Sleep 0 - 1

Ester Delhoofen


Ester Delhoofen is a medical doctor licensed in the Netherlands. She has extensive complementary training in anthroposophical (Waldorf) medicine, many years of professional experience with children 0-4 years of age, and is the mother of three children.



how to get young babies into a good sleeping pattern

problems that parents experience
* your six-week-old baby falls asleep quietly in your arms. you put him down, but immediately (or just after a few minutes), he wakes up and starts crying. you pick him up again and hold him until he is back asleep. in the meantime, you canít take a shower or get anything done in the house. and at 6 oíclock in the evening, he starts crying a lot. is he hungry? does he want attention? you canít eat dinner anymore!
* you have a three-month-old baby, and it seems as if there is an increasingly chaotic pattern of sleeping and feeding. he sleeps only briefly and drinks often.

parents of babies are often very tired. they are unable to maintain their good mood and their sharp memory. they may start feeling dizzy, or become mentally foggy. this is especially hard on mothers returning to a demanding job in which they need to focus. itís not only sleep deprivation that can cause a kind of drowsiness. the hormones that circulate in nursing moms help moms to relax and contribute to a feeling of fatigue.

below are some developmental facts that present-day parents need to know and understand before they act on advice.

development of sleep in the first year
in the uterus, the baby is very protected and sleeps a lot. suddenly, after birth, there are many stimuli from the outside world. the world is overwhelming, and everything touches the child deeply. because the nervous system is not ripe yet, the baby is very vulnerable. in the first two weeks it seems as if the newborn is still in a different world. she easily sleeps two hours in a row. she sleeps fine everywhere, even in a busy living room. in the first weeks after birth, the child sleeps about 16-20 hours per day. sleeping develops in a rhythm and has different states. one of these is the rem (rapid eye movement) state. rem is the lightest sleep state. during this state, the child dreams, organs are working, the eyes are moving hence the name and breathing is irregular. in this state, the child processes information and learns. (research has shown that new synapses between neurons are formed during rem sleep.) most newborns make uncontrolled movements which can wake them up easily. the child may seem awake in the rem phase. in the first weeks, she can open her eyes and even cry, but she is still asleep.
sleep of newborns is about 50% rem sleep. in contrast a two-year-old the amount of rem sleep is 30%, and a child going to school has only 20% rem sleep. during deep sleep, (the non rapid eye movement,) the heartbeat and breathing are slow and regular because the body is resting. deep sleep strengthens the immune system.
each sleep cycle consist a non rem sleep phase followed by a rem sleep phase lasting a total of about one hour. it is longer as the child grows older. after a cycle of three to four hours, newborns wake up because they are hungry.

after every 90 minutes, a mother starts her rem sleep in which she dreams and moves. after every cycle, the rem sleep is a little longer. when a mother sleeps with a baby in her arms next to her body, the baby follows the rem sleep cycle of the mother. research shows that the baby sleeping with the mother nurses about every one and a half hours. when you sleep separately (for example, the baby in a little bassinet next to your bed or co-sleeping under a different blanket,) the breast feeding interval is at least twice as long because the baby is able to follow his own rhythm.

after six to eight weeks, babies have a day and night rhythm. however, it isnít a 24-hour rhythm, but a 25-hour one! the sleep times change: the baby first wakes up at five and the day after at six and yet another day later at seven. it takes the baby until he is three to four months old until he has a 24-hour rhythm. (if adults are put into dark, they go back in this 25-hour rhythm.)

advice
advice differs for each individual child and individual parents.

the first weeks:
for a newborn, it is healthy when life after birth is similar to what it was in the uterus. it is especially important to protect him against too many stimuli in his surroundings and to keep him warm enough.
body contact and being held is also important for a newborn. by holding him close to your chest, he feels the rhythm of your heart. holding stimulates the breast milk and your bonding.
if the baby cries a lot in the first two weeks, or if he only wants to look in one direction (and not in the other), go to a good osteopath or to a cranio-sacral therapist. in many cases, the crying can be solved.

rhythm
immediately following birth, it is important to get into a predictable rhythm with a set order. the normal order is the following:

1. sleep
2. nurse immediately after she awakes (for a maximum of half an hour)
3. spend time together, including letting her burp and change her diaper
4. then quiet as soon as the baby is tired. give her a pacifier and put her in her bassinet. most babies have great need to suck before they fall asleep. do not interpret this as hunger! a pacifier is often not recommended for the first three weeks because parents sometimes use it when the baby is hungry. then the baby doesnít have enough energy left to empty the breast. the first two weeks you can put the baby on her side.

the time between feedings is two to four hours. (count from the start of one feeding to the next.) do not feed the baby before two hours have passed because the digestive system needs some rest. awaken the baby during the day after four hours. you do not have to wake her up at night.

