Tools for a Newborn not Sleeping

newborn not sleeping? these tools will help

Newborn not sleeping? One of the main occupations of infants is sleep but for parents, finding sleep remedies for babies can be the interrupting point in every other occupation of the parents (beyond holding, feeding, and caring for the newborn). Here, we are covering how to support the newborn fighting sleep as well as the parents struggling to get newborns and babies to sleep safely. These strategies support the whole household. Let’s take a look at this important area of occupational performance.

Supporting sleep hygiene, or good sleep habits in parents as well as in babies can be an area that occupational therapy professionals address as a daily occupation for the whole family unit.

Tips for a newborn not sleeping

Sleep remedies for Babies

This sleep remedy information is essential for parents of newborns, but also pediatric occupational therapy practitioners who may be working with parents of newborns.

When a newborn is not sleeping, supporting parents of newborns, babies, and even toddlers is an area of support that OT practitioners can address. Pediatric sleep is an occupation of the whole family!

Let’s break down practical advice for creating an effective bedtime routine for both the baby and the parent.

Strategies for newborn not sleeping

Occupational therapy providers can offer skilled interventions for occupational therapy to support parents of babies fighting sleep so that it impacts the occupational performance of others in the home, including everyday tasks, caring for other children in the home, work, daily self-care, emotions, mental status, and cognitive thought processes.

This occurs through parent education, documenting strategies using a sleep journal, analyzing results, and making suggestions based on the dynamic needs of the family. We cover all of this below, as well as sleep strategies and tools to support newborns and babies in sleep.

Newborn fighting sleep? Create a routine

Parents of newborns have a common problem, all beginning with the newborn fighting sleep.

The issue is that there are several things at play here, occurring in a cycle.

  1. The newborn fights sleep.
  2. The parents try different strategies.
  3. The baby sleeps for a short period but wakes.
  4. The sleep deprived parents try the easiest strategy to get baby back to sleep.

Then the cycle continues. But what really happens is that the baby is on a maladaptive sleep routine, or rather, the fact that the baby fighting sleep has become part of the routine.

Additionally, children with challenges in sleep will likely impact the sleep routines of their caregivers and everyone else in the home. When the baby’s sleep is consistently poor, the parents may adapt strategies such as co-sleeping, which results in insufficient sleep.

The importance of establishing a bedtime routine is enormous. It’s been found that parents instructed to introduce bedtime routines have reported rapid improvements in sleep quality.

Your new baby will not be ready to follow a set sleep schedule during the first couple of weeks, so looking for signs that they might be tired is the best way to tell when you should put them to bed. They might be crying more, wanting to be held, having heavy eyelids, or sucking on their thumb. You can help them to fall asleep by gently rocking or bouncing them, feeding or swaddling them.

The transition from holding the baby to laying them down in their crib is where things can get difficult. 

So often, the young infant or baby is comforted by the warmth and proprioceptive input offered by the arms holding them in close. The baby can even feel the heartbeat of their mother that they were so close to for months in the womb. That comfort is quickly stopped when they are placed into a cool sleep surface. It can be an abrupt change that wakes up baby into a state of startled irritations.

When parents experience this situation over and over again night after night, the sleep quality in the home suffers.

So how to support restful sleep in babies and in the whole household?

One suggestion that is hard for many parents is that you should not let your baby fall completely asleep in your arms. This is because they will get used to this comfortable position and may start wanting to fall asleep this way every time.

Establish a nightly sleep routine to establish rhythm in sleep needs:

  • start with a warm bath
  • Include slow massage with a warm towel
  • Sing nightly lullabies
  • Complete the night time routine in a dimly lit and quiet space
  • Include bedtime stories along with toddler siblings or other family household members

Create another routine for nighttime feeding ritual:

  • Diaper changes often wake up baby in the middle of the night. Be prepared with diaper, wipes, spare clothing, and a bag or place to put dirty diapers right at the changing area
  • After the diaper change, then do the feeding
  • Sit in a rocking chair or lounge chair 
  • Keep the lighting low
  • Softly hum or sing
  • Pat baby’s bottom slowly and with a rhythm

The disruption to sleep can be a source of anxiety for parents, especially as insomnia becomes expected. Having a calm sense can actually support baby more than the worry or anxiety. This can be easier said than done, however, and having a few regulation tools for parents can be a help.

