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Free Access to Journals and Research Articles in Support of World Breastfeeding Week

August 8th, 2013 by avatar

Several well known journals have stepped up to provide free public access during the entire month of August, 2013 in support of World Breastfeeding Week.  If you do not already have access to these publications, which are normally available through a paid subscription or membership, now is the perfect time to peruse them, read those articles that interest you and get caught up on some new information and recent research.

If you have a great resource on the topic of breastfeeding that you think we might benefit from, please leave the information in the comment section.

I would like to thank and acknowledge all the childbirth educators, lactation consultants, nurses, midwives, doctors, doulas, partners and family members who support mothers and babies who desire to breastfeed.  What you do toward helping mothers and babies to get off to a good start is very appreciated.

Participating journals (click on the image to be taken directly to the journal website.)

Taylor Francis Online

Journal of Human Lactation

Breastfeeding Medicine

Journal of Midwifery and Women’s Health

Babies, Breastfeeding, Childbirth Education, Healthy Birth Practices, Healthy Care Practices, Infant Attachment, New Research, Newborns, Research , , , , , ,

Selfish vs. Selfless: Conflicting Views of Motherhood and the Role of Self-Care—New Qualitative Data Emerges

May 9th, 2013 by avatar

With Mother’s Day coming this Sunday, many women will be enjoying their first Mother’s Day celebration.  Hopefully, all mothers will be pampered, celebrated, honored and cherished.  For many women, finding a balance of being the mother and taking care of yourself and meeting your individual needs is often a struggle.  Walker Karraa takes a look at a recent study examining the importance of self care for new mothers and asks how birth professionals can stress the importance of new mothers making time for themselves as they transition to their new role. – Sharon Muza, Science & Sensibility Community Manager

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http://flic.kr/p/6AH9mg

I have a confession. One year I volunteered over 2,000 hours at my children’s school. Yes, I was one of those moms. From wearing an orange vest directing carpool in the morning, to planting the garden with the green team, Xeroxing homework packets for the teachers, and planning the Spring Auction, I chose to put everything into public displays of affection for motherhood. Selflessness was superior parenting.

Fast forward a few years and I am rounding the corner on my PhD.  I am now one of those moms. I barely know the name of the Principal, miss school functions regularly, never volunteer in the class, and avoid direct eye contact with anyone on the PTA at all cost. I am caring for myself in ways that don’t directly involve caring for my children. Many would perceive it as selfish, or at a minimum, I am recognized as not being “an involved parent”.  I feel the judgment from other parents.

I would imagine anyone reading this right now understands the mine field of guilt, disappointment, and distress we walk through regarding balance between self-care and caring for children. Childbirth professionals often find themselves torn between the demand for caring for clients and the need for self-care.

A paradox for women lies between the need for self-care and the social construct of selflessness as superior in parenting.  Moreover, socio economic stressors regarding childcare and ongoing employment bear critical weight on time and resources for women to engage in self-care in addition to caring for their infant, other children, and family. Women need and deserve physical, intellectual, mental, emotional and spiritual health and well-being—yet engaging in self-care is a social construct that views it as selfish, or a luxury. And dare I say we engage in keeping this paradigm alive by extoling the virtues of some women who display self-sacrifice and dishing about the deviance of others who are not at the PTA meeting. We compare ourselves to both, often rejecting the parts of ourselves that are in desperate need of time, privacy, exercise, prayer, creativity, recovery. For that matter we could all use a nap, a shower, and time to do with as we want, desire, or dream.

New Study Emerges

This push and pull of visions of perfect martyrdom with the need for self-care is at no other time more present than new motherhood.  A recent qualitative study, “The Role of Maternal Self-care in New Motherhood” by Barkin and Wisner (2013) explored women’s perceptions of the role of maternal self-care in postpartum period and the barriers to employing self-care. Critical to postpartum wellness are increasing understandings of the mechanisms of self-care and their importance in the lives of new mothers. In a qualitative study of three focus groups consisting of 31 new mothers (had given birth during the year prior to enrolling in the study), Barkin & Wisner (2013) examined the relationship of 1) women’s perceptions of self-care, 2) how women applied self-care in new motherhood, and 3) the barriers to practicing self-care.

Semi-structured interviews with three focus groups elicited responses regarding the responsibilities associated with new motherhood, changes experienced since the birth of their child, feelings in response to those changes, describing constructs of a ‘good mom’, and the circumstances surrounding their high functioning and low functioning periods.

Transcripts related to maternal functioning were extracted and grouped into one of three categories: (1) women’s valuations of the role of self-care in new motherhood, (2) applications of self-care and (3) barriers to practicing effective self-care.

Barkin & Wisner (2013) noted two conflicting themes where women were both aware of the importance of self-care while holding the belief that good parenting is tantamount to selflessness. Participants described knowing that even the most basic self-care such as good nutrition and rest were of paramount importance, however they experienced barriers to engaging in self-care for themselves. One participant described the dilemma in this way,

“Because I really didn’t pay attention to myself. Like my main focus was on him. Making sure he was eating every hour. And as far as me, when a counselor came in and she was like, ‘Well, are you eating breakfast?’ ‘Are you eating lunch?’ And you really have to stop and look back and think like okay, yes, I need to take care of myself as well as the baby’. But you don’t really think about that until someone brings it to your attention.” (Barkin & Wisner, 2013, p. 5)

Participants described breastfeeding as a source of conflict.  Barkin and Wisner (2013) reported,

There was also substantial discussion of maternal self-care in relation to breastfeeding. For a portion of the women, breastfeeding was physically and mentally uncomfortable. The women described guilty feelings associated with deciding to artificial milk-feed their child. Despite the guilt, some of the mothers made the ultimate determination to transition to formula feeding. This was recognized as an act of self-care. (p. 5)

Conversely, where selflessness was seen as synonymous with motherhood, some participants reported what the authors called “potentially unhealthy degrees of selflessness” (Barkin & Wisner, 2013, p. 5) such as neglecting their hygiene or refusing to let trusted family members care for the baby.

