Introduction

Newborns may spend up to 18 hours per day sleeping [1]. The ‘organization’ or architecture of their sleep changes dramatically over the initial few months: Their activity during REM (dreaming) sleep becomes progressively less, and the duration and proportions of different sleep stages (REM and non-REM or quiet) change over time [1]. The biological rhythms of sleeping and waking also become progressively more organised [2] so that sleep patterns become more established by around four months of age [3]. These patterns of change in sleep continue, but changes occur more slowly, throughout infancy and childhood [3]. This is normal and is part of the extraordinary development and growth that occur in the first year of life. Infant sleep recommendations have changed as scientific knowledge has expanded regarding the benefits and risks associated with different sleep strategies in infants and children [4].

Parents who are struggling with their infants and young children may seek out support through healthcare professionals, friends and/or family, or through social media. Options include phone, telehealth, day stay or residential (over a number of days and nights) services, and these may be provided through private or public health systems. Many families seek out social media influencers and other online support networks as sources of assistance with sleep and settling techniques [5]. These can be extremely helpful for some families but their messaging can be very varied in quality, and may conflict with safe sleep recommendations as well as with one another.

Across Australia, many local, state and territory governments provide free support services during the early years (birth to four years of age) for families with children who are struggling with sleep. Historically known as a Sleep Schools, these publicly funded health services acknowledge that parents are the experts in knowing their children and their family situation. These services deliver best practice, evidence-informed education, and are focussed on enhancing the parent-child relationship. They provide support to parents with strategies to achieve their parenting goals, including sleep and settling while respectfully exploring the unique characteristics of the infant and their family.

Families need access to clear and scientifically-based advice, to assist with settling their infant.

To complicate matters for parents, there is no standard terminology for settling techniques. However, a commonly shared aspect across the majority of infant settling techniques is to watch for cues that signal that the infant is tired, and to place the infant in their safe sleep cot or portacot prior while they settle to sleep, to assist them in developing self-regulation. The information in this guide will outline how healthcare workers can assist parentsand care-givers with safe settling techniques

Why is sleep important?

Sleep contributes to the learning and development of an infant by fostering nervous system development and memory consolidation [6]. Factors that can influence sleep disturbance in infancy and early childhood include the sleep environment [7], biological factors [8], medical illness, and familial factors such as instability in the parental relationship or familial aggression [9]. Lack of sleep is one of the biggest factors leading to tension and issues in relationships when parenting young children [10]. The attachment between caregiver and infant is also an important part of healthy brain development, learning, and emotional security [11].

What is infant ‘settling’ and why is it important?

Settling describes techniques used by the parent or care-giver to assist the infant and child to settle and fall asleep on their own or ‘self-regulate’ their sleep [12]. It is essential to also follow Red Nose safe sleeping guidelines while settling an infant [13].

There is no ‘best time’ to introduce specific settling techniques – this is a decision for parents and caregivers, depending on the needs of the infant and parents. But it is important to consider the normal developmental processes as babies grow because they can contribute to sleep issues. Sleep patterns are constantly maturing through-out the first several years of life. Infants develop more of a day-night routine and more stable sleep patterns by around 4 months of age, but this is also the time that infant settling issues often arise [14]. Around one third of infants struggle to have uninterrupted sleep overnight and/or have problems settling to sleep [15].

It is also important to weigh up any recommended strategies with your own family’s needs and circumstances. Australian research has shown that providing support to mothers through education about sleep and providing settling strategies decreased infant night waking, and improved their mother’s stress, anxiety and depression [16]. On the other hand, trying to adhere to strict sleep routines because they claim to foster self-settling or promise success can add enormous pressure to parents, particularly when things aren’t going as planned. One study found that 19.4% of 1460 infants who had persisting severe sleep problems at 3, 6, 9 and 12 months of age, had higher risk of emotional problems and anxiety when they were followed at 4 and 10 years of age [17]. Indeed, a recent meta-analysis identified a significant relationship between poor infant sleep and a range of subsequent mental health symptoms or diagnoses [18].

Problems with infant mental health can be exhibited through crying, restlessness and sleep issues [19]. It may be important to consider whether other medical problems are present if your infant is not settling despite repeated efforts using the settling tools discussed below.