Getting them comfortable with their own bed early on will help with healthier sleep hygiene. Instead, notice when your baby is starting to drift off and put them in their bed before they are completely asleep.

They will wake up many times throughout the night to be fed or changed, so be prepared for them to wake every few hours.

Know that sleep is a fluid area development…meaning that routines will change sometimes nightly as the baby develops.

When to start a sleep routine with newborns

Getting into a routine right away with your baby is important not only for them but also for you. Sleep at night when your baby is asleep and as you need during the day. Make a habit of doing chores during the day like cleaning or showering while your baby naps, or even nap while they do. You can even schedule to have someone watch your child once a week during nap time while you run errands. This will allow you to get things done that you need without having to watch your baby every second.

Start a nighttime routine of changing your baby into their pajamas and then reading them a book (or singing them a song) before putting them to bed. This will set you up for success for when they are older and starting to fight sleeping a little more. Your baby will still wake through the night for a couple of feedings at this age, but it will start to happen less and less. If your child is having trouble falling asleep, it may be because:

  • They are hungry
  • They are spitting up
  • They have had too much or not enough sleep
  • Their swaddle is too tight or too loose
  • They are having a sleep regression (usually around 4 to 6 months old)

Recognize that sleep routines change over time as as development happens. What works at one stage may need to change at other stages.

Newborn Fighting Sleep due to sleep location

During the first weeks and months after birth, learning how to help your baby sleep can be a challenge for many parents.

It is important to pay attention to the place you are letting your baby fall asleep during their first couple of weeks of life.

They will quickly learn to become comfortable in whatever place they are in, so if they learn to fall asleep in your arms, this will be how they will always want to fall asleep. Unfortunately, this is not a practical option for either of you, so get your baby used to falling asleep in their crib from day one.

One thing that new parents consider doing is having their baby fall asleep in bed with them. Doing this has been proven to lead to higher rates of sudden infant death syndrome (SIDS). 

The first step to effective sleep routines is deciding where the baby will sleep whether that be in a crib or bassinet.

The risk of SIDS which could be avoided in this case by simply putting your baby to sleep in their own bed. A bassinet or a crib can be used for your child’s bed which can easily be kept in your room or in your baby’s room, whichever you prefer. Make sure that your baby is falling asleep in a smoke-free area, and that their bed meets safety standards by going to cpsc.gov. 

This includes leaving out the pillows, sleep positioners, toys, and blankets.

positioning strategies for a newborn not sleeping

One strategy to support the newborn not sleeping is thinking about bed and sleep positioning. Your baby should be put to sleep on their back on a firm but soft surface just as they are falling asleep.

If you put them to bed while they are still slightly awake, they will learn that they can fall asleep on their own, without the need of a parent to rock them to sleep. Do not put them to sleep with a tv in their room, as it can affect their ability to fall asleep. Read more about how electronics effect sleep in your child for more information.

Baby’s Head and Sleep

During the first few months of a baby’s life, they will not yet have strong enough muscles to lift their head or push something off of them like a blanket if they need.

This is why it is important to lay your baby on a firm but soft surface on their back with nothing else around them.

Do this every time you put them to sleep. Keep soft objects, loose bedding, stuffed animals, or anything that could trap your baby away from them.  You will want to make sure that your baby’s face and head are not covered while they sleep.

To help you remember this, the saying “Back to sleep, tummy to play” was created to help your baby sleep. You can find out more about it here.

More tools for the newborn not sleeping

Sleep clothing- For clothing, it is suggested that your baby wears no more than one layer more than what you would wear in that same space. Typically this means that your child will be comfortable in a onesie and swaddle. Do not let the swaddle come high enough that it touches their face.

