Matt Dwyer: Hey, I’m Matt Dwyer and welcome to Sleep where Professor Harriet Hiscock and Associate Professor Emma Sciberras from the Murdoch Children’s Research Institute help you identify sleeping problems in your children from infancy through to secondary school and give you easy-to-understand steps to improve their sleep cycles and overall health. Harriet, you’ve helped so many families rest easier at night because it’s kind of like a flow on effect: if your kids aren’t getting the sleep, chances are, the parents aren’t either. What exactly do you do and how important is sleep? Not only in general, but, you know, in each developing stage? Infancy, toddler?
Professor Harriet Hiscock: I’m a paediatrician. I’ve been at the Royal Children’s Hospital in Melbourne since 1993 and I direct The Unsettled Babies Clinic there.
We see lots of babies every week with sleep problems and crying problems and, I guess, sleep is one of the fundamental parts of life for all of us. If we don’t sleep, we know as adults we get pretty cranky and then it can affect our mood and then it starts to affect our memory. But it also that has a similar effect in babies. If they don’t get enough sleep, they can get pretty cranky and cry a lot and be really difficult to settle, which in turn makes it really hard for parents to look after them. Then they can start to have their sleep disrupted, which affects their mental health and wellbeing. It also makes it harder just to be a parent day-to-day when you’re feeling exhausted and you’ve got no energy left to do the things you might want to do and to have fun with your baby.
Matt Dwyer: Emma, you’ve got a slightly different approach, but just as important, what sort of role do you play when it comes to managing and maintaining healthy sleep cycles?
Associate Professor Emma Sciberras: Most of the work that I’ve done in sleep is for older children and adolescents. So helping families to implement strategies, to help improve sleep in children and, I guess, try to deal with some of the difficulties that can happen with sleep problems. We noticed that if kids are tired, they can have difficulties with learning, they can have difficulties managing their behaviour at home. So, really, providing strategies around those sorts of things.
Matt Dwyer: And we want to start out as early as possible when it comes to putting our babies into healthy sleep cycles. Well, how much sleep do they actually need?
Professor Harriet Hiscock: Every baby’s different, but typically a newborn baby might sleep for somewhere between 16 and 18 hours per 24 hours. So really, when they come home, usually from the hospital, they might just be feeding and sleeping and feeding and sleeping. It’s really not until they’re about three weeks of age that they start to wake up a little bit more between their feeds and sleeps. They start to look around, check out their environment, and have periods of time when they’re just a bit more awake and interactive. Coincidentally, that’s the time that they also start crying and that peaks at around six to eight weeks of age. No matter where you’re born, if you’re born in Melbourne, Thailand, London, Africa, all babies, follow that sort of similar pattern.
Matt Dwyer: Why exactly do they need that amount of sleep?
Professor Harriet Hiscock: They need that amount of sleep for a number of reasons. They certainly need it for growth. If you don’t get enough sleep, it affects some of the hormones that are produced in your body overnight including growth hormone which, you know, helps you get longer and bigger. It’s also important for the immune system.
Whilst there haven’t been studies done in babies depriving them of sleep, there have been in adults. And they’ve done studies where they’ve stuck the common cold virus up the nose of adults and sleep deprive them or not sleep deprive them. The adults who have sleep deprivation, they tend to get the cold and the cold lasts longer compared to the adults who don’t get the sleep deprivation. We can’t quite ethically do that with babies.
Matt Dwyer: What happens during the sleep cycle? I mean, they sleep for 18 hours, what actually happens? 18 hours, that’s a long time.
Professor Harriet Hiscock: Yeah. Well, the same sort of sleep cycles occur across the lifespan. So we all start off awake and then we go into what we call REM, or rapid eye movement, sleep before we move into non-REM, or non-rapid eye movement, sleep which is really our deep sleep. Babies tend to have more light sleep than older kids and adults. So often parents will come and say to me, “Oh, my baby’s so restless. They just don’t get a deep sleep. They’re always moving around in their cot and moving their head and legs.” And that’s actually often quite normal because they’re just having more REM, or light sleep, than we do as adults. Typically babies will pass through these sleep cycles every 30 or 40 minutes in the first few months of life. Then the sleep cycles start to get longer, about 60 minutes in school-aged kids and then by the time they get to us as adults or adolescents, those sleep cycles are 90 minutes long.
