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MATERNAL AND INFANT SLEEP – REALITIES, RESEARCH AND STRATEGIES
By Libby Rosen, RN, BSN, IBCLC, and Leslie Arnold, CNM, ARNP, MSN
N
ew parents have many daunting adjustments to make,
and they begin with the pregnancy. New mothers are
faced with changes biologically, socially and psychologically.
Maternal sleep is one such change, and biologically we need
sleep to feel rested, to be alert and to function effectively. The
birth itself often interrupts sleep, and the demand of an infant
who needs frequent feedings exacerbates this change in early
maternal sleep patterns.
INFANT & MATERNAL SLEEP
New parents seek help and support most often regarding
infant sleep and feeding.1 The interactions and the relationship between parent and baby have a profound effect on the
patterning of the infant, whether it be sleeping, feeding or
self-soothing.
Parents often anticipate that their baby’s
sleep will mirror their sleep.2 In an effort
to get more sleep, new mothers sometimes
change their plans regarding feeding method
or place of infant sleep. Minimizing disruption
of sleep plays a positive role in the continuation of the breastfeeding relationship during
the early months. The American Academy of
Pediatrics recommends that all infants should
be breastfed for at least the first year of life.3
If we can establish rhythms and patterns for
sleep of new mothers and babies, we might
be more likely to achieve the Healthy People
2010 goal to have 50 percent of mothers
breastfeed for at least the first six months.
The challenge of understanding the maternal-infant relationship in the context of sleep was addressed
at SLEEP 2007, the 21st Annual Meeting of the Associated
Professional Sleep Societies. An oral abstract presentation by
Ramos described a parental interactive bedtime behavior scale
which identified six factors that reflect the maternal-infant
relationship.4 These factors include: awareness of signals,
promptness, accurate interpretation of signals, availability,
rhythmicity (routine versus a schedule) and maternal warm
affect. Ramos also has pointed out that there are two types of
bed sharing: planned and reactive.5 Reactive bed sharing is
something to which parents resort in an effort to obtain more
sleep.
A 2003 study reported that 44.7 percent of infants spent at
least some time in the parental bed at about 4 months of age,
and that routine bed-sharing rates doubled between 1993 and
2000 to a reported 12.8 percent.6 Bed sharing is reported to
be more common among Asian, Hispanic and African-American families, among younger mothers, and in low-income
families. Glenn and Quillin also reported that mothers who
breastfed and co-slept obtained more sleep than those who
used separate sleep surfaces.7 Research also has found that
although mothers reported that the baby slept in a crib or
bassinette in its own room or the parents’ room, it was very
common for babies to end up in the parents’ bed regardless of
demographic background.8
Often the parents’ perception of their infant’s sleep does
not match reality. In a study that used video
taping of the infant’s sleep, parents reported
that 42 percent of 2-month-old and 78 percent of 9-month-old infants slept through the
night; actually only 15 percent of the babies
at 2 months and 33 percent of the babies at
9 months slept through the night. The other
infants had periods of awakenings that did not
disrupt their parents’ sleep.9
Infant sleep development begins in utero at
about 24 weeks gestation and has more identifiable stages by 34 weeks. As a newborn, rapid
eye movement (REM) sleep and non-REM
(NREM) sleep are equal, with REM sleep
occurring first in the cycle. By about 6 months
of age the baby has sleep patterns that more
closely resemble that of an adult. Quillin and
Glenn found that infants average 14.65 hours of sleep in 24
hours, with less than half of that time (6.15 hours) occurring
during the mother’s usual sleep time.10 They also reported
that co-sleeping increased the overall amount of sleep for
breastfeeding mothers, although this sleep occurred during
more sleep periods in 24 hours.
About seven to eight hours of uninterrupted sleep is
considered the average amount required for restfulness, and
people function more effectively and generally feel better
when they are rested. But Quillin found that at four weeks
postpartum, mothers average 6.15 hours of night sleep and
7.53 hours in 24 hours - much of it interrupted.11 Rosen
found 6.6 hours to be the average by polysomnography with
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and support
most often
regarding
infant sleep
and feeding.
LESLIE ARNOLD, CNM, ARNP, MSN
Libby Rosen, RN, BSN, IBCLC, is a PhD
candidate at the University of Kansas
School of Nursing and an instructor
at Baker University School of Nursing,
Stormont-Vail HealthCare Campus, in
Topeka, Kansas.
Leslie Arnold, CNM, ARNP, MSN, is a
nurse midwife in private practice at Lincoln Center OB/GYN in Topeka.