Barriers

While some engaged in self-care shared examples of taking time to exercise, delegating infant care to partner, taking showers, applying cosmetics, socializing with friends, and dining out—many women reported barriers to self-care. Lack of time, limited financial resources, and one’s own inability to set boundaries were reported as significant barriers to self-care.

Implications for Childbirth Educators and Doulas

In addition to a call for more research, the authors concluded:

The development of a behavioral intervention aimed at improved self-care practice among new mothers is the long-term goal of this research. Interventions should be tailored to the mother’s individual circumstances and preferences. Self-care strategies that are both attractive and feasible for the individual woman will be more effective. Additionally, the availability of such an intervention will enable health-care providers to make better recommendations to women who are struggling to care for themselves and their infant concurrently. (Barkin & Wisner, 2013, p. 6)

This is where we share!

How do you cover the topic of self-care in your childbirth education classes, or prenatal sessions?

What do you consider some good examples of feasible and attractive self-care strategies that you suggest to your clients?

What have you learned about self-care strategies from your clients?

What are your thoughts regarding the causes of this paradox between self-care and selflessness?

As we educate our next generations of families to navigate the waters of parenting, how might we offer support, education and support for women to not only practice self-care, but prioritize it?

References

Barkin, J. L., & Wisner, K., L. (2013). The role of maternal self-care in new motherhood. Midwifery, http://dx.doi.org/10.1016/j.midw.2102.10.001

Babies, Guest Posts, Infant Attachment, Maternal Mental Health, New Research, Newborns, Parenting an Infant, Research , , , , , , ,

The I-Baby: A Baby’s Brain On Technology

April 11th, 2013 by avatar

Regular contributor Kathy Morelli takes a look at babies and media and technology exposure.  If you are working with expectant families or with families parenting young children, you have an opportunity to share the impact of media on developing brains.  Take a moment to read today’s post and share how you bring up this topic with the families you work with. – Sharon Muza, Community Manager, Science & Sensibility. 

http://flic.kr/p/DVbyu

Today’s babies are definitely digital natives! They grow up in a world saturated by media. The research about the effects of media on child development is in its infancy (no pun intended). 

On one hand, some research suggests when the developing brain is over-exposed to multi-tasking, attentional and learning difficulties can result. On the other hand, other research contradicts this finding. Additionally, there are lots of claims from DVD and TV producers that using their media enhances learning and social growth. 

What’s a parent to believe?

First Off: Parent with Awareness and Moderation

Put some perspective on this issue by reframing parenting around media issues as similar to parenting around other issues. 

Parenting with awareness and moderation through the infant years, around any topic, depends on three important tips.     

Tip One: Parent, Heal Thyself 

Encourage parents to be aware of their own emotional reactions to their baby. Have them own their emotions as their own, not their baby’s.

If the parents themselves have felt abandoned as a child, they may need to do their own hard emotional work, centering on their reactions to their baby’s dependency needs. Feelings around their own issues persist no matter what media is in use in the house. Parents should recognize them as their own feelings and work to own them. 

Tip Two: The Baby is an Individual  

All the statistics and information in the world doesn’t change the fact that each baby is an individual, with individual needs.

All babies need one-on-one attention from their caregivers, but some need more than others. Some babies cry more than others, some have colic, some are calmer and quieter than others. And learning occurs differently in each individual.

Have the parents look for clues. If their baby needs more attention than they think he needs, remember he is an individual and cannot be compared to other babies in their life. If their baby has a negative reaction to some type of media, have the parents either reduce its use or don’t use it at all. It might be a signal that he needs more interactive attention from the parent.  If the baby seems confused, frightened or agitated by some imagery or sounds from media, don’t force him to watch it. Cut it out of the home’s media diet. 

Tip Three: Baby, It’s YOU

There is no substitute for the parents. Have parents plan to spend meaningful time with their baby. A baby’s healthy development depends on attentive, personal, touchable, multisensorial, fully embodied experiences.

Newborn Baby’s Brain – Not So High Tech

First, an infant’s growth is intertwined on all levels; physical, mental and emotional growth are all related. In other words, brain development, movement, emotional development, and language are all inter-related and unfold together, at a biologically prescribed pace.   

Second, in the first three years of life, there are multiple critical periods (windows of opportunity) when a baby must be exposed to particular life experiences in order to learn particular skills. If these windows are missed, it’s extremely hard (or impossible) to learn the skill at a later time in life. The windows of opportunity are biologically based on brain development (Zero to Three, 2012). 

For example, vision and language are two skills dependent on critical windows of time. Acquisition of binocular vision and depth perception depends on a normal early experience with vision in the first few weeks of life.  Language skills must be acquired before five years of age, or there is little chance of developing language later in life (Zero to Three, 2012).  

Third, babies are born with immature brains. Experts estimate in order for the human brain to be fully developed at birth, the gestational period should be 18 months.  But human babies come out in nine months in order to compensate for the size of the human female pelvis (Christakis, 2009).  

Many baby experts refer to the first three months of life as the “fourth trimester” (Karp, 2003).  In the fourth trimester, a baby is still very fetus-like.  At at the beginning of life, a baby’s brain is only a quarter of its adult size and will grow about 20% in just the first three months of life. Her brain structures are in place, but are waiting to grow, based on her experiences. (Stamm, 2007). 

Think of the huge differences between a four day old baby and a four month old baby. That four month old child is cooing and smiling right at their parents, enticing them to connect! That newborn is depending on the parents to connect with her to help her grow (Marvin & Britner, 2008).      

