24 January 2013

Controlled Crying: Let's Address the Stress Response

Hello Everyone & Happy New Year – a bit late I know!
Source unknown. If owner wants removed please let me know.

In my last post Controlled Crying: Historical Perspectives (origins of the idea) I said this one would be about recent research but I’ve changed my mind. 

The reality is that people will, in general, do what they want to do regardless of the research.

This is mainly because of what is known as ‘confirmation bias’ - our tendency to favour information that confirms our beliefs, especially when it comes to issues which are charged with emotion.

Ultimately parents will decide for themselves what level of stress (if any) results from their attempts at controlled crying/sleep training.

Having recently read a comment on another blog by a mother having suicidal thoughts related to her baby's night-waking, it is with respect and compassion for parents who are, or have been in similar dark places that I put forward the information in this post.

STRESS-RESPONSE SYSTEMS

The Center on the Developing Child at Harvard University uses the three terms below to refer to the effects on the body of the stress-response systems (not to the stressful event itself):
  • Positive – brief increases in heart rate, mild elevations in stress hormone level
  • Tolerable – serious, temporary stress responses, buffered by supportive relationship
  • Toxic – prolonged activation of stress-response systems in the absence of protective relationships
These 3 short video clips explain the stress-response systems and how, for better or worse, early experiences are built into our bodies and brains (total duration 4:52):

1.  Experiences Build Brain Architecture

2.  ‘Serve & Return’ Interaction Shapes Brain Circuitry

3.  Toxic Stress Derails Healthy Development


MAJOR SHIFT IN POLICY UNDERPINNING EARLY HUMAN DEVELOPMENT

In January 2012 the American Academy of Pediatrics (AAP) released a Policy Statement and Technical Report... 

urging all those working in the field of Pediatrics to have a:
“…greater focus on those interventions…that reduce external threat to healthy brain growth.”
and stating that:
“the prevention of long-term, adverse consequences is best achieved by the buffering protection afforded by stable, responsive relationships that help children develop a sense of safety, thereby facilitating the restoration of their stress-response systems to baseline [steady state].”
From the Technical Report:
“The…framework that guides this report suggests that many adult diseases are, in fact, developmental disorders that begin early in life.”
  • "early experiences are built into our bodies;
  • significant adversity can produce physiologic disruptions or biological memories that undermine the development of the body’s stress-response systems and affect the developing brain, cardiovascular system, immune system, and metabolic regulatory controls;
  • these physiologic disruptions can persist far into adulthood and lead to lifelong impairments in both physical and mental health."
THE BIOLOGY OF STRESS:  IT’S COMPLICATED (TELL ME ABOUT IT!)

Responses to stress involve activation of the following systems:
  • HPA axis (hypothalamic-pituitary-adrenocortical); and the
  • SAM system (sympathetic-adreno-medullary), which results in
  • increased levels of stress hormones, such as
  • CRH (corticotropin-releasing hormone), cortisol, norepinephrine and adrenaline.
These changes co-occur with a network of other mediators that include:
  • elevated inflammatory cytokines; and the
  • response of the para-sympathetic nervous system, which counterbalances
  • both sympathetic activation and inflammatory responses…
…the dysregulation of this network…(eg too much or too little cortisol; too much or too little inflammatory response) can lead to a chronic ‘wear and tear’ effect on multiple organ systems, including the brain. 
(Summarised from Technical Report mentioned above)

Common beliefs about controlled crying:
  • It teaches babies to be independent and deal with adversity
  • It is a realistic expectation to think babies ‘should’ sleep through the night
  • Too much attention will 'spoil' babies - create a 'rod for your back'
  • We don't remember what happens to us as babies
  • It is an essential part of the treatment for post-natal depression
“…abundant clinical research indicates that the successful treatment of a mother’s depression does not generally translate into comparable recovery in her young child unless there is an explicit therapeutic focus on their dyadic [two people treated as one] relationship.” 
(AAP Technical Report: The Lifelong Effects of Early Childhood Adversity and Toxic StressJack P Shonkoff & Andrew S Garner, Pediatrics 2012;129;e232)
"Neuroscience has demonstrated that all mammals share a…developmental attachment mechanism and a common stress-regulating neurophysiology."    (Nature, Vol 33, 2005, p807)
COMMENTARY
Copyright Neil Matterson, Pharmasoft Pub
Many parents are overwhelmed by distress and exhaustion when trying to cope with their crying babies; just getting through the next 24 hours becomes the priority. This is especially true when they are also trying to meet the needs of siblings and/or doing paid work without support from other caring adults.

