Saturday, February 26, 2011

Risk-Taking As A Parent

My last post was about the risks involved in turning your baby's car seat so it faces forward.  One of the responses I received when I shared the link to the post with my mothers' group was: "What are we supposed to make of this - it's just a bunch of statistics?  The statistics don't say it never happens, so how are they relevant?"

This is an interesting question.  How do you make a decision in the face of uncertainty?  How do you evaluate a risk that has an 0.003% chance of occurring.  It does seem a little meaningless.

As parents, it is one of our roles to make fair decisions on behalf of our children.  And it is one of the stressful things about parenting that the best decision does not necessarily leap out at us.  I think new parents in particular feel pressured to make Absolutely The Best Decision For My Child Every Single Situation, and that we have failed if we don't.

The fact we feel this way is, I think, a result of being bombarded with well-meaning advice while soaked in anxious over-protective I-have-a-newborn hormones.

SIDS and Kids is undoubtedly a benevolent organisation.  They are trying to save your baby's life and your distress by letting you know simple steps you can take to reduce the risks to your baby.  Let's take the 'put your baby to sleep on her back' advice.  We are told that this is 'safer' or 'much safer', so most of us (me included) choose to do it.  But what if your baby just refuses to go to sleep on her back for longer than an hour at a time, and every time you try to put her down that way she screams with discomfort?  By contrast, she goes off to sleep quite easily and soundly if you put her on your tummy.

By this stage, you are desperately sleep deprived and you wonder: how much of a difference will it make really if I sleep my baby on her tummy?  A girlfriend confesses to you that she always slept her baby that way.  Your mother comments that in her day, everyone slept their babies on their tummies and she doesn't know any who died.

So you search around and come up with a figure - let's say you discover babies are 6 times more likely to die on their backs than their tummies.  Oh dear, you think, that seems like a lot.  I'd be an awful, irresponsible parent if I slept my baby on her tummy.  Then, if you are like me, you imagine coming in to find you baby has stopped breathing, and just imagining it is so horrible that you are quite willing to undergo further sleep deprivation to keep them on their backs.

But what if I were to tell you that you are not confused because you are sleep deprived, hormonal, or stupid.  You are actually confused because you don't have all the information.  Here's why:

Let's say God shows up on your doorstep tomorrow and gives you this choice:
Tricky dilemma.  But not because you're stupid.  The problem is that God has only told you about the relative risk.

Imagine how differently you'd answer the question if:

  • if you don't take the deal, your death tomorrow is almost certain, but God's offer can make it almost 70% likely you will survive (eek!); or
  • even if you don't take the deal, you have only have a one in a billion chance of dying tomorrow - God's offer only improves that to one in three billion (hmm...)
This extra information tells you what the absolute risk is.  It puts the risk in context.

We are always told about public health risks as relative risks not absolute risks, because they seem easier to understand, and because the relative risk is what the government or non-profit body is interested in.  By promoting the 'sleep baby on back' message, SIDS and Kids reduces the number of SIDS deaths significantly, because they look at the whole population and don't much care whether the baby that is saved is your baby or the one down the road.  

A relative risk is useful to know about if the cost of taking action to avoid the risk is small.  But as soon as the cost becomes large, you want to know the absolute risk.  If the cost of God's offer was $1, you'd probably pay it and not enquire further.  But if God was asking $10 million and you would have to rob a bank to pay, you might do this to save yourself from almost certain death, but probably not to improve your chances of not dying by only a tiny amount.

Which brings us back to the tummy sleeper dilemma.  When you hear that your baby is 6 times more likely to die on their tummy, this sounds like they are very likely to die that way.  This is not true.  They are very unlikely to die while sleeping at all.

SIDS and Kids claim to have reduced SIDS by 85% since the early 1990s, estimating they have saved over 6000 lives.  Sounds like a lot, stuck out there on its own.  6000 families not devastated by a preventable loss.  But then there have been something like 5 million babies born in Australia in that time, and the chance that your baby would have been one of the 6000 is about 0.1%.  By sleeping your baby on their tummy, you do not eliminate the risk of baby dying in their sleep, you just reduce it to about 0.015%.

This starts to put the risk in perspective.  You are not superhuman.  You need to sleep.   And what's more, if your baby is screamingly uncomfortable on their back, continually putting him in that position is not doing much for his quality of life.  Depending on how you value these things, you might decide that tummy sleeping is worth it, or you might decide that you and your baby can put up with a reduced quality of life for a while in order to make that small reduction in the chance of death.

But wait, it's not that simple.  We've only looked at the risks if you don't sleep your baby on her back, not the risks if you do.  If you sleep your refluxy screaming bub on his back, you will be chronically sleep-deprived.  When you are chronically sleep-deprived, what do you suppose happens to:
  • the risk you'll crash the car?
  • the risk you'll forget to check the temperature of the bath-water properly? 
  • the risk you'll develop PND and not be able to do much at all? and
  • the risk that you'll accidentally fall asleep with the baby somewhere unsafe on a sofa?
I don't have exact figures, but chronic sleep deprivation is equivalent to being a little intoxicated when it comes to driving a car, and with respect to the sofa sleeping I have seen studies putting the risk of the baby's death somewhere around 17-30 times higher than sleeping the baby in a cot.  You start adding up these risks and you haven't made your baby safer at all, you have just exchanged one kind of risk for a different set of risks.  In fact, tummy sleeping for some babies may even be safer.

But this is still not the end of the story.  It's one thing to discuss dry statistical risks, but that is not how humans think.  I was at a dinner a few months back where I mentioned I was co-sleeping, and one of the other girls looked at me in horror.  She was working at the coroner's office, and she had just been dealing with the family of a baby who had died during co-sleeping.  I talked about the statistics and how it really was safe if you followed safe co-sleeping guidelines, but she shook her head and said, 'Maybe, but it would just be so horrible to know you killed your own baby.'

No kidding.  This illustrates two points - and psychologists have actually shown these points in studies.  We tend to feel worse when something bad happens because of something we did than when it happens because of something we failed to do.  Secondly, a risk seems much worse when we can vividly imagine the unpleasant consequences than when they all seem kind of vague and wishy-washy, regardless of whether the statistical risk is the same.

So if you feel cot-sleeping is the norm, and you come in to find your baby dead on his back in the cot, it's devastating but you at least feel you did everything you could do.  On the other hand, if you have deliberately decided to co-sleep instead (despite being told this is unusual and risky) if your baby dies in the bed, you will partly feel it was your fault for co-sleeping.  You feel this way because you didn't just adopt the status quo but made an active choice to do things differently.  In co-sleeping coronials in Australia, there is an assumption that the baby was smothered even if there is absolutely no evidence of this.  Whereas in cot-death coronials in Australia, there is an assumption that the baby died from natural causes.  Why?  Because it's so easy to imagine how smothering could occur during co-sleeping, but hard to visualise how a baby could die from being left alone, notwithstanding that studies show babies are less likely to die when they sleep in the same room as their parents.  We just don't know how or why being in the same room makes a difference, exactly, so it just doesn't 'feel' relevant.

