Babies can be trained to sleep consistently

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Today, we'll learn what you can do to help your infant sleep well, with my guest, Dr. Zafer Soultan.

He's the chief of pediatric pulmonology medicine at Upstate and the director of the Upstate Pediatric Sleep Center.

Welcome to "The Informed Patient," Dr. Soultan.

Zafer Soultan, MD: Thank you, Amber. Thank you for this opportunity.

Host Amber Smith: One piece of advice that new moms often receive is to sleep when the baby sleeps. Is this good advice?

Zafer Soultan, MD: Absolutely. They need to rest in order for them to take care of their baby, so sleep is very important for mothers, as it is for the baby.

Host Amber Smith: Now, how much sleep do newborns need and how does this change over their first year of life?

Zafer Soultan, MD: Newborns need a lot of sleep during the first year of life. They need anywhere between 14 to 18 hours of sleep. So how does it change over the first year? Yes, indeed, there will be a little bit decrease in the hours of sleep toward the last few months of infancy.

Host Amber Smith: But at the beginning they sleep a lot.

Zafer Soultan, MD: They sleep a lot. It's basically, they sleep, and they wake up just because they're hungry, so they wake up to eat.

Host Amber Smith: So that's generally what wakes them up, is that they're hungry?

Zafer Soultan, MD: Yeah. They are hungry. They have a small stomach, and they eat 1 ounce, 1 ounce and a half. So, they wake up to feed. So they sleep, although there are many hours, they are divided in intervals. They are couple of hours or three hours of sleep, then wake up, two to three hours sleep, then wake up to feed.

Host Amber Smith: And does that happen all through the night? Is it normal for them to not sleep through the night?

Zafer Soultan, MD: They don't have the circadian rhythm, the day and night clock, mature yet, so they don't differentiate between day and night.

And yes, that's normal to happen throughout 24 hours a day. We're talking now about the newborn in the first couple of months.

Host Amber Smith: Do newborns dream?

Zafer Soultan, MD: Newborns go into what we call active sleep, or rapid eye movement sleep, which means a time when our muscle tone is kind of relaxed and our eyes kind of moving right and left.

So they do a lot of that comparing to adults or older children. So older children have this stage of sleep approximately 20%-25% of the sleep time. Newborns do that half of the time or maybe even more. So a lot of times, mothers will observe that while they're asleep, they're moving, rapid eye movement, they're moving their eyes right and left.

So that's the time when older children dream. So the question now, since they have a lot of rapid eye movement sleep, this stage of sleep where our eyes move quickly, and during this stage, we dream, so the question, do newborns who have a lot of it dream a lot?

Probably not. Probably, they haven't yet matured that system of dreaming. Probably, that takes a couple of years to develop.

Host Amber Smith: Now, at what age would a baby be expected to start sleeping through the night? Is it unusual? You said the first couple months it would be unusual, right?

Zafer Soultan, MD: It's unusual if they don't wake up to feed, not that they slept. They need to get a certain amount of milk, so we (pediatricians) don't like it if they don't get it, and they sleep a lot, and they are not waking up to feed. How come? They're supposed to wake up every two, three hours to feed.

Now that age when they start the process of not necessarily sleeping through the night, when they start to have some sort of consolidation, some sort of sleeping for five to six hours during the night, is by 3 months. This process, by 3 months, they start learning how to do that, and hopefully they are going to be successful by 6 months of age. So, it is expected, but that doesn't mean it's going to happen at 6 months. It's a learning process for them.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with pediatric sleep specialist Dr. Zafer Soultan about common sleep problems in children. What are the best strategies for teaching an infant to sleep well? What do you end up talking with patients (parents) about?

Zafer Soultan, MD: As I mentioned, at 3 months, they start learning the day and night.

So at 3 months of age, the parents need to help the baby learning this process, help them distinguish between daytime and nighttime, which means in the daytime, we expose them to light when they wake up. We play with them. We sing for them. We have toys and noises and activities, of course, suitable for age.