My beliefs influence my objections to controlled crying and any other form of sleep- training. Depending upon the frequency, duration and intensity of each attempt, I believe it can be disrespectful of babies’ efforts to communicate and undermine their ‘sense’ of trust and safety.

I also believe controlled crying to be a ‘cultural construct’ ie an attempt to manipulate normal infant sleep behaviour to fit our lifestyles. Importantly, it also goes against what we are pre-programmed to do as mammals, including our vital need for skin-to-skin contact.

Just like we see in other species of mammals...
“The infant actively seeks to adhere to as much skin surface on the mother’s body as possible.”                                                                                                                        (Harlow 1958, in Effects of a Secure Attachment Relationship on Right Brain Development, Affect Regulation and Infant Mental Health, A N Schore, Infant Mental Health Journal, Vol 22, 2001)
“...we know from daily life that we exist for other people first of all; for whose smiles and well-being our own happiness depends.” Albert Einstein
In concluding I suggest we would all benefit from a willingness to re-evaluate beliefs and attitudes which undermine normal human development; including those surrounding controlled crying/sleep-training.

Wishing you joy & peace for the year ahead.

Julieanne

PS:  After an extensive search, the only official policy/position statement that relates specifically to controlled crying was published in 2004 by the Australian Association of Infant Mental Health Inc (AAIMHI). If you know of any others I would really appreciate a link.

PSS:  I've been a bit slow off the mark with my first post for 2013. At the beginning of December I had successful surgery in Sydney to 'fix' a brain aneurysm (via an artery in my groin - amazing). It's a huge relief not to have to walk around with a time bomb in my head! How lucky I am to live in Australia and have access to some of the best medical care in the world.

21 November 2012

Controlled Crying: Historical Perspectives


Hi Everyone

Research published last month by the Australian-based Murdoch Childrens Research Institute (MCRI) concluded that:
“…parents can feel confident using, and health professionals can feel confident offering, behavioural techniques such as ‘controlled comforting’ and ‘camping out’ for managing infant sleep.”
I started wondering where this idea came from in the first place and decided to investigate its history.

Controlled Crying – Origins
In the late 1800s Western societies began to rely more on science than Bibilical/spiritual leaders or individuals with personal experience to answer life’s dilemmas, including those writing about the care of children.

Women’s role in society shifted as more demanded the right to vote and worked outside the home. The movement of women into ‘male’ occupations provided a platform for those with feminist leanings to perceive womanhood as becoming more equal to men. For example, in his 1980 book The Changing Folkways of Parenthood Herbert Costner wrote:
“… the adoption of 'manly' occupations (by women) and the application of the 'manly' ways to the feminine sphere of activities, e.g. 'rational-scientific' methods in the care of the home, in the preparation of food and in the care and training of children, became 'self-respect' symbols to women whose self-image no longer included a conception of themselves as irrational and flighty, and, in general, inferior to men."
Mothers’ groups in the US - once led primarily by members of the clergy - began to invite those considered to be experts (rational/scientific) in the emerging field of child development. Possessing moral integrity (as with religious principles) started to become less of a societal focus than productivity and accomplishment. Parental values and child-rearing shifted to match what was fast becoming a more capitalistic society, resulting in more emphasis on children having the capacity to be effective producers and high achievers.

Dr L Emmett Holt (1895-1974)
In 1894 Dr L Emmett Holt first published “The Care and Feeding of Children: A Catechism for the Use of Mothers and Children’s Nurses” which remained popular until about 1934. He recommended strict schedules for feeding and toilet-training and minimal affection and advised that:
"A really contrary infant might try for an hour, or even for two or three hours, to get the best of his mother by crying. She must never give in, provided she is convinced that nothing is physically amiss with the child. Habitual criers should be left alone most of the time; otherwise they might become 'nervous.' Babies under six months old should never be played with, and of kissing the less the better."


John B Watson (1878-1958)
In 1928 John B Watson and his wife Rosalie published “Psychological Care of Infant and Child” and although highly criticized, the book became a best-seller. Prior to becoming regarded as an expert in child-rearing, Watson was best known for developing ‘behaviourism’ as a psychological theory. Unlike Sigmund Freud’s focus on introspection and consciousness, he advocated for an objective, scientific approach to the study of psychology.
The overall theme of Watson’s views can be pretty much summed up by the following example of advice to parents:
"Never hug and kiss them, never let them sit on your lap. If you must, kiss them once on the forehead when they say good night. Shake hands with them in the morning."
Watson & assistant testing grasping reflex (Photo:  F Hamburger Jr)
Using methods which today would be deemed highly unethical, Watson tested his theories on how to condition children to express fear, love, or rage - emotions he viewed as the basic elements of human nature – by dropping and catching infants to generate fear (photo right).

