Babies and Bedtime with Dr. Heidi Szugye
How much sleep do babies need and - perhaps more importantly - how can you help them get those ZZZs so you can get some rest, too? Pediatrician Heidi Szugye, DO offers some tips for creating a safe and comforting sleep environment that will allow your baby (and you) to thrive.
Babies and Bedtime with Dr. Heidi Szugye
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John Horton: Welcome, and thank you for joining us for this episode of The Health Essentials Podcast. My name is John Horton, and I'm your host. Today, we're talking to pediatrician Heidi Szugye about how to make bedtime better for babies. As adults, we all know the importance of getting enough sleep. Babies, of course, have their own ideas. Dr. Szugye is here today to talk about how much sleep babies need, and offer some tips to get them the rest they need. We'll also talk about crib safety, the practice of co-sleeping, and meshing a feeding schedule with bedtime. Dr. Szugye, thanks so much for being with us here today. Let's start by having you tell us a little bit about your work here at Cleveland Clinic. What's your main focus area and what are the patients that you typically see?
Dr. Heidi Szugye: Sure. Thanks for having me today, John. So, I'm a board-certified pediatrician and pediatric hospitalist. I've been working for about the last eight years in the hospital setting, so I take care of children that are admitted to the hospital with various conditions. It could be pneumonia, it could be a stomach bug. We help them get better and then discharge them home. We also staff our nurseries in Fairview and Hillcrest. So, we take care of newborns when they're born, until they're discharged. Recently though, I'm making a career transition. I got my International Board Certification in Lactation, and am going to be starting a Breastfeeding Medicine Clinic here at Cleveland Clinic Children's. Our goal is to help families meet their breastfeeding goals and help them work through any challenges that they're having with breastfeeding.
John Horton: Very exciting. Well, let's get the conversation on sleep started with a basic question. Basically, how much shut-eye time do babies need, and how should those hours be split up during the day?
Dr. Heidi Szugye: So, the AAP recommends about 12 to 16 hours of sleep for infants less than a year of age. That sleep amount really decreases a little bit over that first year. So, in the first three months, that's when babies are going to need the most sleep, typically 14 to up to 16 hours a day. Once they hit three to four months, they require a little bit less sleep, but still a good chunk of sleep compared to you and I. So, 12 to 15 hours per day. I find it easier in those first three months, and even sometimes up to six months, to think about sleep more in, how long should the baby be awake? So, you're not sitting there adding up. I mean, 16 hours is a long amount of time, so you don't want to be sitting there adding up the hours, could be tedious and daunting. So, really up until six months they say.
Sometimes it helps to figure out, how long should my baby actually be awake? So, typically in the first six weeks of life, babies can stay awake for about 30 to 45 minutes, before they start to get sleepy and need a bit of a nap. As they approach 10 weeks, it gets closer to 60 minutes or an hour. Then by five months, they usually can stay awake for two hours. Then by five to seven months, it's usually two and a half to three hours. Then we can start changing that lingo around sleep and start using things like nap time and bedtime. But sometimes it's not even until six months when we can start saying that my baby takes a certain amount of naps a day, or has a distinct bedtime. By three to six months, babies are usually taking three naps a day. By six to nine months, it's usually about two naps a day. Then somewhere between 13 and 18 months is when we say kids will often drop down to one nap a day.
John Horton: That sounds great. My kids are all teenagers now, and to be honest, they're up way more than what I want. When we're talking about babies, what happens when babies don't get enough sleep? Other than either parents just being absolutely exhausted.
Dr. Heidi Szugye: Yeah, I've been there! So, sleep is really important for growing babies. Babies really grow a lot in that first year, physically. Also they're going through a lot of brain growth and learning a lot of new things, and sleep is really important to make sure that babies are developing properly, as far as their language, their gross motor skills and their overall behavior. So, sleep is also really important for physical growth, and adequate sleep is linked to lower rates of obesity in children later on.