Room temperature- Make sure that their room is not too hot and not too cold. If their chest is sweaty, they are too hot and you should take off one of their layers. A small fan in the baby’s room can help too, and additionally, the white noise from the sound of the fan can drown out other noises in the home and act as a white noise machine.

Thinking about these considerations, it’s also important to consider development.

Newborn Fighting Sleep? What’s normal?

So, when a newborn is not sleeping through the night, what is typical for the age and the stage? Did you know that newborns fight sleep as a developmental stage?

For the first 3 to 4 months your baby may only stay awake for about 1 hour at a time, but they will then start to get into a routine of sleeping every 2 hours for a longer amount of time.

Up to the time they are three months old, they should be getting about 14 to 17 hours of sleep. Make sure they have no less than 11 hours and no more than 19 hours of sleep.

During the first three months, that hour can go by very quickly and it can seem like the newborn is fighting sleep, when they are actually developmentally on track. After about an hour, the newborn may have something waking them: hunger, diaper changes, and just overall short circadian rhythms.

Between 4 to 6 months old, they will be getting about 12-15 hours of sleep, but should not be getting less than 10 hours and no more than 18 hours of sleep.

When we see problems here is that not all babies easily fall into this sleep regimen. There can be real challenges limiting sleep. Consider the areas stated above:

  • Routines or lack of them
  • Technology use
  • Positioning needs
  • Environment
  • Temperature
  • Clothing
  • Feeding schedule
  • Many other considerations!

Around 4 to 6 months old is when your baby will most likely have what is known as a sleep regression. A sleep regression is when your baby is able to sleep for longer lengths of time at each sleep cycle and will not need to be put down for a nap as many times during the day. 

The baby fighting sleep at this stage is also developmental as this sleep regression happens right when the baby is beginning to develop more mobility and motor control.

It’s important to remember that every child will sleep differently and stay asleep for different lengths of time. Some may prefer to fall asleep on surfaces that are firm while others may love their swaddle. Differences can also come from sensory preferences which impact a baby’s sleep.

Documenting Sleep remedies for babies

Taking all of these developmental stages into consideration, as well as the sleep remedies listed above, there is more to the process.

Occupational therapy practitioners can provide intervention by supporting parents and families with use of a sleep diary. A sleep diary can be used by parents of newborns and babies to document hours slept, and tools used as a support.

When a sleep diary, or sleep journal is used, the family is able to track sleep habits and routines, including successful and unsuccessful tactics. Occupational therapy practitioners can then use information from the sleep journal to identify needs and make recommendations based on the baby’s development, family dynamics, strengths and needs of the family.

This article on AOTA suggests a sleep diary with questions such as:

  • What time did you start trying to put the child to bed?
  • What time did your child go to bed?
  • What time did your child fall asleep?
  • How many times did your child wake during the night?
  • What time did your child wake in the morning?
  • How much awake time did your baby have during the day before?

Other sleep journal questions can include:

  • What did you do before bed to encourage sleep?
  • What sleep strategies were used? (rocking, dark room, sound machine, etc.)
  • How long did the baby sleep?
  • Where did the baby sleep?
  • How long did they sleep before waking?
  • How many times did the baby wake during the night?
  • Reasons for waking during the night? (Example: diaper change, feeding, etc.)
  • What time did the baby wake for the day?

When it comes to sleep remedies for babies, there can be a lot of trial and error. Try to enjoy this time with your young child!

Colleen Beck, OTR/L is an occupational therapist with 20+ years experience, graduating from the University of Pittsburgh in 2000. Colleen created The OT Toolbox to inspire therapists, teachers, and parents with easy and fun tools to help children thrive. As the creator, author, and owner of the website and its social media channels, Colleen strives to empower those serving kids of all levels and needs. Want to collaborate? Send an email to contact@theottoolbox.com.

Occupational Therapy for Down Syndrome

Occupational therapy interventions for down syndrome

Occupational therapists (OT practitioners) provide skilled services to help many different people, with or without a diagnosis. In this article, we will talk about Down syndrome, more specifically common interventions and strategies when providing occupational therapy for Down syndrome.

Occupational therapy interventions for children with Down syndrome.

