Sleep Research Part 2: Effectiveness of Controlled Crying

There is possibly no more emotive topic for new parents than controlled crying. People feel very strongly, and everyone feels they have to defend their position. I will lay my cards on the table and say that I don't personally use a crying method, but this post is not about telling you whether controlled crying is right or wrong. Instead, it summarises the studies on the effectiveness of controlled crying, to help you make your own informed decision about whether it's worth trying.

I was just going to have one post on controlled crying, but I have too much information so it looks like I will need to divide it up. This post is therefore just on the effectiveness of cc methods. The next post will be on the risks of crying methods.

You may also be interested in Sleep Research Part 1: What is a normal sleep?

What is 'controlled crying', exactly?

For some people this means letting your child whinge for a bit in their cot, for others it means full on screaming for a set time or until the child falls asleep. So that we're not confusing apples with oranges, here is the terminology I will use:

• extinction - leaving a child to cry until they fall asleep. This is the accepted term in paediatric journals. Extinction refers to the extinction of the presence of mum or dad to help the baby fall asleep. This method is sometimes also known as letting a baby 'cry it out'. These days this method is associated with Marc Weissbluth .
• graduated extinction - leaving a child to cry for a short time (say 5 minutes), then returning for a minute to comfort the child without getting them out of the cot, then leaving them again, and so on until they fall asleep. The time-controlled leaving and returning involved in this method is why it is known as 'controlled crying'. It was devised by Richard Ferber . Tizzie Hall also suggests this method. Tizzie's version involves leaving the child for the same interval of time each time. Ferber's involves leaving the child for progressively longer intervals of time.
• communication-sensitive extinction - leaving a child to whinge / grizzle / sob a bit to see if they go to sleep but intervening if their sounds escalate into screaming – this method involves trying to decipher different kinds of unhappy noises and ignoring some while responding to others. Jo Ryan and Sheyne Rowley suggest this method. I have made up the name because it doesn't appear to have an agreed upon name. My impression from reading medical research journals is that medical professionals would consider 'controlled crying' to be the graduated extinction method proposed by Ferber, my anecdotal experience is that many parents in Australia practice communication-sensitive extinction and call it 'controlled crying' (and say that those who really let their baby scream are 'doing it wrong') while others are adamant that communication-sensitive extinction is not 'controlled crying'.
• self-settling - a general term used to describe settling techniques where a parent leaves a child to fall asleep without assistance, with or without crying.
• active settling - a general term used to describe active, hands on methods of helping a baby go to sleep, such as rocking, patting, and feeding the baby to sleep.
• settling by movement - using the movement of a car / pram etc to get the baby to sleep - sometimes considered a kind of active settling, but sometimes separated into a different category because it does not involve the child being able to see / touch the parent.
• social settling - mostly used with slightly older babies and children, involves settling child to sleep through quiet play / reading / talking / singing lullabies etc.

As you can see, a variety of crying and non-crying settling methods are used. The communication-sensitive extinction method hasn't really been studied (that I could find), although it clearly comes generally under the heading of baby sleep strategies I will refer to as self-settling strategies.

How effective are crying methods?

Extinction and graduated extinction are the most studied methods of improving a child's ability to go to sleep and stay asleep independently of parental assistance. Many of the studies have been conducted without control groups, so it is impossible to tell whether the sleep training method made a difference or the children just grew out of the problem. However, in the few controlled studies that have been done, they do appear to have a significant but by no means guaranteed success rate. Here are some examples where the success rate was quantified:

• A small study of 2 - 4.5 year olds used a combination of a set bedtime, a bedtime routine, and then ignoring the child. If an older child came out of the bedroom, parents were required to smack the child once and return him or her to the bedroom without talking. Parental compliance was recorded with audiotape. 7-15 months later, half the children had improved sleep, but as they were not compared with a control group it is hard to say whether the method made things better, worse, or had no effect at all (Rapoff).
• A study of 208 9 month – 4 year olds found that a set bedtime, a bedtime routine, and ignoring all crying 'significantly reduced' sleep problems in 78% of children at 3 months after the method was started. Parents recorded what they did with a diary (Seymour et al).
  
• In an Australian study of about 150 8-10 month olds, half the mothers were given one-on-one instruction in how to do controlled crying. Two months later, 70% of the mothers who were taught controlled crying said their sleep problems were resolved, as compared to 47% of those not taught controlled crying. Success here meant the mothers responded 'no' when asked whether their baby had a sleep problem, not a more objective measure of sleep improvement.  After four months, the success of the controlled crying group had fallen slightly to 64%, and of those not taught crying 51% indicated their sleep problems had resolved. 12% of the mothers taught controlled crying said they used it 'all the time', 65% said they used it 'most of the time', and 13% used it 'about half the time' (Hiscock and Wake).
  
  Two key difficulties with interpreting these results is: a) we don't know whether the mothers using controlled crying all or most of the time were the only ones whose children's sleep improved, and b) controlled crying was not the only strategy taught (although it was the main one). If we assume that the mothers using controlled crying all or most of the time where the only ones whose children's sleep improved (the most favourable scenario for controlled crying), then controlled crying had an 87% success rate for those that tried it.  Interestingly, 2-3 years later, 69% of mothers from this study reported that their infants' sleep problems had resolved – and there was no difference in the amount of parents with a problem for the controlled crying group as compared to the the non-controlled crying group (Lam, Hiscock and Wake).
• 33 children aged between 6 months and 4 years with night waking problems were divided into groups, and one group tried extinction. The average number of night wakings in this group was 2 per week after extinction, as opposed to the group who did nothing, which had an average of 8 night wakings per week. I do not have information on how many children in each group saw an improvement (Rickert and Johnson cited in Ramchandani et al).

In some cases I was able to obtain the original studies mentioned above, but in others I relied on two major academic overviews of studies on sleep training methods – which show the above examples are typical and some of the strongest available in support of controlled crying methods (Mindell; Ramchandani et al).

As you can see, the studies do not suggest crying is an 100% effective solution. What seems to happen is the authors report that the method was 'effective' in their summary or abstract because it had a statistically significant effect, and this is simply repeated by those giving sleep advice to parents without looking at the size of the effect. This leads to parents being given the impression that crying methods always work, and they rationalise that if they didn't work for someone that parent must not have 'done them right'.

But the truth is that if there is a 'right' method that works for all babies, no one has yet established what it is – which makes it pretty difficult for you to implement it with your baby. Crying methods in general (when repeated as necessary and even when combined with a bedtime routine) appear to be effective in the short-term for only 50-80% of babies / children over 6 months of age. This is not to be sneezed at, but it's not as compelling as you may have been led to believe. In the long term, it is doubtful whether crying methods are any more effective as non-crying methods for babies, as sleep problems during the first year do not seem to have much bearing on sleep problems down the track.

Persistence of sleep problems

One of the reasons parents try crying methods is that they are warned that if they do not, they will be setting themselves up for years of trouble. But how true is this?

Numerous studies now suggest that only a very small percentage of children have persistent sleep problems:

• An Australian study of 483 infants found that most sleep problems in the first 2 years of life are transient. Only 6.4% of children had persistent sleep problems for those 2 years (Wake et al).
• In a study of 308 mothers and their babies at 8 months, 10 months, and 3 years, only about 8% reported a sleep problem at both 8 months and 3 years of age. 89 of the 308 children had sleep problems at 3 years of age, but only 23 of those of these had been babies with sleep problems at 10 months (Zuckermen et al).
• A longitudinal study of 83 children followed from birth to 4 years of age found that sleep problems in early childhood bore no relationship to which children were self-soothers before 12 months of age (Gaylor et al).
• An academic overview of various other studies suggest that most children naturally grow out of waking by five years of age at the latest, and that along the way they grow into and grow out of sleep problems (Middlemiss).
• A large study of Japanese children found that 80% developed a habit of frequent night-time waking and crying between 18-21 months, but by preschool age, less than 20% of these children still had sleep-related night time crying (Fukumizu).

