Case Study 1 – 6-month-old exclusively breast-fed baby – waking hourly at night and parents wishing for a gentle respectful approach to improving sleep.

Background – Rosa was born at term, labour progressed well, but the second stage of labour was long and slow and due to Rosa being ‘distressed’ she was born by emergency caesarean in the late evening.

Mum Kerry wished to breastfeed and was given help to get Rosa to the breast. However, due to the need for medical care, a busy shift and father John being sent home ‘to get some rest’ by morning Rosa had been given a top-up of formula.

Kerry persevered through weaning off top-ups, a suspected (but not diagnosed) cow’s milk protein allergy and ongoing pain from a wound infection.

By 6 months, however, she was exclusively breastfeeding and starting to enjoy motherhood.

Kerry came to me asking for help with Rosa’s sleep. At roughly 3 months Rosa has started to stretch her night feeds out to roughly 4 hourly and Kerry was happy with that. In the last month, however Rosa was waking hourly overnight, not napping for longer than 20 minutes in the day and appeared tired.

Kerry found this change in her sleep distressing as it reminded her of how hard it had been in the first month of Rosa’s life and she did not want to experience the overwhelming exhaustion again.

Kerry and her partner John were committed to gentle parenting and were aware of attachment and baby brain development. They were also aware that night feeds were necessary at Rosa’s age but they felt hourly waking was unsustainable and wanted some support to change this. Kerry was also retuning to work in 2 months and was wondering how she would cope on so little sleep.

This is a very familiar scenario and one which I support with frequently.

What do we do first?

Let’s look at all aspects of Rosa’s day – she is starting to have some solid foods, she wakes early with no set wake time and at present bedtime is variable as John likes to do her evening bath.

Firstly – reassurance – this is very common and sleep architecture changes dramatically between 3.5 and 6 months. Short naps are also very common.

Secondly – as an average Rosa ‘needs’ 3 hours of day sleep with a ‘nap-gap’ of 2-3 hours in between – this gives roughly 3-4 naps a day, she also ‘needs’ 11 hours of sleep at night.

Let’s break this down – if Rosa woke at 6.30am (we can hope!!) she would then most likely want a nap about 8.30 – often this first nap-gap is the shortest!

Assuming a 30-minute nap – Rosa would then potentially have another nap at somewhere between 11am and midday.

This next nap may be longer so potentially still 20-30 minutes – taking us to approximately 12.30pm. Rosa then may well struggle over the afternoon and have a late long nap around 4pm ish. Bedtime may well be fraught due to Rosa being either over or undertired depending on the timing and length of these naps.

So, to assist with a calm bedtime – getting some flexible structure around naps will help – the how and where does not matter – focus on the timing.

So now bedtime – a short, calm, consistent bedtime is far more beneficial than an elaborate ‘ideal’ one that is not consistent.

At present Rosa feeds to sleep at bedtime and during the night – although occasionally she is sick and Kerry identifies that she is not hungry. Feeding for comfort over night is very normal and is not a problem unless the parents deem it to be one!

So, our starting point for Rosa is a set bedtime and wake time. This ‘cements’ her circadian rhythm and helps with sleep cues. Working on nap timing is also the first task!

Next instead of removing Rosa’s primary sleep cue – breastfeeding – we add to it. This is known as gentle behaviour modification. At 6 months, it is best to take a long time over making changes to sleep! Adding in singing, rocking, patting and cuddling help Rosa associate sleep with other cues rather than feeding. After 2-3 weeks of adding in cues then we can start to move feeding earlier in the settling process. Feeding can then be used for comfort but not for falling asleep on the breast. This is a huge change for many babies. As an end point, once all of these sleep cues have slowly been removed, and the baby does not associate the parent with falling back asleep, then babies sleep for longer stretches.

The easiest way to improve sleep is to place baby down where you want them to sleep all night. However, this may be a huge step initially as most 6-month-old babies are in their parents’ room or their bed. This is a personal choice and there is no right or wrong.

Ideally Kerry and John have added in cues for 2-3 weeks, they now have some choices;

Kerry can place some limits on night feeds but keep Rosa sleeping where she currently is (cot in their bedroom at the start of night and parental bed after 11pm ish). Option 1
Keep Rosa in her own cot all night and continue to feed to sleep at each waking. Option 2
Just work on day-time nap timing and bedtime and continue as they are overnight. Option 3
Work on daytime, bedtime and night time before midnight and continue as they are overnight from midnight onwards. Option 4

With all of the above options – by immediately fixing (with some 20-minute flexibility!) a set bedtime and set wake-up time, and a consistent bedtime routine – sleep will improve without doing anything else!

3 key points!

Be consistent – which ever choice the parents make they must stick at it! Gentle behaviour modification slowly teaches a baby (or child) a new way of falling asleep. Choosing small achievable goals to gently change sleep means that it becomes manageable for parents and baby.
With any change, however gentle, sleep will get worse before it gets better. Every time a change is made, your baby’s sleep will deteriorate, and you will feel like you are back at the beginning. This is normal. The only way to see results is to follow a plan which complements how you feel, this means it is achievable and you can be consistent.
Whichever method you currently get your baby to sleep by, make sure that you are not placing them down until they are in a deep sleep. Once baby has an adult pattern of sleep (i.e. somewhere between 3.5 and 6 months) they go straight into deep sleep. If we place them down as they are moving straight into this deep sleep, then they will wake up and you have to repeat the process. It is much easier to wait an extra 10 minutes until they are absolutely limp and in deep sleep

This gives an idea of how individualised a sleep approach should be – there is no one-size-fits-all as families are different with different priorities. Contact us HERE for more information.