Recently the Otago Daily Times (and the NZ Herald by extension) published this article: Sleep lessons halve obesity rates in children. Eye catching isn't it? Well we took issue with the title and the reporting as well as the study itself. In response we wrote a letter to the editor which they declined to publish as they felt the criticism should be directed to the researchers.
We disagreed so have published the letter below:
Letter to the Editor
With regards to your article entitled Sleep Lessons Cut Obesity, published on Wednesday 8 March, I am concerned about both the misleading headline and quality of research promoted in the article.
I am a fully qualified senior nurse with a Masters in Health Science. I am also a co-founder of The Baby Sleep Practitioners, providing specialised advice to families about baby sleep, feeding and emotional needs.
Overall, the study the article references was poor quality and the methodology was inappropriate for the study design. Thankfully, this has been acknowledged by the investigators.
1. It was very disappointing to hear that health professionals providing advice in sleep education group discussed outdated methods, for example: putting new-born babies down to sleep while awake without using any settling techniques; feeding in a dark area and the use of extinction methods in some cases.
2. Even though the results between the 3 groups were statistically insignificant with no difference in sleep quality or duration it was still reported that the sleep intervention group had reduced obesity. This minor difference 0.4kg weight/0.7cm length could be explained as subject bias - parents are likely to record results inaccurately, either unintentionally or intentionally.
Sleep deprivation resulting in poor memory unintentionally skewing data or by recording more activity, less unhealthy food and less wake ups intentionally to make themselves feel better about their situation through their own self believe.
The investigators did acknowledge that the non-sleep intervention control group could not be isolated from external sleep advice – it would be impractical and unethical. This includes strong influential routes such as sleep consultants, social media, the internet, magazines and well-meaning friends and family.
3. Progression of developmental milestones is one of the many factors that seems to be overlooked in this study. For example a baby learning to crawl or walk would clearly have a direct effect on BMI especially given the wide range of what is accepted as developmentally appropriate.
4. I agree that obesity is becoming a problem in preschool children and that the evidence suggests that an overweight pre-schooler leads to an overweight adult. This is of concern due to the associated poor health outcomes, for example the increased risk of heart disease and type 2 diabetes. However formula fed and breastfed infants need to be treated differently without perpetuating mother blame in society around how we feed our babies. It is inappropriate to be labelling a breastfed infant as overweight. A breastfed baby cannot be overfed as any excess weight is required to sustain a baby through periods of illness when ones immune system is developing. This excess weight will be latter lost if the toddler leads an active lifestyle with a diet consisting of variation that is quantity controlled by the baby preferably through self-regulation of sleep and appetite. Therefore, a mother should never feel guilty about putting her baby to the breast for any reason.
Formula fed babies are less likely to lose excess weight gained in infancy and education should be focused on paced bottle feeding and encouragement of babies to feed themselves solid foods with the aim of slowing down the rate at which they eat. The rate and which a baby eats is an important part of developing self-regulation but also will ensure a baby still grows to its genetic potential. If this study or a similar study was to be repeated in future I would advise that the rate at which a baby eats should be an area that needs to be focused on.
There are too many weak areas in this study – before the results can better stand up to scrutiny and peer review, conclusions should not be drawn and promoted.
Amy Sherpa, RN, MHlthSc (Nursing)
The Baby Sleep Practitioners®
Specialised nurses for your baby’s feeding, sleeping and emotional needs
Having a baby can be one of the most wonderful experiences of our lives and often it’s something that many of us have had absolutely no experience in. Not a scrap of it. The learning that takes place is exponential. That, on the back of exhaustion, hormonal changes, financial stress, relationship changes and the feeling like your sanity is balancing on a knife’s edge, puts families in an extremely vulnerable position.
Caring for a baby is one of the most important things many of us will do. I would say it is the most important thing – and yet we get pretty much no up to date education on many of the challenging and vitally important aspects of this.
In the media the bulk of the content is either showing picture perfect families who don’t have a bother on them, or we see trivial, outdated and at times harmful ‘information’ around life with a baby.