Infant settling and self-regulation

Research highlights that when infants are taught to re-initiate sleep without intervention it improves their capacity for self-regulation and increases the duration of their longest period of self-regulated sleep [12]. An infant who always requires parental assistance to get to sleep will require parental assistance to return to sleep if they wake at night and will disrupt their parents’ night sleep. Encouraging self-settling improves the wellbeing of both the mother and the child. Self-regulatory behavior is achieved through the infants own exploration such as gazing and touch as well as learning those behaviors from their care-giver [20]. Thus, infants who are placed in their cot awake and learn to self-settle develop more sustainable sleeping patterns [21]. Further, a review highlighted that the most successful management programs focused on teaching parents to be less involved with their babies’ settling [22, 23]. Whilst aspects of crying and poor sleep are developmentally normal, parents need tools to help settle their baby, establish good sleep routines and assist the infant with self-regulation and self-soothing [15].

Routines, sleep associations, sleep hygiene and settling

Routines are pivotal to settling, self-regulation and good sleep hygiene [2]. Bedtime routines teach the infant to associate certain patterns of behaviour, or environments, with the process of going to sleep, and they can be helpful, or they can become a problem. Problems typically arise if the infant does not know how to self-regulate without it and if the parent is required to participate every time the infant wakes or needs to settle.

A bedtime routine is taught when the caregiver repeats the same behaviour over time, before bed and/or before sleep, such as a nightly bath or story in a quiet room [24]. A short three week intervention trial taught the parents of over 400 infants to use a set bedtime routine, and in just one week reduced the time infants took to fall asleep, and reduced their night-time waking [24]. Common sleep associations include the use of a dummy or pacifier, or white noise (such as music, a ceiling fan), or being driven in the car to sleep. The Red Nose safe sleep recommendations advise using a pacifier at every sleep if one is being used. But if the pacifier has become more of a hindrance than a help because the baby can’t replace it themselves but also can’t go to sleep without it, then it is probably better to no longer use it at any sleep [25]. In this case, removing the sleep association can then help establish better sleep regulation.

Sleep hygiene is the overall environment and routine that promotes healthy neuro-hormonal patterns in an infant as well as positive sleep associations to assist with ‘winding down’. Strategies that can assist with supporting sleep hygiene and self-regulation include reducing stimulation before sleep, putting the infant in the cot drowsy, and allowing enough time in bed for a heathy sleep duration [26]. Amongst the factors that make up sleep hygiene, blue light exposure from television or a mobile phone blocks the production of melatonin, or sounds coming from a device may stimulate or agitate an infant. Both international and Australian research demonstrate a trend toward decreased sleep duration in children [27, 28]. In Australian data, 50% of children aged 4-5 years had at least one sleep issue and children with more hours of media use at age 4-5 years had shorter sleep duration at age 6-7 years [27].

A recent meta-analysis highlighted the benefits of parenting support, whether group sessions or one-to-one sessions with one or both parents [15]. Infant sleep problems can be triggered when the parent actively helps their infant to fall asleep, for example by patting them as they fall asleep [15]. Infants who are rocked to sleep, held or fed are more likely to develop sleep disturbance issues and poor sleep associations [29]. However, it can be hard to work out if parents started to do this, and the associations developed, because the infant was already difficult to settle.

Feeding, sleep and settling

Although decisions to stop breastfeeding prematurely, change to infant formula, or commence complementary feeding may be influenced by infant sleep patterns or changes, unless a food sensitivity is suspected, care should be taken by parents and health professionals when considering altering a feeding regime to manipulate sleep patterns. While the type of feeding might affect the babies’ frequency of waking, it does not affect their duration of sleep. A recent systematic review reported that babies who were exclusively breastfed woke more frequently at night than formula fed babies, or those having complementary feeds, but the total sleep duration over 24 hours was not different between the groups [30].

Attachment

Attachment is the relationship between a child and parent or caregiver that supports the infant or toddler to feel safe, secure and protected [31]. Attachment is important for the healthy development of a child and for parent/caregiver and child mental health. Research indicates that poor attachment can result in an increase in night waking and sleep problems [32]. Although poor attachment is not the sole cause of sleep problems in babies and toddlers, it is a factor that needs to be considered when supporting parents and caregivers with sleep and settling concerns.