John Horton: OK, great. You hear a lot of talk about sleep regression, basically when babies, they start sleeping, you think you're out of the woods and you're actually going to be able to get some rest yourself. Then all of a sudden, they go backwards. How common is that? What can you do if that happens?
Dr. Heidi Szugye: Sure, so, I have three kids myself. I have 7-year-old twin girls and a 2-year-old boy, and I've been there and it seems like without fail, every time you brag about your child sleeping through the night or finally sleeping well, the next night is a doozy. It seems like without fail. So, it's best to just talk about it. Or not talk about it rather. But really, you first want to make sure that the baby's not hungry. So, are their basic needs being met? Make sure that they don't need their diaper changed. Then you want to make sure there's nothing more worrisome going on. So, make sure that the baby doesn't have a fever, there's no injury, there's no ear infection going on. If you have any concerns at all that your baby is inconsolable, has a fever, you want to call your pediatrician right away.
Then once you've ruled out those things, it's very common to have babies go through these ebbs and flows in their ability to sleep well and through the night. Some people swear that these are associated with certain ages or leaps, and the literature really hasn't panned out to show that these happen at specific times for every single baby. So, it can vary by your baby versus someone else's baby. But I think the important thing to know is these won't last forever. These are phases, and they typically last about two to three weeks, and then children revert back to sleeping better. The big thing you can do is make sure you're having a consistent bedtime routine and consistent sleep environment. So, consistency really is key.
You want to avoid overstimulating babies before bedtime, avoid screen time, set up a nice bedtime routine that includes something like reading a book, singing a song, maybe breastfeeding, things that will wind them down and calm them. Do those things every night before bed, so they understand that this is bedtime. You don't want to make a lot of drastic changes that could potentially make things worse or set up new, bad sleep habits. The last thing is you want to make sure that you're putting your baby to bed when they're drowsy and sleepy, but not completely asleep. This really gets them learning how to fall asleep on their own. So, if they do wake up in the middle of the night, they have that experience and practice, getting themselves back to sleep.
John Horton: That's great advice on setting a sleep schedule. Let's shift the focus a little bit now, and telet's talk about sleep safety. I think with that, a great place to start is with, I mean, just the crib itself. What are the standards right now, as far as the crib that they should be in? I'm guessing that I did it wrong. My kids were sleeping in my crib, which was circa 1970, which I'm guessing is not going to cut it these days.
Dr. Heidi Szugye: Yeah, I probably would put that crib in the garbage. No, after 2011 is when they came out with safety standards that banned cribs with drop-side railings that can injure children. So, unfortunately those drop-side cribs made our lives easier as parents, but they were dangerous for babies, and babies were getting injured. So, you want to make sure that your crib was manufactured after 2011. Obviously in the stores, it's easy to ... They don't sell cribs manufactured after 2011. But if you're getting your crib from a friend or a garage sale, resale shop, you want to just look at the date of manufacturing.
The other thing that you need to watch out for is that the slats and openings in between the rails of the crib need to be at least six centimeters apart, so that the baby's head can't get stuck within those slats and get injured. You want to make sure that the crib doesn't have any decorative cutouts or holes, same concept, anything that the child could get their arm, leg, stuck in, or head. Then you want to make sure that the corners of the crib don't have any posts on them that the baby could potentially get clothing stuck on, and cause any strangulation or anything like that.
John Horton: OK. Well, my crib, it's definitely not up to current standards. So, on the same thing, I remember with my kids too, also putting padded rails around the crib, so that way they didn't clonk their head on anything. That was a few years ago, what's the current advice when it comes to using those padded rails or the padding around the rails?
