One of the most common questions parents have for their pediatrician is about sleep in infants, children and adolescents. Sleep cycles, circadian rhythms and nutritional needs change dramatically through childhood, so today, let’s talk specifically about sleep in infancy (the first year of life), and tackle sleep challenges in older children in future articles.

Jokes about newborn babies keeping their parents up are common among parents, but sleep deprivation can be serious and significantly impacts the entire family’s functioning and mental wellbeing. There is a strong correlation between sleep deprivation and depression, including postpartum depression, which in turn can negatively affect the baby’s attachment and ability to sleep, resulting in a cycle of disrupted sleep that can last months.

Most newborns (roughly the first three months of life) have variable sleep cycles and have not developed much of a circadian rhythm. They sleep between 14 and 17 hours a day, but some babies sleep a little more or less than that. Newborns need to sleep every one to two hours. Generally speaking, especially for exhausted nursing parents, the rule of thumb is to sleep when the baby sleeps to remain well rested.

Newborns need to be fed every two to four hours around the clock. By about six months of age (12-14 lbs), their stomachs are bigger, so they typically need fewer daily feedings. It is usually around this time that they no longer need night feedings to maintain their metabolism, so larger feeds just before bed and the introduction of solid foods after six months can help them sleep longer through the night and wake less often.

While by four to six months, babies take on a more predictable sleep pattern with about 12-15 hours of sleep, including two to three longer naps during the day, it’s not uncommon for a baby to wake more at night at around four months. This ‘four-month sleep regression’ happens because of brain and body changes taking place at this age, including the development of an internal circadian rhythm, which usually only lasts for two to six weeks. It can be very disruptive to parents who may have finally started to feel rested, but it will pass. Try not to react with more frequent night feedings or too many other interventions, as these will become habits that will be harder to break later on.

So what can parents do to help everyone get more sleep? Here are some helpful safe sleeping tips for infants:

• Create a calm, consistent and soothing sleep environment, which includes dim or no lights, quiet or a consistent sound machine (variable sounds like TV, songs, even lullabies or household noise can disrupt a baby’s sleep.)
• Optimize opportunities for attachment and attunement—meaningful, undistracted connection with parent or parents throughout the day and at bedtime—so that nighttime isn’t the only time they get that attention.
• Establish simple bedtime rituals that cue the baby that it is time to sleep, such as bathing, singing, reading books, etc.
• Keep a consistent bedtime and nap schedule once the baby is about three to four months to help set their developing circadian rhythm.
• Avoid late afternoon or evening naps after seven to eight months if these disturb nighttime sleep.
• The American Board of Pediatrics recommends room-sharing for infants but not bed-sharing, because of the risk of suffocation and SIDS for the baby. A bedside bassinet, crib or specifically designed sleeping surface remains the safest option both at night and for naps during the day. Couches and chairs are never safe places for a baby to sleep, either alone or with a caregiver.
• As a pediatrician, I cannot recommend co-sleeping, but the reality is that for many families the risks of co-sleeping are outweighed by the benefits of sleeping with the baby, such as increased connection, night nursing on demand and co-regulation, so a few words about safer co-sleeping if your family decides to do so:
  • If a caregiver has been drinking or using anything that makes it harder for them to wake up, if they smoke cigarettes or if the baby was premature (born before 37 weeks), then co-sleeping is far more dangerous.
  • If you do decide to co-sleep with your baby, safer co-sleeping recommendations include keeping all adult bedding and pillows away from the baby, placing them on their back in their own bedding on a firm mattress, keeping other children and pets off the bed, and making sure that the baby cannot get trapped by a frame or headboard if they move in the night.
• Baby vital monitors like the Owlet have not shown evidence of preventing SIDS, and often only cause parental anxiety and reduce the parents’ sleep even further. They are not recommended.
• Swaddling a baby when they sleep is safe in the newborn period but should stop before a baby can roll over, or at three to four months, whichever comes first.

What can you do if your baby already has sleep problems? The good news is that it’s never too late to establish good sleep habits. The first, most important rule is to lay the baby down sleepy but not yet asleep. If they fuss, offer everything but breast or bottle so they get used to falling asleep without these—that means comforting, touching, singing, snuggling, etc. Later, once falling asleep without breast or bottle has been established, you can slowly remove these other inputs until the baby learns to fall asleep on their own.

This way, when they wake in the night, as all babies do, they won’t need breast or bottle to fall back asleep and the parent may be able to sleep through these nighttime arousals. It may take a little bit to change these expectations if the baby has been nursing to sleep, but it will work if you stick with it.

A word on “crying it out”—letting the child cry without responding until the crying behavior stops. Some studies on this method have demonstrated elevated infant cortisol levels and undue stress on the baby, while others have not shown harm. I don’t think this method makes sense from an attachment lens—why tell your baby that you won’t come and help them when they cry for help—but there are a few exceptions. Specifically, if sleep deprivation is causing an impending divorce, or one or both parents are losing their mind, then draconian sleep training may be better in the long run for the family.

I hope these tips help, and if you’re sleep-deprived and exhausted by your baby, please remember this season won’t last forever. Your high school sophomore will likely let you sleep through the night.