Watson also used his two sons as subjects for his theories and promoted them as ‘the behaviorist's plan in action’. It’s interesting then to read that five years before her death in 1935 Rosalie, the mother of his sons, wrote an article for Parents’ Magazine called "I Am the Mother of a Behaviorist's Sons” saying:
"In some respects I bow to the great wisdom in the science of behaviorism, and in others I am rebellious. I secretly wish that on the score of [the children's] affections, they will be a little weak when they grow up, that they will have a tear in their eyes for the poetry and drama of life and a throb for romance. . . .I like being merry and gay and having the giggles. The behaviorists think giggling is a sign of maladjustment."
Later in life Watson publicly regretted much of his advice to parents saying that he ‘did not know enough’ to do a good job.

The Ferber Method
Dr Richard Ferber
 According to Wikipedia ‘Ferberization’ is an approach that can be traced back to Holt’s book (see above) and “…is a technique invented by Dr Richard Ferber to solve infant sleep problems. It involves ‘baby-training’ children to self-soothe by allowing the child to cry for a predetermined amount of time before receiving external comfort.”

The first edition of Dr Ferber’s book "Solve Your Child's Sleep Problems" was published in 1980. In an article called “Sleeping with the Baby” written by John Seabrook for The New Yorker in 1999 Dr Ferber had changed his original views about co-sleeping ie "Although taking your child into bed with you for a night or two may be reasonable if he is ill or very upset about something, for the most part this is not a good idea…sleeping alone is an important part of his learning to be able to separate from you without anxiety and to see himself as an independent individual."

Dr Ferber told Seabrook:  "I wish I hadn't written those sentences…that came out of some of the existing literature. It is a blanket statement that is just not right. There's plenty of examples of co-sleeping where it works out just fine. My feeling now is that children can sleep with or without their parents. What's really important is that the parents work out what they want to do."

Dr Ferber made modifications to this effect in the 2006 edition of his book (Wikipedia). With respect, I find it contradictory then that in a 2004 Q&A session published by the Children’s Hospital Boston in Pediatric Views, he hadn’t seemed to have relinquished much at all; either to his original views or the prevailing physiological and anthropological knowledge re infant sleep. 

Following is the first question and answer:
"Q:  At what age should a baby who still wakes at night be considered to have a sleep problem?
A:  By 3 months old most babies are waking only once or have started sleeping through the night; they should definitely be doing so by 4 or 5 months old. So, for example, if an otherwise healthy 6-month-old (and certainly an 8-month-old) is having problems going to sleep, is waking up for extended periods, or is waking repeatedly during the night, then there is definitely a problem."
Seabrook also adds an insightful cultural observation in his article:
“Perhaps the American veneration for a night of unbroken sleep is another culturally determined prejudice, posing as science. Here, if you're awake, you're supposed to be busy with wireless communications. Sleep is the only private time you've got left, and it's not surprising that people tend to make a fetish of it.”
It seems many Australian parents share such 'veneration', but I see it, for the most part, as a cultural deficiency in postnatal support. I think something is definitely amiss when some are willing to pay a sleep 'whisperer' up to $2500 with no guarantees.  

Most telling to me regarding the origins of controlled crying is the persistent negation of the role that breastfeeding plays in what we now know to be the normal neuro-physiological synchrony of mother-infant sleep. Sadly, I don’t think a whole lot has changed.

More Quotes:  1916-1931
"This disease (rickets) is confined almost exclusively to infants who are artificially fed. ...Just what exists in breast milk that prevents, and what is absent or present in cows' milk which permits or causes the symptoms of rickets to appear, has not been clearly defined.