One of the studies that is repeatedly cited in academic sleep articles as indicating a sleep problem will be persistent unless addressed by methods like controlled crying studied a group of 60 children once and then once again three years later (Sudesh et al). This study found that 87% of the children with sleep problems at the start of the study had them three years later. However, in interpreting these results it is important to recognise that this was a small sample, and the children were all toddlers or preschoolers at the start of the study – the youngest was 15 months and the oldest was 4 years old. Of the 23 children with persistent sleep problems, over half had environmental stresses at the time of follow up, such as the unexpected absence of the mother, or illness or accident. The definition of a 'sleep disturbance' was 3 or more bedtime struggles in a week where it took over an hour to settle the child. The study did not consider whether parents had sought to address sleep problems with any kind of sleep training method.

Those 'bad habits' of rocking / feeding / patting your baby to sleep

A very comprehensive British study investigated how much of a difference settling techniques made to how well children sleep by following 259 children for a year (Morrell and Cortina-Borja). These children were between 12-19 months at the start of the study. What they found was that using more active settling did increase the probability of your child having a sleep problem, but not by very much. They found that most parents of babies without sleep problems used a variety of settling methods, including active settling on average about 30% of the time. When they combined data on the child's age, the settling technique of the parent, the parents attitude and level of emotion about sleep, and the baby's temperament, these factors ALTOGETHER only correctly predicted sleep problems for 2 out of 5 babies. Settling technique alone predicted even less.

In a large American survey of over 5000 parents of children between 0-36 months, babies who were breastfed or bottlefed back to sleep, slept in the same room as their parents, or had an irregular bedtime routine did have more night wakings. But again these factors IN TOTAL only explained 20% of the statistical variance between children with less night wakings and more night wakings. In other words, for 4 out of 5 children, these 'bad habits' appeared to have no effect on whether they were night wakers or not (Sadeh et al).

The worst case of the 'bad habits' causing problems is made by a very large Canadian study of 1741 children who were followed longitudinally at 5 months, 17 months, and 29 months, it was found that at 5 months, about 1 in 4 children did not sleep 6 consecutive hours. At 17 months only 7% of children did not sleep 6 consecutive hours, and at 29 months, 10% of children did not sleep 6 consecutive hours . At 6 months, infants were more likely to sleep for less than 6 consecutive hours if they were breastfed. At 17 months of age, children who were actively rocked/patted by their parents were 4.5 times more likely not to sleep 6 hours in a row, but this was only about 2 times as likely in children at 5 months or at 29 months. At 5 months, only 43% of the children who slept 6 hours in a row were left to self-settle (with or without crying), but at 17 months and 29 months, about 75% of the children who slept 6 hours in a row were left to self-settle (Touchette et al). It should be noted that this study was conducted using only a parental questionnaire, and this method has been shown to have significant discrepancies when compared to sleep diaries and direct observation.

Judging whether a method 'works'

In the majority of studies, the effectiveness of controlled crying (or any other method) is judged by parent's reports. But parents only report the night wakings they are aware of. If your aim is to reduce disruptions to your sleep, then this is an effective way of measuring what works. But if you are concerned to train your baby to sleep well (for example, because you think this has health benefits or will improve their IQ), then you need to know whether the method actually improves the baby's sleep.

After sleep training, parents may believe their child is sleeping continuously at night when the child is actually awake for a substantial amount of time. In a study of 59 kindergarten children, where sleep was monitored by use of an actigraph on 4-5 consecutive nights, parents reported the children woke on average 0.5 times a night whereas the actigraphs revealed the children woke an average of 2.7 times a night. 29% of the children slept for less than 90% of the time the parents believed they were sleeping, and 41% had significantly fragmented sleep. Nearly all children woke up at least once a night (Tikotzky and Sadeh). These children had successfully learned not to wake their parents at night for the most part, but that did not mean they were getting a good night's sleep.

What age is controlled crying effective?

There is scant evidence on the effectiveness of crying methods before 6 months. The studies on the effectiveness of sleep training tend to be on babies 6 months and older.

One would expect them not to be effective for the majority of babies before 6 months because the child has limited capacity to appreciate or learn from what is happening.

I found one study of trying sleep training (exact method unspecified) in very young babies - namely 3 to 12 week old babies. It found that only 10% more of those using the method slept 5 hours a night by 12 weeks of age when compared to those who hadn't (St James-Roberts and Gillham). This is a fairly small difference for the discomfort involved. In babies under 12 weeks of age, babies do not learn not to cry by being ignored – except for babies with colic ('persistent criers'), prompt parental attention has been found to signficiantly reduce the amount of crying - for babies with significant persistent crying, nothing helped (St James-Roberts et al).

After 6 months there appears to be a limited window of time before the toddler stage, when the child is capable of both getting out of bed and a more complex appreciation of their world, factors such as family discord or psychological insecurities are major factors in sleep disruption – it is not just a matter of teaching children to break habits of parent-assisted settling (Smaldone).

Controlled crying is most effective when it is used through the night

For sleep training to be effective at improving settling and night waking, it is important that parents consistently use the method during the night, and not just at bedtime. A small intensive New Zealand study using video recording and parental diaries to ensure parents adhered strictly to the program looked at the effect of controlled crying (graduated extinction) for seven children. When the controlled crying was done only at bedtime one child rapidly learned to self-settle except when ill, two children showed increases in time to settle, one child occasionally settled but mostly did not, and one showed a steady reduction in the time to settle. However, when the parents chose to use controlled crying every time the child woke up at night, as well as during bedtime, there was a noticeable effect on all seven children. (Healey et al).

Coming up next...

Potential risks and side-effects of controlled crying. After that I will look at the effectiveness of non-crying methods.

References

Fukumizu et al, 'Sleep-Related Nighttime Crying (Yonaki) in Japan: A Community-Based Study' (2005) Pediatrics Vol 115(1), p217.

Gaylor et al, 'A Longitudinal Follow-Up Study of Young Children's Sleep Patterns Using a Developmental Classification System' Behavioural Sleep Medicine Vol 3, p44.

Healey et al, 'Treating sleep disturbance in infants: What generalizes?' (2009) Behavioural Interventions Vol 24, p23.

Hiscock and Wake, 'Randomised controlled trial of behavioural infant sleep intervention to improve infant sleep and maternal mood' (2002) British Medical Journal Vol 324, p1062.

Lam, Hiscock and Wake, 'Outcomes of Infant Sleep Problems: A Longitudinal Study of Sleep, Behavior, and Maternal Wellbeing' (2003) Pediatrics, Vol 111, p203.

Middlemiss, 'Infant sleep: a review of normative and problematic sleep and interventions' (2004) Early Child Development and Care Vol 174, p99.

Mindell, 'Empirically Supported Treatments in Pediatric Psychology: Bedtime Refusal and Night Wakings in Young Children' (1999) Journal of Pediatric Psychology Vol 24 (6), p465.

Morrell and Cortina-Borja, 'The Developmental Change in Strategies Parents Employ to Settle Young Children to Sleep, and their Relationship to Infant Sleeping Problems, as Assessed by a New Questionnaire: the Parental Interactive Bedtime Behaviour Scale' (2002) Infant and Child Development Vol 11, p17.

Ramchandani et al, 'A systematic review of treatments for settling problems and night waking in young children' (2000) British Medical Journal Vol 320, p209.

Rapoff et al, 'The management of common childhood bedtime problems by pediatric nurse practitioners' (1982) Journal of Pediatric Psychology Vol 7, p179.

Sadeh et al, 'Sleep and sleep ecology in the first 3 years: a web-based study' (2009) Journal of Sleep Research Vol 18, p60.

Seymour et al, 'Management of night-waking in young children' (1983) Australian Journal of Family Therapy Vol 4., p217.

