Infant care researcher and clinical director Dr. Pamela Douglas explains an emerging evidence-based paradigm in infant sleep that does away with sleep training. She shares with Adriana the importance of providing babies with rich sensory nourishment, and what long naps have to do with excessive night waking.
What is your go-to solution when your baby is unsettled and can’t sleep? Share your secrets with our community @birthfulpodcast on social media.
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Related Birthful episodes:
- The Possums & Co. website, including:
- Catnapping Could Be the Answer to Better Baby Sleep, BellyBelly
- The Discontented Little Baby Book, by Dr. Pamela Douglas
- The Possums & Co. blog, including:
- From “Crying Expands the Lungs” to “You’re Going to Spoil That Baby”: How the Cry-It-Out Method Became Authoritative Knowledge, Journal of Family Issues
- The Epidemic of Baby Sleep Training, Sarah Ockwell-Smith
- The History of Sleep Training, Integrity Calling
- The History of Sleep Training, Intuitive Parenting
One thing you can do for you is… support your own sleep, to help you in supporting your baby’s sleep. One way that you can do so is to have your levels of certain vitamins and minerals checked at your next appointment with your care provider. While it’s completely physiological for your iron levels to drop in pregnancy, for example, sometimes it’s a bit harder to rebound and nourish your body during postpartum. Iron, magnesium, and vitamin D have all been noted to have impacts on your ability to fall asleep and stay asleep, so if you’re feeling restless, investigate further!
The one thing you can do for the rest of us… learn more about the history of sleep training, and how it’s a practice that was created and perpetuated with very little understanding of baby’s physiological needs. The field of infant neurodevelopment has exploded over recent years, and it’s time that we collectively update our views around sleep training, similarly to what we’re doing with perinatal practices like episiotomies or optimal cord clamping. To help with this, we’ve linked a few articles in the show notes for this episode, like The Epidemic of Baby Sleep Training by Sarah Ockwell-Smith and The History of Sleep Training from the Integrity Calling blog.
Can You Let Your Baby Sleep Whenever They Want?
Adriana: Welcome, Pam! I am so very excited to have you here on the show.
Pam: Thanks, Adriana. I’m delighted to be with you.
Adriana: Why don’t you tell the listeners a little bit about yourself and how you identify?
Pam: I’m a GP researcher. So a general practitioner and researcher, founder of the charity known as Possums & Co., also founder of the programs for parents with babies that are known in the research as “Neuroprotective Developmental Care” and founder of the Possums Baby and Toddler Sleep Program. I’m an adjunct associate professor at Griffith University here in Australia and also affiliated with the primary care clinical unit at the University of Queensland. And I have two children and four stepchildren and a wonderful, adorably-precious bunch of grandchildren.
Adriana: Tell me, Pam, what does Neuroprotective Developmental Care mean?
Pam: Well, it’s, it’s a suite of programs. Evidence-based programs- detailed in something like 30 research publications now- that deal with the challenges that can emerge across feeding of our babies, across sleep, those cry-fuss challenges that can be just so difficult for families. And also integrated deeply into our programs, are strategies for supporting parent mental health and emotional wellbeing.
So that’s the territory that’s covered by our Neuroprotective Developmental Care programs. Does that make sense?
Adriana: And fits perfectly into our conversation today, which is trying to figure out how to navigate life and baby sleep— which tends to be, I find after the birth, the biggest hurdle for people, even sometimes harder than breastfeeding (even though those can be connected). So in that conversation of navigating life and baby sleep, what are some realistic expectations that people need to understand when figuring out how babies sleep?
Pam: There’s, you know, a number of things that I’d like to communicate there about infant sleep… but I wonder, Adriana, whether the first place for me to sort of start is, is just acknowledging upfront that parents will get huge amounts of conflicting advice about their baby’s sleep and, and actually in our world today, there’s a very heavy focus on what you might call “sleep training”. And really, wherever parents turn, they’ll get advice that comes out of, well… really the 1950s/1960s, was when sleep training originated. You might call it, technically, a first-wave behavioral approach to baby sleep. And that advice says things like, “Sleep breeds sleep.” “First tired signs, get the baby down.” “Don’t let them be awake for more than a particular window of time before you put them down.” “You’ve got to teach the baby to self settle.”