The time between birth and two years old is naturally and biologically a period of extraordinary growth. An infant’s brain naturally grows based on genetics and interactive experience (Zero to Three, 2012; AAP, 2011; Stamm, 2007) 

The Infant Brain – How Babies Learn  

Babies Learn by Social Interaction:  Popular hype says any type of stimulation helps the infant brain grow and learn. But the consensus of child development specialists everywhere is  normal infant development depends on normal social stimulation  involving all the senses (touch, sound, sight, smell) (Vygotsky, 1978; as cited in Fenstermacher et al, 2010).   

What is normal social stimulation with all the senses?

It is responsive care by the parents (caregivers) using all the senses, including skin to skin contact, movement (swaying, walking, gentle dancing), holding, feeding, cuddling, talking,  loving direct eye contact, smiles, gentle play, comforting, and mature acceptance and modulation of your baby’s changing feeling states (angry, happy, sad) (Cozolino, 2006; Wallin, 2007). 

Emotional Attachment Style is Learned: A baby’s emotional template is encoded neurologically based on her earliest experiences with her parents and other caregivers. The biological attachment sequence enacts no matter what type of care a baby receives.

A good quality, secure attachment is created by good quality and consistent interactions between baby and parents. The human brain is plastic, so the attachment template is continuously updated and developed throughout life, but it is much easier on a person to begin life with healthy connectivity patterns, than to correct them as they go along (Wallin, 2007).        

Neglect & Abuse Affect Brain Growth: Research shows children growing up in neglectful and abusive homes, who are rarely spoken to, who do not have the opportunity to explore, may fail to develop the neuronal pathways necessary to learning (Zero to Three, 2012).

No Media vs Hey, It’s Educational!   

Parents of the under two set are understandably concerned by the conflicting messages out there about screen time.

American Academy of Pediatrics (AAP, 2011) strongly discourages any media consumption by children younger than two.

The AAP’s policy statement is based on research findings that media time tends to elbow out time spent in unstructured, creative play time and interactive activities with a parent or caregiver.  High quality, multi-sensorial interactions with a consistent caregiver are essential for healthy child development.

Yet, media is an integral part of our culture. On the average, 100% of children under two watch 1 – 2 hours of media every day and 14% watch over 2 hours a day (AAP, 2011).  40% of all children younger than two years live in households where the TV is on all day long as background noise (Courage & Setcliff, 2009). 

So what’s a parent to believe?

Does media consumption hurt babies?

Many parents say they are comfortable with allowing their under 12 month babies to watch educational media. There are a lot of educational firms pushing DVDs for the under 12 month old set, claiming learning enhancement and improvement for school readiness.

Are their claims substantiated by research?

The Research

What follows are some key points from the research about media consumption, learning and attentional effects on the developing brain.

Media, the Developing Brain and Attentional Difficulties

In 2004, Dimitri Christakis, MD, MPH of the University of Washington, reviewed data from an existing study. He found an association between children under three who watch on average more than two hours a day of television and attentional difficulties. In 2007, further studies by Christakis and his colleague, Fred Zimmerman, found the attentional difficulties were more precisely linked to program content. That is, cartoons and fast paced media seem to be linked to attentional difficulties, but not educational and appropriately paced programs. Christakis theorizes that over-stimulation of the developing brain with flashing and changing sights and sounds might be harmful to the developing brain (Christakis and Zimmerman, 2007; Christakis, 2009; Zimmerman et al, 2009).

On the other hand, there are researchers such as Tara Stevens and Miriam Muslow (2006) who feel the evidence linking media usage and attentional difficulties is highly correlational and Christakis and Zimmerman did not properly account for other factors in their information. Clearly, there is a need for the National Institute of Health to fund a large scale study to see if and how the digital native brain is affected by media saturation.   

How Babies Learn from the Screen 

Video Deficit Effect: Research about screen learning versus live learning indicates infants learn less from video than from live interactions; this is called the “video deficit effect.” The video deficit effect persists to about three years of age (Barr, Muentener, & Garcia, 2007; Zack et al, 2009).

The video deficit effect is mitigated by repetitive viewings, media content design and the context in which the media is used (Barr, 2010).

Repetition: So, babies under 12 months will retain behavior after seeing it performed once by a live model. But it takes repeated viewings for a baby to learn the same behavior from a screen.   

Content design: Retention of information is also enhanced in the under 12 month set by story content. If the story lines are simple, in sequence, and uninterrupted by multiple story lines or commercials, retention is enhanced. (think Teletubbies).

Context: In addition, if the media is in the context of a family situation, that is, if there is an appropriate adult moderator present, to discuss, distract and limit screen use, retention is enhanced and deleterious effects are reduced (Christakis, 2009).

Individual learning differences: In addition, there are differences in how and how fast individual babies learn. In general, at about the age of 12 months, a child becomes capable of seeing something on a screen and then performing it himself. But there are individual variations, and these variations persist into toddlerhood (Barr, 2007).     

But, as discussed above, child development specialists agree infants primarily learn via social-interactional-sensorial methods.

Educational Claims

Let’s take a look at the claims made by current educational DVDs targeted at infants.

In 2010, Susan Fenstermacher and her colleagues conducted an overview of 58 popular DVDs (culled from a total of 218 made between Fall 2007 and Spring 2008) marketed as educational to parents for their infants. A total of 17% of 686 claims made by the producers were that the DVDs provide socio-emotional educational content. However, the researchers found that only 4% of all the scenes were socio-interactional in content and these scenes were not of high quality.

In general, producers of DVDs do not use research-based child development learning principles, despite their claims. Of course this may be changing as these producers begin to use child development experts as content consultants.  

Language Development and Media

Language: Research shows babies learn language from being directly spoken to by their caregivers. Babies don’t learn language from the television or from observing conversations between adults, they need direct attention.

Matthew LaPierre and his colleagues (2012) found that children from eight months to eight years are exposed to over 4 hours of TV a day. This can be reduced by not having a TV in the child’s room.