By contrast, women from cultures where co-sleeping is the norm feel the opposite - they feel it would be unbearably horrible if they deliberately chose to leave their baby in a cot alone and away from their protection then came in to find the baby dead.  They would blame themselves for not keeping the baby close.  Whereas if the baby dies in the bed, it's horrible, but they feel they were as present to protect their baby as possible.

Your own peace of mind is relevant here, when you choose which risks you will live with.  It makes sense trying to avoid even a very tiny risk if it's easy to do, and if you didn't you would be so anxious and unhappy you can't think straight.  Academics speak of this psychological aspect of risk-taking as risk salience.  A risk is more salient (seemingly important and relevant) when you can vividly imagine the horrible consequences that might result.

It never seemed that risky to have a second drink on Friday nights, even though I knew it might well put me over the limit.  I could still drive pretty well so it didn't seem such a big deal.  But then I went and worked in the magistrate's court for a while, listening to people being publicly humiliated as they lost their licence over that second drink - and suddenly the thought of being dragged up for public humiliation in front of all my colleagues seemed extremely unattractive.  Unattractive enough to refuse a second drink or get a taxi.  The risk hadn't changed at all - I always knew I would have to go to court and lose my licence if I was caught drink driving - but seeing all the drink driving cases made me feel that this risk was salient and worth avoiding.

Some of the mothers in my mothers group read the post about forward / rear facing car seats and said: that's nice the risk is small, but it still worries me so my baby is going to stay rear-facing for as long as possible.  One of these mums made the point that she had recently been in a car crash, so the thought of her baby being in a car crash was all too real for her.  On the other hand, other mums (me included) who had very nearly crashed the car because their baby was so unhappy in the rear-facing car seat felt that the risks caused by an unhappy baby were more vivid - and were prepared to turn the car seat forward even before knowing whether the statistics offer us any support.  

Neither of these choices are right or wrong.  They just remind us that we are not robots, and that in real life decisions, unless the risks are very large, salience is usually more important than the bare statistics.

Initially as a new parent, I felt trapped and a little overwhelmed by all the warnings.  And for me, it did not help to have well-meaning friends tell me that "I was just overthinking things." or "My parents did that and we turned out all right."  

What did help was to come up with a more structured way of thinking about the possible dangers than just reacting and feeling guilty.  Now, when I'm confused or worried making a decision that seems risky, I try to run through the following points:
  • Do I actually know how likely this awful thing is to happen - meaning, a percentage or approximate percentage figure?  Or am I just reacting to the fact that someone has told me it's more risky?  (If I can't figure out the approximate figure, I pick the highest figure that seems likely then run through the rest of the questions.)
  • How hard / unpleasant is it to avoid taking the risk?
  • Can the risk actually be avoided or just delayed? (eg. giving finger foods to a baby poses a risk of choking whether you start them at 6 months or 10 months - unless I want her to stay on milk / purees forever, we have to brave this choice at some time.)
  • How much of a difference (in absolute terms) do the steps I'm taking actually make - what risk still remains?
  • How horrible would I feel if the horrible thing actually happened?
  • How do the steps I take to avoid the risk create other pressures and strains on my life and those around me?  Do these pressures and strains actually create other risks that are more risky?
  • How horrible would I feel if the other risks actually happened?
  • Are people going to judge me for taking this risk?  Do I feel I can live with my decision despite their disapproval?  (Usually for me, this involves being clear on what my reasons are.)
Using this way of thinking, I was able to come comfortably to the decision to toss out my baby's alphabet foam play mat after reading this article about the possible risks.  No, I don't know exactly how risky it is.  Some countries have left them on the shelves, other countries have pulled them.  But the cost of avoiding the risk is so low (baby has plenty of other toys to chew on and rugs to crawl on, the playmat won't really be missed) that I'm happy to chuck it out, even if the risk turns out not to be significant.  On the other hand, I have decided to keep my baby's Sophie the Giraffe toy, even after knowing that other babies have either choked or gagged on it.  

I think the absolute risk must be quite small, particularly if I don't let her play with it unsupervised, and Bethany really enjoys the toy.

That said, I tend to just ignore risks if I haven't had the time to look into them properly.  I don't really know about the risks from non-organic foods or plastics, for example - and just try to choose organic / natural material if it's available but not worry to much if it's not.  If you are keen to know about more choices you can make to reduce risks to your baby, SafeMama provides a run-down particularly on risks from common baby and household products, with alternatives you can select instead.  Mind you, there is not much here on absolute risks - it just helps you select a safer option when the options are otherwise fairly equal.  Want to know why you see "BPA-free" on products - look at the glossary of this site.

But the truth is that if you avoided every last risk you were warned about as a parent, you'd wrap your baby in (organic, non GM) cotton wool and never leave the house.

I do think those who warn parents about risks (SIDS and Kids, Kidsafe, the ABA, your child health nurse etc.) are doing a good thing.  I certainly want to know what are the safer options.  But I think they would be doing parents more of a favour if they helped them evaluate the risks in context rather than creating black and white choices that don't necessarily fit with the complexities of real life.  Without context, the warnings save lives, but they lead to much unnecessary angst and guilt, not to mention unfair judgements of parents who make one of the 'blacklisted' choices.

Friday, February 18, 2011

Rear-Facing Car Seats

I had a request from one mum to write a piece on when you turn your baby from rear-facing to front facing.  This has been the subject of some discussion in my mothers group recently.

The Legal Stuff

As of late 2009 / early 2010, all Australian jurisdictions except the Northern Territory had legislation which requires children to be in a rear-facing car seat from birth to 6 months.  Britax, which makes Safe'n'Sound capsules have summaries of the requirements by State.  From 6 months on, placing your baby in a forward facing car seat is legally permissible.

The Risk of Forward Facing Car Seats

The risk is that in a front-on collision, the baby's head will slam forward abruptly.  Their delicate spines, which are not yet fully formed, stretch apart with the force of the heavy and fast-moving head, so their spinal cords can literally be ripped from their skulls.  It is not just a matter of head strength.  Just because your baby holds their head up well doesn't mean they are strong enough not to suffer this kind of injury.

Of course, a rear-facing car seat does not protect a baby in a collision from behind, but these kinds of collisions are far less severe - front-ons tend to occur when you slam into a car coming from the opposite direction, as opposed to being bumped from behind. This article quotes a study which found that children under 2 were 1.75 as likely to suffer a serious injury in a forward-facing car seat than a rear-facing car seat.

In Scandinavian countries, it is common to keep children in rear-facing car seats until age 5, and injury rates for children in these seats are significantly lower than other arrangements - although unfortunately they were compared with booster seats and seatbelts, not 5 point harness-type seats (Carlsson and Norin).

Here is a brief video with footage from crash test dummies in front and rear-facing car seats so you can see what happens:

I have not been able to find anything which suggests it is safe to turn a baby before the age of 2.  Everything I have read indicates that the longer you leave them rear-facing, the better.  However, in practice, many parents turn their children before 2 years of age because:

  • their children exceed the maximum height or weight limit of the rear-facing seat and it is no longer safe to ride in that seat; or
  • their children are happier riding forward-facing.