So, you know, “Put the baby into the cot, drowsy, but awake.” “Don’t let the baby get overtired, overstimulated.” “Try to get 12 hours overnight.” “Don’t let the baby develop ‘bad habits’.” “Don’t let the little one go to sleep with the breast or the bottle.” Don’t even let the little one go to sleep, perhaps, in arms— because that’s viewed as, as a bad habit.
So I think any conversation about a different way of making sense of baby sleep just has to start with an acknowledgement that this sleep training approach is so dominant out there. And parents will get lots of advice that the sleep training approach is best for their baby’s developmental outcomes and best for the family.
But if we actually look at the research- and I think there’s been five systematic reviews, now, that draw together all the existing research and analyze it (and one I published with a co-author, but there’s another four)- we actually find, when we bring together all this research, that the sleep training approach isn’t decreasing the frequency of night waking.
And there’s also growing evidence to show that the sleep training approaches ramp up anxiety and distress within a family. And so seeing this happening in the research years ago now, I (with, with some various colleagues) went right back to the research literature and, uh, put together a completely different way of making sense of baby sleep.
So, you know, what are some realistic expectations for parents around baby sleep? Well, one of the most important things to communicate is that baby sleep needs are incredibly biologically variable. So, we can have say a newborn who might hardly need nine hours total in a 24-hour period of sleep. And that, that newborn might only be taking, say, half an hour, total during the day- 10 minutes here in 10 minutes there- and admittedly, that newborn would be at the very low end of the curve of biologically-normal sleep needs.
But that baby is absolutely normal, with normal developmental outcomes. And then we can have a newborn at the other end of the bell curve of baby sleep needs, who might actually need 18 hours total in a 24-hour period!
So we just want to support families in understanding the healthy function of the baby’s biological sleep regulators.
Adriana: Let me ask you a question, in terms of that broad scale of how many hours are possible — you mentioned between nine and 18?
Pam: Yeah. Depending on the age of the bubby, yeah.
Adriana: So, that was going to be my first question: like, are we talking nine to 18 range at… one week? And how does that shift for a six-month-old, or what is that kind of range?
Pam: Yeah, so sleep needs do shrink throughout the first year of a baby’s life. So a six-month-old is likely to have a range that could still be, you know, the eight-and-a-half, nine hours total. If the baby’s at the low end of the sleep need curve, but it, you know, it might be more like, say, 16 hours or something for a very high sleep needs baby. Trying to capture it in figures- because it’s such a broad range- really doesn’t help parents at all, actually.
Adriana: Let’s flip it. If we’re not going to look at a specific amount of hours- just to know that there could be a really wide range of how many hours they need- how then can somebody recognize that their baby is, is getting the right amount of sleep for what their baby’s needs are?
Pam: So, you know how there’s been a real movement in breastfeeding support to trust that if we’re offering the breast frequently and flexibly, the baby- as long as there’s no underlying problems- will take the amount of milk that he or she needs? Well, similarly, with a baby’s sleep needs, we can actually trust our baby’s biological sleep regulators.
If we’re having days that, that meet the baby’s milk needs- however, we’re doing that- and have days that are full of rich and changing sensory nourishment, then actually babies will take the sleep that they need and we can be incredibly relaxed about that!
There is a situation that emerges quite commonly, of what we would call “excessive night waking”— and that’s different to developmentally-normal night waking. So, “developmentally-normal night waking” right throughout the first year of life and, really, into toddlerhood.
And I hate to say it, but, but it’s really clear from, from big cohort studies looking at, at normal night waking frequency, our little ones can wake every couple of hours, right into toddlerhood, actually.
But we just want to support everyone getting back to sleep really quickly! So: no burping, no holding upright, no changing the nappy (once you get out of those, those very early weeks).