They’re having a laugh. That’s what I’m thinking as I read a baby magazine waiting to see the Dr, and I bet my 4-month baby would be too, if only he knew what the ‘experts’ were advising. ‘Don’t rock your baby as you can’t replicate this in their cot…’ I thought to myself, how the heck am I supposed to get my baby to sleep without rocking or feeding him?
Are they trying to make me feel guilty or incompetent because I do this? Does this person know anything about baby sleep biology? Clearly not!
‘Do this’, ‘do that’ and ‘DON’T do this!’ What has parenting information come to? A prescriptive list of Do’s and Don’ts? It’s looks like a list of rules you’d give to your 15-year-old baby sitter.
In NZ mainstream media I think that the most prevalent advice out there falls under the banner ‘parenting for dummies, by dummies’. But here’s the thing – we are not dumb. We want up to date information and intelligent discussion around challenging aspects of parenting. Surprise.
I recently had the TV on in the morning and it caught my attention that they were about to discuss how to travel over the holidays with your kids. OMG. I braced myself and sat down to watch it. Of all the issues they could discuss they chose this. Do they think we are simple? Who does not know to pack food for their children on a long car trip, relax and have regular toilet breaks? Needless to say, I was pretty offended.
Being a parent of a 2 year old and 7 month old and working in the baby sleep industry, I have got my eyes pretty open to what it going on out there - and it’s not pretty. There is SO much guff around that undermines parents confidence in their ability to learn and grow with their baby, and to figure out how they are going to approach things in a way that optimises their babies health and growth, whilst encouraging them to do it in their own unique way.
I always wonder when I see sleep packages for sale with continuous pop up boxes showing you names and locations of parents worldwide that are purchasing this routine at that precise moment. There are just so many, as I start to feel like i’m the only one in the world who is not purchasing this, my baby is going to be I think - are these people even real?
Anyone who knows anything about health education or improving health literacy in an area of health care, knows that it’s key to empower people. We need to feel good about ourselves, our abilities and what we are trying to achieve, as well as understanding the key concepts behind what we are doing. Teach a man to fish! Handing out rules, do’s and don’ts and the like don’t help, in fact they can cause harm – they stop you thinking critically about your own situation, using your own common sense and applying it to your own situation.
With great education and empowerment parents can better understand baby sleeping, feeding and health and can use this information to guide their unique journey with their child.
I am so tired of reading and hearing advice that makes out our babies are born with an innate drive to make our lives difficult, and that we are quite helpless at knowing how to care for them. When you see headlines in popular baby literature like ‘why is getting my baby off to sleep so difficult’ or ‘why am I so hopeless at getting him to sleep’, ‘suddenly it’s not so easy to get baby to sleep’, ‘Your baby should be awake around 45 minutes to an hour’, ‘you need to teach your baby to self-settle’, ‘getting your baby to fall asleep’ and those examples are only from one article - avoid, avoid, AVOID!!
With all this ridiculousness, it’s no wonder we can end up confused, stressed and feeling inadequate. It is these kinds of outcomes that put women at risk of developing postnatal depression and increases the risk of family violence, let alone the poor outcomes for babies themselves due to poor advice. How sad is that?
Broccoli will keep your baby awake
Yoghurt will sabotage your baby's sleep
So many of my clients have been concerned about giving their baby the ‘forbidden foods’ with fear it will disrupt their baby’s sleep. I was equally concerned about this advice so I went and did my research! I have skim read many chapters of baby sleep books (because they were so boring), browsed the internet, revised my physiology of the human body and looked more in depth into the evidence of what hormones control sleep (my brain hurts). Before I launch into my findings, a couple of quotes from the internet just about made me fall off my chair.
‘Yoghurt will sabotage your baby’s sleep’
‘Food pouches are cupboard drugs’
I hope your now understand my drive to get to the bottom of this. The internet can be a dangerous place as your sole source of information on health topics as a vast majority is not scientifically sound and many use pseudoscience to confuse the casual observer.
It seems apparent to me that someone came up with this supposedly scientific reasoning as to why certain foods will sabotage your baby’s sleep and what foods will help your baby sleep. It does not stop here, did you know you also MUST not give your baby red meat or acidic foods before bedtime because it is difficult to digest and might give your baby a tummy ache? Don’t miss the advice around portion size, this MUST only be the size of your baby’s fist otherwise you may be breeding obesity. Rules, rules, and more rules…I am tired of them! Especially because they are a waste of time listening to, let alone investing time in following them.