The Likelihood of Injury / Death

Talking about babies having their spines ripped apart is obviously a rather emotive topic, so before you beat yourself up for turning your baby's car seat - let's just look at the risk in context.  Yes, motor vehicle accidents is a leading cause of deaths in children, but that still doesn't mean it's likely to happen to you or your baby.

I think it's important to put the risks in perspective by looking at the overall likelihood of death or serious injury as a result of car accidents.

An article published by the Australian Bureau of Statistics in 2006 indicated that 587 children aged between 0-14 yrs died between 1999-2003 as a result of motor vehicle accidents, and that in 44% of these cases (258 deaths), children were passengers in the vehicles.  Only 17 of all the children who died in traffic accidents were under 1 year of age, which is pretty much exactly 1/15 of the total passenger deaths - as the 258 deaths span 15 age ranges, this means that infants under 1 year of age do not appear to be dying as passengers in car accidents any more frequently than older children.  By contrast to those 17 babies under 1 who died in car accidents, 29 died by accidental drowning, 88 by choking or suffocation, and 39 from assault.

17, it must be said, is a very small number.  But that is just deaths.  What about injuries?

A study of Victorian accidents (Lennon et al) showed that the risk of fatality for children under 1 year of age around this time was 8.5 deaths for every 1000 accidents - so we could take an educated guess that if there were 17 deaths, there were about 500 accidents involving babies between 0 and 1.  About 1/5 of all children involved in accidents resulted in hospitalisation (Lennon et al), giving an estimate of 100 hospitalisations across Australian for children under 1 year of age from motor vehicle accidents between 1999-2003 .

About 250,000 women gave birth in 2003, a fertility rate which had decreased from about 275 000 in 1999, so we would expect just over 1 million children in Australia had been between the ages of 0 and 1 at some time during that period of 17 deaths and 100 hospitalisations.  Remember, these figures of 17 and 100 are drawn from all babies, including those sitting on a parent's lap or in a vehicle with no restraints at all.  About 25% of children under 3 in the Victorian crashes were not wearing seatbelts or restraints (Lennon et al).  Failure to wear a restraint made the risk of serious injury about 3.2 times more likely.

Making a Choice

We have a rear or front facing car seat which can take a baby up to 18kg - such seats appear to be available in Australia.  One mother in my mother's group imported a rear-facing car seat which can take a child up to 25kg from Sweden.

When considering whether to turn your baby's car seat, it's important not to just consider spinal safety, but the overall risk of having an accident with the two positions.  Some parents find their babies are very unhappy in the rear-facing position, and carry on in a very distracting way.  I myself have almost run into a gutter once I have been so distracted by my baby's crying.  (We were going round a bend, literally and metaphorically.)

On the other hand, another mum in my mother's group pointed out that she was more distracted once the baby was forward-facing, because he kept dropping his toys and they'd fall to the floor, then he whinged because he didn't have a toy.


Carlsson and Norin, 'Rearward-Facing Child Seats - The Safest Car Restraint for Children?' (1991) Accident Analysis and Prevention Vol 23, p175.

Lennon et al, 'Rear seat safer: Seating position, restraint use and injuries in children in traffic crashes in Victoria, Australia' (2008) Accident Analysis and Prevention Vol 40, p829.

Friday, February 11, 2011

Making Books for Baby

I have some lovely books with cute stories for toddlers and preschoolers, but I wanted some language books for this 6-12 month age.  The problem was that all the books I could find in the shops were either filled with pictures of things that she wouldn't know (like European farm animals, bottles etc.) or were so cartoony that I could barely work out what the objects were.

Also, from what I've read of linguistic theory, I understand that we learn words not just by repetition and association, but also by contrast.  That is to say, we can't just be shown what a 'cat' is - we have to be shown what it is not.

So, if you show a baby a picture of a red car and say 'red car', a baby doesn't know that 'car' means the kind of object and 'red' refers to the colour.  As far as they're concerned, that particular object is a 'redcar'.  But if you were to show them a series of red objects and say 'red car' 'red flower' 'red block' - they should eventually start to connect that it is the second part of the sound that describes the kind of object.  Then you might go one step further and help them understand what 'red' is and is not - by showing them a red car, a blue car, a green car etc.  They then see the first part of the word changes with the colour.

Maybe there are baby books out there that are written using this principle, but I couldn't find them in the shops in Darwin.  Eventually I figured I was after something so specific that I decided to make it myself:

I did this through the program iPhoto on my Mac, which was really easy, cause you just drag and drop your photos, type the text, and then click a button to order online.  But there are other ways to do it.  One of the mothers in my mothers group made a book through Big W Online and the quality was beautiful.  Her book was a collection of baby photos to give to grandparents as a present, rather than a book for the baby, but the idea was essentially the same.  That is, you get to print your own book where the pictures are your photos and you have customised the text.  Pricing depends on the size of the book and whether you have hard or soft cover.

In the book I have pictures of me and her dad, with the words 'Mum' and 'Dad' underneath, as well as other close family members.  Then I found brightly coloured pictures online to illustrate some other words I thought we might learn, such as:

Not really sure about the colour on the passionfruit there, but had a bit of trouble finding a purple fruit.  Probably should have gone with a plum.  Also, strictly speaking, I probably should have aimed to find nearly identical images and just changed the colours, but I thought this would probably do to start with.

Anyway, about 10 days later my book was delivered and I was pleased to find Bethany loves it.  She particularly loves looking at the pictures of her dad and I.  When I say 'dad' and point at him, she often says 'dad' - although at this stage I think she is just imitating me, not connecting the concept.  But by the smiles his picture gets, I think she does recognise his photo.

We also did a few other concepts, such as day and night, and wet season and dry season (we live in the tropics and do not have summer, autumn, winter, spring).  Mind you, this picture was probably a bit of wishful thinking!

Unfortunately, the book is an ordinary soft cover picture book, and I have to be careful not to let her grab it, or she'd quickly destroy it.

I wished I could get a board book, but that wasn't an option with the software I had.  So I decided to look online, and lo and behold, there is an American company which lets you design and order your own custom board book online, called My Custom Story.  Once you create an account with them, you upload all your photos into an album, then create a project to design a 10 page board book.  You design it on a screen that looks like this:

The software was a little frustrating at first, because I couldn't seem to get it to work.  But then I realised that there was just a long delay from when you dragged a layout or picture onto the book template, and when it appeared there.  Once I realised that, and stopped clicking different things to try and get something to work, it was fine.

I then went round the house and snapped a couple of familiar items on my mobile phone and added those:

And I liked that I could do 'eating' and include breastfeeding - something you never find in the baby books off the shelf, where it's all bottles.  (And for bottle-feeding mums, wouldn't it be nicer to have a picture of you feeding your baby a bottle, not some generic cartoon with a generic baby?)

Once you factor in postage, it is about $40 for one of these board books, but I reckon it will be more valuable than 10 books about crap that means nothing to her.  And I'll be able to give it to her and let her play with it, and leave it with her when I go away to work.

