that is sure to be blog gold -- see preview). That first year of sleep with a newborn-turned-infant, however, is a foundational chapter in the war stories of parenthood. If there is one thing we can all agree changes us from regular people to parents, it's utter physical exhaustion.  

To Cry-it-out or Not Cry-it-out

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This has been quite the debate in parenting circles, and I think has unfortunately caused a fair amount of unnecessary guilt (because really, moms do not need any more guilt!). The argument to cry-it-out boils down to behaviorism: if you go to your baby when she cries, she learns that crying gets her the reinforcement of your presence. So, if you keep going to her – or even sometimes go to her and sometimes not – she will cry more to get your physical presence, her greatest reward. The argument for not practicing cry-it-out is more about attachment theory and Erikson’s developmental theory: your baby is learning to trust you and that you will meet her needs; if you show up, she learns she can count on you and if you do not show up, she learns she needs to fend for herself, damaging the attachment basis of your relationship. Honestly, each makes sense in the vacuum of its own theoretical basis, and both theories are pretty well-grounded in research on their own. But bringing up baby is not so cut and dry.

Fortunately, some great researchers have examined the long-term effects of behavioral sleep strategies in infancy, and found that there are no differences between the groups in later ages as children. They looked at outcomes for the child (eg, emotions and behavior, sleep problems and habits), the parent-child relationship (eg, closeness, conflict, general relationship), and the parent (depression, anxiety, stress). I know passions can be quite high on either side of this debate, so let’s take it apart a bit.

 Behaviorism: If you are trying to follow the purist cry-it-out approach, you may lie in bed and struggle with thoughts of letting down your baby in his time of need, but not wanting to break the resolve to end this crying! You and your partner may have a different response in the heat of the moment of midnight anguished screaming, causing stress and conflict and blame in your own bed. None of this is good.

Behaviorism has a long history of “proof,” from Pavlov’s salivating dogs to Skinner’s rats learning to push the lever for more pellets. There are definitely some psychologists who argue that behaviorism explains every single human behavior – it’s all about what follows the behavior (reinforcement) that predicts if that behavior occurs again. Aside from those purists, however, most psychologists take on a more multi-faceted perspective. There are so many influences on human behavior: biology, development, environment, relationships, modeling, thoughts, and emotions. If your baby’s crying does not feel urgent and you would trade not moving from your bed to getting up to deal with it, that’s fine for you. If your baby’s crying sounds like the nursery apocalypse and you feel your instinct to protect him rising up in your very awake body, go to him and do what helps both of you in that moment.

Gentler forms of behavioral techniques have emerged to supplant the traditional “cry-it-out.” These include “controlled comforting,” which is basically gradually extending the time you let your baby cry before offering comfort, or “camping,” which is sitting near your baby but allowing the baby to figure out how to fall asleep without active parental comforting. These have good support in research for being effective for 6-12-month-old babies. In addition, improved infant sleep results in reductions of maternal depression, a significant risk factor for many poor child and parent-child relationship outcomes. Essentially, if your baby sleeps better, you sleep better; the more sleep you both have, the better your overall health and well-being.

“Attachment Parenting”: If you are trying to follow this approach, you may lie in bed and have to physically will your exhausted self to get out of bed right when baby starts crying. There can be a lot of pressure to feel like your actions in this delicate infant stage could cause harm to your relationship later. I mean, you just started this relationship – you’ve got to do everything in your power for it to be the best it can be! The good news is you have about a million chances within every 24-hour period with your baby to show him he can count on you. And the reality is, there is no such thing as 100% available, which is also okay for baby to learn. This gives your baby an opportunity to trust other caregivers, as well as tolerate some distress that is part of life. But all those other moments of feeding, holding, talking, snuggling, reading, carrying, and watching each other count too – you are constantly showing your baby you are there. Thankfully, a secure attachment does not depend on what you do when he cries at night (again, we do actually know this from research, despite some alarmists on the purist side of attachment parenting). This also reminds us of the beauty of technology and the baby monitor – you can LOOK at your baby to ensure there is no limb stuck in the crib, blankets over the face, etc. And even when I stuck pretty closely with letting my first cry-it-out, if I thought she might be in pain or physically suffering, my partner or I would absolutely go in to assess and offer comfort.

Co-sleeping / Bed-sharing

Full disclosure of my personal bias: you could not pay me to co-sleep with my children. The only exception was in those early days of constant nursing when I would lie on my side and nurse, and we would both fall asleep. My bias does not have to do with judgment of this practice as right or wrong, it is purely selfish: I can’t sleep well with my children in the bed, and I need to sleep or everyone suffers. When I did practice co-sleeping incidentally as described above, though, I would wake up with this conflict of alarm bells from the American Academy of Pediatrics (co-sleeping can kill your baby!) and my own instinct that this felt extremely natural, and this is how many cultures around the world live -- maybe because they don’t have multi-bedroom houses, but I think mostly because it is a generationally accepted mother and child practice.