Smaldone et al, 'Sleepless in America: Inadequate Sleep and Relationships to Health and Well-being of Our Nation's Children' (2007) Pediatrics Vol 119, pS29.

St James-Roberts and Gillham, 'Use of a behavioural programme in the first 3 months to prevent infant crying and sleeping problems' (2001) Journal of Paediatrics and Child Health, Vol 37(3) 289.

St James-Roberts et al, 'Objective confirmation of crying durations in infants referred for excessive crying' (1993) Arch Dis Child Vol 68, p82.

Sudesh et al, 'Persistence of sleep disturbances in preschool children' (1987) The Journal of Pediatrics Vol 110(4), p642.

Tikotzky and Sadeh, 'Sleep Patterns and Sleep Disruptions in Kindergarten Children' (2001) Journal of Clinical Child & Adolescent Psychology Vol 30(4), p581.

Touchette et al, 'Factors Associated With Fragmented Sleep at Night Across Early Childhood' (2005) Archives of Pediatric Adolescent Medicine, Vol 159, p242.

Wake et al, 'Prevalence, Stability, and Outcomes of Cry-Fuss and Sleep Problems in the First 2 Years of Life: Prospective Community-Based Study' (2006) Pediatrics Vol 117, p836.

Zuckerman et al, 'Sleep Problems in Early Childhood: Continuities, Predictive Factors, and Behavioral Correlates' (1987) 80(5) Pediatrics 664.

Sleep Research Part 1: What is a normal sleep?

For some months now I have been looking for and reading research about babies and sleep.  Not folklore repeated by some self-proclaimed 'sleep expert', not what happened to your best friend's great aunt's baby, and not something someone read on the back of a cornflakes packet - actual scientific studies from pediatric and psychology journals.

What I found out I will be writing about here over the next couple of posts.  There is far too much information to fit into one post.  In future posts, I will be looking at controlled crying (including short term and long term effectiveness, risks and benefits), and other non-crying methods of dealing with children's sleep problems including co-sleeping (and some other methods you may not have thought of).

I hope this information gives new parents greater confidence when sorting through the conflicting information about sleep, and helps them to find the method that's right for them.  All information presented here is referenced so you can check it for yourself if you wish (although you may have to attend a university library in order to do so).  The source of my information is presented in brackets, and all the sources are listed at the end of the post.

Understanding Sleep Study Methods

(This is just some background information for those who are interested.  If you want more practical parenting information, skip down to the next section.)

In considering the meaning and reliability of the results of sleep studies, you need to consider several things:

• reliability of methods used;
  
• who was studied - the age of the children, whether they were a group of 'sleep problem' kids or a general sample of the population etc.;
  
• how many people were in the study (enough to draw a meaningful conclusion?);
  
• whether the study looks at long term as well as short term results
  
• whether the study controlled for other factors that might influence sleep - such as cultural practices, discord in the family home, maternal depression etc.
  

Bearing these factors in mind helps explain why some studies have different or even conflicting results.

Many sleep studies gather data using parents responses to questionnaires or interviews. These methods can be very unreliable methods of gathering sleep data – as they have been shown to mis-estimate actual sleep times by around 2 hours, and actual nocturnal time awake by around an hour.  Far more reliable methods are actual observation observation of the subject's sleep by the researcher, either using video-recording, brain wave monitoring (EEG) or use of an actigraph (Werner et al).

This is an actigraph - it detects movement a bit like a pedometer:

And leads to print outs like this, which allow you to see when someone was asleep and when they were awake based on the amount of movement:

EEG monitoring is where you have wires stuck to your head that detect electrical activity in the brain, like this:

EEGs give more comprehensive information about exactly what kind of sleep you are having, but they typically require you to sleep in a 'sleep lab' whereas actigraphs can be used in your own home.

In addition to direct observation, daily diaries filled in each morning by a parent also provide highly reliable accounts of sleep for younger babies (Werner et al).  For older children (eg. preschoolers), it has been found that even parental diaries significantly underestimate the amount a child is waking, and overestimate the amount a child is sleeping.

In a study of 59 kindergarten-aged children, where sleep was monitored by use of an actigraph on 4-5 consecutive nights, parents reported the children woke on average 0.5 times a night whereas the actigraphs revealed the children woke an average of 2.7 times a night. 29% of the children slept for less than 90% of the time the parents believed they were sleeping, and 41% had significantly fragmented sleep. Nearly all children woke up at least once a night (Tikotzky and Sadeh). These children had successfully learned not to wake their parents at night for the most part, but that did not mean they were getting a good night's sleep.

How we sleep - the basics:

Normal sleep for adults are controlled by circadian rhythms, ultradian rhythms, and homeostasis. In an adult, the circadian rhythm works like an internal 24-hour clock.

Over 24 hour period our bodies cycle through temperature changes, and particular chemicals (melatonin and cortisol) rise and fall.  Our circadian rhythm helps us go to sleep and wake up at regular times, and it is also responsible for us regularly feeling things like a mid-afternoon slump and later 'second wind'.  Ultradian rhythms make us sleep in sleep cycles that are about 90-110 minutes long. Each sleep cycle contains REM (often dreaming) and non-REM sleep.  Homeostasis is the effect that occurs as time passes since you last slept, and pressure builds up in your body until you feel tired and sleepy again (Jenni and Carskadon).

Newborn babies don't have a 24 hour clock:

Babies are not born with circadian rhythms - these develop over the first six months of life.  They are usually well on their way to being established by the end of months (when melatonin and cortisol start appearing in a 24 hour rhythm), but not fully mature and constant until around 6 months (Jenni and Carskadon).

It is believed that the circadian rhythm develops as a result of the baby experiencing night and day, and also variations in social behaviour according to the time of day (Jenni and Carskadon). A very small study of a handful of babies found massive variation in the time it took an individual baby's clock to mature, from 49 days (1.5 months) to 110 days (3.5 months), and the amount of sleep each baby needed daily fluctuated over time (Jenni, Deboer and Achermann).

For parents, this means that it is important to distinguish between night and day to help your baby's circadian rhythm develop.  This is primarily to do with light and dark (Jenni and Carskadon) so make sure bub gets plenty of daylight during the day and that you don't leave bub in bright lights at night (which has been known to happen in some institutional settings, like hospitals). It doesn't mean that you can't put bub in a dark place to nap, so long as awake times are somewhere light.

It also doesn't mean your baby has to be on routine of daily activities.  But do differentiate your daytime and nighttime behaviour.  You don't have to avoid eye-contact or comforting your baby at night, but you want to keep things quiet and mellow.  Babies react to social cues as well as light-dark cues (Jenni and Carskadon).

It also means that most babies will not be able to follow a strict routine during the first few months, and some will not manage it until about six months.  You don't know what kind of baby you have.  It is only by trial and error over time that you will figure out when they are ready.  But don't fall into the trap of thinking that because little Johnny slipped easily into a routine at 2 months that your baby will too, and there's something wrong with him if he doesn't, or that you have to fight him into a routine when he's too young to get the hang of it. A gentle, flexible routine won't hurt, but you may find yourself waking a tired baby and endlessly settling one that's awake without him learning anything.

Different babies need different schedules, adapted to them and adapted over time:

Once your baby has a circadian rhythm reasonably established, you may want to help him or her have a regular daily schedule.  In doing this, it is important to realise that different babies can have very different sleep requirements, and that even for an individual these fluctuate over time.  This means that if you are trying to follow a schedule in a book, you need to adapt it to your baby.  If your baby is getting very cranky and sleepy, they probably need more sleep - on the other hand, if you are fighting your baby to sleep, he or she may simply not be tired.