When I was searching online, I did find an idea for a budget way to make a baby book , which is simply buying a cheap photo album and then printing off the photos and text and sticking them in there.  Also, a friend of mine has bought a laminator, and we were going to try creating one by printing and laminating pages, then hole punching them and using key rings to connect them.

However, I haven't tried either of those yet, because I thought it would be too much fun to design and have printed a professional looking board book!

Thursday, February 10, 2011

Food Adventures, Tresillian, and Some Feeding Research

We have finally got through the list of allergy inducing foods without incident: citrus, tomato, strawberries, milk, eggs, shellfish, and today - peanuts!  

Yeah, I know it's salty, she just got a dab off my finger to taste.

Yay!  We have also tried a variety of spices - ginger, garlic, paprika, chilli, pepper - and she loves them.  Very pleased about that because we use a lot of these sorts of spices in our cooking.  Now I only have to avoid stuff like honey, unpasteurised cheeses, and added salt.

Amazingly, my husband and I seem to have come to complete agreement on the issue of eating.  I am happy to hold her arms down when I spoon feed her, because she has other ways of clearly letting me know if she wants to eat the food (turning her head away etc).  He is happy to let her taste any and all finger foods (minus choking hazards and the few inappropriate foods), and to be included in mealtimes in her highchair at the table.  We both agree that as she gets older, she should be offered healthy but tasty food at dinner, and if she doesn't eat her dinner we don't make her, but it just goes in the fridge for later in case she gets hungry.

At this stage, my husband gets her to take maybe 1-5 spoonfuls of a puree or baby cereal in the evenings, and then she has a go at various solids, but up until just a few days ago she has been swallowing very little.  Then yesterday, she ate 3 rice rusks and about a spoon's worth of tomato from the finger food.  Today she ate another rice rusk, again about a spoon's worth of tomato, and had a good go at some chicken (given that she only has a millimetre or so of two bottom teeth poking through).

The first finger food Bethany has succeeded in chewing and swallowing in any quantity.

However, introducing solids did not get off to a smooth start here.  At first I wanted to wait until six months, but then after I did some research decided it really didn't matter if I started at four months.  I thought this was good, since I wanted to get her onto solids fairly well in time for me to go back to work.  So at four and a half months started giving some finger food, baby-led weaning style, since she was already really good at sitting up at that age.  I also tried some purees, but she was very insistent on grabbing the spoon and refusing to let me get a spoon anywhere near her mouth, so I didn't do much of that.

Only, then my husband felt (accurately) that he was being left out of all the parenting decisions, so we decided that he ought to be in charge of solids, given that was feasible.  Having done some research, and because I'm a control freak, I still started arguing about when to introduce solids, and because he is also a control freak this only got his back up, and then he decided that she was not to have any solids at all except for tastes until 6 months, because that was the official WHO position.

If I didn't want to continue doing all the breastfeeds, he thought we should introduce formula - but after all my breastfeeding dramas I was not about to give up now.  I had committed to breastfeeding till 6 months, and since there did seem to be some evidence it reduced the risk of allergies if you did it while solids were being introduced, I wanted to continue at least until she was well onto solids too.  

Then come 6 months we had more arguments because my husband not only wanted to do purees, but to hold Bethany's hands down while he did it.  I know this is a fairly common practice, but in all my reading on sleep stuff, I had come across quite a few studies which linked childhood obesity to feeding practices which were strong in parental control.  The evidence seemed to support a hypothesis that babies who are allowed to set the pace of their feeds remain sensitive to internal hunger cues, whereas babies who are pushed to eat come to judge their hunger by social cues such as time of day and how much food is presented to them.  

Our compromise was that he would do purees and hold her hands down, but he would not force the food into her mouth if she was refusing it.  He was ok with this as he had heard somewhere that all a baby's nutrition comes from breastmilk for the for the first 12 months.  No idea where he heard this.  I had heard 25% solids, 75% breastmilk over 6-12 months, and then when I spoke to the child health nurse, she told me more solids than breastmilk by 7 months.  I was sure that had to be out of date, because if you delayed introducing solids till 6 months, loads of children would not be so comprehensively onto solids by 7 months - and I know of so many babies who hardly ate anything until 9-10 months and who were completely healthy.

Then yesterday, after yet another argument about sleep stuff, I rang Tresillian to see: a) what their sleep training method actually was; and b) if they had any tips about how my husband and I could reconcile ourselves to the same sleep goals.  (Tresillian, for anyone who doesn't know, is an advice service that also provides sleep schools), and the nurse I spoke to also repeated the 7 months should be more solids than breastmilk advice.

Quick aside here to vent - was not at all impressed with Tresillian. Ok, in hindsight I realise that mothers who prefer co-sleeping and dislike CC probably shouldn't ring Tresillian, but at the time I naively thought they might address issues and methods other than strict CC.  After all, they advertise themselves as providing 'expert parenting advice' generally.  This was how the conversation went:
Me: Hi, I have a 7 month old baby who wakes many times a night to feed.  I'm actually coping with this fine because I'm co-sleeping, but it's worrying my husband, who would prefer it if I slept in the bed with him.
Tresillian Nurse: I can understand why he would be upset.  I'd be upset if I was him too.
Me: (biting tongue) I was just wondering if you could give me some information. (Asked for information outlined above).
Tresillian Nurse: I know this is not really the method you want to use, but perhaps you have to ask yourself what will happen if you don't let her learn anything for herself.  And you have to think of your husband's feelings.
Uncharacteristically, I politely ignored all this and just continued to ask for the information.  But wow.  Seriously - this is a support line?  Cause from where I was sitting, it sounded an awful lot like a judgement line.  I dislike having my parenting judged by people who have never met me, or my husband, or my baby, or seen our parenting style in action.  I'm picky that way.  Plus to me personally, I found it disturbing that she would assume my delicate husband ought to be offended by sleeping alone, but assumed my 7 month old baby and I didn't have feelings of any relevance in the matter and we should just toughen the hell up?

Fortunately, the Tresillian lady did come up with the idea that I should have a chat with my local child health nurse, who very obligingly saw me for over an hour for a good discussion and helped me talk through my feelings and come up with some ideas.

Anyway, I mention Tresillian in this post about food because I was discussing how to approach night feedings if I am already trying to stretch out Bethany's day feeds in preparation for when I go back to work.  She said that if Bethany dropped her night feeding she wouldn't struggle for food - she'd just start taking more solids during the day (which sounds logical to me - it's just the method of achieving dropping the night feeds that is the tricky part).  I then queried what the balance should be between breastmilk and solids and she said more solids than breastmilk by this age.  I explained that didn't sound quite right and my reasoning, and she said that was what was on the Tresillian website and their information came from the WHO.

Later, I looked at the Tresillian website, and I have to say, I couldn't find her purported advice on solids anywhere, not even in their advice on how a 6-14 mth baby 'should' eat and sleep.  So then I looked at the WHO website, and the only specific thing I could find on the topic was a policy paper entitled Complementary Feeding: Family Foods For The Breastfed Baby, which on page 4 had this diagram:

As you can see, solids do not need to overtake breastmilk in the amount of nutrition they provide until around 12 months.  So there you go, the official advice from WHO on that topic.