If it was true that red meat was difficult for babies to digest then giving it at lunchtime instead of dinnertime is not going to help. Foods take 24-48hrs to pass through the human digestive system. If you avoid high fibre foods like broccoli to help baby sleep better, the unintended outcome will be constipation – then your baby really will have trouble sleeping.
Let me answer the question, will introducing solids make your baby sleep through the night? NO. However, if you are following rules like the above then I would probably guess that since starting solids your baby has been waking MORE frequently.
In a nutshell, there is no evidence that the introduction of any sequence of foods is any better than any other. The latest guidelines recommend a variety of foods from 4-6mths. With the only exception being cow’s milk not to be given until after 1 year of age. The risk of botulism from eating honey is pretty much non-existent: Honey imports are very tightly controlled by the Ministry of Primary Industries (MPI) and there have been no notifications of human botulism in New Zealand through the notifiable diseases surveillance system since records began in 1987.
It’s like someone came up with this idea that nobody challenged and so instead everyone copied and pasted it onto their website. Giving parents false hope that giving their baby banana and avocado and avoiding broccoli and yoghurt will solve all their problems.
The truth is that all these foods are very nutritious as are baby food pouches and we should be trusting that our baby will self-regulate their own intake. Yes, babies do eat a lot from an early age even before they are active enough to burn it off but this is developmentally appropriate and once children reach primary school age they begin to change shape, and becoming taller and leaner.
Unfortunately, if your baby is having sleep challenges, then eliminating foods from their diet is not going to be the magic quick fix.
More importantly than all of this is the early learning that occurs from birth until 2 years, and how parental influence can effect food preferences and eating behaviour which will in turn shape growth and development. The rules above can influence dietary patterns for example fussy eaters or grazers and result in a dietary deficiency in micronutrients such as iron (being a very important mineral for growth). Certain foods needs to be offered up to 10 times before some babies will become familiar with it and accept it.
Back to this supposed scientific reasoning - certain foods contain an amino acid called tryptophan that causes sleepiness and foods that contain tyrosine which is an something of a stimulant. Without delving into the more heavy-going side of human metabolic feedback these hormones are involved in the control of the thyroid and the thyroid can control our sleep: it is true. However, this system runs largely independently from our dietary intake and the amount we consume via these foods has no more impact than an alkaline diet can affect our overall body’s pH.
Your baby’s digestive system is immature and still developing but this is the rationale for offering them a wide variety of foods so that they can adapt and learn to tolerate all foods. Often when babies wake in the night we hunt for reasons why that happened and during the introduction of solids looking at the foods, a certain new food can be an easy target. However, this is way more often than not the wrong reason and we confuse correlation with causation. Why are people trying to over-complicate things and looking for complex solutions when the simple solution is steering then right in the face? Everything in moderation.
Firstly, my intention of writing this blog is for mothers that cannot breastfeed or choose not to breastfeed to feel at peace with that option and feel supported to do so. It is NOT my intention to fuel a breastfeeding versus bottle feeding debate – us mums, we are better than that and quite frankly we don’t have the energy for it!
My baby has been diagnosed with colic, I heard that switching your baby onto goat’s milk formula can help settle their symptoms. Is this true?
This is some outdated advice. There are 2 aspects to this that need attention, firstly the diagnosis of colic and secondly, changing to goat’s milk formula to help improve a formula fed babies symptoms.
Let’s look at colic first.
‘Colic’ was originally a medical term for spasm in a hollow organ and from at least the mid-18th century has been used to refer to cramps in the intestines of babies, causing crying. This crying was said to be caused by wind, constipation or a vague ‘gut upset’.
In 1954 Dr Morris Wessell defined a ‘colicky’ baby as one who cried for 3 hours a day, on 3 days a week for 3 weeks or more. This was over 60 years ago and during this time most western women didn’t breast feed. Also, the breast milk substitutes were quite unsafe for baby’s intestines, it is no wonder these babies cried so much!