Infant crying behaviours

Typically developing infants display an increase in crying behaviours over the first few months of life, usually peaking at around 8 weeks, and then steadily declining by 4-5 months of age. Normalising this peak in crying behavior by explaining it to parents as the “period of ‘PURPLE’ crying” – may help parents to anticipate this change. The “PURPLE” acronym refers to;

Peaks in crying that are Unexplained, Resists soothing, are accompanied by a Pain-like face, are Long-lasting, and occur in the Evening [33].

Taken from http://purplecrying.info/sub-pages/crying/why-does-my-baby-cry-so-much.php [34]

Use of the PURPLE paradigm may help parents to understand the changes in their infant’s crying as a normal developmental phase that will pass.

Choosing a technique that’s right for your family- the self-settling techniques

A settling technique may be something that is discussed and chosen during pregnancy, or the result of observation and experience with other infants [29].

Under 6 months – responsive settling

Newborns aged birth to 3 months have not yet learned to settle themselves. Providing them help to settle and go back to sleep is called responsive settling because it involves responding to infant comfort needs and by helping them feel safe and secure it helps them settle to sleep (34). Settling in the carer’s arms, hands-on settling and verbal reassurance are ways to settle infants responsively.

Settling in arms

• hold and sooth infant

• Try helping the infant to fall asleep in arms with gently rocking or swaying from side to side.

• when the infant is ready for sleep, gently put them into their cot.

Hands on settling

Prior to age six months of age, ‘hands on settling’ is currently considered the standard approach [35].

Several types of hands on settling techniques include -

• Gentle & gradual –gentle patting or holding the infant in the cot

• Verbal reassurance – intermittent check-in with the infant remaining in the cot, quiet singing, talking or using sshhh

• Pick up, reassure, but put down if the infant is becoming more agitated.

Over 6 months of age – responsive settling

After six months of age, infants need less sleep than during their first six months. Day naps become less frequent and they progress to one or two longer day sleeps. “Feed, play, sleep” routines are helpful, recognising that the time between sleep periods gradually increases.

Three key strategies are suggested for settling from six-twelve months of age [10]:

• Responsive Settling. An approach that can include many different strategies and interventions for settling. Sensitive attunement to a child’s cues and needs is recognised as the core foundation of responsive settling [40].

• Parental presence involves lying down on a bed or mattress in baby’s room with a night light on and pretending to sleep where your baby can see you. Parental presence aims to use parent/carer presence as a way of helping baby to self-settle and requires a seven to 10 day commitment [10].

• Camping out is similar to the parental presence strategy. It may be useful for parents/carers that don’t want to sleep in their baby’s room but find it hard to leave baby to cry even for a few minutes. This involves sitting or lying beside the cot and gradually moving this position closer to the door over a one to three weeks period, until baby can go to sleep by themselves [10]

It’s important to be aware every child is different, and a variety of techniques may need to be implemented to assist with settling.

Twins – co-bedding –settling more than one baby

Before safe settling of twins, it is important to safe sleep twins following the Red Nose guidelines [37]. These are:

• Always sleep each infant in their own cot

• Where possible, sleep both twins in the parental sleeping space up to 12 months age

• Place their cots side by side (with all sides up) so they can interact and see each other

• If two cots can’t fit in the parental bedroom, use a room that can accommodate two cots so the twins can remain together

There is a paucity of scientific literature that explores the ‘best’ settling techniques for twins. Safe settling of twins and self-regulation can be done in the same room. Anecdotal stories indicate that having support and using techniques outline above such as gentle and gradual with reassurance, teaches twins to settle well [38]. A large epidemiolocal twin study by UK researchers conclude that both nature and nurture influence sleep patterns, length of sleep and disturbances in twins, but environment was the strongest influence. They also found similar rates of sleep disturbances between twins and singletons, so parents of twins can be reassured that twins do not have more settling issues and multi-birth parents are encouraged to use standard ‘hands-on’ settling techniques as outlined [39].

Summary

The research around infant settling and sleep hygiene provides evidence that can help parents to understand, and deliberately develop good habits that will support their infants and young children to settle to sleep. These strategies can help when concerns have arisen about sleep and settling. It is important that parents choose a strategy they feel comfortable with so that it suits their family and the needs of their baby.

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Last modified: 27/4/23