Anyhoo, I was relieved, given that our baby is nowhere near taking in more solids than breastmilk.

Now for a summary of the information I came across on feeding methods and the timing of weaning:

Solids - Research on Infant/Child Feeding Methods and Later Eating Habits

In a study of 156 2-4 year old children, the following effects were found (Gregory et al):

  • modelling healthy eating practices predicted lower food fussiness and higher interest in food one year later;
  • pressuring a child to eat predicted lower interest in food one year later; and
  • restriction of certain foods had no noticeable effect on the child's eating one year later, however other studies have shown that in older children (particularly girls) this practice lads to emotional eating in the absence of hunger.
In both children and adults, obesity is strongly correlated with eating in the absence of hunger and poor ability to sense when one is full (satiety responsiveness) (Carnell and Wardle).

One study found that it was crucial to introduce lumpy solids to a baby before 10 months of age, and indeed that the earlier that lumps were introduced, the more likely those babies were to be eating family foods at 15 months.  Babies who were kept on smooth purees until after 10 months were much more likely to be difficult to feed, and to be picky eaters who would eat only a small range of foods at 15 months (Northstone et al).

Children like what they know.  Children who are exposed to a limited range of foods tend to be less willing to try novel foods.  Also, repeated exposure to particular foods led to a preference for those foods (Cooke).  Repeated exposure does not mean repeated force-feeding, just repeated 'tastes'.

Research on Baby-Led Weaning

There is very little published research on the merits of baby-led weaning.  Gill Rapley, who wrote the book and advocates the method, apparently did her Masters on it, but I have not been able to get a copy of that.  There is an oft-told-of-study of 33 orphan babies who, when given the option to select their own food from a range of purees put before them, chose a balanced diet.  This is intended to give parents confidence with BLW.  I was interested to learn that this famous study, conducted in 1939 by paediatrician Clara Davis was never published in any detail, and no one has ever viewed the data collected (which was destroyed) or been able to verify the methodology (Strauss).  Also, it's important to recognise that the foods offered to the babies were all healthy - they weren't offered pureed chocolate cake, for example.

Much as I like to encourage my babies cues - and indeed, she is already excellent now at pulling food / cups towards her when hungry or thirsty, or pushing it away when she's not, and distinguishing between thirsty and hungry feelings - I don't think it would be wise to try and get her to voluntarily choose spinach over ice-cream, for example.

There is a recent study which shows that the majority of babies do have the physical skills to handle and eat fingerfood adequately by the time they need it nutritionally, and so have concluded from a nutritional perspective baby-led weaning is 'feasible' for the majority of babies (Wright et al).

Breastfeeding - Research on Infant/Child Feeding Methods and Later Eating

One study found that breastfeeding exclusively until 6 months and then maintenance of breastfeeding until after the introduction of solid food until at least 12 months tended to be associated with less childhood obesity.  Indeed, exclusive breastfeeding for 6 months had far more protective effect than any other factor considered. (Gungor et al).  

That said, a multivariate analysis in another study found that exclusive breastfeeding was not protective, it just appeared that way because it was associated with other protective factors (Reilly et al).  A review of studies of over 69 000 children found that even some breastfeeding signficantly lowered the risk of childhood obesity, even when adjusting for other factors (Savage et al). Very low amounts of sleep at 30 months (less than 11 hours a day) were also predictive of obesity (Reilly et al).

But why is breastfeeding protective?  Here are the possible hypotheses:  
  1. Breastfeeding for 6 months is associated strongly with breastfeeding on demand, which requires the baby to regulate his or her own calorie intake, as well as to distinguish between thirst and hunger in the amount of sucking.  For example, in one study, mothers of breast-fed infants reported variation in their infant's hunger durin the day, whereas bottle-feeding mothers did not (Pridham).  In one study of 3-5 year old children, the children who were not overweight were those who instinctively ate less at lunch if they were given a high-calorie drink beforehand (but not when given a low-calorie drink), being those who were able to follow their internal hunger cues (Savage et al).
  2. Breastfeeding on demand generally tends to be more frequent than scheduled breastfeeding, which means the baby takes in less in a feed, rather than stretching the stomach more earlier.  
  3. Breastfeeding on demand promotes left-brain front cortical activity rather than right-brain assymetry (Jones et al) - this brain wave pattern is associated with a tendence to recognise and act on one's inner desires rather than repress those desires (I go the science of cortical assymetry in great detail in one of my sleep posts).    Someone with left-brain activity might recognise they are full and stop eating a half-full plate, whereas those with high right-brain activity may repress their own inner impulses and be more receptive to the social cue that it is appropriate to finish what is on one's plate.
  4. Breastfeeding conditions the mother to trust and be receptive to the baby's cues when eating, so the mother is more likely to follow the baby's refusals of and interest in food - enhancing self-regulation of food intake (Fisher et al).
  5. Formula has a higher protein content (Redsell et al).
  6. More mothers from a higher socio-economic background choose to breastfeed, and they later tend to have healthier eating practices (Redsell et al).
  7. Babies fed formula tend to be introduced to solids earlier (Redsell et al).


Carnell and Wardle, 'Appetite and adiposity in children: evidence for a behavioral susceptibility theory of obesity' (2008) American Journal of Clinical Nutrition Vol , p22.

Cooke, 'The importance of exposure for healthy eating in childhood: a review' (2007) J Hum Nutr Diet Vol 20, p294.

Davis, 'Results of the self-selection of diets by young children' (1939) Canadian Medical Association Journal Vol 41, p257.

Fisher et al, 'Breast-feeding through the first year predicts maternal control in feeding and subsequent toddler energy intakes' (2000) Journal of the American Dietetic Association Vol 100(6), p641.

Gregory et al, 'Maternal feeding practices, child eating behaviour and body mass index in preschool-aged children: a prospective analysis' (2010) International Journal of Behavioural Nutrition and Physical Activity Vol 7, p55.

Gungor et al, 'Risky vs Rapid Growth in Infancy: Refining Pediatric Screening for Childhood Overweight) (2010) Archives of Pediatric and Adolescent Medicine Vol 164, p1091.

Jones et al, 'Patterns of brain electrical activity in infants of depressed mothers who breastfeed and bottle feed: the mediating role of infant temperament' (2004) Biological Psychology Vol 67, p103.

Northstone et al, 'The effect of age of introduction to lumpy solids on foods eaten and reported feeding difficulties at 6 and 15 months' (2001) J Hum Nutr Dietet Vol 14, p43.

Pridham, 'Feeding behaviourof 6- to 12-month-old infants: Assessment and sources of parental information' (1990) The Journal of Pediatrics  pS174.

Redsell et al, 'Parents' beliefs about appropriate infant size, growth and feeding behaviour: implications for the prevention of childhood obesity' (2010) BioMed Central Public Health Vol 10, p711.

Reilly et al, 'Early life risk factors for obesity in childhood: cohort study' (2005) British Medical Journal DOI:10 p1136.