Adriana: Okay, wait, wait. Let’s… I want to take it back! So many questions… You mentioned that “developmentally-normal night waking” is every couple of hours into toddlerhood, with everybody falling back to sleep quickly. What is “excessive night waking”?
Pam: Yes, that’s an important question. So this is, these are the families who are moving into patterns of the little one waking, maybe every hour, sometimes every half an hour, or every 45 minutes for, you know, whole parts of the night. And this is happening regularly throughout the week.
So any family will, will have the odd, really bad night. And we just move through it as, as we can. And then that bad night’s behind us! But when we start to see patterns of, of waking really regularly like this- every hour or more- then we’ve moved into “excessive night waking”… and we can help that! Because this is simply a disruption to the circadian clock; disrupted sleep patterns like this come out of disruption to the settings on the circadian clock. And if we understand how to work with these two biological sleep regulators- the circadian clock, and then the sleep pressure (the sleep pressure is regulated by the sleep-wake homeostat)- if we understand how to work with these two sleep regulators, then over a period of a couple of weeks, we can actually deal with the excessive night waking and move that family back into much more manageable, developmentally-normal night waking, which may be up to every couple of hours.
Adriana: Well, and some people would say that waking up every couple of hours into toddlerhood- even though developmentally-normal- sounds like not a great time. But what I’m hearing from you is that it’s not so much the waking, it’s the being able to fall asleep quickly… and that the waking is more waking to… feed? Do I have that right?
Pam: That’s right, although, you know, some families might night wean in that first year of life and there’s no guarantee that the baby will wake any less often. I guess there’s a couple of things there to unpack! So firstly, babies aren’t waking excessively because they’re breastfeeding. And even our developmentally-normal night waking may not necessarily be because of hunger, but because of a desire- it’s like this, this biologically-hardwired need- to come up close to the parent body for a breastfeed or a bottle feed or a cuddle. So, the developmentally-normal night waking… it’s a time of life that’s demanding, but, but in fact, it shouldn’t leave parents with unmanageable, severe sleep deprivation.
Adriana: And I think for not being left with the sleep deprivation, the key there is the part where you say, everybody gets back to sleep quickly! So let’s get more into like, how do you get everybody back to sleep quickly?
Pam: So, there’s a number of things to address here. So firstly, a lot of our families are being advised that they need to be burping their babies after feeds or holding the baby upright for a period of time after feeds. And in fact, we don’t need to! Even our little ones who have feeding challenges, we want to sort out the feeding challenges, but they’re not swallowing air the way folks are hearing at the moment. I know this from the research, and burping is really a culturally-specific practice. You know, most human cultures don’t burp their babies! It’s actually quite disruptive at the end of a feed because the little one has dialed right down with all this sort of activation of the parasympathetic nervous system and the cholecystokinin of a feed, they tend to dial right down and drowse into sleep.
If we feel we’ve got to be burping or holding upright, that’s really rousing for our babies! As is feeling that we’ve got to swaddle that little one— but actually the research doesn’t bear that out. And for many families trying to get that little one zipped back up into the swaddle suit, or literally wrapped up, rouses the baby and makes that return to sleep more difficult for everyone.
Changing of the nappy- well, with our newborn skin, and of course with any poop- we do need to change a nappy, but as the little one moves out of the newborn phase, I certainly encourage families to use their barrier cream, but only change the nappy when you absolutely have to in the night, because again, that can rouse everybody.
And then the other thing to consider is where our little one’s sleeping. So the Possums sleep program of course supports all the precepts of safe infant sleep. So the little one does need to be on their back— not on their side, and certainly not on their tummy. The little one needs to be in a safe sleep space.
And, and when we look at the research, we know that, we just know, that most families at some times, some nights at least, will have the little one sharing the bed. So we’re very concerned to just have families know how to share the bed safely. And there are plenty of families who find that the bedsharing supports less disruption in the night.
Certainly we want that little one in the same room as the parents- both day and night actually- that’s, that’s safe sleeping. And many other families will use, say, a side crib (or we call them, “sidecar arrangements”).
I suppose the other thing to talk about there, is our busy minds in the night. And so what we need to do is have some strategies up our sleeve for managing the worried mind that so much, very often, so much a part of having a baby isn’t it?
