We Asked, She Answered: Dr. Jade Wu – What Every Mom Should Know About Sleep

Dr. Wu

[ 00:00:00 ] If you Google like 'postpartum sleep', usually it's baby sleep books that come up, right?  And there's a million of them and some of them are great.  But mom's sleep, very, very little information.  And here's the thing.  Mom's sleep obviously changes postpartum compared to pre-pregnancy and, you know, pre-having kids.  But it doesn't have to be really terrible for a really long time.

Dr. Ruta

[ 00:00:23 ] Welcome to So Glad You Asked, the show where real moms bring us their toughest questions.  I'm Dr. Ruta Nonacs, a perinatal psychiatrist at Mass General Hospital with over 30 years of experience supporting the mental health of moms and helping them navigate the emotional highs and lows and the often unexpected challenges that come with planning a family, pregnancy, and motherhood.

Allie

[ 00:00:46 ] And I'm Allie Hales, a mom of four.  I know what it's like to scour the internet wide awake at 2:00 a.m.  with a million questions, wondering if what I was experiencing was normal.  That's why we created this show.  It isn't just for real moms, it's by real moms.  Every episode is a conversation led by you.  Your questions, your experiences, your mental health, front and center.

Dr. Ruta

[ 00:01:08 ] And we don't just listen.  We provide real, evidence-based answers and reliable resources from trusted experts.  Because moms don't just deserve support.  They deserve solutions.  When Allie and I sat down with Dr. Jade Wu, a leading sleep expert and psychologist, we had such a thoughtful, in-depth conversation about sleep challenges, but we couldn't fit all of that great information into one show.  So, in this bonus episode, we're sharing more of Dr. Wu's practical insights and so many useful tips and tools that will help you to transform your sleep routines as a mom.  So let's get started.  We're really excited that you're here.  We were just talking about all the questions we have for you.  I mean, in some ways you have kind of a niche specialty, but in terms of the patients I see, I think probably 95% of the people would benefit from what you do.  And I was wondering if you could start by talking about you.  You're a psychologist and you're also a behavioral sleep medicine expert, but what does that actually mean when you are in the office and when you're working with new and pregnant moms?

Dr. Wu

[ 00:02:19 ] Yeah, sure.  So I am a licensed clinical psychologist and I specialize in perinatal mental health.  And I separately also am board certified in behavioral sleep medicine, which means I help everybody with their sleep and mental health issues, but especially folks who are pregnant and in their postpartum years.  So what that looks like is I usually talk with folks when they've already noticed that they've had a lot of trouble sleeping or it's their mental health isn't what they would like for it to be during their pregnancy or their early parenthood.  And I work with them to figure out what is the root of this issue; is there something behavioral that we can do to change things?  Is there a different way of thinking about parenthood or a different way to approach sleep where we can sort of get you on a positive cycle where you sleep better and you feel better and you feel more confident and then you sleep better, you know, so we get you on a better path.  So that's what I usually do with my patients.

Dr. Ruta

[ 00:03:14 ] That is very, very much needed and certainly not talked about.

Allie

[ 00:03:20 ] This might be a very, very basic question, but just could you go through kind of what happens to your body when you sleep?  Like why is sleep so important?

Dr. Wu

[ 00:03:31 ] Yeah, sleep is so important.  I mean, it's like, you know, our need for nutrition or our need for water.  You know, it's just such a fundamental foundational piece of our biological need.  That's why we have such a strong sleep drive, right?  Like if you pull an all-nighter, you're going to be very sleepy.  You might be nodding off at your desk or you might be falling asleep at a red light.  You know, our bodies need sleep so much that, you know, you really can't keep yourself up that long without your body just taking over and saying, nope, we're done.  So one way to answer your question of why sleep is important is just to see how much humans do it.  I mean, we spend like a quarter to a third of our life with our eyes closed, unconscious, belly up in this very vulnerable position, right?  So if evolution allowed us or like forced us to have a third of our lives be this vulnerable.  Then what we're doing during that time must be super important.  And so now we do know more specifics, which is when we are, for example, in deep sleep, our brain is clearing out toxins from the brain.  And it's literally flushing out things that we don't need to keep the brain fresh and healthy.  And during this stage of sleep, we're also releasing hormones.  Our immune system is getting a boost.  You know, we're healing our bodies if we're injured or sick.  Our muscles are being repaired.  Our tissue is being repaired.  makes it extra important for postpartum moms, right?  There's just a lot of physical recovery that needs to be happening.  And in other stages of sleep, we're also consolidating our memories and learning.  So if you learn how to play the French horn during the day or how to serve a tennis ball or how to conjugate French verbs, you're actually learning and rehearsing that during your sleep.  So when you wake up, you're going to be better at those skills than when you went to bed.  And also emotions are being regulated especially during REM sleep which is where dreaming happens and sometimes people don't remember their dreams but that's okay it's still happening; your emotions are being regulated, your memories are being tagged as emotionally important or not.  You know, there's shuffling going on of like, what goes in long-term memory?  What goes in not so much?  And what is something we need to really remember and pay attention to?  And by the way, just a really fun fact for lactating people.  So moms who are breastfeeding, for example, they're actually getting more deep sleep as a percentage of their overall sleep.  So even if they're getting up to feed their baby, to nurse their baby, the prolactin that is being released is dramatically increasing the percentage of their sleep that is deep sleep.  So you might be getting more interrupted sleep.  You might be getting less sleep in total, but you're getting more deep sleep.