The responsibility for the failure to conserve the maternal milk-supply, while dual, rests with greater weight upon the physician, who, while realizing the value of natural and the dangers and uncertainties of artificial feeding, has failed to become fired with that enthusiasm which the subject demands."
(A Practical Treatise on Infant Feeding and Allied Topics for Physicians and Students, 1916)
"It is well that a growing infant should cry a little every day. ...The baby should be made to cry every day by slapping him on the buttocks." ...
“When the baby is just born and during the first few days of life, it is very little more intelligent than a vegetable.” …
"Badly managed and spoiled infants often cry vigorously when left alone, and when attention is given to them and they are taken up or talked to, the crying ceases.” …
“How often do we see the young infant stop crying at two weeks of age when it is picked up by either parent. Herein lies the potential juvenile court case. Unless the parents are guided by the physician, even at this early stage, the infant soon learns to put one over on its parents.”
(The Normal Child, by Alan Brown, 1923)
"Few people realize the importance of vigorous, lusty crying in a healthy infant. It is as essential to the infant as exercise is to the adult. It is, in fact, the infant's daily exercise. All young babies should have a crying period during each day...The infant who cries regularly between 5 and 6, or 8 and 10 o'clock in the evening is doing what is called "reflex crying". It is not to be assumed under such conditions that he is suffering either discomfort or pain, but it is to be taken for granted that such crying is good for the baby and is as important as food."
(Alton Goldbloom, 1928)
"The baby should sleep alone in a room or at least have a crib or a bed to himself. Never rock a baby to sleep. Never put a baby to sleep in your arms; it is a bad habit, tiresome for yourself and unwholesome for the baby."
(Canada's Baby Book, 17th Edition, 1928)
"Regularity of nursing is most important. The infant should always be fed exactly at the stated hour and never at irregular intervals, as this upsets the baby's routine and soon leads to stomach trouble. If the infant wakes up and cries before the feeding hour he should be examined to see if he is wet, and if so, changed and then offered some plain boiled water. If the infant is asleep at the feeding hour he should be awakened. It is remarkable how these infants learn to wake up at or shortly before the appointed time. After a few days' training they behave like little machines."
(The Home Care of the Infant & Child, F Tisdall, 1931)

Dear oh dear oh dearie me - what were we thinking!?

My next post will be about recent research and the critical analysis it evoked.

Bye for now & thanks for reading!

Cheers, Julieanne

Sources for this article:
Free ebook “The Care & Feeding of Children” by L Emmett Holt
Article “Psychological Care of Infant and Child: A Reflection of its Author and his Times” by Suzanne Houk
Article “It's All in the Upbringing” by Joanne Simpson
Wikipedia re Behaviorist John Watson (1878-1958)
Quotes 1916-1931 Dr Jack Newman MD, IBCLC


20 September 2012

Mother Guilt: To Be Or Not To Be

Hello Everyone

Sometimes I think we confuse guilt and regret. I know I have and still do. As adults, I don't think anyone makes us feel anything we feel, including guilt. I think we listen to our conscience, weigh things up and then feel what we feel.

Here in Australia it seems most TV coverage about mothering and/or choice of infant-feeding disintegrates quickly into a conflict of 'Us vs Them' - breastfeeders vs bottlefeeders. Comments like "Just one more thing to make us feel guilty" or "As if we haven't already got enough to feel guilty about" tend to become the focus of the reporting, and especially when it's about new research into breastfeeding.

12 April 2012

'Screw Business as Usual' for Maternal & Newborn Services


Hi Everyone

Yes it's been quite a while! Every now & then I get so disheartened with what seems to be such a struggle to improve things for mothers & babies - hence no enthusiasm for writing.

However, I've regrouped to 'take heart' again and go out on somewhat of a limb by submitting my idea to Virgin Unite's competition about what I would do to 'screw business as usual. Virgin Unite is the non-profit part of Richard Branson's company & they do some pretty amazing work around the world.

Below is a copy of my entry. If you feel inclined to vote for it, the link will take you to where you can Like/Tweet/+1. The top 10 ideas will be in with a chance to win.

See what you think & please vote by April 17:

Here’s my idea to ‘screw business as usual’ for maternal & newborn services. It’s motivated by my desire to improve maternity services locally & globally and speaks to the heart of Millennium Development Goals 4 & 5: Reduce Child Mortality & Improve Maternal Health. Local for me is the Hunter Valley, northwest of Sydney, Australia. My name is Julieanne Hensby & I have been a Lactation Consultant IBCLC (International Board Certified) for 19 years.

As UN Secretary-General Ban Ki-moon said at the ‘Every Woman, Every Child’ summit in September last year, “...we believe now that the health of women and children is essential to global development and our future prosperity.”

In this spirit I would like to build a Human Ecology Hub that is purpose-built & energy-efficient. Human ecology is about the interaction between people & their environment and what we need to be physically & emotionally healthy.