Studies have shown that having the television on at home all day as background noise causes language delays and reduced interaction between parents and children (Kirkorian et al, 2012; LaPierre, Piotrowski & Linebarger, 2012).

Profoundly, a study of 1000 infants found that babies who watched over 2 hours of DVDs a day had poorer language assessments than babies who did not watch DVDs. Specifically, for each hour of watching a DVD, a baby knew 6 – 8 words less than babies who did not watch DVDs (Christakis & Zimmerman, 2007).

On the other hand, in 2010, Allen and Scofield found that 2 year olds can learn simple words from very simplified content, from a video.  They found the Blues Clues format was good for this.

Again, the research is not yet complete, but still points to the benefits of parental awareness and judicious use of media.   

Reality vs Fantasy in the Young Mind

Remember babies brain structures are not yet developed. The lower brain centers, the emotional centers, with structures such as the amygdala, are fully formed at birth. The amygdala is in charge of emotional designation. But the neo-cortex, the logic center is not fully formed until the early twenties (Cozolino,2006). Thus, the capacity to differentiate between fantasy and reality is limited in babies, toddlers and children. Babies are wired to empathize with the emotions of the people around them and have the capacity to do so. And remember that babies do retain information from repeated viewings.

For an example of how differently children view reality than adults, studies show children believe that many planes hit the World Trade Center, not just two, as the event was shown over and over again on TV.

So keep in mind babies/toddlers and adults have a different understanding about fantasy and reality as applied to what is viewed on the screen and they also can “catch” emotions from the people around them and from the screen. 

Five Tips for Parents: Media & Infants 

So, when it comes to media consumption, think about parenting a young baby with awareness and moderation. Some age appropriate media is ok, and its ok to for parents to take breaks with a TV show, but don’t let it edge out stroller walks, hikes in a baby back pack in the woods, and bonding time. 

Tip One: There is no substitute for the parent.

Studies indicate using media over 2 hours a day steals precious interactional learning time from the baby.  Encourage parents to help their baby grow by being present with her.

Tip Two: Like any parenting decision that needs to be made, make the decision from a place of awareness and in moderation.

Tip Three:   Be aware of how much your TV is on.

Again, research has found that children in the US are exposed to over 4 hours of TV a day. Reduce this time limiting the number of TV’s in the home, and not putting a TV or computer in the child’s bedroom.

Tip Four: Those educational DVDs? Well, research shows they make a lot of claims and the content is not based on research.   

Since some studies have implicated attentional and language deficits in babies who view more than two hours of media per day, limit the amount of media with your infant. A baby’s primitive brain learns socially and with many senses involved: touch, smell, sight, sound. A baby’s early interactions and experiences are encoded in the brain and have lasting effects. Choose media that has child development consultants working on the production.  

Tip Five: Think twice about exposing your young baby/toddler to violent imagery on the screen. Remember repetitive showings increase retention, babies are naturally wired to empathize with emotions and studies show that children have a different perception of reality and fantasy than adults.

Five positive ways for parents to interact with their babies: 

  • Consistently interact with a baby using prolonged eye contact, gentle skin to skin touching and smiling
  • Actively watching appropriate media with a baby is a way for parents to get a needed sitting rest and also enhances learning and mitigates negative effects
  • Baby massage is a wonderful tool for parents. Studies show it reduces anxiety and depression in both parents and babies (Field, Hernandez-Reif, M. and Diego,  2006)
  • Teach her to regulate her emotional states by appropriately soothing her when necessary. She is learning how to accept and tolerate her own emotional states from parents, so remain calm and consistent.
  • Remind parents that they don’t need to be perfect, they just need to be good enough!

 References 

American Academy of Pediatrics, Council on Communication and Media (2012). Policy Statement: Media Use by Children Younger Than 2 Years. May 15, 2012 from  http://pediatrics.aappublications.org/content/128/5/1040.full.html

Barr, R, Muentener, P, and Garcia, A. (2007). Age related changes in deferred imitation from television by 6-18-month-olds.  Developmental Science,10(6), 910-922.  

Christakis, D (2009). The effects of infant media usage: what do we know and what should we learn? Acta Pædiatrica, 98, 8–16.

Christakis, D. and Zimmerman, F. (2007). Associations between content types of early media exposure and subsequent attentional problems. Pediatrics, 120(5), 986 -992. doi: 10.1542/peds.2006-3322

Courage, M. and Setliff, (2009). Debating the impact of television and video material on very young children: Attention, learning, and the developing brain. Society for Research in Child Development, 3(1), 72-78.

Cozolino, L. (2006). The neuroscience of human relationships. New York: W.W. Norton & Company. 

Fenstermacher, S. K., Barr, R., Brey, E., Pempek, T. A., Ryan, M., Calvert, S. L. and Linebarger, D. (2010). Interactional quality depicted in infant and toddler videos: where are the interactions?. Infant & Child Development, 19(6), 594-612. doi:10.1002/icd.714

Field, T., Hernandez-Reif, M., & Diego, M. (2006). Newborns of depressed mothers who received moderate versus light pressure massage during pregnancy. Infant Behavior and Development, 29, 54-58.

Kirkorian, H. L., Pempek, T. A., Murphy, L. A., Schmidt, M. E., & Anderson, D. R. (2009). The Impact of Background Television on Parent–Child Interaction. Child Development, 80(5), 1350-1359. doi:10.1111/j.1467-8624.2009.01337.x. 

LaPierre, M., Piotrowski, J., and Linebarger, D. (2012).  American children exposed to high amounts of harmful TV. Unpublished paper presented at International Communication Association’s annual conference (Phoenix, AZ, May 24-28, 2012).

Marvin, R.S. & Britner, P.A. (2008). Normative Development: The ontogeny of attachment. In J. Cassidy & P.R. Shaw (Eds),  Handbook of Attachment, (pp. 269-294). New York: The Guilford Press.