Savage, 'Parental Influence on Eating Behaviour: Conception to Adolescence' (2007) Law, Medicine and Ethics p22

Strauss, 'Clara M Davis and the wisdom of letting children choose their own diets' (2006) Canadian medical Association Journal Vol 175(10), p1199.

Wright et al, 'Is baby-led weaning feasible?  When do babies first reach out for and eat finger foods?' (2010) Maternal Child Nutrition Vol 10, p1111

Tuesday, February 8, 2011

Baby Photo Competition

So, I have been suckered into entering into a baby photo competition.

I never thought I'd be one of those mothers who pimps her baby out in this way.  But when I saw some friends posting their entries on facebook, I was suddenly saddened that I had no 'cute' photos of Bethany.  Don't get me wrong, I think she's adorable.  But I had never gone to the trouble of getting photos to show her cuteness.  I always take mobile phone snaps of her doing stuff, but not thinking about whether she looks pretty.  So I decided to capture her cuteness.

My sister Steph helped me out by borrowing her husband's fancy camera and setting up a couch with a white sheet, then we took it in turns to entertain the baby while the other photographed.

Bonds is running the competition (Baby Search 2011) - you can just follow the link to get the details to enter your baby.

Anyway, the results weren't too bad!  I picked out the best ones from what we took today and posted them on facebook to get feedback.  Thanks to everyone who gave it!  Now I have narrowed the list even further, and also cropped the images, adjusted the contrast, and blurred the backgrounds a bit to make her stand out a bit more, as there appears to be no rule against doing this.

What do you reckon?  Which of these should I enter?

Photo 1

Photo 2

Photo 3

Photo 4

Photo 5

I love the personality in no 5, but wonder if they are looking for something more in the vein of photo no 1?

Now, just for fun, here are some of the photos that didn't make the cut, but which make me giggle:

You want me to smile and look cute?  How can I do that 
when I'm plotting to take over the world? MWAHAHAHAHA!

A mobile phone case, eh?  Don't try any funny business.  
Yeah, I'm talking to you.  I've got my eye on you.

Enough with these photos already, Mum!

Friday, February 4, 2011

Sleep Research Part 4: Non-Crying Methods of Teaching Your Baby To Sleep

This is the final sleep research post. I hope people have found them useful!

If you find this post interesting, you may also be interested in What is a Normal Sleep?, Effectiveness of Controlled Crying, Risks of Crying Methods, and Viewing Crying Methods in Perspective.

Because crying methods are controversial, and because they were a staple of Western parenting methods for much of the 20th century, there is quite a lot of research about them. Comparatively, the research on non-crying methods is sparse. The way I have approached this post is to summarise the research I have found by technique.

Be calm, affectionate, and responsive when you put your child to bed

There have been a lot of studies about what parents do when they put children to sleep (eg. pat, nurse, leave to cry etc.), but little research about how they do it. A 2010 study (Teti) looked at the question: does it matter how emotionally available the mother is when she puts the baby to bed? The study looked at 39 families with infants between 5 weeks and 24 months old.

What it found is that the more mothers assisted their infants to wind down with sensitive, calm, affectionate, and responsive behaviour (including gazing into the child's eyes while nursing, cuddling, quiet play such as reading a book or gentle talking, not persisting in forcing the child into an activity they did not want to do, not showing irritation or anger towards the child, and not leaving the child to cry or at least not leaving the child to cry for no longer than a minute), the easier the child settled to sleep and the less sleep disruptions they caused during the night. The combination of sensitive, calm, structured, and affectionate behaviour was described as maternal 'emotional availability'. (An example of a mother who scored low on 'emotional availability' was one who persisted in trying to read to her child when he wasn't interested, pulled him back into bed when he got out, and threatened to take away his toys unless he went to sleep.)

Whether the mothers particularly cuddled, nursed, patted, or read to their babies did not show any relationship to sleep quality. It was how they did these things that mattered. The study controlled for the mothers' age, education, family income, employment status, co-sleeping or separate sleeping arrangements, and found none of these factors were relevant to sleep quality in the families studies (although the sample was probably fairly homogenous).

The authors suggest that the reason why emotional availability helps children sleep is that feeling safe in one's sleep environment assists sleep.

Scheduled Waking

One treatment for night-wakings is 'scheduled waking'. This is where parents are instructed to wake their child 15-60 minutes before the child usually wakes and to resettle the child to sleep. In one study of 33 children between 6 and 54 months, this has been found to significantly reduce the number of night wakings as much as crying it out, although the method took longer to take effect (Rickert and Johnson). This has been observed to be reasonably effective by a number of studies but it can be hard for parents to stick to (Mindell).

Positive Routines

In one study of 36 children aged between 18 and 48, all with settling problems, implementing a positive bedtime 'wind-down' routine was compared with crying it out. The study found that the wind-down routine was as effective as controlled crying in reducing settling problems (Adams and Rickert).

Co-Sleeping & Room Sharing

Co-sleeping works differently from other sleep training methods. Instead of training the baby to do anything, it adjust the environment so night wakings become more palatable to mum.

A 1994 study of 50 9-24 month old infants with sleeping difficulties compared co-sleeping and controlled crying. Half the infants were treated with controlled crying. The other half required only that a parent sleep in the same room as the child. Sleeping in the same room as the child was as effective as controlled crying. Both reduced parental perceptions of a sleep problem by 60%, and actigraphy recordings showed that both resulted in significantly more sleep for 52% of the children (Sadeh).

Does co-sleeping affect night wakings or daytime behaviour?

Studies have shown that co-sleeping babies sleep more lightly and have more frequent night-wakings, but also that mothers and babies who are co-sleeping have sleep cycles that fall into sync (Mosko, Richard, and McKenna). What this means is that yes, co-sleeping babies tend to wake more, but that the wakings can be less disruptive for the mother because she is not woken unexpectedly out of deep sleep but comes into semi-waking naturally and is able to address the infant's needs quickly and return to sleep easily.

One study looked at differences in behaviour between 83 pre-school children who: a) co-slept at infancy, b) solitary sleepers in infancy but started to co-sleep at or after age one; or c) didn't co-sleep. The study found that solitary sleepers fell asleep alone and slept through the night a full year to year and a half earlier than co-sleepers, and at pre-school age co-sleepers woke 'sometimes' whereas solitary sleepers woke 'rarely'. Another study of 6 month old Swedish infants found that co-sleeping was associated with waking more than 3 times a night, although it was not clear at this age whether co-sleeping caused the waking, or the waking caused parents to try co-sleeping (Möllborg et al).

However, children who had co-slept since infancy 'were more self-reliant (e.g. ability to dress oneself) and exhibited more social independence (eg. make friends by oneself)' during the day. They also breastfed for longer. There was no difference between the groups on when the children were toilet trained (Keller and Goldberg).