And in the nighttime, as we kind of discussed, they're going to still need to wake up to feed. But when they do wake up, we don't play with them, and we don't make noises, and we have the light dimmed in the bedroom, and we get the room a little bit colder. So then we are helping them, we're assisting them distinguishing between daytime and nighttime. And therefore, I'm hoping that by 6 months of age, they will master this.

Host Amber Smith: What are the clues that a baby is getting tired and ready to go to sleep?

Zafer Soultan, MD: When they start to do certain things, they need to sleep.

It's like, they rub their eyes, they reach out to their ears. They're not interested in playing or looking at you.

They look to the other side. You want to play with them. You want to tell them, "Come and play." So the way they do it, by turning to the other side, that means they're telling you that "I'm not interested. I want to sleep."

Host Amber Smith: Now you mentioned the room should be cooler. Why is that?

The way our body's set up, that the colder we are, the more we make that melatonin, which kind of triggers sleep. So we recommend that temperature at, like, 70 degrees or maybe 69. The older (kids), you can go down to 68 and 65 sometimes.

Now, the room needs to be dark, but what about a night-light? Is that good to have on in the room?

Zafer Soultan, MD: It's not, like, good to have. So baby doesn't require night-light. So a night-light maybe for family and safety ... but if it's an older child (who) demands the night-light, that's OK. It's basically dimming the light. The light has to be dimmed in the whole house in the evening, including the bedroom.

Host Amber Smith: Now, I'm thinking about a baby who doesn't ever exhibit signs that it wants to go to sleep. How can you encourage them? Do lullabies help?

Zafer Soultan, MD: We talked about training, or assisting, the baby, the same thing, like, you're teaching your baby how to ride a bike, let's say, or how to walk when you start assisting them and encouraging them and holding their hands and putting objects for them to hold onto.

So the same thing you need to do to assist them with this process, which means doing some sort of a bedtime routine. So our brain loves bedtime routine, so we change the diaper, we feed, we sing a lullaby, we dim the light in the room. We are all quiet. We don't have noises in the house, nobody jumping and making a lot of noises, so the baby will feel the difference.

This is a bedtime routine. So we have a little bathing, lowering their body temperature, hugging, very soft, very calm, and dimming the light and singing the song and maybe rocking maybe a little bit and then putting them in the crib. So the sleep process will be putting the baby in the crib to teach them how to sleep on their own, how to soothe themselves to sleep.

So the process of learning how to sleep in the night, the main, main, main thing, or paramount importance, of that process is when the baby will learn how to sleep on his or her own. So after all these bedtime routines, including the lullabies, the baby should be put in the crib to fall asleep on their own, not while asleep -- they should be still awake, but very, very drowsy.

Host Amber Smith: And the babies are put to sleep on their back only?

Zafer Soultan, MD: Yes, (on the) back to sleep is important to prevent sudden infant death syndrome. There are quite few recommendations, but the main one is to put (them) on a little bit semisolid mattress and on their back only.

Host Amber Smith: Now, how do you feel about those sleep sacks, or bundling the baby rolling like a burrito almost, to keep them bundled in and snuggled? Are those useful? At least in the first couple months?

Zafer Soultan, MD: Perhaps. Perhaps it soothes the baby down, and the baby associates it with sleep, and they go to sleep because of this. Yes.

Host Amber Smith: What about pacifiers? Do you ever recommend the use of pacifiers?

Zafer Soultan, MD: Pacifier is recommended by the American Academy of Pediatrics after the baby is finished with learning the breastfeed. So after the baby masters breastfeeding, a pacifier, provided we follow the rules, the condition of the pacifier to be one piece and to be wide on top, so the baby won't swallow it.

A pacifier has a lot of benefits. It supports the airway, keeps it open, soothes the baby to sleep, so there's no objection.

Host Amber Smith: Well, let's talk about some of the things that could cause a baby to have a tough time sleeping and what parents can do about it.

I'm thinking about teething, and that would be later in the first year?

