The first 6 weeks
The newborn child is amazingly attractive to the majority of people. Many of your friends and relatives will want to hold, touch and advise. This can be strengthening, but when offered in excess, it is quite tiring. As one of my patients said to me ‘every man and his dog has an opinion’ about feeding and sleeping in the newborn. So do I, and here it is.
As this book is aimed at being of assistance to parents, there needs to be something to help with. If your baby feeds well, gains weight as expected, and sleeps like an angel, then there is no problem. Parents come for help when one or more of these areas is not functioning well.
The problems of feeding are dealt with in the Chapter on Food, Feeding and Breast Care
The remaining problem is sleep. Poor sleep in the newborn is so common that it is almost accepted as normal. Indeed, during the first six weeks, waking for feeds three to four hourly is normal. However long periods of crying are not expected. In this first six weeks of life in most cases, when the child is normal and healthy, is a cycle of feed – sleep – feed – sleep – feed – sleep. Many families are not this fortunate and report problems with excessive crying. I will discuss sleep problems in the newborn in two ways: Prevention and Management.
Prevention of Sleep Problems in the Newborn
Excessive crying in the newborn infant can have multiple causes. The child may be unwell. This needs to be excluded. My advice applies to healthy, normal infants. If you consider ill-health as a possible cause, then contact your medical adviser. Once you are convinced that the child is well but tearful, then a diagnosis is needed. Two causes dominate above all others. Hunger and tiredness. Many other diagnoses are mentioned widely in society. These include colic, wind, reflux, silent reflux, and minor lactose intolerance. All of these can occur, but I generally find that if hunger and overtiredness are treated, the problem of excessive crying disappears in the majority of families. In other words, I use the other diagnoses last, not first.
The hungry infant has every right to express a negative opinion. This problem and its treatment are dealt with extensively in the chapter on feeding. I will not repeat that information here except to say that hunger needs to be excluded as a possible cause of crying. Check that chapter for the appropriate methods.
We now have a child that has been checked by an appropriate professional and deemed to be well. You have excluded hunger, as the weight gain is excellent. The child is still tearful and requires much handling to settle. The dominant cause is fatigue or overtiredness. How to recognise overtiredness is discussed extensively in the chapter on Sleep Problems. In this section I wish to discuss preventing the problem. The prevention of overtiredness is the second thing which I emphasise to my patients with young babies. The first item having been adequate weight gain. Causes of overtiredness in our culture are usually easy to identify. Forgive me for stating the obvious, but overtiredness is the result of not getting enough sleep. But how do you know what is enough sleep? The majority of newborn infants will sleep 17-18 hours per day, and sometimes up to 20 hours. You would be amazed at the number of raised eyebrows I get when I mention that number.
The major cause of overtiredness is overhandling. Newborn infants are a centre of attention. They bring joy, celebration and many visits from attentive relatives. There is an unfortunate tendency for friends, relatives, partners, guests, in fact almost anyone, to want to hold the baby. Babies will often doze off in someone’s arms, but they do not achieve the depth of sleep required to achieve their best rest.
Prevention of overtiredness requires some planning. It is usually the mother who has to be the policewoman, as it is she who copes with the consequences.
For the newborn baby, keep waking times as short as possible. They have limited stamina, and cannot be meaningfully awake for long at this age. Waking times in these first few weeks may be 30-45 minutes. Shorter is better than longer. Waking times are for feeding, changing, bathing and enjoying touch. Once the feed is completed, the nappy changed, and the baby prepared for bed, then put him or her down and allow them to return to sleep as rapidly as possible. Try to avoid loving relatives playing ‘pass the parcel’ with your baby for hours on end. They will leave, the baby will be overtired, and then you have a difficult time because the child has become too tired to sleep well, and possibly too tired to feed efficiently.
Now some of you may be thinking or saying that your feeding takes 40 minutes. ‘How can I get the child down in 30 to 40 minutes?’ My experience is that the majority of babies who are breast feeding well or those who are bottle feeding will take their necessary volume in 20 to 30 minutes. There are plenty of exceptions, but the majority of babies will have taken the required volume of milk in about that time.