Stamm, J. (2007). Bright from the start. New York: Penguin Books.

Stevens, T. and Mulsow, M. (2006). There is no meaningful relationship between television exposure and symptoms of attention-deficit/hyperactivity disorder. Pediatrics, 117(3), 665-672. Retrieved May 21, 2012 from http://pediatrics.aappublications.org/content/117/3/665.full.html

Wallin,D.J. (2007).  Attachment in psychotherapy. New York: The Guilford Press.

Zack, E., Barr, R., Gerhardstein, P., Dickerson, K., and Meltzoff, A.N. (2009). Infant imitation from television using novel touchscreen technology. British Journal of Developmental Psychology, 27, 13–26.

Zero to Three (2012). General brain development. Retrieved May 15, 2012 from  http://main.zerotothree.org/site/PageServer?pagename=ter_key_brainFAQ#bybirthZimmerman, F. J., Gilkerson, J., Richards, J. A., Christakis, D. A., Dongxin, X., Gray, S., & Yapanel, U. (2009). Teaching by Listening: The Importance of Adult-Child Conversations to Language Development. Pediatrics124(1), 342-349. doi:10.1542/peds.2008-2267 

American Academy of Pediatrics, Babies, Childbirth Education, Guest Posts, Infant Attachment, Newborns, Parenting an Infant , , , , , , ,

Parents’ Singing to Fetus and Newborn Enhances Their Well-being, Parent-Infant Attachment, & Soothability: Part Two

February 26th, 2013 by avatar

Regular contributor Penny Simkin discusses the research around parents’ singing to their babies in utero and the post birth benefits.  She also shares how birth professionals can encourage clients, patients and students to start this practice during pregnancy.  Part one of this two part series can be found here. – Sharon Muza, Community Manager, Science & Sensibility

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What is the research evidence for postnatal benefits to parents or babies  of singing to the baby before birth?

• Fetuses can sense audio vibrations and rhythms early in pregnancy. Later in pregnancy they hear and distinguish various sounds. (4)
• They recognize their parents’ voices after birth (1)
• Newborns prefer their parents’ voices over the voices of strangers (1)
• Repetitive prenatal reading of one story by one parent every day for weeks results in the newborn’s recognition of and preference for that story. (2)
• Fetuses respond to music by calming, becoming active, changes in FHR (depending on the music) 5,6)
• Premature babies are calmed by calming music. (7)
• Newborns and young babies are calmed by familiar music, as demonstrated by the universal use of lullabies.

Combining these findings, a proposal

In light of all that has been learned about babies, I think we can combine it all into a simple approach to enhance bonding, soothe the baby, empower parents with their own unique tool that no one else, even the experts, can do as well as they. (8) I propose that we who provide care and education for expectant parents urge them to do the following at around 30-32 weeks’ gestation (or earlier or later):

Simple steps to singing to the baby in utero and after birth

1. Choose a song that you like and is easy for you to sing. It might be a lullaby or a children’s song, but it does not have to be. It can be one of your favorite songs or a popular song of the day.

2. Sing it every day. Both parents can sing it together, but each of you should also sing it alone much of the time. It can be played with a musical instrument some of the time, but it also should be played without an instrument much of the time.

3. When your baby is born, after the initial lung-clearing cry, sing the song to your baby. The baby can be in your arms or with a nurse in the warmer. If your baby is crying, try to sing close to his/her ear or loud enough that he/she can hear it at least during the pauses to take a breath.

4. Continue singing it every day, especially during times when your baby is crying (and has been fed; don’t use it as a substitute for feeding!)

5. Sing it when bathing or diapering your baby, when soothing or helping your baby go to sleep.

6. Sing it when your baby is upset and you can’t pick her up, such as when driving in the car and you can’t stop or take the baby out of the car seat; or at a checkup if the doctor is doing something painful.

Maia sings to her sister in utero ©Penny Simkin

If parents feel they can’t sing or are too embarrassed to do it, I suggest choosing a poem that has a nice rhythmic meter, and recite that to the baby. I recommend Mother Goose Rhymes or poems in books by AA Milne, such as “When We Were Very Young” and “Now We Are Six;” or Shel Silverstein’s “Where the Sidewalk Ends” and others.

Film clips showing baby’s reactions to familiar songs 

Recent students in my birth class took my suggestion to heart, singing “Las Mañanitas,” from their Mexican culture, to their unborn baby frequently. The dad would lie with his head on the mother’s pregnant belly as they sang. They even videotaped sessions while the mother was having a non-stress test that showed the baby’s heart rate steadying when the dad was singing, and rising when he was not.  We also see the dad singing to their sweet little daughter right after the birth. Though she cries pretty hard when being suctioned and rubbed with blanket, she calms down with his singing.

I’ve just completed a film for children (9). In the film, we see 4 year old Maia singing  ”Twinkle, Twinkle, Little Star” to her baby sister before birth and again right after birth. Neve, her sister, calms down when she hears Maia singing the familiar song.

Enjoy these heartwarming scenes in the video below.

Conclusion

Maia sings to her newborn sister ©Penny Simkin

In conclusion, when parents sing one (or possibly a few) songs repeatedly to their child, before and after birth, it is a once in a lifetime opportunity to build a unique, meaningful and fun connection with their baby. The child already knows and loves the song as sung by his/her parents more than any other song, sung by anyone else. Parents always have their voice with them and can use it to comfort, soothe, and play with their child for years to come. Parents have the opportunity prenatally to give their baby a gift that becomes a gift for them as well.

Singing to the baby before and after birth is a lovely and very special thing to do. Would you consider introducing this ritual to your students, clients and patients?  Have you already done so?  How has it been received?  Do you have any stories about parents who have practiced this connection? Please share in the comments section, I would love to hear about it.  If we all get the word out to expectant families, it could have a very positive impact.