Matt Dwyer: Now if we’re struggling to get them into a healthy sleep cycle are there permanent effects if we don’t get them?
Professor Harriet Hiscock: Yeah, not permanent. So you’ll just see the temporary effects, but it’s not like, “Oh my God, my baby hasn’t slept for the last few weeks properly there’s going to be lifelong issues!” No, I can reassure you that’s not the case, but certainly the longer it goes on, it is harder to try and shift patterns. I think a big myth out there is that we all think that babies just know how to go to sleep. Actually, sleep is a learned skill and we actually have to teach babies how to put themselves to sleep,
Matt Dwyer: You know, as a new parent, how do we tell if our child is experiencing sleep difficulties?
Professor Harriet Hiscock: I might throw it too Emma with this. What did you notice Emma, with your little one?
Associate Professor Emma Sciberras: So some personal experience, my little one’s two now, and after working in sleep for many, many years with children and adolescents, it was my first experience managing sleep in an infant. I guess in terms of the initial experience of having a child, the sleep deprivation that you experience is quite significant. I think when you’re in that sleep deprived state, all you want to do is sleep and so it can be really hard to determine what’s normal and what’s not. And, in my experience, having that initial period of acceptance around some night waking, and there was quite a lot of it. Also, I guess once my child started to get a little bit older, speaking to other mothers that were in my mother’s group and other people that had had children to understand how often their child was waking in the night.
Professor Harriet Hiscock: Emma brings up a really good point: what’s the blur between normal and a problem. At a very simple level, I’d say if it’s a problem for you as a parent, it’s a problem so go and ask for advice from a trusted health professional about it. But night waking is normal. Babies need to feed overnight and it’s certainly up to six months of age that they will often be waking. After six months of age, they can get enough of their nutrition during the day to not have to wake up overnight and feed, but many parents choose to keep feeding after that time point and that’s a personal decision.
Matt Dwyer: What are the biggest causes of sleep trouble?
Professor Harriet Hiscock: Yeah, the biggest issues that we see the first few months, I think just like what Emma’s saying, you have to go with the flow. I think for the first three months, this baby’s just come into the world. They’re learning to bond to their main caregiver, which might be the mom or the dad, or both, or someone else, that they’re adjusting to this big bright world. So the first few months, just go with the flow and that might mean to get your baby to sleep you have to put them in a carrier or you have to have them in the pram for some of the daytime naps. After three months, we can start to help babies learn to put themselves to sleep and the first step in that is recognising when your baby’s tired. So the sorts of signs they might show you is that they might be frowning they might be clenching their arms and their fists and jerking their arms and legs. Then they start to cry, but crying is often a late sign. By then, if you’re trying to put them to bed, it might be too late.
So step one is recognise when your baby is tired. Step two is, then, say, “Okay, it’s bed time”, and have a consistent sort of routine. That might be giving them a cuddle, wrapping them, and then taking them into a dark, quiet room and putting them down into their cot or bassinet drowsy, but still awake, because you want them to be able to put themselves to sleep.
The tricky part is that, a lot of parents get into this, particularly if they have had a baby that’s cried a lot, is they pat their baby off to sleep or they feed them to sleep. So every time that baby comes out of the deep sleep up into light sleep and wakes up from their sleep cycle, they want to be patted again or rocked again or have the breast or a bottle feed again before they’ll go back to sleep.
So I guess, as a parent, it’s recognising those tired signs and then getting your baby calm, but letting them do that last little bit of going off to sleep without you patting them or rocking them or feeding them to sleep.
Matt Dwyer: I guess on the opposite side of that, are there signs that we can then feel confident about that our babies are getting enough sleep?
