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Wake-up call Postpartum

Wake-up call

Surprising reasons why you can't sleep (even after baby does).

At kindergarten drop off this morning, a fellow mom stopped to show me pictures on her phone. “See, I told you my niece looks just like your daughter!” she beamed. I agreed and smiled back whole-heartedly, carefully studying her friendly face. Then as we parted, I fought back the tears—I had no idea who this woman was. I hung my head to ride out the wave of exhausted bewilderment, only to notice I was still in house shoes. Ah, the joys of long-term sleep deprivation. Had it finally gone too far?

You’d think I was in the throes of the up-every-two-hours gauntlet with a newborn, but (although I’d certainly been there and done that) my youngest child, my 17-month-old daughter Gianna, had been sleeping through the night since she was 1. I however, had not.

For that first year, I was convinced that always responding to little Gianna’s night waking had fostered a peaceful association with sleep. I reveled (as much as one can revel on minimal sleep) in watching how my consistent, loving responses to my sweet daughter seemed to chip away at her very need to cry for me. She self-soothed, lengthened her sleep (albeit slowly) and now goes down as smooth as butter—both for bedtime and naps! It had been a fairy tale of sleep training avoidance. Except for one glaring problem: A year of interrupted sleep had inadvertently completed someone else’s sleep training—mine.

The unique phenomenon of momsomnia
In the postpartum period, sleep loss is largely driven by psychological factors unique to new moms. Postpartum hormone balance can come into play, and of course, the frequent night waking of a new baby can wreak havoc on mom’s normal sleep patterns. Infuriatingly, my brain woke me at the old feeding times, even as Gianna slept without a peep. And some nights, sleep just refused to come at all. Had I permanently reprogrammed myself for sleep deprivation?

It’s easy to assume that the normal sleep loss from waking with baby at all hours would cause moms to fall asleep quickly every chance they get, but often the opposite is true. “The nature of the postpartum period contributes two of the three components of persistent insomnia,” says Katherine Sharkey, MD, PhD, FAASM, a researcher in the departments of medicine and psychiatry and human behavior at Brown University’s Alpert Medical School in Providence, Rhode Island. According to Sharkey, the first ingredient in the recipe for insomnia is predisposition, the second is a sleep disrupting event (ahem, a baby moving in) and the third is perpetuation (usually anxiety over sleep deprivation, in this case). This means for those of us who are prone to sleeplessness in some way (i.e., genetically or psychologically), the experience of being repeatedly wakened can lead to persistent (rather than transient or short-term) insomnia. “It normally takes 6 to 12 weeks before babies get into any kind of predictable sleeping pattern and up to a year or more before they sleep all night,” says Sharkey. During this time, as mom’s sleep deficiency mounts, the uncertainty over when and if she’ll be able to catch up can often equal serious anxiety.

Inside the mothering mind
The anxiety dynamic is one reason Cognitive-Behavioral Therapy for Insomnia (CBT-I) has proven one of the best tools for “momsomniacs.” Jennifer Tardelli, MA, LPC, NCC, a women’s counselor practicing in Atlanta, says CBT-I works by alleviating the anxiety of living with interrupted and inadequate sleep. She teaches her clients who are moms to do everything they can to maximize good sleep habits, but when they have a bad night with baby anyway, staying relaxed is essential. CBT-I involves deep abdominal breathing, mindfulness and visualization, as well as skills for “reframing” the night-waking lifestyle.

Reframing works like this: Your body is screaming at you that the amount of sleep you’re getting—or not getting—is not OK. Yet, to get ahead of it and mentally stop the anxiety-insomnia cycle, Tardelli explains, “You learn to tell yourself, ‘Tomorrow is not going to be my best day, but I’ll survive. I have the strength to endure.’” Tardelli says reminding yourself that the circumstance is temporary improves the chances that it will be.

Sharkey, who currently conducts research on postpartum sleep problems, concurs: “We have great data showing CBT-I can teach people how to fall back to sleep when they seem to have forgotten.” This is especially important for moms because of the natural psychological vulnerabilities we have. Several studies show CBT-I actually improves insomnia better than sleeping pills. And since some meds can have scary side effects (as in, “Honey, where’d I leave my car?”), postpartum moms are typically more comfortable with a drug-free approach. By providing mental skills, the positive results of therapy also tend to be long-term, unlike meds. But experts insist there’s a time and a place for sleep aids, “particularly for short-term relief while moms are learning the long-term skills needed to reestablish healthy sleep in therapy,” explains Tardelli.