Why does it vary?  Because homeostasis is different. When an individual does not get enough sleep, this creates what is known as 'homeostatic sleep pressure' to encourage the individual to go back to sleep. Homeostatic pressure is very strong in babies, which is why they can't stay awake for very long at a time, but it varies from baby to baby (Jenni and Carskadon). Studies suggest that the amount of sleep a child needs varies dramatically.  At age 6 months, both 10.5 hours and 18 hours have been found as sleep patterns for individual infants (Jenni and Carskadon).

In one recent study of Swiss children aged 12 months, a normal sleep was found to be anywhere between 11.4 hours and 16.5 hours within a 24 hour period (Jenni, 2007). This study followed the same children over several years and found that shorter sleepers tended to stay shorter sleepers, and longer sleepers tended to stay longer sleepers, indicating strongly that individual children need different amounts of sleep.

There is now also evidence that the chemicals in the brain that trigger sleep timing and duration vary from person to person (Tafti, Aeschbach). It also seems normal for an individual to need less sleep as they get older, but for this not to reduce steadily over time but instead for children to have 'progression' periods, but then 'regression' periods where they need more sleep again (Jenni, 2007).

Sleeping in 45-50 minute cycles:

Ultradian rhythms are noticeable more quickly, within a couple of weeks of birth, but baby sleep cycles are 50 minutes.  They do not develop longer, adult-like sleep cycles until they are about 6 years of age (Jenni and Carskadon).  Much has already been written on this and this information is commonly found in popular parenting books on sleep, so I won't repeat it here.  But it is the reason your baby often wakes after about 45 minutes, or multiples of 45 minutes (eg. 1.5 hours), as at the end of each sleep cycle they come into a lighter sleep.

Sleeping through the night:

Most, but not all, infants have the capacity to sleep an 8 hour stretch by 9 months and many achieve it as early as 6 months (Jenni and Carskadon).  For those that have this capacity, some may not actually sleep 6 hours in a row unless they are in certain circumstances - which is a Western-style solitary sleep arrangement and sometimes bottle feeding.  In one large Canadian study, infants were less likely to sleep for 6 hours in a row at 6 months if they were breastfed (Touchette et al).  Co-sleeping babies are also less likely to sleep through at 6 months - a 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).  On the other hand, co-sleepers are less likely to be bothered by the wakings (Keller and Goldberg), something I will discuss in a future post.  At 29 months, about 10% of children are not sleeping for 6 consecutive hours (Touchette et al), although this figure is probably higher because the study was conducted by questionnaire, and these tend to underestimate night wakings (see discussion of sleep study methods above).

Failure to sleep through the night by 6 months of age does not necessarily indicate a persistent sleep problem (something I will discuss in a future post).

Ideas about a 'normal sleep' varies dramatically between cultures:

Ideas about 'normal' sleep have been developed primarily by studying white, middle-class Americans. But studies of other cultural groups are showing that a 'normal' sleep is a surprisingly variable concept. For example:

• In a study in Southern Mississippi it was found that 4.9% of white children aged 8 napped, but 39.1% of black children, although both racial groups got the same total amount of sleep in a 24 hour period (Crosby).

  
• Italian children typically have no bedtime schedules or rituals. A study of Italian children between 2 and 4 years old found that they sleep less than American children, they stay up later, and usually fall asleep without adult assistance (Jenni and O'Connor).

  
• Dutch 3 month old children were found to go to bed earlier than American children and sleep an average of 15 hours a day, as opposed to the American 3 month olds, which sleep an average of 13 hours a day, although there are questions around how much of the time in bed children are actually asleep (Jenni and O'Connor).

  
• In Japan, school-aged children have a nap after dinner and then are woken so they can do their homework for a few hours after their parents have gone to bed (Jenni and O'Connor).

  
• In a Swiss study comparing sleep duration, bedtimes, and settling difficulties found that children in the 1970s were expected to go to bed earlier and had greater bed-time resistance, compared to children in the 1990s (Jenni and O'Connor).

  
• In traditional Balinese society, both infants and adults sleep and wake throughout the day and night when they feel like it, and infants are expected to fall asleep anywhere with any degree of audio and visual stimulation (Jenni and O'Connor).

  
• In various countries including Italy, Mexico, China, and Japan, daytime napping is the norm for adults as well as children, and there have been times in their history where it was not only normal but institutionalised (eg. Shops and offices shut down at expected nap times). (Jenni and O'Connor).

  
• In the middle ages in Europe, the normal sleep pattern was to have a 'first sleep', a wakeful meditative period in the middle of the night, and then a 'second sleep'. It was believed to promote good digestion and religious behaviour (Jenni and O'Connor).

• In 19th century America, the recommended sleep for three year olds was 12 hours a day, and 8-9 hours for 7 year olds (Jenni and O'Connor), 'sleep problems' did not emerge as a complaint until around the 1920s when health experts began to state that American children had remarkably little sleep, and parents began to be advised to get their children to bed earlier. This was when sleep routines and methods of getting a child to sleep emerged (Jenni and O'Connor).
  
• Mothers of the Ache tribe in South America mothers sleep sitting up with their babies in their laps (Small).




  

Coming Up Next...

Stay tuned for the next post in this series where I will summarise the latest research on the effectiveness and effects of controlled crying.

References

Aeschbach et al, 'A longer biological night in long sleepers than in short sleepers', (2003) Journal of Clinical Endocrinology and Metabolism, Vol 88, p26.

Crosby et al, 'Racial Differences in Reported Napping and Nocturnal Sleep in 2- to 8-Year-Old Children' (2005) Pediatrics Vol 115, p225.

Jenni and Carskadon, 'Chapter 1: Normal Human Sleep at Different Ages: Infants to Adolescents'

Jenni, Deboer and Achermann, 'Development of the 24-h rest-activity pattern in human infants' (2005).

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

Jenni and O'Connor, 'Children's Sleep: An Interplay Between Culture and Biology' (2005) Pediatrics Vol 115(1), p204.

Keller and Goldberg, 'Co-Sleeping: Help or Hindrance for Young Children's Independence?' (2004) Infant Child Development Vol 13, p369.

Möllborg et al, 'Bed-sharing among six-month-old infants in western Sweden' (2010) Acta Paediatrica

Small, Our Babies, Ourselves: How Biology and Culture Shape the Way We Parent (1999) First Anchor Books.

Tafti, Maret, and Davilliers, 'Genes for normal sleep and sleep disorders' (2005) Ann Med Vol 37, p508.

Tikotzky and Sadeh, 'Sleep Patterns and Sleep Disruptions in Kindergarten Children' (2001) Journal of Clinical Child & Adolescent Psychology Vol 30(4), p581.

Touchette et al, 'Factors Associated With Fragmented Sleep at Night Across Early Childhood' (2005) Archives of Pediatric Adolescent Medicine, Vol 159, p242.

Werner et al, 'Agreement Rates Between Actigraphy, Diary, and Questionnaire for Children's Sleep Patterns' (2008) Archives of Pediatric Adolescent Medicine Vol 162(4), p350.

Tis the Season - Present Buying for New Mums

The other day at mother's group, one of the mums remarked on how much improved her present buying skills for new mums is now that she has a baby.  We reflected on some of the well-intentioned but completely inappropriate gifts we had previously given our friends who had babies.  And also how some of the gifts we had received that we thought would be great turned out to be useless and vice versa.

So what is a good affordable present?  Here are some ideas.  (NB: none of the suggested brands or shops have asked for or paid for this endorsement):


1. Large wraps or other swaddling aids.

Why? Swaddles help babies sleep.  Also, a swaddling aid is a good gift because it doesn't matter if someone else buys this as well, as mum will need more than one.

What? You can buy large wraps, some with lovely patterns, or a zip up pre-made swaddle like the Ergo Cocoon is also a great choice.  The Ergo Cocoon has been popular with other mothers I know because of the two-way zip (you can do a nappy change without taking the whole thing off).  When our baby got a bit bigger, we had a bit of trouble with the zip rubbing under our baby's chin.  You can also buy an arms up swaddle Love Me Baby Swaddle, which many babies tend to prefer after about 2-3 months because it allows them to sleep with their arms up, a naturally preferred position.

