Adjusting Expectations: Navigating Sleep with a Premature Baby

As the first-time mom of a preemie, I was overwhelmed. I didn't expect to have my baby when I did, so I had to try to figure out not only how to be a mom, but also how to care for a tiny baby whose needs were different from term babies. It was hard to find information on parenting a preemie when I needed it. We got through it and I now have a delightful, thriving boy. If you are the parent of a premature baby, this post is for you. In this blog, we review how preemies sleep in the hospital and how their sleep may be different over the first year. We also offer tips and strategies to help you navigate sleep with your preemie.

The Science

Preemies, are babies born before the 37th week of pregnancy. Many preemies who born very early will have with conditions that require them to spend days, weeks, or months under constant medical supervision in a Neonatal Intensive Care Unit (NICU). On the other hand, preemies who are born closer to their due date may be able to transition to a traditional hospital nursery and go home within a few days of birth.

It's important to know that preemies will often sleep differently than their full-term counterparts, especially during the first few weeks. Studies suggest that babies spend a lot of their time in a sleep-like state while in the womb, so you may find that your baby sleeps most of the day and night. Term babies sleep a little less each day as they grow and their sleep begins to consolidate at night over the course of the first six weeks. In contrast, preemies have been shown to sleep ~17 hours every day until their due date without a difference in the amount of day-night sleep.

Preemie Sleep in the NICU

Many NICU preemies will spend long durations of time in an incubator, where they may be exposed to constant light, noises, and treatments. This can make it hard for preemies to sleep. NICU staff often use a combination of techniques to help preemies sleep better, including using different types of lighting, playing soft music or white noise, and swaddling. Interestingly, the scientific literature is mixed on whether or not these actions help preemies sleep.

One action that does seem to help with preemie sleep and development is Kangaroo Care, which involves placing your baby on your chest for skin-to-skin contact. Providing preemies with regular intervals of Kangaroo Care (e.g., one hour a day, three days a week) reduces a baby's stress and improves sleep outcomes.

NICU nurses will also typically follow a specific feeding schedule to ensure that preemies get enough nutrients. This usually means that preemies will need to be woken up for feedings at regular intervals.

One study suggested that NICU babies with Neonatal Abstinence Syndrome may benefit from time under a weighted blanket, but this should only be done under the supervision of a qualified professional and for brief bouts of time. At this time, we (and the AAP) do not recommend that parents use weighted sleep sacks (more on weighted blankets and sleep sacks in this blog).

Preemie Sleep at Home: The first few weeks

Once you bring your baby (or babies, see our twin/multiples blog here) home, you may find that your baby can sleep for many hours without waking. While this may seem ideal, preemies may not naturally wake up to eat. As a result, your pediatrician may recommend that you wake your baby for feedings at regular intervals during the first several weeks.

Many preemies have underdeveloped head and neck control and they are more likely to have respiratory issues during sleep putting them at an increased risk of sudden unexpected infant death syndrome. This is one more reason to ensure you are following safe sleep guidelines and putting your baby to sleep on his or her back on a flat surface that is approved for sleep (see the American Academy of Pediatrics Safe Sleep Guidelines here). Finally, preemies may also get easily stressed and overstimulated, leading to a harder time settling into a regular sleep routine compared with full-term babies.

How can you manage sleep for your preemie?

Consider the following during the first few weeks at home, at least until your baby's due date:

• Don't try to force your baby to stay awake. It's ok if your baby is awake for very short bouts of time at first. Your baby may only be awake enough time for a feeding before going back to sleep and that's fine.

• Soothe your baby by rocking/shushing/walking/gentle bouncing to facilitate sleep if your preemie has been awake for an hour or more.

• Follow your pediatrician's guidance on waking your baby for feedings. This might mean setting an alarm to offer feedings at appropriate intervals overnight.

• Consider using white noise during sleep to prevent sounds from startling your baby. Keep the level under 35 decibels, and don't put white noise right next to your baby.

• Always avoid putting your baby to sleep in locations that are not approved for sleeping (e.g., swings, car seats etc.). Preemies are often not strong enough to keep their bodies in a position that maintains an open airway.

• Don't worry about creating "bad habits." It is ok if your baby falls asleep eating and it's also ok if you hold your baby for sleep. As noted above, studies have shown that sleep improves when preemies experience regular skin-to-skin contact sleep with their mothers.