References:

  1.  Brazelton B. Cramer B. (1991)The Earliest Relationship: Parents, Infants, and The Drama Of Early Attachment . Da Capo Press Cambridge, MA.
  2. De Casper A. 1974, as described in Klaus M, Klaus P, Kennell J. 2000. Your Amazing Newborn. Da Capo Press, Cambridge, MA..
  3. Odent M. 1984, Birth Reborn. Pantheon Books: New York
  4. Klaus M, Klaus P, Kennell J. 2000, Your Amazing Newborn. Da Capo Press, Cambridge, MA.
  5. Verny T, Kelly J. (1982)   The Secret Life of the Unborn Child. Dell: NY
  6. Chamberlain D. (2013) Windows to the Womb. North Atlantic Books: Berkeley, CA.
  7. Lubitzky R, Mimouri F, Dollberg S, Reifen R, Ashbel G, Mandel D. 2010. Effect of music by Mozart on energy expenditure in growing preterm infants. Pediatrics 126;e24-e28. DOI: 10.1542/peds.2009-0990.
  8. Simkin P. (2012) Singing to the baby before and after birth.  International Doula 19(3):30-31
  9. Simkin P. (2013) “There’s a Baby: A Children’s Film About New Babies.” PassionflowersProductions: Seattle.

 

Babies, Childbirth Education, Guest Posts, Infant Attachment, Newborns, Parenting an Infant , , , , , ,

Recent Study Finds that Controlled-Crying Causes No Apparent Long-term Harm: Should We Recommend This Practice to Parents?

October 30th, 2012 by avatar

 

 

“Crying it out” and sleep issues have always been a “hot” topic amongst parents and many of today’s parents look to childbirth educators and others for information on how best to prepare for and deal with their infant’s sleep habits.  Talking about infants and sleep can be as flammable a topic as talking politics.   Today’s post is by regular contributor Kathleen Kendall-Tackett takes a look at recent study on the long-term effects of controlled crying and shares her thoughts on the validity of the study and examines the potential shortcomings and limitations.  How do you speak about sleep and infants in your classes or with your clients and patients?  Do you have information that parents have found particularly helpful? Let us know in the comments section of today’s post.- SM

Image credit: Fotolia stock photo

A recent article in Pediatrics (Price, Wake, Ukoumunne, & Hiscock, 2012) reported on the long-term effects of a controlled-crying intervention for parents of infants 8 to 10 months old. The children were assessed five years post-intervention and showed no apparent harm. The media response to these findings has been overwhelming. Could this be the answer that weary parents have been waiting for? The authors certainly thought so. In fact, they concluded that practitioners could “confidently” recommend this approach.

Before we recommend this approach to parents, let’s step back for a moment and consider whether this recommendation is warranted. We must critically evaluate both the current study and where it fits within the larger literature in maternal-child health. In my view, there are a number of serious limitations to this study that call into question whether we should recommend this practice to parents.

Study Design

In the Price et al. (2012) study, the researchers randomly assigned parents to either intervention or control groups. In the intervention group, parents received instruction in controlled crying, i.e., to wait an increasing amount of time before responding to their infants’ cries, or “camping out,” which involved staying with their infants until the infants fell asleep on their own. The parents in the control group received “usual care,” which meant no specific recommendation regarding infant sleep. At earlier time points, the authors found that the controlled-crying intervention prevented depression in mothers and improved babies’ sleep.

At the five-year follow-up with 225 families (69% of the original sample), the researchers found that the intervention did not adversely affect the parent-child bond, the mother’s depression level, the child’s level of adjustment, or their cortisol levels. Indeed, they noted, that there were no adverse effects. However, there were also no long-term benefits. Still, the authors concluded that practitioners could recommend this technique to prevent postpartum depression and improve infant sleep.

Study Limitations

There were a number of limitations to this study. Below is a brief synopsis.

The Impact of Context: The Cumulative Effect of Childhood Adversities 

Context is an important consideration when evaluating potential harm caused by a parenting technique. In other words, how many parental missteps does it take for children to show evidence of lasting harm? Fortunately, children are resilient and don’t require perfect parenting.  However, chronic bad parenting does harm children and the effects are cumulative (Shonkoff, Boyce, & McEwen, 2009). Chronic bad parenting has also been described as childhood adversity in such major research studies as the Adverse Childhood Experiences Study (Centers for Disease Control and Prevention, 2010) and New Zealand’s Dunedin Multidisciplinary Health and Development Study (Danese et al., 2009).

So does controlled crying cause infant harm? If it occurs in families with generally warm, responsive, and loving parents, probably not. Because children are resilient, they can endure a lot. Family strengths can buffer any potential negative effects.

I am more concerned about the impact of controlled crying when it takes place in high-risk families. This is a key limitation in Price et al. study. A full 31% of their original sample was lost to follow-up. Most of these families were identified as “high disadvantage.” In other words, the group most likely to be negatively affected by controlled crying was not in the follow-up study.

Assessing “Dose”: The Chronicity and Severity of the Experience

When assessing potential harm of a practice, it’s also important to consider chronicity and severity. In terms of infant sleep, we need to know how often controlled crying was used in an average week, how many weeks or months that the parents employed these techniques, and in an average episode how many minutes elapsed before the parents responded to their babies. I would expect more long-term negative effects if parents did not respond to their babies’ cries for long periods of time (such as 45 minutes or longer), and that they used this technique for months on end. In contrast, if parents used this technique a few times and for a few minutes, there probably wouldn’t be any negative effects.

Chronicity and severity is basically a way of factoring in “dose” of the intervention. This important nuance was totally absent from the Price et al. study. From their article, we know little about what the parents actually did. A full range of practices was grouped together in the “intervention group.” Indeed, we also don’t know what the “control” group did. These parents could have easily implemented a controlled-crying program for themselves using one of the myriad of books for parents on sleep training. Given the wide range of practices that likely occurred in both the “intervention” and “control” groups, I am again not surprised to see no significant difference.

