Tag Archives: breastfeeding

Normal Baby Sleep – What to Expect (feeding and development) PART 1.

NOTE. This is a collaborative post, for a list of authors please see the end of the post.

 

Infant sleep problems represent some of the most common concerns reported by parents of young children.  Ask any new parent and most will complain about lack of sleep. Many will also be worried that what they are experiencing isn’t “normal” and believe that their child has a problem that needs fixing.  So they search books, ask friends and family or even their doctors about what to do about a child’s problematic sleep patterns.  And to top it off, they feel immense anxiety and worry about them.

Part of the epidemic of parental angst about children’s sleep is that we live in a culture in which parents are repeatedly told that they need to worry about their child’s sleep, that there will be dire consequences if their child doesn’t get enough sleep. Another problem is that most new parents, having had little experience with children prior to having their own, have little awareness about what truly is “normal” when it comes to infant sleep

Simply being made aware of normal sleep patterns can help alleviate the stress and anxiety parents feel, leading to happier times for the entire family.

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So what is normal?

In this series of posts, we’ll tackle some of the more common sleep concerns parents have with the hope that they can see them as normal, developmental stages for their child.

 

“My child wakes every hour, all day and night, to feed”

Whether it’s every hour, or every two hours, or even three, parents are often concerned when their young infant is waking regularly for feedings.  This concern is not surprising given the focus on “sleeping through the night” that our culture pushes. But sleeping through the night is not biologically normal, especially for a breastfeeding baby.

At the time of birth, a baby’s stomach can only hold a teaspoon’s worth of milk, meaning that he or she will need to feed frequently to meet the many demands for energy that accompany this period of growth.   Although the stomach grows relatively quickly, the fat and protein content in human breastmilk is much lower than in the milk of other mammals and thus infants are required to feed often, resulting in greater night wakings (Ball, 2003; Ball, 2009).

Human breastmilk, being designed for infants who need to feed on cue day and night, is easily and quickly digested.  Formula, however, is typically made from the breastmilk of another species – cows – and is higher in fat while also containing myriad additives which make it more difficult, and thus slower, to digest.  This can affect infant sleep, resulting in unnaturally deeper infant sleep (more time spent in stage 3-4) (Butte, Jensen, Moon, Glaze, & Frost Jr., 1992), a stage of sleep from which it is most difficult to arouse to terminate breathing pauses (especially for arousal deficient infants), thereby potentially diminishing the infant’s capacity to maintain sufficient oxygen.  Even so, formula use does not necessarily provide parents with more sleep overall (Doan, Gardiner, Gay, & Lee, 2007).

Infants whose primary source of energy is breastmilk will often wake frequently to nurse, something that is essential for the breastfeeding relationship to continue (Ball, 2009). However, regardless of feeding status, many infants wake regularly during the night (Weinraub, Bender, Friedman, Susman, Knoke, Bradley, et al., 2012).  Waking through the night is normal and biologically adaptive.  In fact, though it is often reported that sleep patterns consolidate in the second year, the pattern differs in breastfed children.

Breastfeeding moms may wake more often, but report greater total sleep.  For example in a study following breastfed children for 2 years, it was found that these children continued to wake frequently throughout the second year of life, a pattern more in line with cultures in which co-sleeping and full-term (aka “extended”)  breastfeeding are more common (Elias, Nicolson, Bora, & Johnston, 1986).

cosleep1

Night wakings serve to protect the infant.

Night wakings have been reported as being more common in infants who bedshare with a parent, yet the wakings and bedsharing (when done safely) may actually protect the infant from SIDS (Mosko, Richard, & McKenna, 1997; Mosko, Richard, McKenna, & Drummond, 1996).  The critical period for SIDS is up to 8 months of age (with the peak at 2-3 months) and night wakings may serve as a protective mechanism.  In fact, if we look at parenting historically and cross-culturally, frequent night-wakings coupled with co-sleeping and breastfeeding are the norm for which we should be comparing other infant sleep behaviours.

 

“My child was sleeping through the night and suddenly it’s stopped.”