Occupational Therapy For Down Syndrome

Occupational therapy practitioners work with many diagnoses. In pediatrics, the diagnosis of Down Syndrome may be seen in early intervention services, in school-based therapy, or in the outpatient setting.

An occupational therapist will perform an evaluation and develop an individualized plan of action designed to meet specific needs. Occupational therapy interventions may be related to areas such as:

  • Oral motor concerns impacting feeding
  • Positioning and feeding techniques
  • Physical motor skills including gross and fine motor skills
  • Achievement of motor milestones including rolling, sitting, position changes, and use of the arms and legs, etc.
  • Facilitation of self-care skills
  • Refinement of fine motor skills
  • Sensory needs
  • Social or emotional needs
  • Self-regulation needs

This list may not include every area addressed in occupational therapy. Let’s go into more detail about OT and the individual with Down syndrome.

First, let’s cover the diagnosis of Down syndrome.

WHAT IS DOWN SYNDROME?

Down syndrome is a genetic disorder caused by additional copy of chromosome 21. In regard to functional performance, the typical characteristics of Down syndrome include:

  • Low muscle tone
  • Relatively short limbs, including hands, fingers, and thumbs
  • Mild to moderate intellectual disability
  • Developmental delays

People with Down syndrome are often active members in their communities, able to participate well in school and social events, and can raise a family. Each case is unique, and health professionals such as occupational therapists are available to help improve functional independence along the way. 

what is Occupational therapy for Down syndrome?

In order to fully understand the involvement between the occupational therapist and person with Down syndrome, it is critical to learn the role of the OT.

During the initial evaluation of a person with Down syndrome, the occupational therapist will assess many different skills to determine the specific needs. They will try to answer broad questions like, “How independent is the person with activities like eating, dressing, and playing?”, and specific questions, such as, “What types of grasps do they use?”.

Developmentally appropriate assessments will be used to measure fine and gross motor skills, cognition, and sensory regulation. 

down syndrome: Fine Motor Skills

The whole body is responsible for strong fine motor skills; starting with core then shoulder strength, moving down toward strength and mobility in the hands and fingers.

The general decrease in muscle tone and joint stability that is common in those diagnosed with Down syndrome, makes the development of fine motor skills more challenging. 

Physical features impacting fine motor skills

The hands of a child with Down syndrome have a typical pattern of development, including shorter hands, fingers, and thumb than the average child, that can further decrease dexterity.

The palms may also lack the curvature that is required for skills like thumb opposition. We call these the arches of the hand, and they are useful during any skill that requires the hand to move around an object, big such as a water glass, or small like buttons. 

Because of these physical features, coupled with general muscle weakness and loose joints, occupational therapy for Down syndrome will likely offer activities to increase fine motor skills.

Gympanzees has a great article on developing fine motor skills for children with Down Syndrome.

Dexterity and Down Syndrome

  • Use small items, like beads/pompoms/Cheerios/buttons, to pinch, place, string, glue down, or count.
  • You can increase the challenge by encouraging holding onto multiple items in one hand, but only placing one at a time – much like we hold a set of coins and use a singular hand to find and place the correct coin. This is referred to as in-hand manipulation

Joint Protection and down syndrome

  • Braces or splints may be used to help support the joints in a functional position, while the child continues to build strength. 

Arm Strength and down syndrome

  • Weight bearing through the arms is a great way to build shoulder strength for fine motor development – try animal walks, wheelbarrow walking, or crawling through tunnels!

Hand Strength and down syndrome

  • Get those fingers moving by shaping playdough or putty; roll, squeeze, poke, smash, and pinch it! Increase the challenge as the skills develop by selecting firmer putty or by adding additional steps to the activity. 
  • The OT Toolbox has great resources for overall fine motor hand development

Gross Motor Skills for down syndrome diagnosis

Just like fine motor skills, the base of gross motor skills is the core. A person needs that proximal stability first, before they can build movement skills.

Increasing the core strength leads to improved balance, coordination and dynamic movement control. These areas are addressed as they impact functional participation in feeding, self-care, learning in the school setting, and participation in functional tasks.