A2Zzz 18.3 | September 2009
¬ Continued on Page 20
LIBBY ROSEN, RN, BSN, IBCLC
¬ Continued from Page 19
20
a range of 4.1 hours to 9.12 hours in a group of 44 mothers - 22 breastfeeding and 22 formula feeding; there was no
statistical difference in sleep parameters between groups using
both wrist actigraphy and home polysomnography.12 Signal
and colleagues reported a mean of 7.29 hours of sleep at six
to seven weeks postpartum, with a range of 4.37 to 9.72 hours
using wrist actigraphy and sleep logs to measure the sleep of
eight first-time mothers.13
Women with postpartum mood disorders ranging from
depression to the less common occurrence of psychosis, or
anyone with a history of mental health issues prior to pregnancy, may be more prone to experience these issues during
the postpartum period if they are sleep deprived.14 Differentiating fatigue from depression can be a challenge. If fatigue
is the only measure of sleep quality, it may not be an accurate
assessment of maternal sleep. Therefore, fatigue, sleep quality
and depression should be measured in order to determine the
primary issue
Fatigue also may be related to impaired sleep in new mothers with respect to their role as caregivers. In a study of 133
mothers, Doan and colleagues found that those who exclusively breastfed slept 40 to 45 minutes more per night, averaging 7.2 hours of sleep.1 Mothers who supplemented their
nursing babies with formula in the evening averaged only 6.4
hours of sleep.
STRATEGIES TO HELP NEW PARENTS
At the beginning of the pregnancy mothers often report
changes in their sleep patterns that may include an increase
in napping or more sleep disruptions related to frequency of
urination and physical discomfort. Some mothers believe that
these changes help prepare them for what sleep may be like
during the postpartum period. As the fetus becomes more
active, mothers may be awakened by fetal movement during
the night. Using a sleep activity record, the mother can document her sleep and fetal movements during the last month of
the pregnancy in order to anticipate when the baby may be
most active after birth.15 This kind of preparation, along with
education about normal infant sleep and wake patterns, can
be useful anticipatory guidance for new parents. Establishing routines for bedtime can begin by singing the same song
or reading the same book during the last weeks of pregnancy
and continuing this during the first weeks of life to establish
rhythmicity in the newborn.
Stremler and colleagues conducted a small, randomized
clinical trial that tested strategies to facilitate maternal and
infant sleep. These strategies included parental education
about sleep hygiene and normal infant sleep patterns.16 The
intervention group of parents reported fewer sleep problems,
and the mothers slept for 57 minutes more than controls as
measured by wrist actigraphy; the 15 infants in the sleep intervention group also obtained an average of 46 minutes more
sleep. This economical teaching method is easy to implement
and has strong potential to improve family sleep patterns.
Stremler is replicating the study with a larger sample of more
than 240 families.
Sleep technologists who are given the opportunity to address sleep issues with expectant parents should encourage
good sleep hygiene. This includes: consistent bed and wake
times; using the bed for sleep and sex only; avoiding caffeine,
exercise, and meals just prior to bedtime; and creating sleep
environments that are quiet, dark and cool. Encouraging
parents to nap when the baby is napping is another important
and under-utilized strategy.
Either prenatally or during the early postpartum period,
parents should be given the opportunity to learn about infant
sleep cycles and the differences between infant sleep and adult
sleep. This will help them to differentiate between the sounds
and movements that a baby may make during active sleep and
true awakenings from sleep. Parents also can more effectively
meet the needs of their baby when they know the differences
between states of hunger, sleep and irritability. Some studies
have suggested that allowing the baby to self soothe and settle
into sleep on its own, rather than feeding or rocking the baby
to sleep, may help the child establish better sleep patterns.
The American Academy of Pediatrics recommends that
babies sleep in the same room with parents, although not
in the same bed.17 However, studies have shown that many
parents reactively bed share regardless of this recommendation. Parents who bed share need to be aware of how to make
this as safe as possible. Bed sharing should occur only in nonsmoking households, with non-obese parents who are neither
overly tired nor under the influence of drugs or alcohol, and
on a firm mattress without extra bedding.18 Sharing information about safe surfaces for infant sleep is important because
many parents put a child to sleep on unsuitable surfaces such
as a sofa or recliner.
CONCLUSION
Sometimes the best advice for new parents is, “This too
shall pass.” Helping parents learn to set up bedtime routines
with good sleep hygiene will set the stage for healthy sleep
patterns. All parent educators should stress that each baby
and family is unique, and there is no one strategy that will
work for all families. It is also important to offer information
about “typical” hours of sleep and the fact that most babies
do not sleep through the night until they have doubled their
birth weight at about 4 to 6 months of age. Listen, educate
and offer suggestions to new families that are coping with the
adjustments of parenthood. Remind families and friends that
the best gift they can offer is to hold the baby while the new
parents nap.
REFERENCES
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Ramos K. Parental responsiveness to children’s sleep
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