For those women who are finding that breast feeding is taking a long time, say an hour, ‘this is only a problem if it is a problem’. If you feed for an hour and the child goes to sleep efficiently and then gives you three to four hours sleep, that’s fine. Do not change anything that is working well. If, however, the baby is difficult to settle after such a long feed, there are a couple of hints.
Watch the sucking style of the infant. On first attaching, sucking and swallowing is quite rapid. Some of you may even hear the first mouthful ‘hit the bottom’ as it reaches the stomach. After several minutes the sucking will often change to a more leisurely style. The child is becoming more relaxed as the stomach fills. At some point of time the suckling becomes ’social’. To put it bluntly, the child may get to a point where you are being used as a dummy or a soother. The sucks become intermittent, and the baby is often in a shallow sleep by this time. The time taken to get to this point varies for each baby-mother team. The only question to ask of yourself is whether your baby is feeding from you, or using the nipple as a dummy. If you think that the latter is the case, then draw the feed to an end and prepare your baby for bed.
The keys to preventing overtiredness in healthy newborns:
- Ensure that milk intake is adequate and ensure that weight gain is good.
- Avoid prolonged handling, particularly by visitors and friends.
- Aim to achieve 16 – 18 hours sleep per 24 hours.
Management of Overtiredness
This is discussed extensively in the Chapter 4 on Sleep Problems, but a couple of points are worth emphasising in this section on children in the first six weeks of life.
As you may have read elsewhere, the treatment of the overtired child involves teaching ‘independent sleep skills’ and increasing the number of hours sleep per day. In the newborn, the body’s reaction to light and dark is not present, but will establish itself by about six weeks. Thus in the first few weeks, many babies do not have a long period of sleep at night. In addition to the developing response to day and night we now add the ability to sleep independent of mother’s body. Babies do sleep before birth and by definition all of this occurs in close and unavoidable contact with the mother. After the baby’s birth I encourage mothers to allow the transition to sleep to occur alone as often as possible. If sleep is achieved in your arms, that’s fine, but as soon as possible, place him or her down to sleep alone.
The overtired infant will have trouble achieving sleep and will protest to the best of his or her ability. How do you respond?
Elsewhere I have described a program of minimal reassurance, or ‘crying down’. For the very young child, the guidelines are a little gentler than for the older child of say six months or more.
The baby in its first few weeks is extremely sensitive to fatigue, and so prolonged periods of crying are counter-productive.
If you are happy that your baby is well, has a full stomach, and needs to sleep, then place him or her in its cot. Dress, wrap, and cover in a way that is appropriate for the weather, and then leave alone. If the baby has gone into a deep sleep in your arms, this may be no problem at all. Sometimes however, they rapidly awaken and cry. The plan of action is the same for both styles of crying. Do nothing for five minutes. If five minutes is too long for you, try three. The longer break tends to be more useful than the shorter. If the baby has not settled in five minutes then attend and give reassurance. Check that the baby is safe. Give a little soft touch on the cheeks or forehead, let your child hear your voice. To the best of your ability, let your tone be calm, confident and loving. Please avoid the traps of rocking, prolonged patting, wheeling or walking around the house. Give reassurance and comfort for about one minute, and then leave for another five minutes. Repeat this cycle, slowly increasing the time that the baby is alone.
The majority of babies who are well and have an adequate milk supply will achieve sleep within 15 minutes. A little warning here. Different times of day make a difference. Settling times through the night are often shorter, mornings may be a little longer. Afternoons and early evenings may be the most difficult. As the baby becomes increasingly tired during the day, his or her ability to perform the transition from wakefulness to sleep decreases. His or her ability to achieve sleep becomes a little weaker. This is sometimes complicated by a lower milk supply in the breast feeding mother in the early evening. The baby may be both overtired and hungry.
If you consider hunger as a potential problem, the appropriate care is discussed in the Chapter 1 on ‘Food, Feeding, and Breast Care’, If tiredness is the major cause of crying, then the program of minimal reassurance as described should work for you.