Adjusting expectations over time

Although your baby may quickly catch up to full-term babies in many areas of development, you should adjust your expectations around sleep based on your baby's due date. For example, if your baby was born three weeks early, their sleep development will be closer to that of a full-term baby than a baby who was born six weeks early. This means that you'll need to do a little bit of math when you look at sleep charts to determine how many naps or night feedings your baby might need (see our age-by-stage sleep chart here).

You'll also need to adjust your expectations around sleep training. Many preemies also have medical issues like reflux or gastrointestinal discomfort that can lead to the development of challenging sleep associations (e.g., you may need to hold your baby upright for 30 minutes after every feeding and your baby may begin to rely on being held to fall asleep). These types of sleep associations can also develop for full-term babies, and we generally recommend that parents wait until six months to sleep train unless they have specific guidance from their pediatrician to start earlier. Our 0-6 month class offers gentle approaches for establishing great sleep skills in preemies and term-babies alike, without sleep training.

Preemies may continue to have respiratory issues during sleep, even after six months. You should ask your pediatrician whether it's appropriate to engage in sleep training at any age and ensure that any medical conditions that your baby may have are under control first. If your baby is not ready for traditional sleep training, but your current habits feel unsustainable, consider trying to make gradual adjustments like the ones we recommend in our 0-6 month class (the approaches in this class can be used even if your baby is older).

Need more help?

Check out our other blogs on toddler sleep issues. If you also have a baby, check out our 0-6 month and 6-15 month classes. If you just need to talk things through with someone, please feel free to book a one-on-one consultation with us. We are always happy to help.

As working moms who also have formal education in sleep medicine, nursing, and behavior analysis, we always appreciate it when you share our blogs and resources with other parents who could benefit from the information. Please explore our site for other free resources. We have blogs on schedules, travel, and more!

References

Ardura, J., Andrés, J., Aldana, J. and Revilla, M.A., 1995. Development of sleep–wakefulness rhythm in premature babies. Acta Paediatrica, 84(5), pp.484-489.

van den Hoogen, A., Teunis, C.J., Shellhaas, R.A., Pillen, S., Benders, M. and Dudink, J., 2017. How to improve sleep in a neonatal intensive care unit: a systematic review. Early human development, 113, pp.78-86.

Gu, Y., Tang, Y., Chen, X. and Xie, J., 2024. Best evidence summary of sleep protection in premature infants in the neonatal intensive care unit: a narrative review. Translational Pediatrics, 13(6), p.946.

Curzi‐Dascalova, L., 2001. Between‐sleep states transitions in premature babies. Journal of Sleep Research, 10(2), pp.153-158.

Valizadeh, S., Hosseini, M., Jafarabadi, M.A., Mirnia, K., Saeidi, F. and Jabraeeli, M., 2017. Comparison of 2 methods of light reduction on preterm infants’ sleep pattern in NICU: a randomized controlled trial. Crescent Journal of Medical and Biological Sciences, 4(4), pp.211-6.

Vitale, F.M., Chirico, G. and Lentini, C., 2021. Sensory stimulation in the NICU environment: Devices, systems, and procedures to protect and stimulate premature babies. Children, 8(5), p.334.

Hwang, S.S., Parker, M.G., Colvin, B.N., Forbes, E.S., Brown, K. and Colson, E.R., 2021. Understanding the barriers and facilitators to safe infant sleep for mothers of preterm infants. Journal of Perinatology, 41(8), pp.1992-1999.

Chen, W.Y., Wu, Y.Y., Xu, M.Y. and Tung, T.H., 2022. Effect of kangaroo mother care on the psychological stress response and sleep quality of mothers with premature infants in the neonatal intensive care unit. Frontiers in Pediatrics, 10, p.879956.

Gelfer, P., Cameron, R., Masters, K. and Kennedy, K.A., 2013. Integrating “Back to Sleep” recommendations into neonatal ICU practice. Pediatrics, 131(4), pp.e1264-e1270.

Loewy, J., Stewart, K., Dassler, A.M., Telsey, A. and Homel, P., 2013. The effects of music therapy on vital signs, feeding, and sleep in premature infants. Pediatrics, 131(5), pp.902-918.

Orsi, K.C.S.C., Llaguno, N.S., Avelar, A.F.M., Tsunemi, M.H., Pedreira, M.D.L.G., Sato, M.H. and Pinheiro, E.M., 2015. Effect of reducing sensory and environmental stimuli during hospitalized premature infant sleep. Revista da Escola de Enfermagem da USP, 49, pp.0550-0555.