Professor Harriet Hiscock: Yeah, look, certainly if your baby is waking up pretty happy and having periods during the day where they’re awake and interactive and happy before going to sleep, that’s a pretty good sign. So rather than an absolute amount of sleep they’ve got to have, it’s more about their temperament and are they happy and interacting and developing normally. I guess the other thing, as you were saying is, what causes sleep problems? We do see some babies who right from the get-go are really hyper alert and really what we call ‘vigilant’ about their surroundings. Those babies, you know, no one can get them to sleep and settle them in the first few months of life. So I think parents need to take the guilt off their shoulders, we have enough parenting guilt, so that they just go, “Okay, my baby’s like this. I’m going to go with the flow until at least three months of age when I’ll try some of these more, you know, hands-on settling strategies.”
Associate Professor Emma Sciberras: And I think I found that really helpful. So I remember being in the hospital after I’d given birth at about four o’clock in the morning. We went back to the room and I remember my little one was awake for that whole time, for at least three hours, and was just lying there with her big eyes open.
And I was thinking, ‘is this child going to go to sleep?’ And we found it really hard initially because she was really alert. I think the other thing that we found with her is that she didn’t have as many obvious tired signs. One of the things that we found helpful with that was kind of having a set time to put her down again because she was kind of just on the go and interested in everything.
And so putting her down every hour and fifteen minutes and then slowly extending that out as she got older was something that we found helpful.
Professor Harriet Hiscock: Yeah, that’s great. And I think that that structure, you don’t have to be like to the minute and rigid about it, but that overall sort of structure actually helps babies learn to anticipate what’s coming in their day and that, for them, is reassuring.
And then that helps them start to go to sleep and learn to do that by themselves. If you’re doing something different every time it’s nap time, that’s actually very confusing to the baby.
Associate Professor Emma Sciberras: And Harriet, I guess one of the things that I heard a lot of early on before the three month mark was, I was doing a lot of baby carrying, and I was getting the message a lot that, you know, you’re setting up bad habits.
Professor Harriet Hiscock: Yeah.
Associate Professor Emma Sciberras: For your baby. Can you set up bad habits? Before three months?
Professor Harriet Hiscock: No, that’s a fantastic point, Emma, I don’t think you can. And I think, you know, some of these babies are just born very alert and they won’t close their eyes on the world cause they’re so interested. And some of the babies with colic, which is just another way of saying that they’re crying for more than three hours a day for more than three days in a week, you can’t do anything to settle them. Sometimes carrying them is the only way that will help them calm down. So certainly before three months, I say, do what you need to do to survive.
Associate Professor Emma Sciberras: Survival mode.
Professor Harriet Hiscock: Absolutely. And, you know, a bit of a serious point; if you ever feel like you are getting angry towards your baby, put them in the cot and walk away, they’re safe there. Never, ever, ever shake a baby because that’s what we know can lead to brain damage. And that is a permanent consequence.
Associate Professor Emma Sciberras: And I guess, just on the baby carrying thing too, I think another piece of advice that you hear a lot is, you know, resting when your child’s resting.
And I think that’s really hard when you are doing a lot of that baby carrying. So I guess just highlighting the importance of getting additional support and getting people to come over and also do a bit of that carrying too.
Professor Harriet Hiscock: So
Associate Professor Emma Sciberras: you can actually get some rest.
Professor Harriet Hiscock: Absolutely.
And certainly in our clinic we talk about this with moms: who else can help you out?
Is it, friends, family, et cetera? I think we’ve got to, as mums, take the pressure off making sure our house is perfect and everything is done. Being a parent is a 24-7 job and people just say that flippantly, but it really is. I will often say to moms, “When your baby is sleeping or resting, try and rest. You won’t sleep, but do try and rest. Don’t run around the house doing the housework because you need your rest and sleep to be able to function and look after your baby the best you can.”
Matt Dwyer: As the baby gets older, at what age do we start to transition into newer sleep cycles and newer methods to keep them asleep? Do things start changing at a certain age?
Professor Harriet Hiscock: Yeah, they certainly do. From six months I think it gets a lot easier often by then. You’ve started solids and not just having milk feeds and that sets up a bit of a rhythm for the day as well.