Imagine you’ve been waking regularly with night feeds and arousals, but as time passes they are decreasing.  Then you realize you’re now sleeping in nice, long chunks.  Hours of sleep all at once!  And it’s wonderful.  Then suddenly, as quickly as it came, it’s gone.  Your wonderful, sleeping-through-the-night child is suddenly waking again.  This experience, which is a reality for many, can cause frustration and despair accompanied by the feeling that you’ve done something wrong, or that you must do something get their uninterrupted sleep back again.

But here’s the thing: You didn’t do anything.  A return to night waking after periods of sleeping through the night is entirely normal.  Many children’s sleep will cycle like this for a while.  In fact, researchers looking at sleep patterns have found that often between 6 and 12 months, infants who had previously been sleeping long stretches suddenly start to wake more frequently at night (Scher, 1991; Scher, 2001).  In fact, in one long-term study looking at child sleep between 3 and 42 months found that there was no stability in night wakings or even sleep duration during this time (Scher, Epstein, & Tirosh, 2004).

What causes the change in sleeping pattern?

There are likely a variety of reasons, unique to each child.  For some, it may be a growth spurt or teething.  For others, it may be a cognitive leap that has them buzzing more so than usual or the appearance of separation anxiety.  Just recently a study reported that babies tend to wake more often when they are learning to crawl.   And for some, we may never know the actual reason.  But as children age and each develops a circadian rhythm, they will go through cycles of sleep – some more convenient for parents than others.  Parents need to be aware that these changes are entirely normal, even though they can be frustrating. Hopefully once you know that changes are to be expected, you can be better prepared or at least not add anxiety to the sleep disruptions you are forced to deal with once again.

baby-can-not-sleep-if-mother-stress

For Part 2 of this post please CLICK HERE.

Co-Authors

Tracy Cassels, University of British Columbia,www.evolutionaryparenting.com

Sarah Ockwell-Smith, babycalming.com

Wendy Middlemiss, University of North Texas

John Hoffman, uncommonjohn.wordpress.com

Kathleen Kendall-Tackett, Texas Tech University,http://www.uppitysciencechick.com/sleep.html

Helen Stevens, Safe Sleep Space

James McKenna, Mother-Baby Behavioral Sleep Laboratory, University of Notre Dame, www.cosleeping.nd.edu

References

Ball, H. L. (2003).  Breastfeeding, bed-sharing, and infant sleep.  Birth, 30, 181-188.

Ball, H. L. (2009).  Bed-sharing and co-sleeping: research overview.  NCT New Digest, 48, 22-27.

Ball, H.L, & Volpe, L.W. (2013).  Sudden Infant Death Syndrome (SIDS) risk reduction and infant sleep location –Moving the discussion forward. Social Science & Medicine 79, 84-91

Butte, N. F., Jensen, C. L., Moon, J. K., Glaze, D. G., & Frost Jr., J. D. (1992).  Sleep organization and energy expenditure of breast-fed and formula-fed infants.  Pediatric Research, 32, 514-519.

To Swaddle or not to Swaddle?

Is any issue more emotive in the babycare world at the moment?

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Emotive in general, but also a point that I am asked to comment on at least once per week in response to questions from, mostly, potential BabyCalm teachers – concerned that BabyCalm “advocate swaddling”. My answer is always “BabyCalm don’t advocate anything! That’s not what we do – we’re all about empowering parents and in order to truly empower we must allow the parent to make his or her own informed choice – and sometimes that choice may be something that makes our heart sing, othertimes it may be something that makes us uncomfortable – BUT – and it’s a big but! – we have to learn that our feelings must stay that – OUR feelings.”

So, what’s the deal with swaddling and BabyCalm?