Dr. Heidi Szugye: Sure, so, the padded bumpers that some people call them, can actually cause suffocation, strangulation, and unfortunately entrapment. They've been linked to 100 infant deaths in the past 30 years. So, we really recommend not to use them. They don't prevent injuries, they don't really serve any benefit and can be potentially harmful. You'll see a lot of bumpers even marketed as mesh or safe for sleep. But they're not actually safe for sleep, so it's best to avoid them. Your toddlers and older kids, as they get more mobile in their crib, can actually use them to help boost them up and fall out of the crib. So, there's legislation currently. The Safe Cribs Act has gone through the Senate to ban the sales of these. But currently you can still unfortunately find them in stores and marketed towards parents. So, try to get the word out to avoid the bumpers.
John Horton: That's a great tip to pass along. On the same idea, I mean, should you have pillows or stuffed animals? I mean, everybody gets their little bears and things like that. Should those be in the cribs with babies?
Dr. Heidi Szugye: So, no. Up until the age of 12 months, stuffed animals, loose blankets and pillows should all be kept out of the crib. So, all you should have in the crib is a flat fitted sheet, nothing loose that could potentially get in the way of the child's breathing. That's the biggest concern we have, is that something will obstruct their airway. Instead of breathing in fresh oxygen, they actually re-breathe their own CO2, and that's what we think can cause Sudden Infant Death Syndrome. So, anything at all. Even hats is another thing. Babies might be wearing hats in the crib, and then if it falls off it could get in their airway. So, flat sheet is all we should have in the crib.
John Horton: All right. I'm guessing, another question that we see a lot that comes over, involves sleep sacks. Obviously, I mean, they are absolutely adorable when you put these kids in those little sacks. But I mean, are they safe too? Is that the way to go?
Dr. Heidi Szugye: Yeah. So, sleep sacks are a great alternative to a loose blanket. They often snap or zip up, and they're safe in that they don't come off like a loose blanket could, and obstruct their airway. You want to make sure that their hands are free, so there's some sleep sacks that used to be made that would swaddle the infant. You really want to have the infant’s arms free, so that if they did roll over, they could roll back over. If they have any built-in swaddle over the legs or hips, you just want to make sure that you're not swaddling too tightly, as that can affect hip development. But, yeah. They're a great alternative. We get a lot of blankets, I think, for baby showers and things like that from well-meaning family members. But it's best to save those and use them for when your kids are older, or use them as picnic blankets or tummy time on the ground when you're supervising your child.
John Horton: That'll keep granny happy, you've got to use the blanket here and there. So, as we've been talking about a bunch of different things here, let's talk about the baby's room and how you would set up just an ideal sleep environment.
Dr. Heidi Szugye: Sure. So, you want to make sure that when you put your baby down to sleep, you always put them on their back. So, since the AAP came out with recommendations for safe sleep, the whole Back to Sleep Movement, we've actually cut SIDS risk in half. So, that's the first thing I tell all parents is, when you're putting your baby down, put them on their back. In addition, you want to make sure that the sleep environment is a calm place to sleep. You want to make sure you're sending the message that this is a place for baby to sleep. You don't want it to be overly hot, overly cold, you want to make sure that it's dark and dim. So, sometimes blackout curtains can help with that. Baby monitors are great so that you don't have to go in and check on your baby, and creak open the door and walk in and potentially wake them up.
Sound machines can also be helpful for simulating that womb environment. So, we often call those first months after baby was born, the fourth trimester. So, if you think about it, they're used to being in mom's womb and hearing the sounds outside, mom's heartbeat. They're used to a little bit of movement. So, anything that simulates that womb environment is nice. Sound machines have the added benefit of drowning out other noises. So, if you have siblings of baby, or other sounds, the vacuum cleaner going, that can help drown out some of that. Then you want to keep toys out of the room. Again, send that message that this is not a place to play, not have it overstimulating. Once you've set up a nice sleep environment that's calm and dim, you want to make sure that it's safe. So, you want a room that's free of any smoke exposure. Cigarette smoke has been linked to SIDS. If you have any mobile on the crib, they're not necessary, but some parents find they might help your baby sleep better. You want to make sure that those are secured well, so that they don't fall on the baby.