The study found that early co-sleeping tended to be part of a deliberate style of parenting that encourage the child's autonomy through being 'baby-led' – however even when controlling for this parenting style, early co-sleeping had a positive effect on infant independence. More of the deliberate co-sleepers had children night wakings than the parents with solitary sleepers, but the early co-sleepers psychologically adjusted to having the baby in the bed and found the night wakings more rewarding than disruptive (Keller and Goldberg). By contrast, babies who were solitary sleepers in infancy and who later became co-sleepers had frequent, disruptive night wakings (Keller and Goldberg). This is consistent with findings that co-sleeping is not associated with sleep problems in cultures where co-sleeping is routine, such as China (Jiang et al), and Japan (Latz et al). In Egypt where co-sleeping is normal, teenage co-sleepers were found to have better sleep and solitary sleepers to have increased sleep dysregulation (Worthman and Brown).

It is also consistent with another study that found parents who co-slept every night and parents who slept apart from their babies every night at 6 months had more positive interactions with their babies at 9 months, whereas parents who some nights slept with their babies and some nights did not had much less positive baby-parent interactions (Taylor et al). In addition, mothers who co-slept at 6 months were found to have less maternal depression at 9 months than both the solitary sleepers and the inconsistent co-sleepers (Taylor et al).

If you co-sleep with your baby, how long can you expect to co-sleep for?

It appears that if you stop before 9 months, it is no more likely that you will co-sleep with your child as they get older than if you had never co-slept at all. However, after this time, a persistent pattern of co-sleeping is likely. In a longitudinal study, 493 Swiss babies were followed from birth until 10 years of age to track bed sharing and night waking. This study found that less than 10% of children shared a bed with their parents in the first year of life (bed-sharing defined as sharing the bed at least once a week), but by 4 years, 38.1% of the children were sharing a bed at least once a week. At 8 years, 21.2% of the children were sleeping at least once a week in their parents bed and 5.1% did so every night. Interestingly, the study found that children sharing a bed with parents at 6 months old were not more likely to share the parents' bed during childhood than children not sharing at that age. However, children who were bed-sharing at 9 and 12 months tended to persist in bedsharing for 3 years.

In a study of deliberate early co-sleepers, many expressed the view that the child initiated a move to his or her own bed before th e age of three, and that it was a smooth, happy transition (McKenna and Volpe).

Is co-sleeping safe?

Bed sharing is associated with a higher risk of SIDS, but it is important to recognise that it is not sharing a bed that is the cause of this higher risk. It is infants being placed on their side (who then role onto their tummies), bedding in the bed which may smother the infant or make them too hot, sleeping with your baby on a sofa, sleeping with your baby and another child, or bed-sharing while intoxicated or if mum smokes (Ostfeld, Middlemiss, Blair). The exact reason why smoking is a risk is not known – it may be due to effects of smoking chemicals passing into the baby's body in utero, or it may be that residual chemicals in the mother's mouth and lungs are breathed out onto the baby while they are sleeping, affecting the air quality and elevating the risk of SIDS.

However, bed sharing has also been associated with a longer duration of breastfeeding (Möllborg et al), and breastfed babies have a significantly reduced likelihood of SIDS. Therefore, if you are sleep deprived and considering making a choice between changing to formula feeding (so you can share the burden of night feedings with your partner, and so the baby sleeps longer between feeds, which is regularly the case with formula) or co-sleeping – don't assume that cot-sleeping with formula is the safer choice. Breastfeeding appears to be far more protective than safe co-sleeping is dangerous. Statistics gathered on co-sleeping are so muddled by the inclusion of unsafe co-sleeping arrangements (unsafe bedding, intoxicated mothers who roll onto their infants etc.) and the variable of breastfeeding (as co-sleeping is highly correlated with breastfeeding, which is highly protective of SIDS, breast-fed babies are about half as likely to die of SIDS – see Venneman) that it is currently impossible to say.

As James McKenna argues, because the Western world has come to accept solitary sleeping as the cultural norm, this shapes the way statistics are gathered. So when an infant dies in a cot, solitary sleeping is never presumed to be the cause, and if no cause is apparent, the death is written off as the mysterious 'SIDS'. By contrast, if an infant dies when co-sleeping, it is frequently presumed that overlying must have occurred, even if there is no evidence of this (McKenna and McDade). It is also assumed that co-sleeping occurs very rarely, which makes it look like co-sleeping deaths occur frequently among a small number of co-sleepers. In practice, very large numbers of women co-sleep occasionally, and up to about a third co-sleep regularly (Hauck et al., 2008), but the amount of co-sleeping is underreported, not least because many women do not like to admit they engage in a purportedly 'dangerous' practice.

Co-sleeping babies sleep lighter than babies who sleep alone. It has been proposed that co-sleeping may protect against SIDS by helping babies to regulate their sleeping patterns and avoid stopping breathing (Mosko, Richard, and McKenna). While this is a logical theory, and perhaps explains why infants sharing a room have a lower rate of SIDS, there is no evidence yet as to whether it actually works in practice. A counter-argument is found by one study of 5 week and 6 month old babies has found that when usually co-sleeping babies are put to sleep on their own, they actually sleep more heavily with less active and more quiet sleep (Hunsley and Thoman). They argue that this puts co-sleeping babies at greater risk for SIDS when they are not sleeping with an adult (eg. day sleeps). As of 2000, the American Academy of Pediatricians Task Force on Infant Sleep Position and Sudden Infant Death Syndrome neither advocated or warned against co-sleeping, however, they noted that the following were hazardous ways of co-sleeping (Task Force):

• If a mother chooses to have her infant sleep in her bed to breastfeed, care should be taken to
observe the aforementioned recommendations(nonprone sleep position, avoidance of soft surfaces or loose covers, and avoidance of en-trapment by moving the bed away from the wall and other furniture and avoiding beds that present entrapment possibilities).
• Adults (other than the parents), children, or other siblings should avoid bed sharing with an infant.*
• Parents who choose to bed share with their infant* should not smoke or use substances, such as alcohol or drugs, that may impair arousal.

It is interesting to note that overlying the baby is not the biggest risk of co-sleeping, it is (similarly to a poorly made cot) entrapment between the bed and the wall (about 50% of co-sleeping deaths), or entrapment between the mattress and another part of the bed such as a bed-rail (about 30% of co-sleeping deaths) (Scheers et al). The very worst place to co-sleep with your baby is the sofa (Task Force). In the Chicago Infant Mortality Study, the deaths of 260 infants were explored and it was found:

“An increased risk of SIDS was observed for bed sharing, but multivariate analysis indicated that the risk was primarily associated with bed sharing when the infant was sleeping with people other than the parents.” (Hauck et al)

A side note on the Hunsley and Thoman study: Because less active and more quiet sleep can be a response to severe stress, such as circumcision, the authors of this study decide that the co-sleeping babies were severely stressed when sleeping alone (as opposed to non co-sleeping babies who sleep alone). This may or may not be true since the stress levels of the babies weren't measured. The idea that less active and more quiet sleep indicates severe stress has been derived from studies that did not specifically look at stress patterns in babies who co-sleeping. As co-sleeping affects the way infants sleep, the heavier sleep when apart from parents may simply be normal for co-sleepers, and not an indication of stress. The other problem with the conclusion is the presumed direction of the causality. Even assuming the babies are stressed, an alternative and equally plausible hypothesis is that a generally high level of stress (from the infant's biology or environment) when being put to bed caused both infant fussiness, and the co-sleeping more than twice a week. It is therefore the stress that causes the co-sleeping, not the co-sleeping that causes the stress. 'Usually co-sleeping' in this study was defined as infants who co-slept twice a week or more for at least 6 months. This is a problematic definition of co-sleeping, because it includes infants who are co-slept with reactively in response to temperamental sleep problems as well as infants who are co-slept with for philosophical reasons. It is likely the study included primarily reactive co-sleepers given that infants were selected for the study if they exhibited 'fussiness' that was troublesome to the parents. It may well also have captured parents who employed methods such as letting the child cry to sleep when the child slept alone, a method that might be all the more stressful for a child if it was applied inconsistently – and combined with sporadic co-sleeping.