In short we present the idea of swaddling to parents as one of many, many ways that they can soothe their baby (and those of you who have attended a BabyCalm class will know how little of it is taken up with soothing techniques – in short it’s the smallest part of what we do!) and it is just that “presented”. As with any other method we present we always disccuss the pros and cons of the technique and we help parents to know how to do it safely, with the minimal amount of risks as possible – be that dummy use, bedsharing, babywearing or swaddling. I am always concerned when somebody says “That’s dangerous – never do it” (FSIDs and bedsharing anyone?) or “That interrrupts feeding – never do it” because things are NEVER that cut and dried………..sure most things in life have risks, but most have benefits too and ways to reduce those risks.

swaddled-baby-small

 

 

 

 

What would you suggest in this scenario? A mum with a 6 week old baby who confesses to you she’s not coping, her baby is very fretful and sleeps fitfully. She is at the end of her tether, she admits that the exhaustion and lack of sleep she’s experiencing is now affecting her bonding with her baby, she’s desperate. She also tells you that she is happily formula feeding, baby is in her own cot (and she wants it to stay that way) and babywearing isn’t for her. She’s tried swaddling and it really seems to help, she’s using a fleece blanket and pulling it really tight all around the baby. This scenario is precisely when swaddling can be a God send – this scenario is the norm in the UK, outside of the AP bubble of breastfeeding, bedsharing and babywearing………..but, this scenario is when swaddling can be dangerous and why we still teach swaddling in BabyCalm, we teach how to reduce those risks as much as possible.

Think of another scenario – Mum of a 6wk old baby who confesses to you she’s not coping, her baby is very fretful and sleeps fitfully. She is at the end of her tether, she admits that the exhaustion and lack of sleep she’s experiencing is now affecting her bonding with her baby, she’s desperate. She is breastfeeding and open to suggestions of babywearing, bedsharing and co-bathing…..what would you suggest here? would it be different to the above? Of course it would! but……..what if this mum’s informed choice was *still* to swaddle rather than bedshare/babywear/cobath/skin to skin? is that your position to tell her what NOT to do? even though she’s thoroughly considered the pros and cons and made her decision – most definitely NOT!

In my opinion telling somebody NOT to swaddle – ever, is just as bad as telling them to ALWAYS swaddle, as certain baby experts might! Frankly it is none of our business what parents do and I’m always shocked that some in this profession think that it is by passing on their own strong feelings (often backed by hunches and opinion, not evidence) to vulnerable new parents. This is NOT letting the parent make an informed choice!

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So what are the pros and cons of swaddling? What does current research and our own anecdotal opinion tell us?

PROS

  1. Swaddling can help promote new sleep cycles/less waking.
  2. Swaddling can help prevent prolonged crying. (but see 8 below!)
  3. Swaddling can help breastfeeding when a baby has flailing hands making latch difficult (but see 2 below!)
  4. Swaddling can help a baby to not accidentally scratch his face
  5. Swaddling can stop loose blankets going on top of the babies face
  6. Swaddling can prevent a baby from rolling onto his tummy during sleep.
  7. Swaddling Can give parents a technique to calm their baby and thus time to calm themselves, this is heightened for parents who make the choice to formula feed and not bedshare/babywear etc..
  8. Swaddling can help a baby feel ‘held’ and perhaps as if still in utero.

CONS

  1. Swaddling can lead parents to miss baby’s early hunger cues
  2. Swaddling can inhibit breastfeeding, particularly in the early days
  3. Swaddled babies cannot suckle on their own hands as they may have done in utero
  4. There is an increased risk of SIDs shown in studies when babies placed to sleep on stomach swaddled
  5. Swaddling can cause hip dysplasia if babies are swaddled too tightly over hips
  6. Swaddling can cause respiratory compression if babies are swaddled too tightly over chest
  7. Swaddling has been linked to less arousability, if the swaddling was not started until 3months of age.
  8. Swaddling prevents a baby’s freedom of movement and expression.

If a parent would still like to swaddle their baby after considering the above, how best to do so as safely as possible?

When Swaddling Always Remember:

  1. Never swaddle over a baby’s head or near their face
  2. Never swaddle a baby who is ill/has a fever
  3. Ensure the baby does not overheat – only swaddle with a breathable/thin fabric
  4. Only swaddle until a baby can roll **
  5. Always place a swaddled baby to sleep on their back
  6. Do not swaddle tightly across the chest
  7. Do not swaddle tightly around the hips/legs. Legs should be free to “froggy up”
  8. Begin swaddling well before 3 months of age, if breastfeeding only once feeding established and never in the first few hours postpartum (in the hospital!) when skin to skin is necessary!

** The American Academy of Paediatrics recommends swaddling for babies 0-14weeks only.

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I’m being a bit lazy here as it’s the first day of school summer holidays and I want to take my kids out on a picnic – so here’s a great summary of up to date swaddling evidence.