So having some simple strategies for managing that and for quieting our mind in the night, it’s really empowering for families too.
Adriana: Now, for people who swaddle, for people who burp and go, “My baby has a lot of spit-up, and burping seems to get that air out” and ” I don’t know what I would do if we don’t swaddle!” How do you encourage them to explore these alternatives and see what it’s about?
Pam: Yeah, that’s it. So, I’m always saying- you know, I might argue that “What I’m offering you is with all the latest evidence!”- that doesn’t help parents. All parents can do is experiment their way through and that, that’s your great source of resilience, your great source of strength, actually, because you’re the expert on your baby.
Take an idea and see what happens in your context. Give things a little bit of time, because babies get used to things and then we’re just teaching them something new. It can be helpful too, to just let parents know that even though you get lots of advice- that the baby swallowed air and that that’s going to come up and unsettle the baby, or come up and cause the bubby to spill to do a puke- it’s kind of actually, it’s a kind of misconception around the physiology of at all. This has been one of my research focuses!
Puking is so normal for our babies right throughout; it peaks at about four or five months of age, actually. But it’s not acidic the way people tell you! Actually, reflux coming up, you know, after feeds- whether it’s breast milk or formula- for close to two hours after feeds. It’s close to pH neutral and it’s not causing acid and pain the way people think.
It’s true that the gut is like a second brain. So, the gut is highly innervated. And when our little ones rouse in the night, you could say, they’re starting to rouse up out of sleep, starting to get a bit of a grizzle, we call that the sympathetic nervous system dialing up. Well, the gut gets active at the same time that the sympathetic nervous system also dials up the gut. And then you will hear the baby pass some flatulence or the baby might do a little puke or, or burp.
And naturally, parents think, “Oh, was it gut pain that caused my baby to wake?!” But I invite parents to do this flip, with making sense of it differently. That what’s happened is your little one starting to dial up and starting to communicate to you, coming up out of sleep. And then the gut gets active, but the gut event is not causing the baby to rouse… the baby’s rousing, and then dialing up. And if this is happening excessively through the night, often at the six to eight week mark, parents will say that the little one’s just groaning and grunting, and in and out of sleep for half the night, and they’re not getting any sleep. They think, “Is it gut pain?” “Is it allergy?” “Is it reflux?” Usually what’s happening there is that the circadian clock needs support to hasten into a more mature setting. The little one’s rousing because of his or her metabolism— the little one’s more or less ready to party and see the world and see the day. But the circadian clock is not yet properly aligned with, with the parents’ circadian clock.
Adriana: And we talked a lot about the night; I do want to talk about the day, but I also want to bring in this concept that you’ve been mentioning a couple of times, about the circadian rhythm and how to support those circadian needs.
Pam: Well, what I might do is start with the sleep regulators, the circadian clock, and then talk about the days. So there’s the two sleep regulators, actually, both for adults and, and for babies. There’s… sleep is set by the circadian clock and by the sleep-wake homeostat. And so the circadian clock is set by the sun and we need to keep the cues of daytime noise activity, quite separate to the cues of night (quiet, dark, less activity), even though in the night we’re still eye contacting and meeting our little one’s needs.
During the day we wouldn’t sleep babies in quiet dark rooms. Not only because being in a separate room is not as safe, but also because the quiet, dark room confuses the circadian clock and makes the circadian clock think the bubby’s moved into a little nighttime situation.
So sleep during the day is in the middle of, you know, noise activity, other siblings running… the baby’s following along and sleep will look after itself. So we want to keep those circadian cues quite separate. And evenings I think of as day— so it’s still light-noise-activity (family life!) until the little one’s sleep pressure is so high that he or she is ready for the big sleep at night.
So that’s the second sleep regulator, it’s the sleep-wake homeostat. And this is a system of neuro-hormones that drops right off when we sleep. And so for me, when I wake in the morning, given that I don’t have little ones waking in the night, these hormones are really low. They’re rising all day and they peak at, say, 10 o’clock at night and that’s when my sleep pressure is really high. That’s when I feel sleepy and I’ll put my head down.