So I think that’s a great time to start with a lot of sleep strategies if that’s what you want to do. I think we should also just be aware that 15% of babies are what we call ‘catnappers’. They just sleep for one sleep cycle, two or three times a day. They just have 30 or 40 minutes and that’s it and you can set your clock by it. I see a lot of very distressed parents going, “but he’ll only have one sleep cycle”, but it actually doesn’t matter. Usually these babies tend to sleep really well at night and it’s just a phase that they go through and, just anecdotally, sometimes what I find is once they start crawling, they physically exhaust themselves and then they start to string together two sleep cycles and have a longer nap.
Matt Dwyer: Are they still getting the same amount of sleep?
Professor Harriet Hiscock: Often they don’t get quite as much sleep because they just are catnapping and they can sometimes wake up from that cat nap really grumpy. What I say to moms and dads is, “try and resettle them in their cot for 15 minutes but don’t try after that. If it’s not working, if you can tell they’re not going to settle, pick them up, put them in a sling, put them in the pram, go for a walk and try again. next nap”. Hopefully they’re having four or five naps a day, and these will start to drop off as the baby gets older. So certainly by the time they’re getting towards 12 months of age, they’re usually having two naps a day: one in the morning and one in the afternoon. Sometime around, 18 months or 2 years, they might start dropping down to one nap per day. You can often tell this cause you put your baby in the cot and they just won’t go to sleep. They’re just playing and mucking around or they’re actually not tired. That’s often a bit of a sign that they’re dropping down to one nap per day, but that transition time can be a really messy couple of months when they’re going between two naps on some days and one nap on the others. Could you tell when you’re little one was transitioning?
Associate Professor Emma Sciberras: Yeah. So she transitioned about 18 months, we were doing the morning and afternoon nap, and I must say I was pretty keen for it to become one nap. I was finding that a little bit restrictive. But yes, just like you described, it was actually more the afternoon nap that she stopped having. So what that meant is that she had the morning one and it was a really long awake time. So we needed to kind of slowly push her back to go for that middle of the day nap.
Professor Harriet Hiscock: And how did you do that?
Associate Professor Emma Sciberras: Well, I think I combined approaches initially. So I think I started by pushing it back. It was around 9:30 to start off with and then we got her to stay up until about 10 o’clock. Then I think I pushed it to around 10:15, but then once she could get to that point, it was just easy for me to change it to 12 and just have a couple of days that were a bit tough. I had to keep her really engaged and entertained until 12 to keep her awake.
Professor Harriet Hiscock: Yep.
Associate Professor Emma Sciberras: Initially I guess when we did that, her naps were kind of around the hour mark but over a couple of weeks, she just began to naturally extend them to have a good two hour nap.
Professor Harriet Hiscock: Great. I think one of the real challenges around this is when your baby is in daycare and how you manage naps in that setting. I guess from a baby’s point of view, the more consistent you can be across home and daycare the better. So I encourage parents to write down and have a conversation with the educators from the day programs or if they’re in long day stay or whatever it might be, just have a conversation about, “this is how I settle my baby at home,” and see if they can do the same thing so your baby gets some consistent messages which will help.
Associate Professor Emma Sciberras: Yeah. I must say that we were onto that with a plan at childcare and I think the staff were really supportive because I think from their understanding of what I was doing at home and what was working it actually made their life a lot easier
Professor Harriet Hiscock: yeah.
Associate Professor Emma Sciberras: at childcare. I think the thing that that happens sometimes is that they might not take a nap, because it’s so exciting and there’s so much stimulation going on. I guess in our experience, just trying to manage that by going for an early bedtime once we got home from childcare, it was the only way we could survive at home because it was quite a hectic kind of 5:00 to 7:00 PM period.
Professor Harriet Hiscock: The ‘arsenic hours’ as we sometimes call them. I had the opposite experience. My firstborn, would sleep well at daycare, but I think when he came home, he wanted to see me. With my husband, he was fantastic. He took a day off a week and he would sleep really well for him. But when it was my day to have him, he would not sleep.
I don’t know if that’s a compliment or not, but you know, again, you just sort of got to go with that flow a bit. Try and encourage them, have your routines, have them trying to go down for naps, but also realise that they’re negotiating going between different caregivers and different settings so being a bit patient.
Matt Dwyer: So you want to try and get the routine happening a little bit more organically.