So what’s BabyCalm’s position on swaddling? To be honest we don’t really have one! other than we are committed to letting parents make their own choices and helping them to have the information they need to do so. For some swaddling is an amazing tool, for others it’s quite the reverse! There is no “one size fits all approach” when it comes to new parents and babies and *THAT* is our position!

Sarah (Founder of BabyCalm)

Should bedsharing/ co-sleeping only be for breastfed babies?

I think it’s time to look at this issue a little more, of all the things I write about unbelievably the most contentious is my suggestion that only mothers who are breastfeeding should share a bed with their baby. In fact I have received a fair deal of angry backlash in response to this, mostly by mothers who think I am being “anti formula feeding” and spreading incorrect information, so I think the time has come for this idea to have it’s own blog post.

So – why do I believe that mothers should only share a bed with their baby if they are breastfeeding? Particularly when most of the safe co-sleeping/bedsharing guidelines omit this point.

Let me start by saying I believe this is an area that is in desperate need of further research, I am still saddened that bedsharing research misses the most important points, it is VITAL that well constructed research is undertaken accounting for all of these variables, but most importantly accounting for feeding method.

Before I go further I would like to quickly point out the following:

Bedsharing – sharing a bed with your infant

Co-Sleeping – sharing a room with your infant

I have used the term co-sleeping in the title of this post purely for SEO purposes.

cosleep

The following are reasons you may want to think again if you you formula feed and share a bed with your baby:

1) Formula fed babies are at greater risk of SIDS than breastfed babies (wherever they sleep). See here for more. It makes sense to me then to be warier of introducing anything that may further compound this risk, with this in mind alone it is vital that if sharing a bed with a formula fed baby every single safety recommendation for bedsharing is followed exactly.

breastisbestor1

2) Formula fed babies are in general less arousable than breastfed babies during certain phases of sleep, this means that babies who are formula fed tend to awaken less readily than those who are breastfed if there is a threat to their life during certain sleep phases (this may be in part a reason for point 1 above). In particular this difference is seen the most during active sleep states at 2-3mths, which is the peak SIDS risk period.

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3) Mothers who breastfeed experience different sleep to those who formula feed and awaken more regularly than formula feeding mothers during the night. Breastfeeding mothers seem to be more in tune with their baby during the night and as such may be more arousable than mothers who formula feed and may be more likely to awaken if there baby stops breathing/falls etc.

I guess the problem comes when we feed our babies via another method than nature intended – nature understandably does not then provide the same protection and it is important we respect that.

To quote from University of Notre-Dame’s Sleep Lab’s website:

“all else being safe, bed-sharing among nonsmoking mothers who sleep on firm mattresses specifically for purposes of breast feeding, may be the most ideal form of bed-sharing where both mother and baby can benefit by, among other things, the baby getting more of mother’s precious milk and both mothers and babies getting more sleep – two findings which emerged from our own studies.”

Here’s a great video interview with Dr. James McKenna where he speaks more about breastfeeding mothers bedsharing and SIDS:

4) Mothers who breastfeed are far more likely to adopt a cradling/side laying position with their baby (the advised position to adopt when sharing a bed with your baby) and are more responsive to their baby’s movements in the night – this is currently being researched by two centres – Durham University sleep lab in the UK and James McKenna’s sleep laboratory in the University of Notre Dame.

bedshare

For all of the reasons above I personally only feel confident in advocating bedsharing if the mother is breastfeeding, however unpopular my opinion may be, it has nothing to do with my opinions on breastfeeding V formula feeding (for the record I don’t have one – I have 4 kids, one was breastfed for 4mths, then moved onto formula, one was breastfed for 8wks, then moved onto formula, one was breastfed until 6mths and the last I breastfed for 4yrs!) and everything to do with keeping babies safe.

by:

Sarah (Founder of BabyCalm)

You can read more of Sarah’s articles HERE.

 

References.