Zafer Soultan, MD: Yes, whenever the baby is in pain, teething, colic, acid reflux, ear infection, fever, cold, they cannot breathe from their nose because they have a cold and their nose is stuffy.

Acid reflux and vomiting and heartburn for the baby and crying, yes, these are unusual.

Typically, the baby cries when they go to sleep, it's because they are not ready yet. They didn't finish their training. It's not failure of the parents. It's the baby hasn't been able yet to soothe themself to sleep.

In the first three months. The baby soothes themself to sleep by mom rocking them and holding them. Now we are going to start at 3 months teaching the baby how to soothe themself on their own. So they don't know what to do, and they cry. The most common reason is just crying because they haven't been trained yet, more than teething.

But if the baby is trained, and they've been falling asleep on their own, and now they are crying, that means there's something wrong, as I mentioned.

Host Amber Smith: So do you then have to figure out, "Oh, is it an ear infection? Are they teething? Do they have a fever?" You have to figure out what's causing the discomfort then, it sounds like.

Zafer Soultan, MD: Yes. And there are breathing issues. There are breathing issues. There are babies who have a congenital anomaly. The airway, the nose, the mouth, the throat, is not normal and tend to be narrow or tends to close up when they sleep. And then the parents will notice the baby is not crying, but they kind of choke while they're asleep. They make noises when they breathe. They stop breathing, they struggle to breathe. Their chest and abdomen moves in a unusual way. They breathe fast. They have retraction, sunken chest, whenever they breathe. So that's a breathing issue, and that indeed wakes up the baby. They keep waking up to breathe.

Host Amber Smith: That sounds like that could be a serious issue, though, that they would need to bring to the doctor's attention.

Zafer Soultan, MD: Yes. Yes. Absolutely.

Host Amber Smith: Well, want to ask you more about that, but before we get into that, what if you have a baby who cries when you're trying to train them to sleep, but they cry when the caregiver leaves the room?

How do you train them to get used to being alone?

Zafer Soultan, MD: You've got to keep training them, so do not give up, same like your baby keeps falling when they're walking, and then you just say, "OK, don't walk." No. So you don't give up.

There are different techniques, and you're going to choose one of them. The fastest one, if you can do it, is to let them cry out. You put them in the crib, and you leave the room. Within a couple of nights, the baby will learn that they're going to sleep on their own. Of course, leaving the room, but you're going to leave the door open and keep monitoring what's going on with the baby.

A little bit gentler way is that you put them (down), and they cry, and you keep coming back to check on them, but you do not carry them. You keep them in the crib, but you keep coming back.

And there's another way where you put a chair, and you sit next to them, but you don't touch them, and you don't sing for them, and you keep watching them crying. And over time you keep moving your chair away from the crib.

And there's another way, is that you keep carrying them. They cry, you carry them a little bit, and then you put them back. You carry them a little bit, and then you put them back. And they keep crying, and it's a process. It's going to take a few weeks

Eventually, you will notice that when you, for example, if you did the way that "I will let them cry, but I will keep coming back," I will start by coming back in one minute, then in two minutes, then in three minutes, then in four minutes. Then in five minutes, when you come back in six minutes, you notice they fell asleep already, they learned.

If you keep carrying them and putting them back, over time, you learn, OK, after 10 minutes of this process, they slept. But you are enforcing. You are enforcing the baby and forcing them to learn how to sleep by themselves. That's why the training is important. So with the training, try to, in the first three months of the training period, which is between 3 months to 6 months, it's good to start teaching the baby to cry a little bit. Don't jump directly to the baby and carry them whenever they need anything. Start the process. Start testing the system and encouraging the baby to sleep on their own.

Host Amber Smith: So that's got to be harder to do if you're sharing a bedroom with the baby, if you have the crib in the corner of your room.

Zafer Soultan, MD: Yeah, a little bit, but you could. Some people opt to put the crib in their room. Some parents do that. So then they leave the bedroom. They don't stay in the room until the baby falls asleep. I mean, it's a process.

Now, the norm is that they learn. I mean, how many times do we see a baby unable to walk, unless of course, if there are underlying issues?