What to avoid?  Wraps that are less than 120cm x 120cm.  Wraps made of synthetic materials that won't breathe - meaning they may cause the baby to overheat and also be fire hazards.  Choose breathable materials - muslin for the heat or stretch cotton for colder climates.  Baby sleeping bags like Gro-bags are super for when a baby gets a bit older but not good for newborns because they generally prefer to have their arms contained - so remember this when choosing sizes.

2. Baby Clothes.

Why?  All mums like dressing up their babies.  Lots of clothes are needed, as babies are very good at getting them dirty.

What? Most babies are born size 0000, but this will be too large for a premmie baby and too small for a large baby (4kg+).  I would generally choose 000 or 00 clothes, because babies will grow into these sizes, and by then mum will have enough of a handle on parenting to enjoy dressing them up.  Lots of people give clothes, so look for one unique piece of clothing rather than a couple of generic choices.

Lots of interesting clothes are available online: see My Baby Rocks and The Retro Baby for some cool choices, or for fun, you could give a Baby Costume,

or even customised clothing with the baby's name or an image of your choice.

What to avoid?  Clothes that button up at the back.  Little babies can't sit up, so the buttons are a pain to do up, and then the babies don't seem to like a couple of buttons digging into their backs when they are lying down.  If buying cute dresses with buttons or bows at the back, choose size 0 or 1's so baby will grow into them around the age they're sitting up.  Also, look for wide, stretchy necks that are easy to get on and off - envelope necks are good or ones with press studs at the front or on shoulders.  Avoid clothes with small pieces that may become detached and end up in the baby's mouth as a choking hazard.

3. Baby Toys.

Why? An occupied baby is a happy baby.  And everyone likes a happy baby.  Even if someone else gives the exact same toy (which is unlikely), it's always handy to have one for the car, one for the house, one for the pram etc.

What?  Newborns don't really use toys.  They just like looking at things, particularly faces and shapes that are really high contrast.

High contrast books like this one or these ones are great when the baby is really young.  Around two to three months babies start swatting at objects, so toys that can hang from a baby play gym are good.  Babies don't start properly grabbing toys and bringing them to their mouths until 4-5 months, so rattles will not be used until this age.  When they start grabbing, objects they can get hold of easily like cloth that scrunches up in their hands are what they prefer.  I have found that the toys by Lamaze are excellent designs that the babies really get into.  An old-fashioned hit that is still a winner is Sophie the Giraffe.

From about 4-5 months on, babies will interact more with toys and be interested in toys that do something in response to their actions.  This is when friends start innocently (or maliciously) giving incredibly annoying toys with flashing lights and awful sounds that chew through batteries.  If you would like to keep these to a minimum in your house, you could direct people to a site like Eco Toys, which make wooden and cloth toys that keep babies entertained without overstimulating them and driving the parents mental.  They have musical instruments that actually sound ok when played with by a baby.

For a slightly older child, here are some more good musical choices for parents who wish to preserve their ears.  A really good Canadian site with more good quality toys is Play and Learn Toys.

What to avoid? Generic stuffed animals.  There's nothing wrong with them, but they will sit on a shelf or in a cupboard until the baby is 1 or 2.  Toys with small parts that will be a choking hazard.  Toys that use lots of batteries.

4. Baby Books


Why? Some newborns are happy to be read to from an early age and many parents like to incorporate reading as part of a bedtime routine.  My baby has not been a fan of books (other than to try and put the book in her mouth and be annoyed when it is not a very good fit) but I remain optimistic that she will like them when she gets a bit older.

What? For babies, books should be made out of cloth or thick card.  There are textured books that babies can start getting into around 5-6 months, like the That's Not My series with simple text and sturdy construction.  Little babies don't follow stories.  Go for simple rhyming or repetitive text, and bright, colourful pictures.  Lots of babies really like looking at pictures of other babies, although my baby doesn't get into this activity.  Starting from about 4 months, babies will start noticing links between objects and language, so from this age on simple books with an object and a word on each page can be enjoyable and help promote language development.  However, I personally think that reading books is about more than learning language - and stimulating interest and creativity is just as important.  Bethany has always loved the illustrations of Kim Toft, which are colourful pictures of Australian sea animals, even though the books are aimed at older children.

I will also do a shameless plug here for the books of my mother in law, Leonie Norrington, my personal favourite of which is 'Look See, Look at Me':

although 'You, Me, Our Place' was the picture book nominated for a CBC award.

Dear God, I recently purchased a New Baby...

Dear God,

I have recently purchased your product, New Baby.  Overall, despite an unnecessarily complicated and protracted delivery process, I am impressed.  This is lucky given your strict No Refunds or Returns policy!

Still, I thought you might like some feedback on the less than satisfactory aspects of the design, for future development purposes.

Despite being advertised as a self-contained unit, I was shocked to find that New Baby seems to required additional products in order to perform the most basic functions safely and hygienically and these accessories aren't cheap.  Is this right?  I can't seem to find the instruction manual in order to check.

Battery life is poor and erratic, sometimes lasting for less than an hour before recharging is required through the Breast Recharger. I'm told that the Bottle Docking Station results in better battery life, but I've found the performance of this device is also erratic, and it requires constant cleaning.   Someone told me that use of the Docking Station may void the warranty, but most of my friends find it useful and reliable, and haven't had any particular problems.  Anyway, sometimes I have great trouble getting New Baby attached to either recharging device.

My main criticism is that your Baby v1.0 software, despite a million year process of research and development and your apparent omnipotence, is not remotely bug free. At least once a day my New Baby's system jams on the 'Crying' application, and despite all my attempts, frequently fails to shut down when requested. Some users have suggested using the Force Quit function, but every time I click on this option in the menu, a box pops up saying:

Warning: Are you sure?  You will lose all unsaved data.  If program is corrupted you may cause irretrievable system malfunction.  We recommend checking for underlying error.  Proceed or cancel?

This is confusing and a bit concerning so I usually click cancel.  New Baby then offers me the option to Send a Report to my Mother in Law, but am not sure what the point of this would be so I click no.

I have been told that the optimal running temperature for my device is 37 degrees Celcius or 97 degrees Farenheit.  Unlike most of my appliances, which can safely operate within a 40 degree range, New Baby seems to be restricted to operating within a degree or two of the optimal temperature.  I'm not sure why you have designed the system this way, but since you have, have you considered adding a temperature gauge?  Perhaps behind the left ear?  I would find it useful.

One last suggestion.  The aesthetic appeal of my New Baby is superb.  Visually very attractive and nice to hold.   But the pre-installed music and sound fx of New Baby are not all sounds I like to hear at any time of the day or night.  Are you aware that most devices these days come with an option to 'mute', preferably by remote control?  I know that one of the sounds is a failsafe alarm, and I suppose this is necessary, but I wish I could adjust the sensitivity.  The timer seems to set it off in the time I dash to the loo.

Anyway, thanks for listening!  Despite these design flaws, I generally find my New Baby a pleasure.  If you could just address some of these issues before I save up enough to order the next one, I'd be grateful.

Thanks.

Yours truly,
New Baby Owner

Funny Mums - The Best of Failbook

Being a parent does not mean you have to lose your sense of humour. You've got twenty or thirty years on your kids of learning to be witty. Not all parental failbooks are exhibits of parents who don't know how to work their computer. Here are some of my favourites...

Dude, You Should Probably Take The Dog Out



Well, You Asked



Owned By Paul's Mum



Well done, Madam



Mother Knows Best



Tips and Tricks: Failbooking Edition



'Ewwww MOM!!!'


see more Failbook

And These Days It's Not Just Parents on Facebook...