  1. Horne RSParslow PMHarding R. Respiratory control and arousal in sleeping infants. Paediatr Respir Rev. 2004 Sep;5(3):190-8.
  2. McKenna JJ, McDade T. Why babies should never sleep alone: a review of the co-sleeping controversy in relation to SIDS, bedsharing and breast feeding. Paediatr Respir Rev. 2005 Jun;6(2):134-52.
  3. http://www.nd.edu/~jmckenn1/lab/articles/USBC-SIDS-PR-10-17-2005.pdf
  4. Parslow PMFerens DWatts AMAdamson TM. Comparison of evoked arousability in breast and formula fed infants. Arch Dis Child. 2004 Jan;89(1):22-5.
  5. http://pediatrics.aappublications.org/content/100/2/214.abstract
  6. http://jhl.sagepub.com/content/16/1/13.short
  7. Kahn AGroswasser JFranco PScaillet SSawaguchi TKelmanson IDan B. Sudden infant deaths: stress, arousal and SIDS. Early Hum Dev. 2003 Dec;75 Suppl:S147-66.
  8. http://www.ibreastfeeding.com/content/newsletter/nighttime-breastfeeding-and-maternal-mental-health
  9. http://www.nd.edu/~jmckenn1/lab/articles/Canada%20safe%20Sleep.pdf

Are you a Dummy Mummy?

Dummy = pacifier to my overseas readers!

I’ve been asked twice this week if I know of any evidence on the pros and cons of dummy use, naturally being the science geek that I  am, I do indeed know of an embarrassingly large collection of trials for both camps of the debate. I thought it might be handy to pop a quick post together to summarise the evidence.

One thing is for sure and that’s dummy use is highly prevalent in the UK.  The Avon Longitudinal Study found that nearly 60% of the 10,950 babies in the sample had used a dummy by four weeks of age!

Dummy Positives:

1) Dummy use may reduce SIDs risk

dummyMitchell, Blair and L’Hoir at the University of Auckland, New Zealand carried out a trial in 2006 which found “a remarkably consistent reduction of SIDS with pacifier use. The mechanism by which pacifiers might reduce the risk of SIDS is unknown, but several mechanisms have been postulated. ” Ditto researchers Moon, Tanabe, Yan, Young and Hauck at the Goldberg Center for Community Pediatric Health recently conducted a population based case-control study of 260 SIDS deaths and 260 matched living controls. Finding that dummy use decreased SIDs risks and that “pacifier use decreased SIDS risk more when mothers were ≥20 years of age, married, nonsmokers, had adequate prenatal care, and if the infant was ever breastfed. Pacifier use also decreased the risk of SIDS more when the infant was sleeping in the prone/side position, bedsharing*, and when soft bedding was present.”  A further study published in the BMJ in 2006 and conducted at Kaiser Permanente Northern California also found once again that dummy use “was associated with a reduction in risk in every category of sociodemographic characteristics and risk factors examined”.

It has been postulated that dummy use helps to keep infants in a back lying position and that this is what contributes to reduced SIDs levels although follow up research did not find this to be the case.

This research has led to the American Academy of Pediatrics & FSIDs recommending using a dummy at every sleep to reduce the risk of SIDS (and waiting  until 1mth in the case of introducing a dummy to  breastfed babies so that breastfeeding can become established).

*note I cannot find any information on whether this was all bedsharing lumped together or co-sleeping following safety guidelines.

2) Dummies can help to calm a fractious baby

dummy3Suckling is nature’s best comforter, if the mum is breastfeeding she has all she needs – although many choose to use dummies to help partners calm the baby or when she needs time alone, but bottle feeding mums are often helped greatly by the addition of a dummy which gives their baby a chance to suck when they are not being fed. Interestingly, there are marked differences in dummy use around the world – as I’ve already mentioned above the Avon Longitudinal study found 60% of British babies used dummies, whereas in their study “Soothing methods used to calm a baby in an Arab country” by Abdulrazzaq, Al Kendi and Nagelkerke which analysed data from  702 mothers from the UAE nationality, other Arabs, other Muslims, Indians and Philippinos in 2009 found that whilst 99.1% used breastfeeding as a soothing method, less than 10% used dummies to soothe their babies!

3) Dummies may help cranial bones re-align.