Despite numerous theories proposed to play a role in infant colic, none have been proven to be causal and the term colic is now outdated. The gut is still involved in cry-fuss issues, but not always in the way many people think, and there is still no conclusively effective dietary treatment option for infant colic.
Infant ‘colic’ like behaviour can have several independent causes, for example, lactose intolerance, food hypersensitivity, unidentified feeding problems, circadian rhythm or sleep misalignments or high neurological sensitivity. You can see how important it is to have a specialised health professional assess your baby if you are having cry-fuss issues with suspect ‘colic’ or have been given a diagnosis of ‘colic’.
The use of hypoallergenic formulae or maternal elimination diets (maternal elimination diets should be avoided unless absolutely necessary) are sometimes advised and can be trailed for certain crying infants with other associated clinical symptoms, but do not work for all infants with ‘colic’. Nor should they be trialled without being advised and followed up by a medical professional e.g. a paediatrician.
With or without a medical diagnosis as the cause of a babys ‘colic’ like symptoms, assessment, education and support around babies feeding, sleeping, sensory diet and maternal mental health can provide opportunities to optimise care and enjoyment of baby and parents while reducing discomfort for baby. Bear in mind most babies that cry and fuss a lot are perfectly healthy – around 5% of distressed infants have identifiable medical explanations for their crying.
Now a bit about goat’s milk and switching to goat’s milk formula for a baby with cry-fuss issues.
Using goats milk before 6 months of age or regular use between 6 and 12 months is not recommended. Goats milk is no more appropriate to give a baby than cows milk. If you need to supplement and breast milk is not available, formulas are a more nutritionally complete product. Goat milk is much closer in composition to cows milk than human milk. Goats milk is high in sodium (as is cows milk) and is very high in chloride and potassium, which makes the renal solute load too high for babies. This can cause gastrointestinal bleeding and result in anaemia and poor growth. Goat milk is also deficient in folic acid.
Goats milk formula is not a suitable alternative to cow’s milk formula in infants allergic to cow’s milk protein as these infants are often allergic to goat’s milk too, nor is it scientifically proven to be advantageous to use goats milk formula in the presence of a lactose intolerance. So really there is nothing to suggest that switching a formula feed baby with ‘colic’ or high level cry-fuss behaviour to goat’s milk formula will help their ‘colic’ symptoms.
During several of our consults we have successfully transitioned babies away from Goats milk formula where we often encountered excessive spilling and symptoms related to the digestive system.
Your baby might be sleeping well now but once the 4 month sleep regression comes you will find it so difficult to get your baby to sleep.
The 4 month sleep regression, it’s touted as a big one. But what is this all about and why is there so much scaremongering?
Many of us have been here. Your baby is a few months old, things are starting to get a little easier and you are feeling pretty good about your newly acquired mothering skills. Then the doubt starts creeping in. People start telling you about sleep regressions and how hellish they can be - you’d better be careful you are not setting up bad habits! <Sigh>
Why do we do this to each other? It is SO unhelpful. For one, it starts making you doubt your judgement and makes it harder for you to follow your instincts. When this happens we often start to feel more anxious about our baby’s sleep making it harder to be in the moment with baby and notice their subtle communications. Research shows us that when we are anxious, angry or worried about our baby’s sleep we find it harder to respond to their cues appropriately and harder to sleep ourselves!
Newborns spend a lot of time in light or active sleep phases when they are squirming and vocalising. This is protective mechanism against Sudden Unexpected Death of an Infant so, your baby will rouse if it senses a dangerous or just unpleasant feeling.
At around 4 months this changes, but in positive way.
Unfortunately, parents can listen to the unhelpful ideas about sleep regression and start to feel insecure and in desperation they turn to and follow conflicting advice that leads them down the garden path to actually promote a sleep regression.
As new mums we can be pretty sensitive to people's comments and advice (which is totally normal!) and know that I have found myself getting a blow to my confidence by other people's comments about my kids or how I am parenting them. So If you can do one thing to help your friend or family member do the best for her baby it would be to always talk positively around her about her baby. It takes a village to raise a child and they need as much help as they can get. Focus on all the great things that parents are doing, what their baby is doing and not what they should be doing!