Was the Intervention Actually Effective, Even in the Short Term? Accounting for the Hawthorne Effect

Another problematic aspect of this study has to do with the research design’s inability to account for the Hawthorne Effect. The Hawthorne Effect was first noted by industrial psychologists who were testing the impact of minute changes in illumination on productivity in factory workers. When they raised the level, employees reported that it was “better” and productivity increased. When they lowered the level, it was also “better” and productivity increased.  In other words, any intervention was described as helpful. It’s basically a placebo effect for behavioral interventions.

The Hawthorne Effect could also be behind the positive results for the controlled-crying intervention. Earlier papers from this same research sample found lower rates of depression and better sleep among the mothers in the intervention group. Yet these results do not demonstrate that it was the controlled-crying technique per se that actually caused the effect. Perhaps it was simply a matter of the mothers appreciating that someone was listening to their concerns. Controlled crying was compared to “usual care.” A better test for the effectiveness of this technique would have been to compare it with another intervention (such as educating mothers about the developmental normality of infant waking at 8 to 10 months, and brainstorming about ways the mothers could get more rest and cope with fatigue). Given that the authors are actually recommending this technique, this standard of evidence is a minimum.

Does Controlled Crying Cause Long-term Change to Cortisol Levels? 

One concern that critics of controlled crying raise is that this technique changes infant physiology and alters the production of the stress hormone cortisol. To address this concern, the authors assessed cortisol levels of the children at two different points during a single day at age 6. They found no significant differences in cortisol levels at age 6 between the intervention and control groups, which further reassured them that their techniques were not harmful.

Unfortunately, these findings alone do not mean lack of physiological harm. To demonstrate lack of harm, the authors needed to measure cortisol levels during infancy: before, during, and after the intervention. Did controlled-crying elevate cortisol levels? How high were those levels and how long did they remain elevated? The authors did not measure this.

The question we need to ask is what happens to babies when their mothers do not respond to their cues? One way this has been studied is by examining the impact of maternal depression on infants. Maternal depression impairs mothers’ ability to respond to their infants’ cues. Infants whose mothers do not respond to their cues  tend to have elevated cortisol levels (Feldman et al., 2009). Even when non-response is temporary, babies still find it stressful. In the still-faced mother paradigm, mothers are asked to not respond to their infants’ cues in a laboratory setting. This research is designed to mimic the effects of maternal depression. The still-faced-mother experiments increase babies’ cortisol levels (Grant et al., 2009). And the effect of chronic maternal non-response can last long past infancy (Douglas & Harmer, 2011; Luijk et al., 2010; Murray, Halligan, Goodyer, & Herbert, 2010).

So why the concern about cortisol? Mainly, it’s this: cortisol is quite toxic to brain cells. If cortisol is elevated for short time, it likely causes no damage. But if cortisol levels are repeatedly elevated because the infants are experiencing long and repeated incidents of being ignored when they cry, it can be a problem. The brain is at its most vulnerable in the first five years, so soaking the developing brain in cortisol is not a good idea (Buss et al., 2012).

The authors of the current study claimed no effect of cortisol just because there was no difference between the groups at age 6. In my opinion, the lack of difference between the groups does not mean lack of harm. For some of these children, the effects of elevated cortisol in infancy could be more subtle. Cortisol levels likely returned to normal in the intervening five years, unless there was ongoing adversity. Unfortunately, cortisol that was elevated in infancy could have still affected vulnerable brain cells, even if current levels are normal. The measures Price et al. used were not particularly sensitive. And these effects would likely not show up without more sensitive measures.

What About Breastfeeding?

The final limitation of this study is rather stunning. Price et al. did not measure the effect of infant feeding method on sleep or maternal depression. Yet feeding method has a direct effect on both maternal sleep and postpartum depression, which are the two main factors the authors claim to address with their sleep intervention. This omission is particularly surprising given that Australia, the authors’ home country, has one of the highest rates of breastfeeding in the world. It is far from a marginal issue.

Recent studies have demonstrated that exclusively breastfeeding mothers get more sleep and are less likely to be depressed than their mixed- or formula-feeding counterparts. They take fewer minutes to fall asleep, sleep longer over the course of a night, and report more daytime energy and better physical health than their mixed- or formula-feeding counterparts (Doan, Gardiner, Gay, & Lee, 2007; Dorheim, Bondevik, Eberhard-Gran, & Bjorvatn, 2009a, 2009b; Kendall-Tackett, Cong, & Hale, 2011).

Given these findings, isn’t it strange that breastfeeding was not even enquired about, let alone controlled for? If the study was conducted in a country with low breastfeeding rates, this omission would be somewhat understandable. But it makes no sense from a study conducted in a country with one of the highest breastfeeding rates in the world.

Conclusion

So what can we take away from the Price et al. study? Should we recommend the controlled-crying technique to parents? Based on the limitations of this study, I do not recommend this approach. The sample size is small, the follow-up sample is missing the children most likely to be negatively affected, their assessment of their intervention did not account for the Hawthorne/placebo effect, they have not measured dose of the intervention, nor have they accounted for feeding method, which recent research has soundly demonstrated as being related to both variables that are of key interest: maternal fatigue and postpartum depression.

My objections to this approach are not new. When I first encountered the Price et al. study, I remembered a study this same group of researchers published 10 years ago in the British Medical Journal demonstrating that controlled crying lessened the risk of postpartum depression (Hiscock & Wake, 2002). I was specifically struck by this response to it from a German physician (Perl, 2002).

As a German, I am unhappy to find fairly undiluted ideas of militaristic Nazi infant care uncritically repeated by these Australian care providers. The Nazis understood very well the crucial effect of letting young babies cry on their future development and made this a central theme in their child care. As a scientist, I find it hard to believe that all of the results of mother-infant sleep research of the 1990s completely escaped the authors’ notice.