Dr. Ruta

[ 00:06:25 ] I think being able to tell moms that their sleep architecture actually changes to some degree is really good because I think there is the psychological feeling like if I don't sleep six hours, seven hours, eight hours, I'm going to be a mess tomorrow.  But if we can tell them like, hey, there's actually this adaptation that might help you, that helps decrease some of the anxiety about falling asleep.  So I think that's a really neat fact to add to the recipe.

Dr. Wu

[ 00:06:54 ] And I'll add one more to give people some reassurance, which is that interrupted sleep is not necessarily bad sleep.  I think we all sort of go into sleep expecting that we should sleep an uninterrupted seven, eight hours.  And that's the only way to get truly good quality sleep.  That's not the case.  We actually all wake up like a dozen or more times at night.  We just don't remember most of those times.  And even if a small handful of those times are remembered.  awakenings that are long enough where you got up and went to the bathroom or fed the baby, that's still okay.  It's not that you're starting over when you go back to bed.  It's not like that interruption is damaging to your sleep.  As long as you don't have sleep apnea or another sleep disorder that's interrupting your sleep many times per hour, it's okay to wake up several times a night.  And that's how humans used to sleep anyways.  We didn't always sleep in one uninterrupted chunk.

Allie

[ 00:07:52 ] I think that's reassuring because I think for me, at least even mentally, if I woke up a number of times during the night in the morning, I would feel like, oh, it's going to be a long day.  I know I'm going to be tired because I kept waking up during the night.  So it's reassuring to hear that your body is going to be okay.

Dr. Ruta

[ 00:08:09 ] And I think what happens is a lot of people know that there are changes to sleep patterns during pregnancy and postpartum.  And I was wondering if you could talk also about like what is normal and when you start to be more concerned about sleep problems.

Dr. Wu

[ 00:08:26 ] Yes, that's a great question because it's tricky to say what is a normal change versus what is a typical change, but that we still want to pay attention to.  So it's very typical for sleep to get worse during pregnancy.  So usually what we see is first trimester, folks are getting really sleepy.  They're like, anytime I see a horizontal surface, I could fall asleep there.  People are like, do I have narcolepsy or is this first trimester?  And usually it's just first trimester.  And then after that, though.  We tend to start having more insomnia symptoms, especially as we get into third trimester.  So that's trouble falling asleep, trouble staying asleep, or just feeling like your sleep is kind of interrupted or not very good quality.  And then we also tend to see more snoring and possibly sleep disorder breathing, especially as we get into the later trimesters.  And sleep disorder breathing is basically when our airway and our breathing are disrupted while we're sleeping.  So sleep apnea is an example.  And apnea is where your airway actually collapses and you don't breathe or you're actually partially not breathing for at least 10 seconds at a time.  And this is happening multiple times per hour.  And so this is a lot more likely to happen during pregnancy.  And a lot of people don't really know that it's a problem until they're well into their third trimester.  So even just snoring can be disruptive to sleep.

Allie

[ 00:09:53 ] Is this just because of the physical changes of pregnancy, how it's affecting your body?

Dr. Wu

[ 00:09:58 ] A lot of it is the physical anatomical changes.  There's a lot more pressure on your abdomen and on your lung capacity.  There's more weight on your chest as your breasts are probably getting bigger during pregnancy.  And also, the hormones like estrogen, for example, are causing more upper airway resistance.  So probably people can relate to more nasal congestion and just a little bit less muscle tone in the neck as well.  So basically all along the airway, there's just more pressure on the airway.  There's less elasticity or less stability in the airway and more likelihood of having snoring or apneas.

Allie

[ 00:10:41 ] What do you recommend to help improve that?  I know mouth taping is like a big thing now.  Is there a certain way you're supposed to lie down, like on your side?  What do you tell your patients and clients on how to improve that?