I have a 3 month old and have been advised to make sure that I put baby to sleep in the same place for every sleep e.g. their bassinet, otherwise it will create bad habits and baby won’t settle in his bassinet properly.
I always find it amazing how some people are of the mind-set that babies are born with an innate drive to avoid sleep. That even though we need sleep to survive and we have survived as a species for a long time, that our babies still ‘do not want to sleep’.
With this is mind it really does seem crazy to think that something as fickle as where your baby lays their head is going to stop them sleeping when they need sleep.
This kind of advice requires a response that really brings things back to basics.
Little babies will sleep when they are tired, anywhere. Whether you put them in their bassinet every time or you rotate through baby sleeping on you, the pram and their bassinet. It does not matter.
When young babies will not sleep when they are tired, it is usually due to one or more of the following reasons:
The problem with this kind of advice is that if you believe it, it can send you down a path that will make your life with baby even more difficult.
Let me explain.
You believe that the reason your baby is not sleeping is because baby needs to ‘learn how to sleep in his bassinet’. To teach your baby how to sleep in his bassinet you begin a routine of specific feeding, sleeping and waking times so that you ‘know’ that your baby is tired when you decide it’s time for him to sleep. You then begin a self-settling strategy once you put baby down that involves teaching baby to sleep without a feed or physical contact. You end up at home a lot, in a dark room, patting and shushing your unsettled baby to sleep - for too long – you feel socially isolated.
This can cause stress for your baby and most likely you too. Furthermore, this type of misdiagnosis and treatment of sleep challenges can lead to unintended negative outcomes for baby and you.
Let me reassure you, you don’t need to worry about teaching your baby to sleep, or self-settle. You will not be setting up bad habits now or in the future – quite the opposite! If you build a trusting relationship with your baby it will give you a greater opportunity to let them regularly sleep in their bassinet when they are ready.
Our clients often receive advice to let their baby self settle, allowing 1 minute of time to enter the room for every week of age e.g. 8 minutes wait to enter for an 8 week old baby.
As a mother, I find it heart wrenching listening to my babies cry, every inch of my being wants to go and soothe them, it’s completely instinctive. I’ve yet to meet a mother that does not feel like this when her baby cries.
So why are we so often advised to go against our basic instincts when our babies cry at night? Surely we can trust that instinctively we know how to care for our babies?
Yes, we can.
Deliberately delaying your response to your baby’s cries to be picked up or fed, or responding in a way that is different to what you know your baby is asking of you, will not significantly help your baby sleep longer at night. Neither will it gradually reduce the amount of crying out behaviour at night, as is often claimed. This is because they have an immature and sensitive Sympathetic Nervous System (SNS) that acts like a switch for them (one minute ‘gooing’ and ‘gaaing’ the next minute crying at full volume without stopping to breathe!). There are many strategies that you can use to dial down the SNS such as feeding, rocking and singing. However, an intention to respond is the best way to prevent your baby becoming distressed in the first place because often even feeding can be difficult once your baby is that worked up.
The belief that delaying responses to your baby’s cues will improve their sleep in the first 6 months is not supported by evidence. In fact, the evidence confirms that delaying responses results in more crying and fussing in babies overall and risks a serious communication breakdown between baby and you. The Baby Sleep Practitioners’ advice is to aim to keep your baby as calm as possible in the first 16 weeks of life. Work on building trust with your baby and learning his or her patterns of behaviour through a lot of trial and error.
Anyone that has experienced night waking of the baby kind would agree that it’s not actually the number of times that you are woken but the period of time that you are awake for (either due to baby or your own difficulty returning to sleep – or both) that makes you feel like rubbish. We also know that a modest increase in uninterrupted night sleep does not help a mothers’ mental health.
Self-settling is a developmental milestone and as with sleeping, is not something that needs to be taught to babies.
Once any underlying problems have been resolved in terms of your babies feeding, sleeping and sensory needs, responding sensibly to their cues will make life easier for baby and you both now and later.
Dr. Harvey Karp is famous for his insights of the 5 S’s explained in his book The Happiest Baby on the Block. Many parents use or have used this method to soothe their baby in those difficult first weeks or even months. The 5 S’s have become so ingrained In the baby sleep world that it’s fair to say it will be around for a while.