So all babies learn, and they do it, but when it took the baby a little while to learn, then it's a process, a little bit difficult time for the parents. And many times parents need to have shifts. The father or the mother who works, maybe they go to sleep in another room because it's a process, and there will be a lot of crying and lifting and putting back.

Don't forget, the same baby will keep waking up in the night asking for the same process until eventually they learn. But it's really worth it, it's really important because the baby learning how to soothe themself to sleep is a clue for eventually having a good set of sleep habits all across childhood until adolescence, but every baby learns. It is going to happen.

They're going to learn.

Host Amber Smith: Now, what are some of the common sleep disorders in infants, and how are they treated?

Zafer Soultan, MD: The most common one is the infant who hasn't learned how to sleep on their own. So, parents' expectation from friends that, their baby sleep on their own by 7 months of age, then, here we go, we have a baby who's 8 months or 9 months, crying all night. This is the way the parents present it, that "My baby does not sleep."

And when we ask, "What do you mean?" they mean that they keep waking up crying, and the parents take them, carry them, cuddle them and rock them as they did initially (at) start of the night, and then they fall back to sleep.

Unfortunately, this is at a cost for the parents. They need to work, and they cannot every two hours wake up and do what's needed for 15 minutes, half an hour. And the next day, they're exhausted, and they do call it that this baby doesn't sleep. So basically, this is the issue. So that's the most common problem.

We have a secondary problem. Babies who are in pain for some reason, whether they do have certain anomalies or disorders which make them be in pain. For example, a common problem is acid reflux, where the baby regurgitates, and the acid burns them, hurts them inside, and they cry.

Again, we talked about teething, ear infections and common colds with obstructed nose. And another common problem we see is the sleep apnea, but sleep apnea in infants most of the time occurs in a baby who has anomalies in their airway and in their tongue and in their face, (which) is not friendly for them to breathe well when they sleep.

So those are the common problems we have in infants. Of course, there are seizures, abnormal movements during sleep that can happen. That's rare.

Host Amber Smith: So when you talk about sleep apnea, what does that look like to parents that are watching their baby sleep? Can they tell that the baby has stopped breathing?

Zafer Soultan, MD: Yes. So parents can see the baby stop breathing. They see the baby struggle to breathe. They seem to be working hard to breathe. They have retractions, sunken chests, when they breathe. They make noises like snoring or abnormal noises. Sometimes they turn blue.

So those are the signs of sleep apnea. However, it's common for babies during the rapid eye movement stage of sleep. Babies do a lot of rapid eye movement stage. Half of the night is spent with that. During that time, the baby will be having disorganized breathing. The parent will notice that they breathe fast, and they stop. Then they breathe, and they stop. That's normal. So I think today I confused the parents a little bit. I did mention a similar sign when I said they have sleep apnea. So they best thing's to talk to your pediatrician.

So when the pediatrician sees the baby whose parents say, "When we put them to sleep, and they're moving their eyes ..." -- many times parents see it -- "... then we notice that the abdomen goes up and the chest goes down, and we notice sometimes they stop breathing."

Yet, the pediatrician looks at the baby, and the baby is well nourished, healthy, doesn't have an anomaly which can block his breathing. Then we just assure the parents, we just tell them that's normal. So yes, indeed, if it is pronounced and concerning to the parents, even though I said most likely it is normal, discuss it with your pediatrician.

Host Amber Smith: How common are anomalies that would cause sleep apnea in an infant?

Zafer Soultan, MD: One of the common ones is the babies who are born with a soft voice box, so this is a common problem in babies when they are born and the larynx, the voice box, is soft, and they make that noise (wheezing).

And those babies, when they sleep, sometimes the airway, the voice box, closes, and they have sleep apnea. One of the common congenital anomalies is trisomy 21 (Down syndrome). In trisomy 21, the tongue is bigger, and the baby is a little bit weaker, so also they're prone to have sleep apnea. So those are the two kind of common issues.

There are many, many congenital anomalies which make the airway close, but those are common.