Then when your baby starts sitting up and moving, it's probably best to remove those so that they don't get entangled in anything, with the mobile or ingest any small parts. You never want to place the crib near a window or where they could get access to curtains that could strangle themselves. If you have any window treatments, you want to make sure that they're cordless, again, so the baby can't reach for those cords and hurt themselves. Then general things like, something a lot of people don't think about is night lights. You want to make sure they're not near any window treatments that could catch fire. Then your basics, making sure that you have a smoke detector outside your baby's room, CO detectors on all the floors. So, it's a good time when you have a baby to do a general house check on all those maintenance things, now that you have a new little one in your house.
John Horton: Those are great tips, and really easy to do. You can just look around the room and just set things up. So, that's great advice. When we talked before the podcast, you mentioned that there was a connection between breastfeeding and a reduced risk of SIDS. Can you tell us a little bit more about that?
Dr. Heidi Szugye: Yeah. So, babies who are breastfed, and even babies who are receiving breast milk not through directly feeding, but mom pumps and gives it via a bottle, have been shown to have a decreased incidence of SIDS. It can actually cut the risk of SIDS in half. So, just another reason to breastfeed, and another benefit of breastfeeding.
John Horton: OK. Great. Now, feeding a baby before putting them down for a nap or at night, seems to be a pretty common practice. So, is that a good idea? I mean, should you have your baby go to sleep with a full belly, or is there anything to worry about with that?
Dr. Heidi Szugye: Yeah. So, you can put your baby to bed after feeding. You have to be careful, I think. If your baby has reflux sometimes laying them flat right after feeding can exacerbate some of that reflux. So, for those babies, we recommend keeping them upright for about 15 minutes after they feed, before putting them on a flat surface. You want to avoid any sort of wedges or anything. I know a lot of parents will try to prop the baby's head up to avoid reflux, but those things can also lead to SIDS and things like that. So, keeping the baby upright after feeding. Otherwise most babies will get sleepy. So, after they breastfeed or have their bottle, they tend to get sleepy, and it's a nice wind-down routine. You never want to put a bottle in the baby's bed with them. It can actually lead to dental carries or cavities, and so you never want to prop a bottle or leave it in the crib with them.
John Horton: OK. All right. Great. Let's talk for a minute about when babies don't sleep in a crib. I know there's an issue with co-sleeping. What are the recommendations about having a baby share a bed with his or her parents, and is co-sleeping, I mean, is it connected to SIDS at all?
Dr. Heidi Szugye: Yeah. So, unfortunately co-sleeping is connected to SIDS, and the risk there is, again, the bed often has a lot of loose blankets, pillows. The parent themselves can unfortunately roll over onto baby, and all these things can put the baby at increased risk for SIDS. We don't recommend it for any babies. But there's certain situations where bed-sharing is even more dangerous. So, especially in babies less than 4 months old, babies that are born premature or small for gestational age, if anyone in the household smokes, if you're on any medications or drugs that might cause you to be extra drowsy. If you're on an old mattress, a couch, a sofa, these are the scenarios that we know have put babies at even higher increased risk of SIDS. You especially want to avoid co-sleeping in any of those situations.
A nice alternative is room sharing, and so I know, especially for breastfeeding moms out there, babies feeding pretty frequently at night and it can get pretty exhausting. So, room sharing is usually what I recommend, at least the first six months, when babies are often waking up in the middle of the night to feed. Put your crib or your bassinet right next to the bed, so that you can feed baby and put them right back to bed. Actually room sharing has been shown to decrease the risk of SIDS by about 50%. So, the thinking there is that you're keeping a close eye on your baby, it also supports breastfeeding. So, recommend the first six months room sharing instead of bed-sharing.