Dr. Wu

[ 00:10:54 ] So I would actually recommend against mouth taping because that's just taking away one other way for oxygen to get into your body, right?  Especially if you have nasal congestion from the estrogen or other ways that are already putting burden on your breathing capacity.  Let's not take away another one.  So don't mouth tape.  But sleeping on your side can help because that's a little bit less pressure on your chest and neck.  You know, sometimes wedge pillows can be helpful and sometimes dental devices, too, like especially if you grind or clench your teeth, which is actually another sign that you may have sleep apnea.  Having a mouth guard can also help.  But really, if you're thinking about getting pregnant or if you're early on in pregnancy, it might be helpful to just get a sleep study.  If you know that you snore or people have heard you gasping or holding your breath during sleep or you're just really sleepy during the day, even aside from being pregnant, those are really good signs that there may be already some sort of sleep disorder breathing going on.  And nowadays they have home sleep studies where you don't have to spend the night in the lab and you can just get a kit that you use for a couple of nights at home.  And that can give you at least a ballpark idea of whether this is something to be concerned about.

Dr. Ruta

[ 00:12:10 ] I think that's very important information.  And I don't recall any screening about sleep during pregnancy.  I mean, there was the like, how are you sleeping after the baby was born?  But nothing that was really consistent.

Dr. Wu

[ 00:12:22 ] Yeah, absolutely.  And during my pregnancies, too.  And I'm in a very good system here.  I'm at Duke.  So I have top-notch doctors and like my team during both of my pregnancies were just they were awesome.  I did not hear a single thing about sleep.  And this is like not to scare people, but like sleep disturbance is actually really important, right?  Like we hear all about not eating raw fish and maybe washing out on the coffee and things like that.  We get lots of really good advice about other aspects of health during pregnancy, but nobody told me anything about sleep.  But if we have significant sleep disturbance, we're much more likely to have depression.  During pregnancy and depression, postpartum, we're much more likely to have complications like diabetes, hypertension during pregnancy and also postpartum.  And the baby is more likely to be born premature, preterm, and we're even more likely to have outcomes like C-section.

Dr. Ruta

[ 00:13:24 ] Is there a typical screening tool you would recommend to providers to screen for sleep problems during pregnancy?

Dr. Wu

[ 00:13:33 ] Yes.  So the typical screener for sleep apnea, for example, is the STOP-BANG.  And that's an acronym that stands for a bunch of things.  But for pregnant women, I would say use just the STOP part, which is snoring, tiredness or rather sleepiness during the day, observed apneas.  So this is where you're holding your breath or you're gasping or snorting during sleep and high blood pressure.  So that's the stop.  And then for women in particular, I would also maybe add a couple of things to look out for.  One is that waking up with dry mouth or morning headache, and also grinding and clenching teeth.  So those are more subtle signs and you don't necessarily see those in men as much, but in women, those are more likely.

Dr. Ruta

[ 00:14:24 ] And I think there were some questionnaires I've seen that that ask questions like, how likely are you to fall asleep while reading a book, while sitting in a car at a stoplight?  And I think those also kind of can give you a sense of the intensity of the problems.

Dr. Wu

[ 00:14:40 ] Yes, that's the Epworth Sleepiness Scale.  Very useful.

Dr. Ruta

[ 00:14:47 ] It's just really interesting because I think people don't know those facts about sleep and mood and anxiety disorders as well as increased complications.  And I think many people kind of poo-poo the association between, you know, sleep issues and postpartum mood and anxiety disorders.  But hopefully we can get them to listen when they're sort of more serious complications.  And these are things that we can potentially fix and manage during pregnancy.  So I think that's really important.  Getting to the postpartum period, what kind of sleep changes do we see there?

Dr. Wu

[ 00:15:22 ] Yes.  So that's where people feel like their world is totally rocked because suddenly everything is different.  You're getting up multiple times a night to tend to the baby, potentially to feed the baby.  Your nights and days are less different because you're probably stuck inside the house a lot more during the day, or you're having less social or physical activity during the day.  So it's kind of almost like you're living in perpetual twilight.  And that's actually one of the really underrated changes that contributes to sleep problems and mood problems postpartum, because we are meant to be daytime animals, right?  We have that circadian clock, which is that 24-hour rhythm of how things should be really different between day and night.  And what I see really often, and what we know from the research too, is that postpartum moms, especially in the first few months, they're closing the gap between nights and days, and they're not getting as much light exposure or physical activity or social activity during the day.  And they're getting a lot more light exposure and they're a lot more awake at night.  Circadian disruption, even regardless of how much sleep you're getting, like sleep deprivation aside, even that circadian disruption is very much contributing to things like depression, anxiety, and fatigue.