Host Amber Smith: Now some of those would be sort of diagnosed at birth, that there might be a risk for that.

Zafer Soultan, MD: Yes. And some of those, the parents are alerted of the possibility of doing that. And actually many of them, the physician who's taking care of this baby, do anticipatory work to rule out this issue because they anticipate this is going to happen.

So they do sleep studies, they do other studies to observe the baby.

Host Amber Smith: You're listening to Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with pediatric sleep specialist Dr. Zafer Soultan about common sleep problems in children.

Now, if parents are struggling with a baby's sleep, how do they reach an expert like yourself?

Do they go through their pediatrician?

Zafer Soultan, MD: Our pediatric sleep center is comprehensive. We do have four pulmonologist providers who are expert in managing sleep disorders in children. And we do have a pediatric psychologist who has expertise in intervening and behavioral therapy for infants and children insomnia.

So it is a comprehensive program, and we do have a sleep lab for sleep study. This is the diagnostic process where we observe the infant asleep to diagnose breathing problems.

So how do we refer to us? We accept self-referral, but it's better if it comes through the pediatrician because one of the common problems I mentioned, that is babies normally stop breathing while asleep, maybe a pediatrician will just assure you, rather than waiting a long time to see the sleep specialist.

Host Amber Smith: When you talk about a sleep study for an infant, how does that work? Does the parent bring the baby into the hospital?

Zafer Soultan, MD: The parents first get evaluated at our center, and the referral for the sleep study, and this is basically like a hotel stay where the baby will be asleep in a crib, and the one of the parents will be sleeping next to them.

However, while the baby is asleep, they're monitored, comprehensive monitoring. Many, many probes and instruments, outside instruments, to monitor everything, from breathing to oxygen, to heart, to brain waves, camera, snoring, noisy breathing, movements.

Host Amber Smith: So you'll get a pretty comprehensive, it seems, list of things that, "Are they working well, or is there something wrong?" You'll be able to tell after that sleep study.

Zafer Soultan, MD: Yes.

Host Amber Smith: Well, what's involved after that? If you detect that there is an anomaly, I mean, how do you fix some of these sleep disorders?

Zafer Soultan, MD: The sleep study is done for two main indications, one of them breathing issues, and the other one, abnormal movement and seizure issues.

So abnormal movement and behavior and seizures, this goes to the neurologist.

The breathing issues while the baby is asleep are either because the airway gets blocked, or they have a problem with the center in the brain which ordered or triggered the breathing.

And each one, we manage it separately. For the blockage, we see where the blockage is, and we try to remove it. Or if it's not removable, it's a matter of weakness or narrowing, then we do CPAP, which is a machine that pushes air on the nose of the baby. And we apply that air by a mask on the nose or little cannulas (tubes) in the nose. Sometimes we treat problems with oxygen supplements.

It's a list of interventions, and on rare, extremely rare, occasions, with certain severe conditions, we kind of open another "nose." We open a "nose" (a breathing hole) in the throat that we call a tracheostomy for the baby to breathe when there is total blockage and the baby cannot breathe.

Host Amber Smith: Do you ever have parents that come in for the sleep study with the baby, and you find out that the baby hasn't been trained to sleep very well and needs help with that? Is it ever that reason?

Zafer Soultan, MD: Yes. Now, many times, our team, because we are experts, we make the diagnosis and avoid doing sleep studies on these babies because we made the diagnosis.

We understand why the baby is not sleeping because that's the common problem, common presentation, that "My baby doesn't sleep." And then we understand that's what we call a behavioral insomnia. That baby needs training, hasn't finished his training yet, needs to be given chance to train and learn.

Host Amber Smith: Well, Dr. Soultan, thank you so much for making time to talk about this.

Zafer Soultan, MD: You're welcome. Thank you for this opportunity.

Host Amber Smith: My guest has been Dr. Zafer Soultan, the chief of pediatric pulmonary medicine and director of the Upstate Pediatric Sleep Center.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe, with sound engineering by Bill Broeckel and graphic design by Dan Cameron.

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