Dr. António Salgado

Paediatrician

Sleep in the first year of life

HPA Magazine 15

A baby’s sleep is a subject of great impact on the lives of families, which lose up to 700 hours of sleep during the baby’s first year of life!
Sleep needs vary widely during the first year of life: new-borns - 16 to 20 hours; infants up to 4 months - 14 to 15 hours; from 4 to 12 months - 13 to 14 hours, with daytime sleep gradually decreasing.

During the baby’s first year of life, there are different sleep patterns. During the first 3-4 months, when the baby first falls asleep, starts a more superficial and active sleep. After the first 20 minutes begins peaceful sleep, which is deeper.
After the first 3-4 months of life, and for the rest of his life, sleep alternates cyclically between an initial Non-REM sleep, a deeper sleep, and a more superficial REM sleep, lighter and closer to awakening. In the transition between sleep cycles there are micro-awakenings. In the first year of life, REM sleep predominates, and cycles are shorter, causing more micro-arousals. It is intended that they are short and that the child falls asleep again.
The day-night cycle is established in the first 4 months. For this, there is a contribution, at the end of the day, of the increase of a hormone that induces sleep, called melatonin. To take advantage of the peak of this hormone, it is important that the child is aware of the day-night transition by opening windows or exposing the child to sunset.
It is necessary to create ideal conditions for a peaceful sleep. During the first few months of life, the baby should sleep in the parents’ bedroom, moving to its own room after 6 months, depending on the child's autonomy and the parents’ wishes. A baby should always be put to sleep lying on its back with his arms free, in its own cradle on a semi-rigid mattress and without pillows and not in the parents' bed. The room must also be airy, free of objects that accumulate dust and with a temperature between 18-20ºC.
The new-born infant should get used to the family's routine. During the day, the baby can take naps in daylight and with noise, as well as on the parents' lap and, by night, should put to sleep in the crib. Once the baby has been fed and still awake, he can be placed in the crib so that he gets used to falling asleep on his own.
Daily routines should be developed to ensure safety by repetition. During the day, natural light, normal household noise and regular feeding and nap times should be maintained. The baby's stimulation should also be greater at the beginning of the day, decreasing in intensity towards the nightfall. Babies can easily be over-stimulated, responding with irritability and crying. Signs of tiredness should be noticed, in order to provide a calm environment, before the baby reaches a state of over-stimulation.

In the period just before bedtime, it is important to establish a routine, always ending in the bedroom where the baby will be put to sleep. Performing the same routine, in the same way and at the same time, helps the baby to realize that it's time to sleep. A bath can be part of the routine (if it is relaxing for the baby), as is reducing light and sound, massage, relaxing music, pampering or conversation. Feeding should not be part of this moment, to avoid associating food and sleep. 
Avoid putting the baby to sleep on your lap. Put the baby to bed when he is sleepy, but still awake, so that he learns to fall asleep on his own, without having to be rocked or breastfed.
Baby can take to bed with him certain soothing objects (fluffy toy, diaper, dummy), to be his sleep companions, which should be with him when he falls asleep and during the night, to help autoregulation and falling asleep.
When the baby wakes up during the night, give him time to fall back to sleep on his own. If he is hungry or needs a nappy change, it should be done in the shortest time possible, in a dim light with minimal stimulation. Gradually, feeding time and the quantity of milk in the bottle should be reduces. If a night light is necessary, choose the red one, which should not shine on the baby.
There are periods of “sleep regression”, when the baby wakes up more often. They coincide with the beginning of REM / Non-REM cycles, periods of greater developmental acquisitions (e.g. crawling, linguistic acquisitions), separation anxiety, changes in the usual routine and even teething. They are transitory, persistence in the usual established routines is therefore recommended. 
As far as “screens” are concerned, they should be restricted to video calls. It is proven that exposure to these, especially the more interactive ones, is responsible for a decrease in the duration and quality of sleep, with more night-time awakenings.
The role of parents' is to help the baby achieve a progressive autonomy, using strategies that will allow self-regulation, where the baby can gradually acquire autonomous sleep. Parents should be aware that these strategies, and others not described in this article, may need persistence and are often not easy to implement. They must be adjusted to the individual reality of each child and family, with the support of their paediatrician.