Dr. Ruta

[ 00:16:45 ] The other thing that I see a lot with moms, and I was wondering how you address this issue, is that moms start to get anxious about going to sleep, about getting their baby to sleep, and that like starting at around dinner time, this anxiety is like creeping in about will they sleep tonight?

Dr. Wu

[ 00:17:05 ] Yeah, I see that very commonly too.  And it's like people know that that's not helpful because then it's kind of building up the anxiety and making it even harder to sleep.  But it's so hard to disengage from that loop, right?  Like once you start worrying about sleep, it really takes on kind of a momentum of its own.  So that's another really good time to be using the out of your head and into your body.  When you're awake, you might not be able to just be there uninterrupted for 15 minutes doing a body scan because you've got little kids running around.  So this is where a 5-4-3-2-1 can be really helpful.  So 5-4-3-2-1 is like a mini get grounded, get in your body exercise.  So what you do is when you notice that you're starting to race in your mind and starting to get too caught up in your anxiety thoughts, look for five things that you see around you.  Like right in this moment, what are five things you see?  And go slow.  Don't just rattle off five objects because our brains are so good at naming objects.  You can do that almost without thinking.  So, really notice the visual quality of five things around you.  Like I'm seeing this like kind of nice satiny texture on my scrunchie.  Like I'm seeing the texture of my cup.  You know, I see the shadow of the leaves, you know, as the sunlight comes in dancing on the wall.  So you see, name five things you see, four things you hear, three things you feel in your body.  Again, that's nonjudgmental.  We're not going to say good or bad feelings.  We're just going to notice three feelings in your body.  Two things you smell and one thing you taste.  So that's all five senses that we're covering there.  And we're moving through them.  It's like a nice little quick out of your head and into your body where now you're settled into the here and now.  That's a really nice tool to have.

Allie

[ 00:19:04 ] I would love to hear your thoughts on sleep aids and when those are appropriate, when you try and wean yourself off, when you shouldn't even touch them.  Just interested in what your thoughts are on those things.

Dr. Wu

[ 00:19:16 ] Yeah.  So I think sleep medications very much have a role to play.  So there are like my patients who, you know, I work with them on basically collaboratively deciding-is a sleep medication or sleep aid appropriate for you?  And usually it's just based on their preference because there are definitely times when a sleep medication can help to bridge you to get through sort of a crisis moment or get through a time when there are just things out of your control and you just need to be able to get through this time very much.  And usually by the time people are seeing me, they have already tried sleep medications and either they haven't worked or they've gained tolerance or they've just reached a point where they're ready to come off of them.  So if they're ready to come off of them and they want to, then I can help folks sort of build up the scaffolding of their behavioral strategies like the ones we've already talked about.  And also some other ones like looking at their sleep schedule and sleep timing to make sure that it actually suits their own biology and a whole bunch of things that we can do to kind of put them in the best position to be slowly taking away that crutch.  And when they're ready to do so, we gradually wean off of a medication in a predetermined taper schedule.

Allie

[ 00:20:40 ] I had a question, too, about sleep aids for babies like pacifiers, Snoos.  How do you feel about those?  Do they help?  Is it a marketing thing?

Dr. Wu

[ 00:20:49 ] What are your thoughts on that?  I think a lot of these answers will be it depends on the family, on the baby.  And I would say the major goal, the top goal for the first three months is just to get the baby to sleep as much as possible, as long as they're also like feeding enough.  Right.  But if they sleep as much as possible as a newborn, that actually sets them up for better quality sleep and earlier sleep independence later on.  So whether you need a pacifier, a Snoo, like whatever you need the first three months, just do it to make it happen.

Allie

[ 00:21:26 ] We did have a couple questions from our guests and I thought that they were very relatable.  I experienced a lot of them too.  She has a toddler and she also has a new baby.  And one of her questions was, How do you transition your baby from infant sleep?  How do you kind of bring your kid through that transition period of baby to little child?