Now with our little ones, their sleep pressure is rising much more quickly, but the function of the daytime nap is just to take the edge off that rising sleep pressure during the day. And, you know, depending on the baby’s sleep needs for some little ones, that’s just a few moments and there’s this sudden drop in the sleep pressure, and then on with the day again.
You know, you, you’ll all be familiar with how often our little ones may drop off at the end of a feed. We put the little one down and then they wake up and, and apart from the natural disappointment that you haven’t had a moment’s break, that is so normal. So normal. And you might do a little transitional breastfeeding, on with the day.
Adriana: But, we’ve been very much conditioned that that is very frustrating and not acceptable, right? Like I, you just got to sleep… you’ve been asleep for 15 minutes, maybe 10… I put you down in the crib and you wake up and now we’re done with this nap? Like that’s not what I had planned in my life! How can I go and navigate my life when I don’t have expectations of what my day will look like, Pam? Help me out, I’m a frustrated mom!
Pam: Yes, I know. I know. I know. And this is huge. It’s absolutely huge because very often we do have the woman as the primary carer and she doesn’t have huge amounts of support around her, often very little, and the idea of a baby’s sleep being a time where she can, well, for goodness sake, just have a cup of tea or even get something done or, or maybe even lie down, is huge. Unfortunately it can really backfire if we’re hooking our need for rest and restoration into the baby’s sleeps during the day. It is sometimes possible to grow bigger blocks of sleep during the day, you know, and sleep training strategies focus on this, but what happens two weeks down the track, three weeks down the track is that we start to slip into patterns of excessive night waking because this growing of big sleep blocks during the day actually disrupts the circadian clock and worsens nighttime sleep.
Adriana: So I want to bring in a couple of scenarios ~to see how those~ so we can visualize what that looks like. So, ’cause you’re talking about having a rich life outside the home and going on about your life and just doing, you know, whatever it is. And that baby will basically cat nap whenever they feel like it.
Adriana: But we know that for some of us that have winters. out and about daily life is not necessarily something that’s available. And also… we are still in a pandemic, which means that we’ve been locked into our houses! So what about that parent, that’s spending basically almost all their day at home with no social activities and a baby and trying to find some solace?
Pam: Yes. Yes. And look, this, the pandemic context and families in lockdown with babies has just been, it’s just terrible. It’s, it’s really, really tough. So the very first thing to say there is enormous self-compassion because babies will dial up inside the house just because our homes are low sensory. So it, it, it’s likely to be a rougher, you know, journey.
The little one’s likely to be more unsettled in a lockdown situation than would otherwise be the case, and enormous self compassion, self-kindness is required there. But I’ve actually written an article- again, freely-available in our blogs on possumsonline.com- about meeting baby’s sensory needs as best we can in the pandemic context, particularly in lockdowns.
And I hear what you’re saying about climates that, that make being outside the house very unattractive. But to the extent that we can rug the baby up, if necessary, if we’re in a cold climate and still get out into the street or a backyard… to the extent that we’ve got windows of opportunity where we’re allowed to be walking or exercising, depending on the particular regulations of lockdown, you might be able to walk with a friend socially-distanced. But anything outside the house will increase the sensory nourishment the baby’s receiving and help keep the little ones more settled, dial them down.
Adriana: And, quick question: What about babies? I’m talking, you know, those first few months, even four or five months, that will only sleep when held.
Pam: Well… and this is, you’re thinking daytimes here in particular, right? But also at night?
Adriana: In particular, but sometimes at night as well.
Pam: Yeah. Yeah. Well this is, this is interesting, isn’t it? Because it’s true that these little ones, you put them down, they wake… but I would say, well, if that little one really needed to sleep, you’d put him or her down and they’d stay asleep, but the sleep pressure is not that high.