Fable & Reward

A small 2004 study of 4 children (aged 2, 5, 7 and 7) with severe tantrums at bedtime, 'treatment' was to add a story at the end of the child's usual bedtime routine. The story was called The Sleep Fairy and it was the story of two children who learned to go to bed without fuss and were, as a result, rewarded by the sleep fairy. If the child settled well and stayed in bed, parents were to place a simple reward (eg. a sticker) under their pillow for the children to find in the morning. Sleep problems rapidly reduced and were maintained at a 3 month follow up for all children (Burke).

Bedtime Pass

A study on 19 children between 3 and 6 years combined crying it out with a 'bedtime pass'. Upon going to bed each child was given a card which was a 'free pass' to leave the room and come out for parental attention. If they cried out beyond this they were ignored. The study found that children given the pass cried out significantly less than children who were just ignored, and that all children given the pass had stopped using it at the 3 month follow-up (Moore et al). Families using the 'bedtime pass' were compared to families who ignored the children without a pass, and improvements in the number of times the children left the bedroom were similar in both groups.

Put Your Child To Bed Later

This revolutionary idea is – if your baby fights sleep, perhaps she or he is not tired. A study compared babies born in the late 70s, early 80s, and late 80s-early 90s. It found that parents in the late 70s tried to put their babies to bed earlier and had far more bedtime resistance (Jenni et al 2005). As discussed in 'what is a normal sleep' below, individual babies need different amounts of sleep.

Be Happy With What You Do

There is increasing evidence that in the majority of cases, it is not the amount of night wakings that parents find stressful, it is their confidence in responding to those wakings. Deliberate co-sleepers tend to be happy with their choice, as do deliberate sleep-trainers. But those who try sleep training but whose babies don't respond, and those who take up co-sleeping because keeping on re-settling the baby elsewhere is too exhausting are those who report the greatest 'sleep problems' (Goldberg and Keller). This does not mean you have to pick on strategy and stick to it. Indeed, a large British study has found that your best bet at avoiding sleep problems is to be responsive to your child's needs and adopt a variety of strategies, including actively assisting your child to settle when they need it (Morrell and Cortina-Borja).

Mothers who are inconsistent co-sleepers (again, most likely reactive co-sleepers) tend to have poorer quality interactions with their bubs than those who are consistent with co-sleeping or non-co-sleeping (Taylor et al). Inconsistent co-sleeping was defined as sleeping 1-6 nights a week in a parental bed, whereas consistent co-sleeping was sleeping even night in a parental bed, though not necessarily for the whole night. The mums with consistent sleeping arrangements were more positive in interacting with their babies and had greater sensitivity in responding to their babies, and the babies were more interactive and cheerful. The study controlled for duration of breastfeeding, infant temperamental intensity, hours worked by the mother, and maternal depression. It did not, however, control for the reason why the inconsistent co-sleeping was employed, or whether the effect on interaction was not due to the sleeping style per se but that sleeping style was indicative of whether mothers had consistent or inconsistent parenting styles generally.

A study of 52 infants at 10 months looked at whether the mother's general level of separation anxiety affected the sleep of the infant, and found that higher levels of maternal anxiety was correlated with more night-waking episodes – statistically, it seemed to affect 9% of night wakings. This was true of actigraphy recordings, not just the night wakings mothers were aware of. Mothers who had high levels of separation anxiety were more likely to assist their child to sleep with active settling, but the maternal anxiety had an effect on night wakings over and above the effect of active settling. This suggests there are some children who settle well with active settling, provided the mothers do it in a calm and structured way and respond to daytime separations in a calm and structured way, and that there are some children who can't learn to self-settle because the mothers are too anxious (Scher 2008).

Medical reasons for sleep disturbance

Approximately 17% of children have anxiety disorders, and approximately 88% of children with anxiety disorders have a sleep-related problem, such as insomnia and reluctance to sleep alone. (Chorney et al). Symptoms of sleep disturbance in early childhood has been associated with anxiety disorders when the children grow up to be adults, and fearful children take nearly an hour longer to fall asleep than non-fearful children (Chorney).

Conditions such as asthma and allergic rhinitis have been found to result in poorer sleep (Smaldone). On a personal note, I was a baby who woke at least 5 times a night in distress most nights until I was almost 3 years old, when they finally diagnosed that I had overlarge adenoids and had them surgically removed. My sleep improved instantly. I had been waking up because it was a struggle for me to breathe when horizontal.


Adams and Rickert, 'Reducing bedtime tantrums: comparison between positive routines and graduated extinction' (1989) Pediatrics Vol 84, p756.

Blair et al, 'Babies sleeping with parents: case-control study of factors influencing the risk of the sudden infant death syndrome' (1999) British Medical Journal Vol 319, p1457.

Burke et al, 'Brief Report: A “Storybook” Ending to Children's Bedtime Problems—The Use of a Rewarding Social Story to Reduce Bedtime Resistance and Frequent Night Waking' (2004) Journal of Pediatric Psychology Vol 29(5), p389.

Chorney et al, 'The Interplay of Sleep Disturbance, Anxiety, and Depression in Children' (2008) Journal of Pediatric Psychology Vol 33(4), p339.

Goldberg and Keller, 'Co-Sleeping During Infancy and Early Childhood: Key Findings and Future Direction' (2007) Infant Child Development Vol 16, p457.

Hauck et al, 'Sleep Environment and the Risk of Sudden Infant Death Syndrome in an Urban Population: The Chicago Infant Mortality Study' (2003) Pediatrics Vol 111, p1207.

Hauck et al, 'Infant Sleeping Arrangements and Practices During the First Year of Life' (2008) Paediatrics Vol 122, Supplement 2, pS113.

Hunsley and Thoman, 'The Sleep of Co-Sleeping Infants When They Are Not Co-Sleeping: Evidence That Co-Sleeping is Stressful' (2001) Developmental Psychobiology Vol 40, p14.

Jenni et al, 'Sleep Duration From Ages 1 to 10 Years: Variability and Stability in Comparison With Growth' (2007) Pediatrics Vol 120, pe769.

Jiang et al, ''Epidemiology study of sleep characteristics in Chinese children 1-23 months of age' (2007) Pediatrics International Vol 49, p811.

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