John Horton: No. That's great. Great advice. So, all right. One of the toughest questions that parents have to deal with, or one of the toughest things that they have, is what you do when you put your baby down and they just cry. You want to go in there. So, what's the line as far as when you go in, when you get them, when you just let them cry it out? What's the best way to approach that?
Dr. Heidi Szugye: Sure. Yeah. So, this is probably one of the most frequent questions we get. So, I think first thinking about prevention is key. So, you need to pay attention to your baby's sleepy cues, and catch them when they're getting tired and put them down when they're starting to get tired, rather than when they're overly tired. So, some of the things they might start to do are yawn, rub their eyes, pull at their ears. They'll start to get clingy. They'll start to not want to interact with a stimulating environment. They literally want to go to that calm place and go to sleep. So, when you start noticing those things, they might start fluttering their eyelids, you want to get them to sleep in that moment. If you wait until they're overly tired, they can cry and cry and cry, and it's really hard to get them to wind down and go to sleep.
Another thing that you can do is, in the middle of the night when you do feed them, change their diaper, make sure you keep things quiet. So, keep the lights off. Don't stimulate. Don't talk to them in a loud voice. But really keep things quiet, so that they're still drowsy when they wake up for those middle-of-the-night feeds and changes, and that'll really help them get back to bed easier. If the baby goes to bed crying or wakes up crying for a few minutes, you can wait and see if they go back to sleep. If not, it's good to go check on them, make sure, like I said earlier, they're not hungry, they don't need their diaper changed. There's nothing worrisome going on, like a fever or anything like that.
If you've ruled out all of those things, then going in and trying to do some gentle rocking, shushing, swaddling, perhaps breastfeeding them, some of these things, try to get them to calm down and go back to sleep. Most babies, contrary to what a lot of people say, are not sleeping through the night until at least 3 months, sometimes up to 6 months of age. So, this is normal behavior. But at some point, around 6 months of age, you can start gradually letting them cry a little bit longer. So, we recommend the first night, listen to them cry for two minutes before going in, comforting them. Then every night expanding that time a little bit more and that'll eventually get them to learn to fall asleep on their own.
John Horton: Yeah. I always remember there was a certain pitch where you knew it was like, maybe they're going to go back to sleep, then there was that pitch where it was like, this is not going to happen.
Dr. Heidi Szugye: That's not happening. Yeah.
John Horton: So, as we've talked about, it's no secret that bedtime can really be a struggle with babies. When is it the time where the troubles get so bad that you should talk to your pediatrician about it and maybe discuss sleep concerns?
Dr. Heidi Szugye: Sure. As with most things, I think if it's starting to interfere with your baby's ability to be awake and function during the day, or your ability to function during the day, I would reach out to your pediatrician and get help. We also have, here at Cleveland Clinic Children's, we have a pediatric sleep medicine specialist, and so you can even, if you've talked to your pediatrician and you're still really struggling, you can make an appointment with one of them and they're wonderful.
John Horton: OK. Great. Great. Is there anything that we haven't discussed here today that would be important for people to know or understand to help babies sleep?
Dr. Heidi Szugye: Sure. I think the important thing to remember is with babies and sleep, most things are a phase, and this too shall pass. I think that's hard to think about when it's 3:00 AM and you're exhausted, and you've been up all night. Especially for those first-time parents that haven't gotten through that first year. But most of these things are a phase, and they will pass, and we're here to help you, too, if you need help. So, reach out to your pediatrician, your sleep medicine specialist, but I promise you will sleep again.
John Horton: I can vouch for that, because I eventually did get more sleep. Although as they get older, you just stop sleeping for completely different reasons. But that's a whole different podcast.
Dr. Heidi Szugye: The worries. The worries are different.
John Horton: Dr. Szugye, thank you so much for being here with us today and talking with us on this topic. If you have sleep or other health concerns about your child, talk to your pediatrician or call 216-444-4998 for an appointment. You can also find more information on children's health at clevelandclinicchildrens.org. Thank you very much for being with us today.
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