Central to the Hub would be a Research Centre for Maternal & Newborn Health. The evidence tells us that what happens when we’re born (our first environment), how we are fed, and the quality of our interpersonal relationships from 0-3yrs have the most significant impact on our lifelong physical & emotional health and that these processes greatly influence the way developing brains are ‘wired’.

Evidence also tells us that when possible, uninterrupted skin-to-skin contact as soon as possible after being born (lasting ideally for about 60-90 minutes) triggers the mammalian feeding sequence common to all species of mammals. This optimizes the chance of being fed breastmilk, maintains the production of ‘nurturing’ hormones in mothers & enhances positive interactions ie bonding. I call this the Mammalian Matrix©.

HOW IS MY IDEA DIFFERENT?

Firstly, the Centre would provide the full spectrum of pre & postnatal services, but also include:
1.  donor human milk bank
2.  facility for breastmilk stem-cell research (as begun by Uni Western Australia) & other relative research
3.  baby-friendly cafĂ© open to the public
4.  retail outlet selling maternity products eg the Mothers Direct shops run by the Aust Breastfeeding Assoc (ABA)
5.  multi-purpose training/continuing education facility eg for health workers from both developing & developed countries to visit, learn and share knowledge re new research findings & best-practice

Secondly, and this is the tricky bit - the financial structure of the Human Ecology Hub would need to enable universal access to maternity services regardless of income. Perhaps the Hub could operate under a combination of for-profit, not-for-profit & profit-for-purpose enterprises. High hopes I know, but where there’s a will...

Thirdly, the maternity services of the Research Centre would:
1.  Operate under the guidelines of the WHO/UNICEF Global Strategy for Infant & Young Child Health and its facilitator - The Partnership for Maternal, Newborn & Child Health
2.  Encourage Kangaroo Mother Care (skin-to-skin) as the norm for all newborns, including those born prematurely and combine high-tech incubator care when necessary. The Bill & Melinda Gates Foundation promote the use of Kangaroo Mother Care and also recently announced a new commitment to maternal, neonatal and child health, family planning and nutrition of $1.5B over 5 years.

As Richard Branson said in his 60th Birthday video, “The 3 most important things in business are people, people & people.” I am confident that I can bring together a team of people for the Research Centre who have the required expertise & whose hearts are in the ‘right’ place.

I began thinking about this in 2008. I know it’s big & I’ll need lots of help but bottom-line, I don’t want to have lived without having tried.

If your votes get me ranked in the ‘Top 10’ I’ll have a chance of being able to elaborate further with Mr Branson about my ideas for both the Research Centre and other ‘ecological’ enterprises which could be included in the Human Ecology Hub.

Thanks for your time, Julieanne

LINK:  Screw Business as Usual for Maternal & Newborn Services

11 December 2011

A 'Different' Christmas Message for Peace

Source: kangaroomothercare.com via Uppsala Academic Hospital, Sweden
Hi Everyone


For the last couple of decades my Christmas sentiments have centred mainly around peace.


Along with social justice, it is also the bottom-line motivation of my work as a lactation consultant.


I believe a peaceful world begins with peaceful people.


I believe one of the most effective ways to optimise our chances of creating peaceful people begins with the relationship between mothers & their newborns.


I believe such relationships are most easily achieved by utilising, when possible, the normal biology of birth & infant-feeding.


This is in no way a judgement call re 'good/not-so-good' mothering & all that nonsense. It's about striving to learn as much as we can for future mothers & newborns.


INFANT SOCIAL/EMOTIONAL COMPETENCE & BRAIN DEVELOPMENT


To better explain, I encourage you to view the video clips below by Dr Nils Bergman, best known for his work & research in Kangaroo Mother Care (KMC), who describes what I have written above as "...creating an attachment environment...that "...optimises the trajectory..." in terms of brain development & social/emotional competence.


Bye for now & wishing you peace.


Julieanne


PS:  I am affiliated with an ebook by Aussies Tony & Nyrie Roos called The Miracle of Kangaroo Mother Care. Lots of good info plus bonuses - you can check it out here.


PSS:  Please ignore this - it's just to prove to Technorati that I'm the author of this blog. (Technorati blog directory verification ID:  JHKUAP9GE2HP)


VIDEOS (11 minutes in total)


What We Can Learn from Horses (3 min)

The Social & Emotional Intelligence of Infants (3 min)

Skin-to-Skin Contact (5 mins)