Understanding the 6 States of Your Premature Baby's Behavior

What Are Newborns' and Infants' Sleep-Wake States of Alertness?

Mother kissing newborn baby
Preemies and newborns spend most of their time in active light sleep. Victor Torres/Stocksy United

Your premature baby's behavior can give you clues to what your child is thinking and feeling. Since a baby cannot yet use words, they communicate in other ways. Once you learn to notice the little things your baby does, you'll have a better understanding of what she needs and what she can tolerate.

At first it can be difficult to figure out the subtle cues, but before you know it, you'll be able to tell if she's hungry, ready to play, or in need of a nap just by watching her or listening to the sound of her coo or cry.

Here are a few of the more common behavior states of alertness to look for in your child. By keeping an eye out for these clues, you can learn more about your preemie's behaviors and anticipate your babies needs.

The 6 States of Alertness for Newborns and Infants

Deep Sleep: When your baby is in a deep sleep, she will have her eyes closed. She won't move too much, although she may twitch or jump (the startle reflex) on occasion. You may notice her breathing seems even and regular. If you try to wake your child from deep sleep, it won't be very easy. It's also not a good time to try to play with or attempt to feed your baby. In the beginning, your premature baby won't spend much time in deep quiet sleep, but as your child grows, she will spend more time in this deep, restful stage of sleep.

Active Sleep: Active light sleep is where preemies and newborns spend most of their time. While your baby is in light sleep, she may move around, and her breathing pattern will not be as regular.

You may notice your child's eyes moving under her eyelids. That's called the rapid eye movement (REM) stage of sleep. During this stage, babies dream and their little brains are active. During light sleep, your preemie may be more easily disturbed by noise or activity going on around her. From this stage, your child may fall into a deeper sleep, or she may wake up.

Drowsy Awake: Babies in the drowsy but awake state look tired. Their eyelids may appear heavy, and they may be opening and closing their eyes. Preemies may be drowsy when just waking up from active light sleep, or after being up for a while when they're ready to fall asleep. While in the drowsy awake state, babies can suck and will sometimes feed quite well. So, you can breastfeed or bottle feed your child during this stage. From here, your child may go on to fall asleep, or she might wake up into a more alert state.

Quiet Alert: When your baby is awake and quiet you may notice that her eyes look wide and she seems attentive and observant of the world around her. Your little one may seem calm and relaxed. She might focus on your face and look you in the eyes. You may even catch a smile!

During this stage, your child is telling you she's ready to interact and play. Your baby will also learn while she's calm and alert. If you see her bring her hands to her mouth or try to suck on her fist, those are clues that she's hungry.

The quiet alert behavioral state is a great time to feed or breastfeed your preemie. Preemies may not spend much time in this state at first, so try to recognize it and take advantage of it when you see it.

Then, as your baby gets older and becomes more mature, you'll notice and get to enjoy more quiet alert times.

Active Alert: When your baby is awake and active she may be moving her body and making faces. She might start to act fussy and restless. She may also become more sensitive to all the noise or activity that's going on around her so she could become irritable.

If you notice your child arching her back or turning away from you, she may be getting stressed. Feeding a stressed or very fussy baby can be hard, so if it's time for a feeding, you'll want to try to get it started as soon as possible.

From active alert babies may begin to cry, or if they can be consoled and calmed down they may go back to quiet alert. 

Crying: Babies cry for many reasons. Your child may be hungry or need a diaper change. She might be overtired or in pain. Some babies cry because they want to be held and comforted. When a child is crying, her eyes may be open or closed tightly, and she may be very actively moving around and frowning.

Some babies can calm themselves, but others need help. If you cannot calm your crying child by offering a feeding, try making the baby more comfortable by changing the diaper, swaddling, holding or rocking her, or giving a pacifier.

Comparing Sleep-Wake Behavioral Patterns in Preemies and Full-Term Babies

Having a preemie is a little different than having a baby born at 40 weeks. It may take a bit more attention on your part to notice and learn your child's unique behavior patterns.

A healthy term newborn may sleep as much as 18 hours a day, but a preemie may sleep less or more than that. However, even if your preemie sleeps more, you'll notice that she doesn't sleep for long stretches because preemies tend to fuss and wake up more often. And, where a full-term newborn may sleep through the night by the time they are three or four months old, your preemie isn't likely to sleep through the night for six months or longer.

It's also easier to recognize the different sleep-wake behavioral states in healthy full-term babies. Preemies do show these states of activity and sleep, but since they are not as mature as full-term newborns, they may not spend the same amount of time in each state as full-term infants do. They don't move from state to state as easily, either. Your preemie may be unpredictable and jump from one state to another quickly or skip states altogether.

Your premature baby's behavior can change from day to day, too. One day she may eat and sleep well, the next day she might be irritable and have difficulty sleeping and eating. But, as your baby grows and matures, the behavioral states will become more noticeable, and the changes from one state to another will get smoother and easier. With preemies, it just takes a little more time.

Sources:

Brazelton TB, Nugent JK. Neonatal behavioral assessment scale. Cambridge University Press; 1995 Jan 17.

Gardner S, Goldson E, Hernandez JA. The neonate and the environment. Merenstein & Gardner's Handbook of Neonatal Intensive Care. 2015 Apr 10;13:262.

Lawrence, Ruth A., MD, Lawrence, Robert M., MD. Breastfeeding: A Guide For The Medical Profession Eighth Edition. Elsevier Health Sciences. 2015.

Riordan, J., and Wambach, K. Breastfeeding and Human Lactation Fourth Edition. Jones and Bartlett Learning. 2014.

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