Excuse me, Mr. Sandman, I need to check on the baby again
Clearly, part of the formula for thriving in the newborn era (and avoiding too much anxiety), despite months of interrupted sleep, is being able to get baby and mommy back to sleep quickly after waking. It can be especially challenging for moms to turn their brains on and off like a switch, since postpartum parents face a slew of new things to worry about.

“The sheer pace of caring for a baby serves as a distracter from processing feelings during the day,” Tardelli explains. When the body finally slows down at night, the mind starts to throw all kinds of things at us. Experts urge moms to take the time to talk about their numerous fears, questions and worries as they arise during the day. Otherwise, they can backlog and show up, top of mind, when (finally) turning in at night. And since that first stretch of sleep from bedtime to baby’s first waking is often the best chance moms have to get the longest—and typically deepest —stretch of sleep, it’s vital to keep a busy mind at bay.

Some extra worrying comes with the territory of being a mom, but too much can signal a problem brewing. “We’re biologically programmed to be vigilant about keeping our babies safe,” says Sharkey, “and that’s a good thing. But sometimes mom’s protective instinct can get pushed into overdrive.” This often translates into a racing mind at bedtime or obsessive-compulsive behaviors, like feeling the need to incessantly check on the baby or perfectly fold every piece of laundry before going to bed. Sharkey urges mothers to talk to a doctor about sleep issues since depression, anxiety, sleep deprivation and even obsessive-compulsive disorder (OCD) can all be interrelated —and are all very treatable.

Harvey Karp, MD, pediatrician and creator of The Happiest Baby on the Block book and DVD, also emphasizes the bidirectional nature of depression and insomnia. “People think of depression as sadness, but postpartum depression is often characterized a worry and anxiety. Depressed moms can become so vigilant that they just can’t  sleep, which creates more of a depressive spiral,” says Karp. When doctors are able to improve sleep, it often reduces depression.

Go to sleep little baby
Karp’s solution to the enormous prevalence of maternal sleep deprivation (lest it cause persistent insomnia) is to get to the original source of the matter: the baby! A major focus of his latest book, The Happiest Baby Guide to Great Sleep, is teaching parents how to get baby to sleep the longest stretches possible from day one through skilled soothing techniques. The idea is this: The sooner parents learn how to activate baby’s “calming reflex,” the sooner baby will get into a pattern of longer stretches of sleep, and the sooner mom can begin to reclaim a normal adult sleep pattern. Karp is currently conducting research to prove something he’s observed during his more than three decades in practice. His hypothesis? By reducing infant crying and excessive (non-hunger-related) waking, the likelihood of mom developing depression and anxiety can be reduced.

Perhaps the most important key to achieving better baby sleep is to pick baby “sleep cues” that continue working even while mom’s fast asleep. So instead of nursing all the way to a deep sleep every time, you’d use low-pitched, “rumbling” white noise and snug swaddling as baby drifts off. “In order to work, sleep cues have to be done correctly and often in combination,” shares Karp. For example, the white noise a typical phone app provides is much too high-pitched. Likewise, Karp says, 5 to 10 percent of babies are “motion babies”—they simply can’t sleep (in the early months) lying still. For these babies, swaddling and white noise will not be enough; they need to sleep in a swing (fully-reclined for safety) to get the longest sleep durations. (Clear it with your pediatrician before going this route.) With techniques like these, babies typically sleep twice as long between night feedings, only becoming fully awake—and therefore waking mom—when truly hungry.

Is co-sleeping a solution?
Mom’s interrupted sleep doesn’t always present a problem, of course. A major determinant of insomnia is if mom can quickly fall back to sleep and make up the additional hours needed (she usually needs eight in total). An ancient and increasingly popular way to facilitate getting back to sleep quickly is to sleep right next to baby. James McKenna, PhD, considered the world’s foremost expert on mother-infant co-sleeping (including bed-sharing), estimates that 75 percent of moms bring baby into their bed at some point during the postpartum period, many out of a necessity to get more sleep.

Moms often find it’s much easier to roll over and nurse the baby than to get up, feed the baby, go through the soothing routine necessary to get the baby to go back into a crib/bassinet/co-sleeping device, and then get back to sleep herself. “When baby is sleeping with a breastfeeding mom, both mother and baby typically drift right back to sleep quickly after the feeding,” says McKenna. His research at the Mother-Baby Behavioral Sleep Laboratory at the University of Notre Dame, where McKenna serves as director, found that breastfeeding, co-sleeping mothers tend to get more total sleep than moms who sleep apart from their babies.