Individuals with Down syndrome tend to have a more challenging time with strength and motor planning to move from one posture to the next due to low tone.

For example, moving from a seated position on the floor to standing. The sequence should be: seated on the bottom, to a 4-point crawl position, to kneeling, to a single leg kneels, then standing. This sequence and combination of movements may pose an extra challenge due to limited mobility, strength, and muscle tone.

Below are some ways to improve occupational therapy for Down syndrome can improve gross motor skills. 

Core Strength and down syndrome

  • There are so many play-based activities that strengthen the core. Almost any activity can be done in prone (on the tummy), which can improve core strength and offer some weight-bearing in the arms at the same time
  • When you think core strength, think balance. Use balance beams, one-foot stand, wobbly surfaces, etc. Just make sure to prioritize safety and comfort. 

Positional Changes and down syndrome

  • The more change, the better. Set up a game or obstacle course that encourages movement up/down, side-to-side, rolling, or scooting.
  • The most important goal is to get that body moving!

down syndrome and Sensory Regulation 

Are children with Down syndrome more or less likely to experience sensory differences? Yes. This is the reason occupational therapy for Down syndrome and sensory regulation will be an important part of the treatment process.

There is one clear reason why people with a diagnosis of Down syndrome may experience more sensory processing difficulties – low muscle tone again. Individuals with low muscle tone may have a harder time processing proprioceptive input. This is the sense that our muscles and joints pick up to tell the body where they are in space. 

Because of this decreased proprioceptive input, people with Down syndrome frequently need more input in order to grade the force of their movements.

For example, they may experience difficulties in choosing how hard or how soft their movements should be. They may knock something down by pushing too hard, or drop something by mistake by not holding tight enough. 

This can also skew how an individual with Down syndrome eats food. They may not feel the food in their mouth very well until it is full, and start over-eating or pocketing food in their cheeks. People diagnosed with Down syndrome often grind their teeth as a way to get more input and stability through the jaw.

  • Increased proprioceptive input
    • Weighted items: vests, lap pads, blankets 
    • Exercise, weight bearing, jumping 

In addition to low tone, another common comorbidity to Down syndrome is hearing loss. This is important to address as a sensory need because an individual may react strongly or under react to auditory stimuli. Sensory tools should be trialed for a few weeks to see what will work best to regulate the child’s sensory system. These tools should be used intermittently throughout the day, and never forced on a child. In order to be effective, they should be voluntary and not be used as a reward or punishment. 

  • Auditory Processing Strategies 
    • Noise reducing headphones
    • Auditory feedback tube (like this)
    • Assistive technology for hearing loss

A Sensory Diet is a great treatment option for sensory processing and Down syndrome. The OT Toolbox also has a great resource called the Sensory Lifestyle Handbook to address and understand sensory processing needs.

For more play-based ideas for early intervention for working with learners with Down syndrome, here is a fun article on outdoor sensory activities.

If you are a fan of the OT Toolbox, you can access all of these resources much easier by becoming a member. As a member, you will:

  • Be able to download each of them with a single click (No more re-entering your email address and searching through folders!)
  • Receive early access to new printables and activities before they’re added to the website (You’ll find these in the What’s New section.)
  • Receive a 20% discount on all purchases made in the The OT Toolbox shop!

For all of these skills, the most important part of occupationl therapy for Down Syndrome is to meet the child where they are. An Occupational therapist will make an assessment of their learner’s current level of functioning, providing a “just right” challenge, that is motivating for that particular learner. Because of potential delays in cognitive ability, and the physical difficulties associated with Down syndrome, these new skills may not develop quickly, and may not progress at all. Occupational therapy can help with adaptations to approach these tasks in a different way, or modifications to the environment to increase independence. 

Sydney Thorson, OTR/L, is a new occupational therapist working in school-based therapy. Her
background is in Human Development and Family Studies, and she is passionate about
providing individualized and meaningful treatment for each child and their family. Sydney is also
a children’s author and illustrator and is always working on new and exciting projects.