Infant Sleep

Figure 1. Sleep is critical for healthy infant development.

Infants 0 to 2 years of age sleep an average of 12.8 hours a day, although this changes and develops gradually throughout an infant’s life. For the first three months, newborns sleep between 14 and 17 hours a day, then they become increasingly alert for longer periods of time. About one-half of an infant’s sleep is rapid eye movement (REM) sleep, and infants often begin their sleep cycle with REM rather than non-REM sleep. They also move through the sleep cycle more quickly than adults.

Parents spend a significant amount of time worrying about and losing even more sleep over their infant’s sleep schedule, but there remains a great deal of variation in sleep patterns and habits for individual children. A 2018 study showed that at 6 months of age, 62% of infants slept at least six hours during the night, 43% of infants slept at least 8 hours through the night, and 38% of infants were not sleeping at least six continual hours through the night. At 12 months, 28% of children were still not sleeping at least 6 uninterrupted hours through the night, while 78% were sleeping at least 6 hours, and 56% were sleeping at least 8 hours.^[1]

The most common infant sleep-related problem reported by parents is nighttime waking. Studies of new parents and sleep patterns show that parents lose the most sleep during the first three months with a new baby, with mothers losing about an hour of sleep each night, and fathers losing a disproportionate 13 minutes. This decline in sleep quality and quantity for adults persists until the child is about six years old. ^[2]

Figure 2. This newborn takes a nap with his dad. Co-sleeping is the norm in many regions of the world, and controversial in others.

While this shows there is no precise science as to when and how an infant will sleep, there are general trends in sleep patterns. Around six months, babies typically sleep between 14-15 hours a day, with 3-4 of those hours happening during daytime naps. As they get older, these naps decrease from several to typically two naps a day between ages 9-18 months. Often, periods of rapid weight gain or changes in developmental abilities such as crawling or walking will cause changes to sleep habits as well. Infants generally move towards one 2-4 hour nap a day by around 18 months, and many children will continue to nap until around four or five years old.^[3]

Sudden Unexpected Infant Deaths (SUID)

Each year in the United States, there are about 3,500 Sudden Unexpected Infant Deaths (SUID). These deaths occur among infants less than one-year-old and have no immediately obvious cause (CDC, 2015). The three commonly reported types of SUID are:

• Sudden Infant Death Syndrome (SIDS): SIDS is identified when the death of a healthy infant occurs suddenly and unexpectedly, and medical and forensic investigation findings (including an autopsy) are inconclusive. SIDS is the leading cause of death in infants up to 12 months old, and approximately 1,500 infants died of SIDS in 2013 (CDC, 2015). The risk of SIDS is highest at 4 to 6 weeks of age. Because SIDS is diagnosed when no other cause of death can be determined, possible causes of SIDS are regularly researched. One leading hypothesis suggests that infants who die from SIDS have abnormalities in the area of the brainstem responsible for regulating breathing (Weekes-Shackelford & Shackelford, 2005). Although the exact cause is unknown, doctors have identified the following risk factors for SIDS:
  • low birth weight
  • siblings who have had SIDS
  • sleep apnea
  • of African-American or Inuit descent
  • low socioeconomic status (SES)
  • smoking in the home
• Unknown cause: The sudden death of an infant less than one year of age that cannot be explained because a thorough investigation was not conducted and the cause of death could not be determined.
• Accidental suffocation and strangulation in bed: Reasons for accidental suffocation include the following: suffocation by soft bedding, another person rolling on top of or against the infant while sleeping, an infant being wedged between two objects such as a mattress and wall, and strangulation such as when an infant’s head and neck become caught between crib railings.

The combined SUID rate declined considerably following the release of the American Academy of Pediatrics safe sleep recommendations in 1992, which advocated that infants be placed on their backs for sleep (non-prone position). These recommendations were followed by a major Back to Sleep Campaign in 1994. According to the CDC, the SIDS death rate is now less than one-fourth of what is was (130 per 100,000 live birth in 1990 versus 40 in 2015). However, accidental suffocation and strangulation in bed mortality rates remained unchanged until the late 1990s. Some parents were still putting newborns to sleep on their stomachs partly because of past tradition. Most SIDS victims experience several risks, an interaction of biological and social circumstances. But thanks to research, the major risk, stomach sleeping, has been highly publicized. Other causes of death during infancy include congenital birth defects and homicide.