Dr. Wu

[ 00:21:49 ] Yes.  Oh, good question.  And this is still fresh in my mind.  I have a five-year-old and three-year-old, so I feel you.  So toddlers can have a nightlight and that won't disrupt their sleep as long as they're getting.  plenty of light during the day.  So the combination of blackout curtain and nightlight is actually a really good one because then there's still, you know, having most of the sort of distracting things from outside, like neighbors, really bright, you know, lights and car, car lights going by.  Those things are still blocked out, but the nightlight, which should be like an orangey, you know, like a warm color can be there too.  To help with the fears of the dark.  So that's a really good combination.  And also the nightlight can also function as a good morning light if you can program it to turn on as like turn a different color in the morning or that you can like with your smartphone from a different room, turn it to a different color in the morning because that helps to set the tone of what is nighttime and what is morning time when it's okay to get up now.  And then just a hot tip for fears of the dark, a really fun game to play is like a daytime or like an evening.  Like hide and seek or search with flashlights.  So like the lights are dim or maybe the lights are off and you and your toddler go together into their room to like search for a toy or whatever with flashlights on.  And so you look under the bed, you look in the closet and it just becomes more of a fun game for them as opposed to like a mystery that's scary.

Allie

[ 00:23:27 ] I like that.  That's really good.  Yeah.  I'm going to use that with my three-year-old.  Another question too is just nighttime routines with young kids.  So you know, she has a great nighttime routine.  Like they eat dinner, you know, they have a bath, they read stories, all the lights are dim, they put him to bed.  And then they've, you know, it's been taking him a really long time to fall asleep.  And she said, you know, they'll lie in the bed with him until he falls to sleep for 30 minutes to an hour, which she said, I know might not be the right thing, but if I don't do that, then he doesn't go to sleep for, you know, an hour or two.  What do you recommend for, you know, helping the toddler go to sleep?

Dr. Wu

[ 00:24:09 ] Yes.  So toddlers, the thing about toddlers is that they desperately want to be with you and they're stimulated by your presence.  And this is even true for babies, you know, as young as like four months.  That's what my daughter did.  Yeah.  So it's kind of a catch-22.  So with toddlers, like old enough that they understand words, like they're kind of verbal, starting at maybe a year and a half or so, here's a strategy that works really well.  It's called bedtime passes.  So you give them, let's say, two bedtime passes.  And these are like physical bookmarks with glow-in-the-dark stickers on them.  That's what we do.  And they go to bed holding them, do a lovely bedtime routine, lots of kisses and hugs.  And then I leave, and then they get to use those passes to call me back.  But once they're out of passes, I'm not coming back until the morning.  Good morning!  Light turns on.  And surprisingly, toddlers will sort of self-regulate to the point where they don't actually even need all their passes anymore.  So like as long as they know that they can call you back and you're not going to be frustrated or like annoyed at them when you come back and they can use those passes for whatever reason, then they end up not needing them as much.  So over the course of a couple of weeks, they you know, they end up falling asleep more independently and more quickly.  I think that's a very good message.

Dr. Ruta

[ 00:25:38 ] And you have so many good messages.  I feel like we could have more and more time with you.  A lot of my patients use the Calm app and partly because they like the narrator's voice.  And I'm thinking, wow, we need a Calm with Dr. Wu.

Allie

[ 00:25:55 ] I was going to say, I'm actually feeling really at peace hearing you talk.

Dr. Wu

[ 00:26:01 ] And you have a great voice, a great way of speaking.  I may actually do that.  I'm actually thinking of doing a podcast where I just kind of like talk about random things or like lead people through meditation.  So I'll let you know when that if that launches.

Dr. Ruta

[ 00:26:17 ] We will sign up for it.  And hopefully all our listeners will, too.

Allie

[ 00:26:21 ] I know it's been so wonderful hearing from you and learning from you.  Oh, my gosh.  Thank you so much for coming on, Dr. Wu. 

Dr. Wu

[ 00:26:31 ] Thank you for having me. I'm just really glad to have a platform to tell people about this because you're right.  Almost everybody with young kids or who are pregnant has sleep concerns.  Also, this is like such a narrow niche that I can count on one hand the number of people that I know who specialize in this particular intersection between perinatal health, mental health and sleep.  So absolutely happy to come back and talk more.  I'm working on my second book, which is going to be about perinatal sleep.  So that's going to be really focused on this particular intersection.

Allie

[ 00:27:03 ] And that wraps up today's show.  We hope it gives you the clarity, reassurance, and tools you need to rest and to take care of yourself.

Dr. Ruta

[ 00:27:11 ] As a reminder, please note that this podcast is not intended to be a substitute for professional medical care. The views, thoughts, and opinions shared today are the speaker's own. Your feedback and questions drive this show, so feel free to send us an email at podcast@womensmentalhealth.org or leave a voicemail at 617-643-9232.

Allie

[ 00:27:37 ] This is So Glad You Asked with Dr. Ruta Nonacs and Allie Hales, brought to you by the MGH Center for Women's Mental Health and the J.  Willard and Alice S.  Marriott Foundation. Additional resources are available at Dr. Ruta's resource hub at womensmentalhealth.org. Listen and subscribe wherever you get your podcasts.