And...


see more Failbook

Memes and Parental Misinformation

Misinformation bugs me.  But there is a particular kind of misinformation that really bugs me, and that is the viral chain-email 'warnings'.  You know the ones?  They go something like 'Warning: Eating Apples Causes Breast Cancer!  My mother ate apples and she died of breast cancer.  Stop eating apples before it's too late.  Pass this on to every woman you know!!!!'

No matter how many times I tell people that I do not want them to forward me this kind of rubbish without at least doing a cursory Google to see if it's complete bullsh*t, there are a few friends who persist.  If someone ignores my polite emails telling them not to clutter up my inbox with such crap, I hit 'reply all' and post an email back to all their friends with information about why it's a hoax, which usually annoys or embarrasses them enough to stop them sending similar crap to me in the future.  It particularly annoys me because sometimes the information is actually harmful - like one that gave inaccurate advice about what to do in a stroke.

The name for a piece of information (or misinformation) that spreads around the internet (or the real world community, for that matter) is a meme, pronounced to rhyme with 'dream'.  The word was coined by popular evolutionary biologist Richard Dawkins in his book The Selfish Gene.  The idea basically is that you can understand the spread of cultural ideas by thinking of memes a bit like genes - the ones that survive and spread are those that can encourage their hosts to replicate them.  Memes on facebook seem to be most effective in the form of replicating status updates.

I don't dislike all memes.  Some are great.  For example:

WARNING, PLEASE READ!!!!!!!!!!!!!!!!!. If someone comes to your front door and asks you to remove your clothes and dance with your arms in the air, DO NOT do this, it is a scam, they just want to see you naked. Please copy and paste this to your status, I wish I had received this yesterday, I feel stupid now.....

Recently, one went round like this (or similar):

Change your profile picture to one of your favorite childhood cartoon characters and ask your friends to do the same. The point of the game? To have no human faces on Facebook only childhood memories by Monday to fight child abuse. Copy and paste to spread the word

I couldn't really see how it would fight child abuse, but as I don't mind being associated with the cause, and I couldn't resist the chance to change my profile pic to Astroboy shooting fire out of his butt, I changed my profile pic.

I saw that lots of my friends did the same.  It was a good quality meme.  It was fun, easy to replicate, and got over the can't-be-arsed factor with the appeal to our urge to protect children.

I was thoroughly enjoying finding out everyone's childhood cartoon characters when suddenly everyone started changing their profile pics back.  What was going on?  Then I saw a friend had the status:

ATTENTION: the group asking everyone to change their profile picture to a cartoon character is actually a group of pedophiles. There doing it because kids wil accept their friend request faster if they see a cartoon picture. It has nothing to do with any Child charities. IT'S ON TONIGHTS NEWS. Copy & Paste this on your status - Let everyone know. Change ur pic back to what it was ASAP!!

Not only did this completely ruin my fun, but it's also one of those memes that I hate.  I was not at all surprised that a quick Google search confirms this is a hoax, because it has all the trademarks of misinformation - the panicky tone, the vague reference to an authoritative source (which news where?), not to mention the failure to spell 'there' correctly.  But boy was it replicating fast.  And not only replicating, but acting as a predator meme, killing off the original fun meme.

So that made me wonder - could I create a meme that would kill the hoax meme?  Out of curiousity, I thought I would give it a shot.  This is what I came up with:

ATTENTION!! No one knows who started the cartoon profile pic campaign against violence idea. No news source has reported it was pedophiles. It was harmless fun. Repost this if you don't repeat every bit of hysterical rubbish you read on the internet, then change your profile pic to whatever the fuck you like.

I posted it to my status, then for a bit of added oomph, I sent messages to some of the friends I thought would be most likely to transmit the meme and asked them if they would kindly post it as their status update, removing the swearing if they preferred.  (A few of them have.  Thank you to everyone who did!)  I'm very curious to see if it will work.  I guess I might never know, but I will take it as a success if I see the meme come back from a friend who I didn't send it to in the first place.  I have been enjoying that the friends who have reposted it seem to get other friends 'liking' their status.

I have also seen some friends resisting both the hoax and original cartoon pic meme with status updates like the following:

what's with all the do "blah blah" with profile pic/wall to raise awareness/help a cause on FB? If you really care donate, contact your local MP, volunteer. Don't be an armchair activist.

As a competing meme, this is probably entirely too sensible to really take off.  It asks people to make an effort, which is a problematic quality in a meme.  Anyway, it's not my cup of tea, because I feel I can enjoy passing on silly memes, that I think 'armchair awareness-raising' memes can have value by influencing the hegemonic discourse (ok, I admit it, I did an Arts degree), and repeating the memes does not stop me from donating to good causes as well.

Anyhoo, as interesting as this all may be, why am I writing about this on a blog about parenting?

Because it has occurred to me that all the baseless information that floats around in the community about parenting is a result of successful memes.  It is a good environment for memes because it is easy to push a parent's buttons (preying on the protectiveness and anxiety we all feel for our children), and parents are sleep-deprived, time poor, and often socially isolated - meaning they have a reduced ability to verify information themselves.  What also does not help is that health professionals also pass on baseless memes.  Who, for example, was told by a midwife or health nurse that the whitish/bluish tinge around your baby's mouth means they have wind?  If you can find me any evidence that this is the case you will blow me away.  (My theory on why it sometimes anecdotally seems to be true is that babies are most often windy after a feed when the skin round their mouth has been pushed back in order to suck a boob/bottle, which has compressed the skin and made it seem whitish/bluish).

It is particularly damaging when a health professional passes on a baseless meme, because it then carries the weight of 'authority', which improves its chances of replication.  This behaviour also reduces the effectiveness of accurate memes by reducing everyone's ability to easily distinguish between accurate and inaccurate memes.  It lowers the quality of all parenting information.

Sometimes an inaccurate meme is passed on deliberately by authorities in an effort to fool parents (who are perceived to be stupid) into adopting better behaviour.  This seems to have been the case with respect to the idea that solids have to be delayed until 6 months.  This meme seems to have started to counteract a meme that was propagated by the bottle-feeding industry that solids had to be introduced before 6 months for the health of your baby / to get them to sleep etc.  The 'delay till 6 months' meme not only encourages breastfeeding for longer (which seems to be good), but also stops overkeen parents introducing solids before 4 months, where the evidence suggests most babies' guts are not ready - so it is perceived to improve public health outcomes (for more on this, see my post on solids).

There's nothing wrong with delaying solids until 6 months, but I have a problem with medical professionals passing on a meme that says you have to.  Why?  Because of the effect it has on parental trust in health professionals generally (once parents learn it's not true, they become less willing to follow accurate advice because they are skeptical it will be accurate), because of the effect it has on health professionals (encouraging them to see parents as gullible 'sheep' instead of people to empower), and because of the effect that all the conflicting information has on a parent's mental health (encouraging feelings of helplessness and inadequacy).

So what can we do to combat poor quality parenting memes?  This is a bit soapboxy, but its kind of the point of my blog:

Firstly, when anyone (including a health professional) gives you parenting advice, ask to know the source of their information.  And if they tell you there's a risk, ask them to quantify it.  If they are patronising in response, give them just a few examples of the conflicting advice you have received from health professionals.   Expect and demand that governments treat parents as intelligent people, and fairly put forward the evidence behind their recommendations.

And secondly, if you repeat advice that worked for you, acknowledge its source or lack thereof and acknowledge that you don't know if it will work for everyone.  Be suspicious of any advice supported only by anecdotes.  This includes if your advice is an Extremely Important Warning, because if your warning is utter bollocks, you are at best cluttering our minds up with rubbish and stressing everyone out unnecessarily, and at worst you may be encouraging people not to do something which is actually beneficial.

Sharing Breastmilk

I'm interested in people's thoughts...  If you didn't have milk of your own, would you prefer to feed your baby breastmilk from a stranger or formula?  Would you be happy if a sister or friend breastfed your baby?  And if your baby was placed in foster care would you want the carer to breastfeed the baby if they were able (as apparently was done with Lindy Chamberlain's baby that she had while incarcertated)?