The 5 S’s if you don’t know are Swaddle, Side or stomach position, Shush, Swing and Suck. I agree that they do work as long as there is not an underlying health, feeding or sleeping problem. Let’s give parents a bit of credit here. When you hear your baby crying your motherly instinct kicks in, you immediately pick your baby up and attempt to soothe him or her by shushing, patting and rocking? I believe following your motherly instinct should really be the focus of solving most baby sleep problems. Mothers loose this ability when they follow rules. For example, when the 5 S’s are not working they lose their confidence and creative problem solving skills. Start questioning themselves, it must be something I am doing wrong? Am I not swaddling tight enough?
So let’s break this down: Where can the 5 S’s fall short?Swaddle:Swaddling is important in the first 3 months to prevent the moro or startle reflex. However, there is no evidence that swaddling reduces unsettled behaviour in babies and we need to be careful not to swaddle to tightly as this can increase the risk for hip dysplasia.
Side or Stomach Position:Side or stomach position aids digestion so can beneficial when there are tummy troubles. When a baby is not receiving enough cream from the breast the milk travels through the intestine so quickly it causes your baby to feel bloated with explosive stools, excessive wind and crying. Creamy milk helps babies turn on the ‘rest and digest’ part of the nervous system so that they become relaxed and settle to sleep easily. Putting your baby to sleep on its side or tummy is not recommended by health professionals nor the World Health Organisation as it is associated with Sudden Unexpected Death of and Infant (SUDI). Not worth the risk!
Shush:Shushing is more commonly achieved by playing white noise. Large doses of white noise can be an unhealthy sensory stimulation for your baby: especially if played too loudly it can damage your babies hearing. Healthy sensory stimulation includes a lot of physical contact with loved ones.
Swing:Swinging or rocking won’t work if the barriers to sleep have not been removed such as if your baby is generally still hungry or if it is not tired enough (you will be rocking for a long time!)
Suck:Some babies love to suck and as long as feeding had been established and mothers are feeding on demand then dummies are fine. If you are ignoring cues that your baby is hungry then this can lead to unintended outcomes such as inadequate milk supply and weight loss.
If the 5 S‘s are not working for you and your baby contact The Baby Sleep Practitioners for advice.
You said whaaaaat?! - Spacing breast or bottle feeds will help your baby sleep better: aim for 3-4 hourly.
This is our first of the series responding to advice that has pointed you in the wrong direction
Many highly influential 'baby sleep advisers' promote spacing breast or bottle feeds in the hope that doing this will reduce the risk of things like chapped nipples, allow more sleep for mother and baby and aide baby's digestion and appetite.
Unfortunately this is not true.
Spaced feeds can make life harder for many women, putting us at risk of developing mastitis and breast abbesses. It can also suppress our milk supply - which leads to a hungry baby that cries even more. Not to mention the stress that it can cause baby when their hunger cues are being ignored - a baby experiences a delay in getting nourishment as a life or death situation. So as you can imagine consistently withholding milk when your baby is genuinely hungry can cause a lot of stress for both baby and you and will not help your baby sleep for longer periods over night.
But as with all aspects of baby care - this is not black and white.
In the early days it can be difficult to know if your babies frequent feeding is normal or if it is a sign of an underlying feeding problem. Bear in mind that it is normal in the new born period for babies to feed twelve times a day or so and want to feed within an hour or less of the last feed.
If your baby has a pattern of consistently returning to the breast within an hour or less - during the day and night - your baby is doing what is refereed to as 'marathon feeding'. This is a reason for your baby to be reviewed by a health professional who has the skills to assess your baby's feeding.
A baby with poor milk transfer can still have good urine and stool output as mother and baby battle bravely on together. If your baby is showing any of the following signs it is important to get a feeding assessment.
It can be helpful at this stage to make sure that when your baby starts to show cues that they require something to try offering them other comforts such as a change in scenery (they may just be bored), a cuddle and a chat, check their nappy etc, as it could be this your baby requires, not a feed.
Gently experiment if you are not sure what baby is trying to communicate to you and over time you will develop good two way communication and interpreting their individual cues and patterns of behavior will get much easier.
Amy and Elspeth