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6.4 Sleep

Rooming-in in Hospital

Baby Friendly Step 7

Step 7 of the Ten Steps to Successful Breastfeeding states:
Practice rooming in - allow mothers and infants to remain together 24 hrs/day.

In their research to support the inclusion of this Step, UNICEF1 found that when mothers and infants were separated, infants

  • breastfed less frequently,
  • secretory activation was evident later
  • clinical jaundice was more common
  • weight gain per day was statistically less.

Babies cared for in nurseries had more crying episodes (and were therefore more stressed) and were responded to less frequently.

24-hr rooming in resulted in mothers experiencing the same number of hours total sleep as the separated dyads, infants spent 33% of the time in quiet sleep compared with only 25% in the nursery group and there was no difference in daytime alertness in the two groups.

This suggests that rooming-in does not greatly alter maternal sleep and it improves infants' sleep.

Workbook Activity 6.5

Complete Activity 6.5 in your workbook.

Addressing the barriers

This Step can be difficult to implement in places where a well-baby nursery has traditionally been utilized for procedures on infants, and separations from mothers.
Suggestions that have worked for others include:
  • staff education. Unless all the staff are convinced that rooming-in is beneficial to the mothers and babies in their care, there will be some resistance and many mixed messages given to parents. To 'mother the mother' while she is in hospital is a natural response from nurses and doctors.

  • parent education. Initially parents may have an expectation that their infant will be cared for in a night-nursery overnight, and taken away for all procedures. Mothers may even express trepidation about having their baby in their room overnight while they sleep. Parenting classes, posters in prenatal clinics and all staff giving the same message about the benefits of rooming-in can change these expectations.

  • call me. Give explicit instructions to all mothers to ring their call bell when baby needs attention - give this message with genuine meaning and a smile. Mothers often report that they didn't want to disturb the nurse, and therefore their experience could be one of feeling unsupported and afraid.

  • supporting an exhausted mother. Long labor, instrumental birth, cesarean birth, unwell from non-birthing reasons, noisy wards, never-ending interruptions ... fatigued mothers are very common.
    • Teaching settling techniques such as skin-to-skin care, breastfeeding lying on her side, and rocking and patting the infant are all excellent skills the mother will need when she is at home.
    • Encouraging the mother's support person to remain with her can be a very enjoyable experience for the new family, and give the mother a peaceful rest. This is family-centered care.
    • Implementing an afternoon 'rest time' with a darkened room, no 'hospital-reason' interruptions and no visiting is often appreciated.
    • Clustering her nursing care and medical care needs to limit interruptions.
    • Asking mothers to use their call bell when they are awake so that vital signs observations or other procedures can be done then.

  • using procedures as education times. Babies cry less when being held or breastfed during procedures such as heel stick. When hearing checks, bathing, weighing, newborn examination, etc are performed in the mother's room it's the perfect time to educate the parents about each of these.

  • staffing allocation. Concern that there is not enough staff is usually not borne out. Parent education is more efficient and effective, and staff time is not used pushing babies to and from the nursery. No staffing for a well-baby nursery is required.

  • mother assistants. Suitably qualified volunteers to watch over a baby at the mother's bedside when she needs to leave the room (eg a mother who smokes) or baby just needs patting to sleep with mother in bed resting.

  • record all separations. Recording the length and the reason for each separation could help some staff to identify unjustified separations, and also highlight genuine barriers that the unit can address.

  • be alert for exceptions. This Step will not be appropriate for every baby or every mother. Stay vigilant to the infants and mothers who require additional supervision.

Is this your problem?

If mother-infant separations are too common in your unit gather a small group of colleagues to address the issues. Start by gathering data on the current situation. Then develop a survey for parents and staff to identify the barriers they see. Once you have identified them you will be able to work with your group and colleagues to address each issue.

Breastfeeding and Sleep

Of all the parenting issues discussed in New Mothers' groups, the number of night wakings their baby has must nearly top the list. Today's parents have busy daytime lives, many employed outside the home, and having a good night's sleep is highly desirable.
Lay opinion all too frequently recommends interventions such as sleeping the baby in another room and not responding to feeding cues, or giving infant formula as the late evening feed, or beginning complementary foods well before the recommended age.

So, what's wrong with these suggestions? First, let's look at what is normal behavior.

What's normal?

Initially wakefulness and feeding are closely related.

  • During the first 24 hours the newborn spends the first 2 hours awake and alert, and breastfeeding. After the initial few days most babies will sleep a total of about 16 hours a day.