The expert consensus currently is that a co-sleeping device (i.e., a bedside, side-car-like sleeper or bassinet) is safer than bed-sharing in our culture—if you can get the baby to sleep in it. Since McKenna is a biological anthropologist, he emphasizes that the baby’s instinct to stay as close as possible to the mother is hard at work here, so if your baby won’t sleep anywhere but by your side, there’s nothing “wrong with him”; he simply has good instincts.

So, if maintaining separate sleep surfaces is best in our American culture, but it’s “biologically” difficult for babies, perhaps the answer is to create a sleep environment like that of a different culture—say, Japan, where sudden infant death is the lowest in the world and bed-sharing is the norm. McKenna details how to achieve this type of safe shared sleep environment in his book Sleeping with Your Baby: A Parent’s Guide to Co-sleeping. “It’s better for parents to learn how to bed-share in a safe environment than to be told absolutely not to, and then end up doing it accidentally or out of desperation in an unsafe environment,” McKenna asserts. Since breastfeeding itself is protective against sudden infant death, reducing the risk by about 73 percent for exclusively breastfed infants, it makes sense to consider the sleep arrangement most conducive to breastfeeding (as well as to getting adequate sleep).

An integrative solution
Scientists call the insomnia I experienced “conditioned arousal.” In other words, Gianna’s night waking during that first year had trained me to wake up out of habit, even when she didn’t need me anymore. Because this type of insomnia has a physiological component, some hormone balancing was in order. My first salvation was a small dose (1.5 milligrams) of melatonin, which is widely available in drugstores, supermarkets and supplement shops. Melatonin is very effective at signaling our bodies to sleep—just what long-term sleep deprived moms need to override baby’s “conditioning” to wake up. According to

Cheryl Burdette, ND, a naturopathic physician specializing in women’s endocrine health, the natural remedy helps the brain work better at producing healthy sleep by “increasing the antioxidant defense system within the brain,” Burdette explains. “It cleans up free radicals in the brain as we sleep at night, causing the brain to work better on its own.” Burdette prescribes melatonin clinically in 1 to 5 milligram doses, usually after baby has begun to sleep longer at night, though it can sometimes be appropriate sooner to help moms who are not bed-sharing return to sleep more quickly. Melatonin does not normally interfere with breastfeeding hormones, but it’s smart to check with your doctor before adding any supplements to your regimen.

Another common sleep trouble culprit is low thyroid function. “Every time a woman becomes pregnant, she has a 10 percent increase in risk of developing hypothyroidism (under-functioning thyroid),” says Burdette, who prescribes natural minerals, high-dose iodine and herbs like kelp to help the thyroid rebound. According to Burdette, a high-functioning thyroid helps moms sleep, combat fatigue and lose weight.

Pregnancy, nursing and the associated physical and (aforementioned) mental stress can also be taxing on the adrenal glands, which are involved in regulating our circadian rhythm. These little hormone powerhouses make us more inclined to get up and go in the morning and then wind down at night. “It’s when our adrenal function is flat that we don’t sleep so well,” says Burdette, who prescribes B vitamins and natural glandular supplements to boost the adrenals.

Progesterone deficiency is another hormonal imbalance that’s quite common after childbirth. “This progesterone drop can contribute to insomnia, but can be effectively and safely treated with natural supplementation or bioidentical hormones,” explains Burdette. The natural remedy to supplement progesterone is called chaste tree (its Latin name is vitex). I noticed an improvement in my sleep immediately after taking this botanical as directed on the bottle, but an integrative physician can take blood levels and prescribe a bioidentical version of progesterone accordingly.

With myriad possibilities for sleep sabotage after childbirth, it’s up to us moms to find the right mix of solutions to get us back on track or prevent the downward spiral in the first place. Finding that my own wearisome torture was hormone-related was an epiphany that literally saved my sanity (and possibly my house shoes). Whatever your individual reasons for long-term sleep deprivation, don’t suffer unnecessarily. Seek help, whether through herbs, therapy or pharmaceuticals. Breathe, walk, vent your feelings. Pop a pill if you and your doctor agree that’s what’s best for you. Your baby needs you to be healthy and happy. Your baby needs you to sleep.