And did you know there is a facebook group for sharing breastmilk?  Eats on Feets is a global network of women who share breastmilk, and there are facebook groups for it everywhere, including one for the NT.

I found out about this because the US Food and Drug Administration has recently issued a warning to mothers about sharing breastmilk this way, warning of the potential risks of chemicals, diseases etc in milk unless it is screened.  The FDA's press release has been widely publicised by Thomson Reuters, whose declared interests include Abbott Laboratories, Watson Pharmaceuticals, and Nestle SA - but if you read right through the article it's pretty fair.  However, the FDA's original press release is here and is a more practical guide as to how to use or donate human breastmilk in the US.

But it's not rocket science - essentially if you want to use another woman's breastmilk, you want to be satisfied that they have taken the same precautions you would take if you were breastfeeding your own baby.  They shouldn't consume drugs which would get into the milk, they should use sterilised bottles and mark the date of expressing etc.  You need to be careful they don't have HIV or other diseases which could then infect your baby.  So, you need to trust your donor and they need to agree to be screened for diseases.

In other words, you can make an informed choice to share breastmilk - it's not necessarily dangerous.  I suppose the point being made is don't just assume shared breastmilk from anyone will be better without doing your homework.

For an in-depth look at the law and ethics surrounding contemporary breastmilk sharing, there is a book by Alison Bartlett and Rhonda Shaw called Giving Breastmilk: Body Ethics and Contemporary Breastfeeding Practice.  There is also a fascinating article by Virginia Thorley about the history of sharing breastmilk in Australia from 1900 to 2000.  It seems we have always done it, but formal advertising for 'wetnurses' has declined over the century, being replaced now by more informal feeding of the baby by family and friends, sometimes known as 'cross-nursing'.

Breastfeeding Diet Troubles

When I was pregnant I put on about 19kg. About 10kg of that was lost at the birth and in the following couple of weeks. I assumed that the weight would fall off fairly easily with the breastfeeding, but this hasn't happened. In fact I've actually put on 2 kg.  Weirdly, I can't see it when I look in the mirror, but I definitely notice it when I see myself in photos.

What I look like:

What I looked like before I got pregnant and would prefer to look like again one day (minus the wedding dress, of course):

People say, 'Don't worry about it, you've just had a baby.' While this is true and I appreciate the moral support, I know it doesn't have to be this way - I am eating rubbish and doing very little exercise, and I am 10kg above my healthy weight range. Also, I am a bridesmaid for my sister's wedding in January and am acutely conscious that she has chosen shape-hugging cocktail dresses for us to wear.

After I had the baby, I went on a bit of an eating splurge, enjoying all those foods I'd restricted while I was pregnant, such as ham, camembert, alfalfa, bacon, leftovers... (I suspect the alfalfa has not contributed particularly to the weight gain, but it's so bizarre that alfalfa is restricted during pregnancy, I can't resist mentioning it). Then, because I'd just had a baby and I deserved some kind of stress relief, I also ate mint choc chip ice cream whenever I felt like it. And after I had to take my little girl for her first needles I ate a whole packet of chocolate mint slice biscuits, which made me feel slightly better. Yes, I have a thing for mint choc chip – it was my favourite flavour when I was six, and for me it is still the ultimate in emotional eating.

At about 3 months post-partum, I thought I better get my act into gear and clean up my diet. I worked out something based on calorie intake (add 300-500 calories for breastfeeding, or about 2000kj).

That lasted about 3 days. Because I had been eating whatever I liked, what I hadn't realised is that breastfeeding makes you hungry all the time. What I also hadn't realised was that I was really relying on those sugar hits to get me through the day, given I was existing on 4-6 hours sleep a night and I had to limit caffeine to about 1 cup of tea a day (again because of the breastfeeding). Argh!

As for exercise, that was a disaster too. I had had dreams of taking my baby for long walks around the city and the nearby botanic gardens, but I had not factored in that my baby would not like this. After all, it's either raining or blisteringly sunny in Darwin and I am forced to cover up the pram so she can't see out. So she is bored and uncomfortably trapped in a little black sweat box and she certainly lets me know about it. The best way to take her for walks is round Darwin's only air-conditioned shopping centre, Casuarina, but you can't really get up speed without ramming into people. So, I do go walking round Casuarina, but fairly slowly, and I spend more time stopping for decaf cappucinos.

Back to the drawing board.

Part of the problem here is, admittedly, motivation. The truth is that I have a lot of trouble motivating myself to prepare healthy food and doing regular exercise at the best of times. When I am sleep-deprived, have a small baby attached to my arms, super-hungry, and my milk-filled boobs (which required a fair bit of support before pregnancy) ache at the slightest bounce – dredging up enough motivation to have a shower is a challenge.

The first thing I had to do, I decided, was sort out my sugar dependency. So I just focused on this one task. Every time I had a sugar craving I ate some fruit. I was grumpy and headachy, but I was able to at least stick to this one idea because fruit was not so horrible, and because I let myself eat whatever else I liked, so long as it was not full of sugar.

Success! I have remained more or less sugar-free, except for cakes at some special occasions. So that's good.

But I am not losing weight.

It doesn't help that you are warned not to diet while breastfeeding as you may jeopardise your milk supply. What can you eat? What is too little? Too much? I must have looked through every Borders in Melbourne for a breastfeeding diet book but there were none, which I thought was astonishing because surely there is a market for this book?! The closest I found was a book that recommended going walking with your pram each day. Not very helpful.

The Australian Breastfeeding Association recommends following the guidelines in the government publication: The Australian Guide to Health Eating. This document gives you the appropriate number of servings from different food groups, and explains serving sizes, but it doesn't tell you how to translate into something practical – like a meal plan and grocery list. The Australian Government Department of Health and Ageing has this more detailed summary for breastfeeding women with a meal plan for one day.  And the Queensland Health Department has this handy .pdf on serving sizes that you can print out and stick on your fridge, and also a meal plan for one day.

Essentially, a breastfeeding mum who is sedentary should have:

• 5 serves carbs, 7 serves vegies, 5 serves fruit, 3 serves dairy, 2 serves meat/legumes

A breastfeeding mum who does about 30 min of exercise a day can have:

• 7 serves carbs, 7 serves vegies, 5 serves fruit, 3 serves dairy, 2 serves meat/legumes, 2.5 serves of treats

Both these recommendations assume that you are also using some oil for cooking or margarine/butter for spreading sandwiches etc. However, you might have noticed that the sedentary mum gets no treat foods at all. This, in my view, is unrealistic for most people. While exercise is the goal, we don't all always manage it, and we still sometimes eat cake. But I reckon that if you take a breastfeeding multivitamin you should be able to sometimes skip a serving or two of carbs in order to compensate for having a nutritionally empty treat. The serving recommendations seem to presume you are not taking a multivitamin, and are made to ensure you get all necessary nutrients as well as appropriate kilojoule intake.

To help figure out how to put this advice into practice, I created a spreadsheet which helps you do a weekly meal plan and grocery list and have filled it in with a sample menu for a lightly active mum. (I would like it to automatically generate the shopping list based on your meal plans, but I don't have the time or Excel skills to do it). I tried to work out meals that my husband also knows how to cook and will be happy to eat. You'll need to multiply quantities in your grocery list given the number of people you are cooking for:

Example One Week Plan (Excel File)

What's more, I have found out that to help save time and stick to the plan, you can get groceries delivered to your door for very little cost. Both Woolworths and Coles have online ordering – and I have found that if you pick the right time the delivery from Woolworths is free. Meat seems a bit more expensive this way, but I have found that a really good local butcher (Parap Quality Meats) can also deliver through a service that picks up various produce from local shops and orders of $65 or more are free, so if you have your meals planned in advance you can buy bulk and save the logistical nightmare of grocery trips with children. I think in other places in Australia you can get fresh local produce by ordering online through a service called Aussie Farmers Direct.  You can create shopping lists that the websites remember, so once you've done one order, it's quick and easy to order again.