In closing their article, Price et al. stated that organizations, such as the Australian Breastfeeding Association, were unduly negative towards controlled-crying techniques and based their positions on research that had not been “updated since the mid-2000s.”

Thus, there is a pressing need to deliver evidence-based information to parents and health care providers, which could be achieved, in part, by updating position statements, policy documents, and training curricula to reflect our current findings that behavioral sleep techniques are both effective in the short- and medium-term and safe to use in the long-term (p. 8).

Given recent findings in neuroscience, childhood trauma and adversity, and breastfeeding and maternal sleep, which are not accounted for in the Price et  al. study, I’d respectfully advise the authors to do the same. I’d further urge healthcare providers who are considering recommending these techniques to consider the limitations to the current study and to consider alternative approaches that can meet the needs of both mother and baby.

References

Buss, C., Davis, E. P., Shahbaba, B., Pruessner, J. C., Head, K., & Sandman, C. A. (2012). Maternal cortisol over the course of pregnancy and subsequent child amygdala and hippocampus volumes and affecive problems. Proceedings of the National Academy of Sciences USA, 109(20), E1312-E1319.

Centers for Disease Control and Prevention. (2010). Adverse childhood experiences: Major findings  Retrieved May 16, 2011, from http://www.cdc.gov/ace/findings.htm

Danese, A., Moffitt, T. E., Harrington, H., Milne, B. J., Polanczyk, G., Pariante, C. M., & Caspi, A. (2009). Adverse childhood experiences and adult risk factors for age-related disease: Depression, inflammation, and clustering of metabolic risk factors. Archives of Pediatric and Adolescent Medicine, 163(12), 1135-1143.

Doan, T., Gardiner, A., Gay, C. L., & Lee, K. A. (2007). Breastfeeding increases sleep duration of new parents. Journal of Perinatal & Neonatal Nursing, 21(3), 200-206.

Dorheim, S. K., Bondevik, G. T., Eberhard-Gran, M., & Bjorvatn, B. (2009a). Sleep and depression in postpartum women: A population-based study. Sleep, 32(7), 847-855.

Dorheim, S. K., Bondevik, G. T., Eberhard-Gran, M., & Bjorvatn, B. (2009b). Subjective and objective sleep among depressed and non-depressed postnatal women. Acta Psychiatrica Scandinavia, 119, 128-136.

Douglas, J.-L., & Harmer, C.-J. (2011). Early morning cortisol response and emotional processing in adults exposed to postnatal depression in infancy. European Psychiatry, 26, 479-481.

Feldman, R., Granat, A., Pariente, C., Kanety, H., Kuint, J., & Gilboa-Schechtman, E. (2009). Maternal depression and anxiety across the postpartum year and infant social engagement, fear regulation, and stress reactivity. Journal of the American Academy of Child and Adolescent Psychiatry, 48(9), 919-927.

Grant, K.-A., McMahon, C., Austin, M.-P., Reilly, N., Leader, L., & Ali, S. (2009). Maternal prenatal anxiety, postnatal caregiving and infants’ cortisol responss to the still-face procedure. Developmental Psychobiology, 51, 625-637.

Hiscock, H., & Wake, M. (2002). Randomised controlled trial of behavioural infant sleep intervention to improve infant sleep and maternal mood. British Medical Journal, 324(7345), 1062-1065.

Kendall-Tackett, K. A., Cong, Z., & Hale, T. W. (2011). The effect of feeding method on sleep duration, maternal well-being, and postpartum depression. Clinical Lactation, 2(2), 22-26.

Luijk, M. P. C. M., Saridjan, N., Tharner, A., Van Ijzendoorn, M., Bakermans-Kranenburg, M. J., Jaddoe, V. V. W., . . . Tiemeier, H. (2010). Attachment, depression, and cortisol: Deviant patterns in insecure-resistant and disorganized infants. Developmental Psychobiology, 52, 441-452.

Murray, L., Halligan, S. L., Goodyer, I., & Herbert, J. (2010). Disturbances in early parenting of depresssed mothers and cortisol secretion in offspring: A preliminary study. Journal of Affective Disorders, 122, 218-223.

Perl, F. M. (2002). Infant sleep intervention or Nazi drill? Rapid response to Hiscock & Wake. British Medical Journal. Retrieved from http://www.bmj.com/content/324/7345/1062?tab=responses

Price, A. M. H., Wake, M., Ukoumunne, O. G., & Hiscock, H. (2012). Five-year follow-up of harms and benefits of behavioral infant sleep intervention: Randomized trial. Pediatrics, 130(4). Retrieved from www.pediatrics.org/cgi/doi/10.1542/peds.2011-3467

Shonkoff, J. P., Boyce, W. T., & McEwen, B. S. (2009). Neuroscience, molecular biology, and the childhood roots of health disparities: building a new framework for health promotion and disease prevention. JAMA, 301(21), 2252-2259. doi: 301/21/2252 [pii] 10.1001/jama.2009.754

About Kathleen Kendall- Tackett

Kathleen Kendall-Tackett, Ph.D., IBCLC

Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA is a health psychologist and board-certified lactation consultant. Dr. Kendall-Tackett is Owner and Editor-in-Chief of Praeclarus Press, a new small press specializing in women’s health. She is a research associate at the Crimes against Children Research Center at the University of New Hampshire and a clinical associate professor of pediatrics at Texas Tech University School of Medicine in Amarillo, Texas. She is Editor-in-Chief of the journal, Clinical Lactation, a Fellow of the American Psychological Association, and is president-elect of the APA Division of Trauma Psychology. www.KathleenKendall-Tackett.com

 

Babies, Breastfeeding, Childbirth Education, Depression, Guest Posts, Infant Attachment, Maternal Mental Health, Parenting an Infant, Research , , , , , ,