Professor Harriet Hiscock: Yes. Yeah. But having some routine, cause they will thrive on that. It doesn’t have to be to the minute but having a thing where they know, “okay, we have time for feed, time for a play, then it’s time for sleep” and having that sort of sequence throughout the day can help.
Associate Professor Emma Sciberras: And what about early waking? What is early waking? What’s considered early?
Professor Harriet Hiscock: Again, there’s no absolute definition, but I think anything before 6:00 AM is pretty rude. That’s how I view it. And there’s not a lot you can do for really little babies, particularly if they’ve been in their cot for 12 hours, they might have had enough sleep. One of the things, and we’ll talk about this in the toddlers and older children, is when they wake up, not rewarding them for that waking. And by that, I mean not giving them time in front of a screen or a television because that can reinforce that behaviour, certainly for the little ones.
If they haven’t fed overnight, you can offer them a feed and maybe that feed is in the bedroom, still dark, still quiet. And if they’ve woken at 5:00 or 5:30 AM, you might be able to give them a feed and they can go back to sleep again for another hour or an hour and a half if you’re lucky.
Matt Dwyer: And Harriet, what about dummies? Are they safe?
Professor Harriet Hiscock: So dummies or pacifiers, as they’re called in Northern America, can be absolute lifesavers for parents, particularly if their babies cry a lot. This is a way of soothing them. So again, I tend to say, “look, go with the flow in the first few months, whatever works is fine.” The issue after that is that the baby can learn to only fall asleep with a dummy. Then the dummy drops out and parents find they’re waking up every three hours and having to go and put the dummy back in. I have seen glow in the dark dummies and all sorts of products to try and help that, but it doesn’t really help.
So there are a couple of options that we can talk about later in the management segment about managing dummies, but I really think they can be lifesaving in the first few months of life. There has been concerns in the past that they interfere with breastfeeding establishment. So the advice really is to try and hold off from giving your baby a dummy for the first couple of weeks of life, at least to let them establish breastfeeding, and then offer it after that.
And there’s good evidence that it doesn’t interfere with breastfeeding rates if you do that after a couple of weeks.
Associate Professor Emma Sciberras: Harriet, can you tell us a little bit about postnatal depression and the links between postnatal, depression and sleep?
Professor Harriet Hiscock: Yeah. Look, there’s very strong links, Emma. Certainly about 10 to 15% of Australian mums will experience postnatal depression and that’s really defined as persistent feelings of: feeling down, feeling sad, crying, feeling hopeless, being so sad you can’t sleep properly or eat or function properly.
And what I’ve noticed a lot with postnatal depression is it tends to fluctuate. So some of today’s mums will have really good days and then they’ll have bad days. And they’ll say, “look, I can’t possibly be depressed cause I have some bad days”. But if these are symptoms that are going on for weeks or months, certainly you need to get help and speak to your nurse or your GP or someone like that.
Or, there’s a very good national group, an antenatal depression association, PANDA, which has a great support for mums and dads, because dads can get postnatal depression too. But what we know from some of the work we’ve done is that if you have a baby with a sleep problem, that doubles to triples your risk of having postnatal depression and that’s in both moms and dads.
There’s a very strong connection between the two and it’s probably not surprising; if your sleep is chronically disrupted and if you’ve got a baby that’s crying and won’t settle, it’s really hard on your mood. And I think it’s also really hard for you to bond with your baby. Another myth we have in our society is that you should just fall in love with your baby the day they’re born. And that actually doesn’t normally happen, particularly if you’ve got a baby who won’t sleep and all they do is cry or they’re vomiting all the time and often not enjoying your baby is a bit of a red flag for postnatal depression. So I think as a mum or a dad, if you’re not enjoying your baby in this context, that’s when you should absolutely be going and talking to someone about it and getting some help.
Matt Dwyer: Thanks so much. There’s a lot of good info there for new parents, or parents having their second, or third child.
Sleep was presented by Harriet Hiscock and Emma Sciberras and produced by me, Matt Dwyer, audio production done by Darcy Thompson and our executive producer is Jen Govern. For more apps, go to podcast one.com.edu.
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And how to tell if that knock on the head could have caused a concussion. Just search concussion podcast to start listening.