After all your planning and heartache listening to the baby cry to sleep for five or 10 or 15 minutes, the baby will achieve better sleep skills. Once you have achieved the correct balance of milk supply, sleeping hours, and handling for you are your baby, sleep achievement will become increasingly easy. Quite often families who start with this philosophy from the earliest days find that sleep achievement is not a problem, and that longer blocks of sleep, say five to eight hours long are emerging by six weeks of age. Your friends will then reward you by saying ‘But you’re just lucky. You have been given a baby who is a good sleeper’.
This concludes my comments on preventing and managing sleep problems in the newborn. As is true in so many areas, prevention is better than cure, and it certainly applies to sleep.
The first four weeks of life with our baby Ryan made little difference to the normal routine of our first boy aged 21 months. Ryan was breast-fed, slept, had a daily bath, several nappy changes, and many cuddles. More cuddles than his older brother had at that age. With our first child I was told I would ’spoil’ him by ‘too much handling’, so as a newborn I only handled him as seemed necessary for his comfort. This time around I had been informed by more recent reading that I could not cuddle a newborn too much. I was delighted to take this advice.
Ryan was very placid and relaxed in his first four weeks. We hardly knew he was around. Suddenly he began waking up between feeds and crying, having only brief intervals of sleep and crying. His feeding behaviour was on and off suckling and crying, and he fell asleep before it seemed his hunger was fully satisfied. When laid down, his arms and legs seemed to tremble and twitch. Even when picked up, Ryan clenched his fist to his chest or under his chin and bore a worried expression. We decided his tension was from not enough cuddles – perhaps he felt insecure? We decided his perpetual waking was because he was not tired enough to sleep, and therefore his feeding behaviour was poor as he had not worked up an appetite while awake. I would like to point out that as our first child was a very sick baby we had no idea what ‘normal’ babies did. Hoping to help Ryan, we picked him up to calm him during crying periods and rewrapped him before laying him down. Then we would be awake perhaps 90 minutes or more at a time, cuddling and talking to him. He always went to bed in tears despite our efforts to make him feel better. For my partner and I this resulted in broken sleep getting only two to three hour sleep periods at best in a six to eight hour night. After several days of this we suffered headaches, and I was aware of having a hopeless memory and poor concentration for any task at all. Our firstborns routine and behaviour was unaffected, but he did appear concerned for Ryan when he cried.
I sought advice. The following suggestions were made;
- Place a hot water bottle in the basinet while feeding so that baby may return to a warm bed.
- Play a womb noises tape.
- Have the radio going near his bed through the night.
- Have baby sleep in our room during the night on my side of the bed, so that when he awoke during the night I had only to reach out and rock him back to sleep.
Really, I was amused and amazed. I could not in my practical mind take these suggestions seriously. Fortunately I had mentioned our problem to a friend who loaned me a copy of the book you are reading now. I actually read it from cover to cover on first reading. So much common sense, so much that made sense! Finally I turned to the Instant Diagnosis chapter and pin-pointed overtiredness as a common indicator and re-read the section on Presentation of Overtiredness. I felt that this was the problem, and after talking to my partner we decided to strictly follow the treatment as advised. That was difficult initially, but Ryan surprised us by transforming his behaviour within a few days. We treated Ryan as follows :
- Using the crying down technique to a maximum of 10 minutes.
- Only handling Ryan during feeds and then for no more than a one hour period.
- Carrying on our usual routine and allowing normal noise levels day and night.
The results within days were as follows :
- When being moved about, Ryan’s limbs were relaxed and without twitches.
- Ryan fed placidly and well and remained awake throughout a 45 – 60 minute feed period.
- He routinely fed then slept throughout a 24 hour period with a minimal of being unsettled.
- Ryan slept for seven to ten hours a night from this time onwards.
Obviously, we settled down. Although two little boys are tiring, we now have enough sleep and enough peace to manage our days effectively and enjoyably.
K & MP