swaddling  
with clear boundaries, the baby feels secure and can more easily relax. when you swaddle him from shoulders to toes, he is limited and feels where he ends. it is then easier for him to let go and fall asleep.
when swaddled, he wonít wake up so easily by the startle reflex or other uncontrolled movements of his arms.
studies have shown that with swaddling babies wake up less frequently and fall asleep much sooner after arousal. the duration of rem sleep is nearly doubled. in combination with predictability it has also a positive effect on crying and restlessness in babies. (google online: swaddling: a systematic review)

swaddling is a very old technique that was applied virtually universally before the 18th century. currently, only a small percentage of children in the western world are swaddled. many mothers nowadays feel uncomfortable with swaddling. perhaps this is because it seems to run contrary to the current cultural bias in favour of personal freedom over limitations.
as you swaddle a baby, it helps to look at him. the baby usually becomes totally quiet and peaceful. a few times in my practice when i showed mothers how to swaddle, the baby fell asleep within two minutes. the child should only be swaddled when he is brought to bed and needs to sleep. if you swaddle, do it correctly and safely!

instructions for swaddling:
for the first seven weeks, you need a 36-inch square sheet. use a non-elastic, cotton sheet (an old flannel sheet is also good) or a light cotton blanket. lay the sheet on a flat surface and fold down the top right corner about six inches. place your baby on his back with his head on the fold, arms down along the sides of the body. take the right corner swaddle it over his right arm and tuck it under his left arm and let him lay on it. then take the left corner and swaddle it over both arms. make sure he cannot remove an arm from the sheet. use safety pins to fix the sheets around the babyís torso. you need to swaddle from the shoulders down to the feet, tighten the sheets together so the feet canít peek out and leave the rest as a tail in the bed. the legs need to be able to bend. avoid loose swaddling and make sure the child can turn his head to both sides. the child always needs to lay on his back when swaddled. also, do not swaddle:- in the first 24 hours after vaccination,- when their is a fever,- with a serious infection of the respiratory system

tucking in tightly
an alternative to swaddling is to tuck in the babyís blankets tightly around her, thereby also confining her arms. the blanket needs to be big enough and tucked in far enough under the mattress. the mattress needs to fit properly. this, in combination with the babyís weight, prevents the blanket from coming loose the blanket should reach her chin.. use woollen blankets (or silk or cotton) and use them lengthwise across the baby. tuck the baby in every time she goes to sleep. when her feet touch the bottom of the crib/bassinet, the baby canít move down and the babyís head this way cannot end up under the blankets.

belly sleeping
most babies sleep deeper and longer when they sleep on their belly. however, research has shown that the chance of sudden infant death syndrome is ten times greater when babies sleep on their belly than on their back.

warmth
a baby who is equally warm all over (including his feet) feels comfortable and is able to relax. cover the shoulders and, if necessary, put socks on and two layers of long-sleeved shirts. however, make sure the baby is not too warm. overheating when a baby is sleeping can be dangerous! do not use a down comforter or synthetic blankets. be aware of the room temperature! if it is very warm put the baby in just a diaper and use thin sheets to swaddle or tuck him in. this way he still feels the boundaries but is not made too warm. if the baby is not warm enough, he will wake up more easily.

the bassinet
a small bassinet, next to the bed of the parents, is a good follow-up to the small house the baby lived in before, the motherís uterus. a small bassinet helps with the feeling of security. a soft pink curtain makes the space even more intimate. it prevents the baby from being distracted by the environment. the mattress needs to be flat and firm, but not cold. (a sheep-skin on the mattress is often too warm.)

co-sleeping at night
it sounds so idyllic to sleep with a baby in your arms. however, during the night, i recommend that if you choose to co-sleep in this way, you keep the baby at armís length under a separate blanket. this will prevent the baby from following the rem cycle of the mother. if you do not do this, and the baby does follow the rem cycle of the mother, the baby will likely awaken every one and a-half hours and will be tired the next day.
further, feed only when the baby is awake and starts crying, and not if he is just a little fussy. keep feedings short and to the point: no noise, little light, and if possible, no change of diaper. the night is from around 8 p.m. till around 7 a.m.

three weeks to three months:
week after week, you can see that the child is more aware of the environment. he starts looking around, and with the first smile at around six weeks, you really can see that your baby is a totally different person than you are.
rhythm and predictability are very important! this is the normal order:

1. sleep
2. unswaddle and nurse immediately after he awakes
3. spend time together
4. after some quality time together, you can leave the baby alone in a quiet spot on a flat surface. instead of the old fashioned playpen, you can put a simple crib in the living room near the place where you spend most of your time. there you can see when the baby gets tired. if he is, he will become fussy and/or start yawning. if you play too long with him, sometimes you cannot see when he gets tired, and you miss the right moment. that causes stress, and stress releases a hormone that wakes him more. if a baby gets tired, he breaks eye contact, and looks away. another way to know if your baby is tired is that if you put a baby down in his quiet spot and he immediately starts to fuss, he is tired. often, this behaviour is interpreted as the baby not wanting to be in there, and more attention is a common, inappropriate reaction.
5. swaddle him upon the first signs that he is tired and give him a pacifier. (the sucking need before falling asleep continues until he is about three months old).
6 your baby soon recognizes this ritual of swaddling. he also recognizes his bassinet, and the song you always sing before he falls asleep. it is important to put your baby to bed awake. he needs to learn to fall asleep by himself. you can stay with your baby until he is asleep. you can put your hand on his head, or caress his back, or you can leave the room. do not take the baby out of his bed again if he starts crying! 95% of babies cry because they are tired. often babies need to cry before falling asleep. itís their way to be totally relaxed afterwards. allow him to cry! you can also leave the room and come back after five minutes and give him the pacifier again. five minutes will seem like a lifetime, but he will be okay. you have already made sure that he is not hungry, does not have to burp, does not have a dirty diaper etc. picking him up can lead to confusion and more crying.
(sometimes however, when your baby is not used to this routine, he can cry longer because habits are difficult to change. if a child cries continually for more than ten minutes, you can make an exception, and offer him your most empty breast. nursing him for one or two minutes, while swaddled, can help him to relax. you can put him straight back to bed afterwards.)
the time between feedings remains two to four hours. the time awake is 45-75 minutes and the time asleep is 75-180 minutes. if you want your baby to sleep through the night, as soon as possible after 6 weeks, you can try to extend the periods between night feedings by offering a pacifier. however, only do this if the baby is gaining enough weight.

ďcat napsĒ (waking up after a short nap)
after you put her down, sometimes a baby wakes up out of her first rem sleep, and cries within 40 minutes. it is not yet time for her next feeding. you can leave her for a few minutes, and see if she falls back asleep, give the pacifier, or just look to see if everything is all right. you can see if her eyes are open or closed while crying, etc. check her without her seeing you. if she awakens prematurely, do not take her out of her bed immediately. wait a few minutes! when she is swaddled, she will often fall asleep again.

over stimulation
noise is stressful for most babies because they do not recognize most noises and cannot filter it out. a music box and background music may seem calming to a parent, but are disturbing to a baby. constant entertainment of the baby can also lead to too much stimuli. when you have a small baby, receive visitors at home rather than going to their place. wait with a baby gym until the baby is at least three months old.

colic and crying in the evening
some very sensitive babies cry at the end of the day. often it is a stress-releasing cry, and the baby is exhausted. do not distract him to try to stop the crying. sucking on a pacifier may help.
- relax, be quiet and let him cry in your arms until he falls asleep.
- walk with him in a sling until he falls asleep. moving with the rhythm of your walk can be calming.
- put him down in his own bassinet confining his arms.
the crying often will stop within 10-20 minutes. after you hear a deep sigh, he will be deeply asleep.
common reasons for ďcolicĒ are:
- stress and over stimulation;
- not dressed warmly enough;
- breast feeding at intervals of less than two hours because in that case the child drinks more front milk than back milk. the front milk contains more sugar and the back milk contains more fat. sugar can cause yeast in the stomach, whereas fat gives the baby a full feeling.
- sensitivities to the food the mother is eating. avoid eating spices, garlic and onion, and try not eating any cow-milk products (milk, cheese, butter) for a few days to see if this may help.

three months to seven months:
after three months, you can help your baby to get into a 24-hour rhythm by feeding at set times. you can start with two set times a day, and allow the other feedings to occur when she naturally wants to drink. in the morning, you might feed her every four hours, and in the afternoon, every three hours.
babies this age are easily distracted. therefore, you need to focus when you feed the baby and make sure she empties the breast.
learning how to fall asleep by herself as part of a predictable routine and a ritual around sleep times becomes more and more important.
provide her with a horizontal surface to play on. here first she discovers her own hands, and next she starts grabbing things next to her from a lying down position. later she grabs and discovers her feet, and after that she rolls over.
you need to stop swaddling before she starts to roll over. most people stop swaddling when their baby is between three and four months. you can exchange the swaddling blanket for a woolen sleeping sack and simply tuck her in tightly under a woolen blanket. in the summer, it is better to use cotton. i advise a sleeping sack when babies get stronger legs and are able to kick off blankets. when a child rolls, it is time for her own crib to sleep in. this is secure and safe.

between six and eight months, the baby goes from three to two naps a day. bring her to bed for her naps at fixed times, for example at 10 a.m. and 2 p.m. the vegetable and fruit meals are right after her first and second naps. breast milk is the dessert. after the feeding around 4 p.m., the baby stays awake until the next feeding.

some people start to give cereal to help babies sleep through the night. i do not recommend this until the baby is eight months because there is a chance that she will become constipated.

summary
sleep problems start when babiesí senses are over-stimulated and fed at unpredictable times. when a baby doesnít sleep enough, the levels of hormones, like cortisone and epinephrine, rise. this causes the baby to be more alert and camouflages the babyís mental fatigue. this results in a baby who is not able to recover.

strict rhythm and uniformity result in predictability. the baby knows what to expect and feels secure. it allows her to relax. one thing is always followed by the next.

ester delhoofen

ester delhoofen, m.d. licensed in the netherlands, has extensive training in anthroposophical (waldorf) medicine and many years of professional experience with children 0-4 years of age.
she is the mother of three small children. she is the founder of www.floweringchild.com with very soft wool/silk undergarments, soft woollen blankets, woollen sleeping sacks, and information about parenting. she also sees individual children.telephone 612 208 1053