  • By 3 weeks of age the average length of the longest sleep is about 3.5 hours. By 6 weeks of age some babies are having up to 6 hours in one sleep.

  • The cumulative hours of sleep per day slowly decreases to 14-15 hours by 3 months and 13-14 hours by 6 months of age. 2

The natural course of settling is seen to proceed over the first 6 months, but even after that age increased waking occurs in up to 42% of children who have already shown the capacity to sleep through the night. 2 Two thirds of babies breastfeed at night, and have their biggest feed at this time consuming 20% of their total daily intake. 3

How can I use this knowledge to help parents?

Knowledge of what is normal behaviour is reassuring to parents. Discuss normal breastfeeding and sleep patterns with expectant or new parents. When putting a baby down to sleep suggest they stay with the baby until he moves from the rapid eye movement stage from which he is easily roused, into the deep sleep stage where he is more likely to stay asleep regardless of movement and noises around him.

Reducing the risk of SIDS

The lay suggestions offered to increase nighttime sleeping all increase the risk of Sudden Infant Death Syndrome (SIDS) for the infant.

Sleep location

The SIDS associations and pediatric societies both advise that infants sleep in the same room as a responsive adult.
  • Room sharing, particularly when the infant sleeps in close proximity to the mother, has been found to reduce the risk of SIDS.
  • It is unclear why this is so, but hypothesized that air movement, human movement and noises all keep the infant from falling in to a 'too deep' sleep from which it is difficult to arouse. 4
  • Striking temporal overlap (synchronicity) in infant and mother arousals has also been described.5 This means that mothers and their infants spend more time in the same sleep stage, creating an awareness of the infant's condition. It also assists mothers to cope with broken sleep - the infant isn't rousing the mother at a time when she in in her quiet sleep phase.
  • It also ensures an adult is able to supervise the infant's sleep to recognize and respond quickly to infant distress or other concerns.
  • Breastfeeding is also facilitated with minimal disruption to mother and infant.

Breastfeeding

The SIDS associations and pediatric societies both advise mothers to exclusively breastfeed their young infants.
  • Formula feeding is associated with increased risk of SIDS. 6
  • Giving infants formula or solid foods in an attempt to increase sleeping hours will reduce their need to breastfeed, reducing the mother's milk supply.
  • At 2-3 months formula-fed infants are significantly more difficult to rouse than breastfed infants - this is the peak time for SIDS. 7
  • Formula feeding increases the risk of infection, which is one cause suggested for these deaths. 8 9 10
  • Breastfeeding is more easily achieved when the infant sleeps in the same room.
  • By being able to respond to early feeding cues, before crying, the infant will breastfeed in a calm state from which it is easier to settle.

What should I remember?

  • The maternal and infant benefits of rooming-in.
  • The deleterious effects of keeping infants in newborn nurseries.
  • How normal sleep patterns progress from birth to older infant.
  • The importance of sleep location for SIDS risk reduction.

Self-test Quiz

Notes

  1. # Child and Adolescent Health and Development (CAH) (1998) Evidence for the ten steps to successful breastfeeding
  2. # de Weerd AW et al. (2003) The development of sleep during the first months of life
  3. # Kent JC et al. (2006) Volume and frequency of breastfeedings and fat content of breast milk throughout the day
  4. # Hauck FR et al. (2011) Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis.
  5. # McKenna JJ et al. (1994) Sleep and arousal, synchrony and independence, among mothers and infants sleeping apart and together (same bed): an experiment in evolutionary medicine
  6. # Zotter H et al. (2012) Breast feeding is associated with decreased risk of sudden infant death syndrome.
  7. # Horne RS et al. (2004) Comparison of evoked arousability in breast and formula fed infants.
  8. # Saadi AT et al. (1999) The protective effect of breast feeding in relation to sudden infant death syndrome (SIDS): I. The effect of human milk and infant formula preparations on binding of toxigenic Staphylococcus aureus to epithelial cells.
  9. # Gordon AE et al. (1999) The protective effect of breast feeding in relation to sudden infant death syndrome (SIDS): II. The effect of human milk and infant formula preparations on binding of Clostridium perfringens to epithelial cells.
  10. # Gordon AE et al. (1999) The protective effect of breast feeding in relation to sudden infant death syndrome (SIDS): III. Detection of IgA antibodies in human milk that bind to bacterial toxins implicated in SIDS.