Co-Sleeping

The location of sleep depends primarily on the baby’s age and culture. Bed-sharing (in the parents’ bed) or co-sleeping (in the parents’ room) is the norm is some cultures, but not in others (Esposito et al. 2015) ^[4]. Colvin, Collie-Akers, Schunn and Moon (2014)^[5] analyzed a total of 8,207 deaths from 24 states during 2004–2012. The deaths were documented in the National Center for the Review and Prevention of Child Deaths Case Reporting System, a database of death reports from state child death review teams. The results indicated that younger victims (0-3 months) were more likely to die by bed-sharing and sleeping in an adult’s bed or on a person. A higher percentage of older victims (4 months to 364 days) rolled into objects in the sleep environment and changed position from side/back to prone. Carpenter et al. (2013)^[6] compared infants who died of SIDS with a matched control and found that infants younger than three months old who slept in bed with a parent were five times more likely to die of SIDS compared to babies who slept separately from the parents, but were still in the same room. They concluded that bed-sharing, even when the parents do not smoke or take alcohol or drugs, increases the risk of SIDS. However, when combined with parental smoking and maternal alcohol consumption and/or drug use, the risks associated with bed-sharing greatly increased.

Despite the risks noted above, the controversy about where babies should sleep has been ongoing. Co-sleeping has been recommended for those who advocate attachment parenting (Sears & Sears, 2001) ^[7] and other research suggests that bed-sharing and co-sleeping is becoming more popular in the United States (Colson et al., 2013) ^[8]. So, what are the latest recommendations?

The American Academy of Pediatrics (AAP) actually updated their recommendations for a Safe Infant Sleeping Environment in 2016. The most recent AAP recommendations on creating a safe sleep environment include:

• Back to sleep for every sleep. Always place the baby on their back on a firm sleep surface such as a crib or bassinet with a tight-fitting sheet.
• Avoid the use of soft bedding, including crib bumpers, blankets, pillows, and soft toys. The crib should be bare.
• Breastfeeding is recommended.
• Share a bedroom with parents, but not the same sleeping surface, preferably until the baby turns 1 but at least for the first six months. Room-sharing decreases the risk of SIDS by as much as 50 percent.
• Avoid baby’s exposure to smoke, alcohol, and illicit drugs.

As you can see, there is a recommendation to now “share a bedroom with parents,” but not the same sleeping surface. Breastfeeding is also recommended as adding protection against SIDS, but after feeding, the AAP encourages parents to move the baby to their separate sleeping space, preferably a crib or bassinet in the parents’ bedroom. Finally, the report included new evidence that supports skin-to-skin care for newborn infants.^[9]

Immunizations

Preventing communicable diseases from early infancy is one of the major tasks of the Public Health System in the USA. Infants mouth every single object they find as one of their typical developmental tasks. They learn through their senses and tasting objects stimulates their brain and provides a sensory experience as well as learning.

Infants have much contact with dirty surfaces. They lay on a carpet that most likely has been contaminated by adults walking on it; they mouth keys, rattles, toys, and books; they crawl on the floor; they hold on to furniture to walk, and much more. How do we prevent infants from getting sick? One possible answer is immunizations.

Many decades ago, our society struggled to find vaccines and cures for illnesses such as Polio, whooping cough, and many other medical conditions. A few decades ago parents started changing their minds on the need to vaccinate children. Some children are not vaccinated for valid medical reasons, but some states allow a child to be unvaccinated because of a parent’s personal or religious beliefs. At least 1 in 14 children is not vaccinated. What is the outcome of not vaccinating children? Some of the preventable illnesses are returning. Fortunately, each vaccinated child stops the transmission of the disease, a phenomenon called herd immunity. Usually, if 90% of the people in a community (a herd) are immunized, no one dies of that disease.

In 2017, Community Care Licensing in California, the agency that regulates childcare centers, changed regulations. Before it was possible for parents to opt-out of vaccinations due to personal beliefs, but this changed after Governor Brown signed a Bill in 2016 to only exclude children from being vaccinated if there were medical reasons. Furthermore, all personnel working with children must be immunized.