Let’s look at the alarm bells rung by the AAP – and I am including the disclaimer that I am NOT a physician, and I am NOT providing medical recommendations, I am just distilling the information they have published. 

The AAP’s most recent official recommendation from 2011 is to practice room-sharing as a safe form of co-sleeping, which has been shown to decrease the risk of Sudden Infant Death Syndrome (SIDS) up to 50%, rather than bed-sharing. Based on multiple studies, the specific risk factors for sharing a bed with a baby younger than one are: the baby is younger than four months old, was born prematurely or had low birth weight; any person in the bed is a smoker; the mother smoked during pregnancy; use of medicines, drugs, or alcohol before going to sleep; a soft surface like a waterbed or old mattress; soft bedding such as pillows or blankets on the bed.

Some of this is common sense. I think most of us do not have to ask the pediatrician if it’s okay to get drunk or high before we sleep next to our baby; of course, we need to be able to awaken alertly and responsively. Also, fluffy comforters and pillows seem like a pretty obvious threat of covering tiny baby faces, and I believe most of us in this day and age have a pretty constant fear that our babies could stop breathing in their sleep (see: obsessively checking baby monitors and tip-toeing to peer over the crib and make sure we can see movement that indicates “he’s still breathing!”).  But if you google co-sleeping, you find lots of arguments to justify bed-sharing, and this can be hard to square with the dire warnings.

The AAP clearly states: “Bed-sharing is not recommended for any babies.” This unequivocal recommendation, however, is at odds with the fact that American families continue to share their beds. Critics of the AAP statements complain that the AAP has lumped together different groups of parents to make one conclusion. There is precedent that the AAP can err on the side of caution, resulting in unintended consequences (so maybe keeping peanut butter away from babies to reduce peanut allergies actually increased the prevalence of peanut allergies . . . ). Considering the perspective of pediatricians who have witnessed first-hand in Emergency Departments the fatal results of bed-sharing, I understand the approach of not wanting to take any chances. It definitely covers the bases to say – just don’t share a bed!

In my own research on this topic, I encountered exactly the issue I have with how research is used in mainstream online information sources. A free online handout produced by a very popular, well-regarded organization states: “Even though the never-bedshare message has been around for a number of years, it hasn’t measurably reduced bedsharing behaviours or infant deaths. Research shows that at least two-thirds of all breastfeeding mothers do bedshare at some point, and almost half of those who are told not to bedshare go to sofas and reclining chairs in the middle of the night, greatly increasing their risk.” Tip: When you read statements like this, ALWAYS look for a reference in small type at the bottom of the page to see where this information originates. These statements did not include the source for these numbers, and contradicts other published evidence that infant deaths HAVE decreased in the United States (by 15% between 2005 and 2014, according to the CDC), although bed-sharing is not evaluated specifically (although the decline in SIDS was the biggest of all leading causes of infant death, at 29%).

Next in the handout, “The latest research shows that breastfeeding mothers and babies who meet seven very clear criteria, which we call The Safe Sleep Seven, are low-risk and can bedshare with confidence.” Again, without citing sources, it is hard to know how this very claim can be made “with confidence.” It is likely extrapolating known risk factors to understandably make the conclusion that bed-sharing without these risk factors is low-risk, but the leap is in the phrase “can bedshare with confidence.” This conclusion could be made from studies showing that only the known risk factors led to infant death, and that those who practiced the “safe seven” did not experience an infant death. There is no record of that type of study at this point.

The dangers of bed-sharing are well-known, but why do we still do it? Well, it might be part of a deeply held belief system, or it might even be a little accidental – I’m tired, the baby is crying and wants to nurse, we end up sharing a bed the rest of the night. It is well established that skin-to-skin contact is soothing and physiologically regulating. My fondest memories from those harried weeks on maternity leave were resting with each of my children on my chest. Those hours were my calmest and most relaxing by far. So, the closeness of bodies is good for parent and child, it definitely makes for a less disruptive nursing routine, it might be less anxiety-provoking with a new baby to have her right next to you instead of waking up worrying if she is okay, and you may even be able to respond sooner to a problem compared to her being in another bed or another room.

This topic is an excellent example of how science can make a positive impact (eg, after recommending babies sleep on their backs, the rates of SIDS decreased significantly) and contribute to guidelines for parents, but the way some of the information is used can lead to more questions than answers. This is part of the beauty of science, that there is always more work to be done and discoveries to be made. 

In the meantime, the best you can do as a parent is to make informed, thoughtful decisions based on what feels right to you within established guidelines and parameters. And to sleep. You and your baby must sleep!