During labour the baby’s cranial bones move and overlap (think of a cone headed newborn!), this is normal and the bones usually return to their normal position over a few days after the birth, mostly via the process of the baby sucking (and the movement of the upper and lower jaw) which stimulates the base of the skull via the palate. Sometimes however things don’t return to normal and often abnormal skull compression becomes noticeable via the baby’s feeding habits and need to suck much more than usual. If the baby’s vagus nerve (the nerve directly linked to digestion) is compressed this can also have noticeable effects on a baby’s digestive system causing pain. All of this is more likely to happen if the labour is long, the baby is malpresented, I often notice babies who laid in an asynclitic presentation during labour are more sucky. For bottle fed babies in particular dummies can be very useful for a baby who needs to suck a lot. Sadly I cannot find evidence to support (or refute!) these claims although anecdotally many chiropractors and cranial osteopaths around the world agree and a recent literature review of “The chiropractic care of infants with colic” by Alcantara in June 2011 published in the International Chiropractic Pediatric Association reported that  “Our findings reveal that chiropractic care is a viable alternative to the care of infantile colic and congruent with evidence-based practice, particularly when one considers that medical care options are no better than placebo or have associated adverse events.”

Dummy Negatives

1) Dummy use increases the risk of Otitis Media (ear infections)

dummy2Science suggests there is a definite link between dummy use and paediatric ear infections. A Finnish study by Niemala, Pihakari, Pokka and Uhari published in Pediatrics  in 2000 found the occurrence of Acute Otitis Media  (AOM) was 29% lower amongst children whose parents had been told to limit dummy use. A Dutch cohort study published in Family Practice in 2008 by Rovers et al found once again that dummy use was a risk factor for ear infections. In their study of the 216 children that used a dummy 35% developed at least one episode of AOM, and of the 260 children that did not use a dummy a smaller percentage of 32% developed at least one AOM episode and for recurrent AOM, these figures were 16% versus 11% respectively.

2) Dummy use causes orthodontic damage

Research suggests that dummy use can cause orthodontic changes, however the research seems to suggest that this happens with long term (2yrs+) dummy use only *. A 1994 study by Ogaard B, Larsson E & Lindsten R entitle “The effect of sucking habits, cohort, sex, intercanine arch widths and breast or bottle feeding on posterior crossbite in Norwegian and Swedish 3-year old children” found that ther was a high prevalence of posterior crossbite in dummy users, however their analyses of covariance revealed that at least 2 years of dummy use was necessary to produce a significant effect in the upper jaw and 3 years in the lower jaw.

* note – I am unable to discover whether the research looked at regular  or orthondic type dummies.

Dummy use has an adverse effect on breastfeeding

breastisbestor1A study published last month by Gerd, Bergman, Dahlgren, Roswall and Alm entitled “Factors associated with discontinuation of breastfeeding before 1 month of age.” found that there was a negative correlation between breastfeeding and use of a dummy, however the famous 2011 Cochrane review into “pacifier use versus no pacifier use in breastfeeding term infants for increasing duration of breastfeeding”  found that dummy use in healthy term breastfeeding infants, started from birth or after lactation is established, did not significantly affect the prevalence or duration of exclusive and partial breastfeeding up to four months of age. However, evidence to assess the short-term breastfeeding difficulties faced by mothers and long-term effect of pacifiers on infants’ health is lacking.
I wonder if you’re now feeling like me? non the wiser! non of this research seems particularly compelling to me and could be used to support either “pro” or “anti” dummy use (and indeed it is!). For the record I don’t really have a position on dummies, I think they work for some families/babies and not for others – I’ve suggested them to some of the parents I’ve worked with and have suggested to others they might want to stop using them. One thing is for sure though there are a few basic guidelines to follow when using dummies:
  • wait until breastfeeding is well established (FSID suggest breastfeeding mums don’t use a dummy for the first 4wks).
  • only give your baby a dummy when they really need it (i.e: to calm crying, or help a fractious baby sleep) but take the dummy away when the baby is calm to prevent the dummy use becoming habitual.
  • try to get rid of the dummy by 6 months, by this time the benefits have pretty much served their purpose – longer use can take you more into the negative camp.
  • Always be led by your baby! if your baby won’t take a dummy – don’t persevere, listen to them!