So when you pop them down, they wake, that’s okay. They’ll cry. Not because they need to go back to sleep, but little ones do cry when they wake, because they’re thinking, you know, “Where’s my mummy?” “Where’s, where’s that loving person’s body?” So they, they’ll cry when they wake, but often families are told, “Oh, if they cry when they wake, it’s because they need to go back to sleep during the day.” We’d say, “Oh, just get them up!” A little transitional breastfeed, but on with the day. Sensory nourishment… sensory nourishment, and we can trust that if they really needed more sleep, they would have taken it.
And that will protect the nights, because if we’re doing a lot of contact sleeping and really trying to keep the baby asleep during the day, the risk is in two or three weeks, we start to get excessive waking at night.
So really it’s thinking differently about baby sleep during the day. We’re not trying to get the baby to sleep. We’re not trying to keep the baby asleep. We want those days before we have to return to work, when we are home with the baby a lot, to be as enjoyable and socially-engaged as possible. Lots of walking, if you can. The concept is that we create life that’s rich and full and meaningful for that primary carer, that woman, and the baby fits in… but it’s happening outside the house where there’s lovely, rich sensory nourishment, which is so good for a baby’s developing brain. It really does optimize developmental outcomes.
Adriana: And I love that concept, to really trust and go about and do things. What about the person that is out and about with their child, and then they have a very unsettled, fussy baby? The baby’s just unhappy- even crying- and then, you know, that makes the whole outing a… not a fun one.
Pam: Yeah. And look, you know, there are days that, there’ll be sort of days that are harder than others with the bubby… but if we’ve got a truly unsettled baby, a baby, you know, where parents, a woman, her heart sinks at the sort of going out because the baby is likely to be crying and screaming. If this is her pattern, her experience, then we’ve got what I would call a clinical problem.
And that’s where my work, you know, our neuroprotective developmental work around the crying baby becomes so important. But I would say something must be happening, probably around feeds, because when we’re out, we’ve got two tools.
So we’ve, we’ve activated lovely, rich sensory nourishment, ’cause we’re out of the house, you know, looking around, seeing the world. How is the tool of milk working for that, for that woman, for that mother and baby? What’s happening with the breastfeeding? Is the breast working as a tool, really, just to dial the baby down as soon as they start to dial up?
And very often, of course it’s not. Or, or, you know, even how’s the woman using the bottle— either with the formula or the express breast milk? How’s that working? We’d be wanting to use the bottle in a way- and again, looking at this developmentally-appropriately- but certainly in those first months of life, we want to use the bottle in a way just as we’d use the breast, that dials the baby down.
So when we’ve got a little one who’s habitually sort of screaming and really fussy when, when the mum is out, I’d say, yep, this is a problem! It is really distressing. It becomes a reason to not want to get out of the house, but then things can get worse and worse because the baby’s sensory needs aren’t being met.
But I’d say if that’s happening, um, you know, I, I would hope for that woman that, that she could get some really good health professional input to sort out why the milk isn’t working.
Adriana: Pam, thank you so very much for this conversation today!
Pam: My pleasure.
Lozada, Adriana, host. “Can You Let Your Baby Sleep Whenever They Want?” Birthful, Adriana Lozada, January 19, 2022. Birthful.com.
About Dr. Pamela Douglas
Dr. Pam has been in general practice since 1987, with special clinical interests in the care of new families, mental health, and women’s health. Her medical research calls for a paradigm shift in the way health professionals approach early life care, in particular, breastfeeding difficulty, unsettled infant behavior, and maternal mood, and offers integrated, evidence-based clinical guidelines.
Her research in women’s studies and creative writing explores the historical and sociocultural factors that explain why early parenthood can be so difficult, and what we as a society might do about it. This aspect of her work casts light, for example, on why different approaches to infant care are so hotly contested.
Dr. Pam aims to empower parents – both in her work developing Neuroprotective Developmental Care, or the Possums programs, and in her writing. She also aims to empower health professionals who work with new families, through educational opportunities.
Dr. Pam is also the author of the book The Discontented Little Baby Book: All You Need to Know About Feeds, Sleep, and Crying, which was fully updated in 2021.
She lives in Brisbane, Australia, and has six adult children and stepchildren, and many very precious grandchildren.
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