Sticking to this eating plan is my next step towards healthy eating.  After that, my next step will be to leave Bethany with my husband (or a babysitter) while I go swimming in the evenings (nice in the heat and for tender boobs), and by the time I'm ready for that she should be partially on solids, so he will have something he can feed her if he needs to while I'm out.

Wish me luck!

Solids

There seem to be two recommendations of when to start solids:

1. start your baby between 4-6 months when they show interest and willingness in taking food off a spoon; and
2. do not start your baby on solids before 6 months.

Needless to say, you can't follow both these recommendations.  So why does the advice conflict and which is correct?

The short answer:

As far as I can work out, the answer is that if you live in a developed country and practice appropriate hygiene in the preparation of food, the risks in introducing solids after 4 months are negligible.  There is nothing wrong with exclusive breastfeeding until 6 months either - and if you are breastfeeding, continuing to breastfeed through the period you are introducing solids is highly recommended.  Even after you introduce solids, most of your baby's nutritional needs will be met by breast milk or formula until at least 12 months of age.

Personally, I reckon that now my baby is at an age where she is putting everything in her mouth and gumming the floor, the risk of her picking up extra bugs from hygienically prepared solids is minimal.

Here's the evidence:

It was previously thought that exclusive breastfeeding until 6 months and delaying the introduction of allergenic foods such as eggs could reduce the development of allergies in children.  The current state of the research is that there is no clear evidence that delaying solids until 6 months makes the development of allergies more or less likely.  The Australasian Society of Clinical Immunology and Allergy (ASCIA) summarises its position based on research into allergies as follows:

Do not:

• introduce solids before 4 months

What can help prevent allergies: 

• breastfeeding up to and during the period of introduction of solid foods
• if breastfeeding is not possible, there is some evidence that hydrolysed formula can help prevent allergies (fully hydrolysed formula is only available by prescription - partially hydrolysed formula is sold as HA formula) 

What probably makes no difference: 

• excluding foods from the breastfeeding mother's diet

• delaying the introduction of solid foods for longer than six months 

• delaying introducing potentially allergenic foods such as egg, nuts, wheat, cow's milk and fish - if the child's going to develop an allergy, they will probably develop it anyway

The tricky part is that the ASCIA also states:

• "more research is needed to determine the optimal time to start complementary solid foods.  Based on the currently available evidence, many experts across Europe, Australia and North America recommend introducing complementary solid foods from around 4-6 months."
• "There have been some suggestions that delaying the introduction of foods may actually increase (rather than decrease) allergy, however at this stage this is not proven." 

This part of the advice is a bit vague for me.  Which experts?  Why do they say 4-6 months is optimal?  And what is meant by 'delaying the introduction of foods'?  Till 4 months?  6 months?  A year?

And no wonder it is vague, when joint position paper of the European and North American Societies for Paediatric, Gastroenterology, Hepatology and Nutrition actually says:

"Exclusive or full breast-feeding for about 6 months is a desirable goal. Complementary feeding (ie, solid foods and liquids other than breast milk or infant formula and follow-on formula) should not be introduced before 17 weeks and not later than 26 weeks."

A quick bit of maths reveals that this advice tells you to exclusively breastfeed (no solids) for 6 months, but to introduce solids before 6 months.  Nice.  In one breath, two major leading health organisations give you a recommendation that is basically impossible to follow.

The reason solids are not introduced before 17 weeks is due to the infant gut not being mature, leading to risks of allergies, infections etc, as well as failure to thrive issues from the infant taking less milk.  As to what time after this is appropriate:

"With respect to neurodevelopment, it is likely that, as with any motor skill, there will be a range of ages in infant populations for the attainment of most milestones. For example, by around 6 months, most infants can sit with support and can ‘‘sweep a spoon’’ with their upper lip, rather than merely suck semisolid food off the spoon. By around 8 months they have developed sufficient tongue flexibility to enable them to chew and swallow more solid lumpier foods in larger portions. From 9 to 12 months, most infants have the manual skills to feed themselves, drink from a standard cup using both hands, and eat food prepared for the rest of the family, with only minor adaptations (cut into bite-sized portions and eaten from a spoon, or as finger foods). An important consideration is that there may be a critical window for introducing lumpy solid foods, and if these are not introduced by around 10 months of age, it may increase the risk of feeding difficulties later on (15). It is therefore important for both developmental and nutritional reasons to give age-appropriate foods of the correct consistency and by the correct method.

The Committee considers that gastrointestinal and renal functions are sufficiently mature by around 4 months of age to enable term infants to process some complementary foods, and that there is a range of ages at which infants attain the necessary motor skills to cope safely with complementary feedings." (taken from the joint position paper cited above)

A look at the detail of the paper reveals no clear reason why there is such a strong recommendation to introduce solids before 26 weeks.  There are some studies that suggest iron deficiency can occur if babies are exclusively breastfed to 6 months, but this probably depends on the amount of iron the baby obtained in utero, which in turn depends on the mother's diet and whether the baby was full term (premmie babies may not have enough iron in their bodies).  The 2002 World Health Organisation (WHO) report on the Nutrient adequacy of exclusive breastfeeding for the term infant during the first six months of life found that breast milk did not provide all the infant iron needs, but for the first six months the infant drew on iron reserves already in his or her body.  After 6 months, complementary feeding was necessary to ensure adequate iron.

The Australian National Health and Medical Research Council states that:

"A number of observational studies and two randomised trials have not identified any benefits from the introduction of solid foods before the age of 6 months."

But when you actually look at the studies they are referring to, both were conducted in the developing Honduras.  It is therefore unclear how applicable these studies are to developed countries like Australia.

The World Health Organisation (WHO) is best associated with the position that babies should be breastfed exclusively until 6 months of age.  But when I looked at the evidence provided by the WHO website, particularly the 2001 The Optimal Duration of Exclusive Breastfeeding: A Systematic Review, the evidence really only supports delaying solids in developing countries or in households with other risk factors - such as smoking, low socio-economic status etc.  There may be a small elevated risk of gastrointestinal infection when starting solids early (as evidenced from a large study in Belarus, but not demonstrated in a smaller Australian study), but such infections are extremely unlikely to result in infant deaths in a developed country.  What the review set out to establish and could basically support was that there was no harm in exclusive breastfeeding for at least 6 months.

When the evidence is this way, why is exclusive breastfeeding until 6 months advocated so strongly in developed countries?  In part, this may be a public policy decision (see the ANHMRC paper p47)  - as it is feared that when parents are given the 4-6 month range, mothers who feel their babies are advanced try to introduce solids before 4 months (17 weeks) where statistically most babies' guts are not ready, and there are higher risks.

Methods for starting solids:


There are two basic methods for starting solids - using purees and spoon feeding, or starting later with finger-foods using 'baby led weaning'.

Purees and spoon feeding allow you to start feeding your baby solids before they can sit up and before they develop the motor skills to do anything other than suck on objects placed in their mouth.  Harder food is a choking hazard for babies without these skills, which typically develop around 6 months, although the age can vary greatly from baby to baby.  For information on how to do this method, including recipes etc, you can find advice on Annabel Karmel's homepage.

Baby led weaning involves waiting until the baby is older and then essentially starting them straight on finger foods.  BLW advocates like that this means less work than a long period of pureeing food etc (although this may be more true for breastfeeding mums than mums doing formula).  Other possible benefits is that the baby learns that food is for chewing not sucking from the outset, so potentially less risk of choking, and that babies develop a positive relationship with food by feeding themselves the quantities they need, not being force-fed.  For more information on how to do this method, see advice from Gill Rapley or for more detailed information this blog.