Perhaps one of the bigger challenges of having a new baby is getting sleep. There’s no end of advice on how to do this, much of it conflicting. No worries. The Academy of Breastfeeding Medicine’s latest guideline comes to the rescue! Intended for maternity care professionals, “Physiological Infant Care – Managing Nighttime Breastfeeding in Young Infants” provides data-based strategies aligned with what we know about maternal and newborn physiology and dispels breastfeeding beliefs and concerns that are not upheld by the research. In this blog post, I’ll summarize its findings as they apply to you, and as a bonus, I’ll paste in the ABM’s infographic “Physiologic Infant Care: Supporting Breastfeeding, Sleep, and Well-Being” at the end.
Chief among these—and this will probably surprise you—is the ABM’s position on bedsharing. Bedsharing is widely condemned as a factor in Sudden Infant Death Syndrome (SIDS). The ABM contends that the evidence does not support this in the absence of risk factors, that it can be done safely (see guidelines here), and that to the contrary, breastfeeding and bedsharing work together to provide important benefits, including reduced incidence of SIDS:
Compared with many strategies that mothers may use to cope with the demands of nighttime parenting, side-lying breastfeeding with proximate sleeping may be one of the safest strategies for maternal and infant well-being, in the absence of hazardous circumstances.
How Can You Maximize Sleep?
Breastfed infants need feeding whenever they indicate hunger, which will be roughly 8 to 12 times in a 24-hour period at irregular intervals. Around 3 to 4 months of age, babies begin to spend more daylight time awake and go longer stretches between feeds, but they may not lengthen their longest nighttime sleep interval for many months after that. As you may already know or will shortly find out, this poses a considerable challenge to getting enough sleep. These ABM recommendations promote both maximum sleep and maintaining milk supply while aligning with your and your baby’s innate physiology. All of them come amply supplied with references to the research.
- Keep close to your baby day and night. Close proximity to your baby enables you to notice and respond quickly to your baby’s hunger signals. As a bonus, baby wearing (see guidelines for safe baby wearing here) and carrying during the day by you or your partner also decrease fussiness and crying. The ABM adds that babies who are carried much of the day may benefit from “tummy time” to develop their motor skills.
At night, bed sharing helps you increase and maintain your milk supply while getting more sleep. This counterintuitive finding is because feedings are more frequent, which helps to stimulate milk supply, but they can be accomplished with less arousal on either your or your baby’s part. Another benefit of prolonged, close contact with your infant is that it helps them regulate their breathing, temperature, and heart rate. Nighttime feedings are especially important if you are going back to work. They help to maintain milk supply because even the best breast pumps don’t do as well as your baby at emptying the breast and stimulating new supply.
- Help your baby distinguish day from night. Babies are born without a functioning circadian clock, the day-night pattern regulated by melatonin. Breastfeeding at night helps them establish this because melatonin is secreted into breast milk according to circadian rhythms. Breastfeeding and bed sharing at night helps by enabling you to feed your baby with minimal disturbance and minimal light. During the day, the ABM recommends not darkening the room or trying to be quiet when baby naps.
- Breastfeed side-lying in bed for nighttime feeds. Curling around your baby in a C-position keeps baby’s head away from your pillow, and when baby releases the nipple, baby naturally rolls onto their back. In an infographic accompanying the guideline, the ABM describes breastfeeding from both top and bottom breasts so that you don’t have to roll over to feed the baby from the other breast. A different strategy to feed on both breasts that I used back in the day was to scoop the baby against my chest and roll to the other side with the baby in my arms.
Beliefs and Strategies Not Supported by Research
In addition to making recommendations that align with maternal and infant physiology, the ABM guideline also addresses beliefs and strategies not upheld by research.
- Babies should sleep alone. Bed sharing with infants coupled with side-lying breastfeeding is the human norm. Nighttime separation from the mother increases infant distress as measured by stress hormone levels even if the infant doesn’t appear distressed. Nighttime separation during the first four months may decrease waking for feeds at night, but those feeds are important for building and maintaining milk supply.
- Babies should sleep long stretches at night from an early age. As we have seen, this expectation does not match infant physiology. As the ABM put it: “The mismatch between Western cultural family sleep expectations and the biological realities of human infants undermines parental resilience and compromises family wellbeing.”
- Formula feeding increases sleep. Exclusively formula feeding mothers may perceive that their babies sleep longer, but sleep patterns are similar in babies of 4 to 16 weeks regardless of how (or where) they are fed. In fact, research finds that formula fed infants and their parents get less sleep than families bedsharing and breastfeeding their baby probably because of the additional time and stimulation involved in needing to rouse, turn on lights, prepare the bottle, and feed while fully awake and alert.
- By not responding to night waking, babies can be trained to self-soothe themselves back to sleep. Babies may cease crying in the night, but they do not cease to awaken or remain awake, and measurements of stress hormone levels show they are still distressed. In addition, by reducing nighttime feedings, sleep training in babies less than six months old can compromise milk supply.
The Need for Social Policies that Support New Families
It’s likely that you have reviewed these recommendations feeling the same frustration I did, namely, that universal paid maternity leave of at least several months length would make recovering from childbirth, adjusting to life with a new baby, and getting breastfeeding going enormously easier, but unlike almost all other high- and medium-income countries, we don’t have that in the U.S. The ABM agrees:
Social practices that support physiologic care. Physiological infant care is best supported when mothers are able to take sufficient time off from work after giving birth to recover, establish breastfeeding, and bond with their infant. At least 12 weeks of paid leave is associated with improved maternal and infant health. . . . Flexible work schedules are important for families with infants. Physiological infant care is also supported when partners are able to take time off from work to support the mother and bond with their infant.
Accordingly, their last recommendation urges maternity care professionals to:
Advocate for at least 12 weeks of paid maternity leave in countries that currently do not have it.
Level of evidence: 1. Strength of recommendation: A.
Academy of Breastfeeding Medicine Infographic