SIDS: Risks and Realities. A Response to Recent Findings on Bedsharing and SIDS Risk (The Carpenter Research)
A recent meta-analysis by Carpenter et al. (2013) examined the risk factors for Sudden Infant Death Syndrome (SIDS). While we commend Carpenter et al. for examining risks associated with incidence of SIDS, we question their conclusions and consider them unsubstantiated. Their analysis used faulty and missing data, and they did not account for confounding criteria used to define bedsharing and risks—a challenge in any meta-analysis.
Carpenter et al. examined some of the most salient risk factors for SIDS events—infant sleep position, parental cigarette smoking, infant birthweight and age. These risks have been well-documented as increasing risk of SIDS events. Thus, it is not surprising or informative to note that these factors remain risks in a re-evaluation of these findings.
While the risks examined do contribute significantly to increasing possibility of SIDS (see Chart 1 below), so do other factors, such as bedding and temperature (see Box below for lists of risks not considered). Without consideration of these risks, it is not possible to determine that one variable, such as bedsharing itself, is inherently responsible for risk remaining in this study. Nor is it possible to say that one of the variables within the nighttime care routine, such as breastfeeding, is not protective.
Chart 1. Adjusted Odds Ratios from Carpenter et al. (2013)
Major Limitations
In addition to these major limitations in making broad, sweeping statements about risk based on this meta-analysis, there are two addition issues that are of significant concern in the paper as a whole. We address these herein.
Treatment of Breastfeeding
The first is the treatment of breastfeeding. Buried deep in the last section of the paper is the recommendation that breastfeeding be supported as a mechanism for protecting infant health, the construction of the hypotheses explored here leads to a very different framework. In attempting to examine whether breastfeeding is protective against risk of SIDS when parents bedshare seems to jumble the role of breastfeeding in a manner that undermines one of the stated objectives of the authors: to address health costs associated with early infant care by reducing SIDS events. Further, the authors seem to overlook the AOR for bottle-feeding and SIDS risk (see Chart 2).
Chart 2. Adjusted Odds Ratios including bottlefeeding from Carpenter et al. (2013)
NOTE: BW = Birthweight
In examining the role of breastfeeding, the authors seem to overlook one essential aspect of infant development—breastfeeding contributes positively to both immediate and later infant health outcomes, not just a reduction in SIDS, though it serves as a protective factor there as well (Alm et al., 2002; Ford et al., 1993; Horne et al., 2004; McVea et al., 2000; Mitchell et al., 1992; Mosko et al., 1997; Scragg et al., 1993). Thus, important in consideration from any perspective is to encourage mothers’ breastfeeding through the infant’s first year of life. However, the authors seem to couch this protective factor in the arena of risk, thus confusing the message for practitioners and parents.
Instead of looking at how each of the variables in the dataset can contribute to risk of infants’ breathing or compromise arousal—the authors focus on whether the act of breastfeeding protects against all risk of SIDS. Clearly that is a standard that cannot be reached. We can, however, easily answer whether breastfeeding protects against SIDS regardless of parental behavior without the necessity of meta-analyses, the imputing of data from 5 of 12 variables, the compromising operational definitions of nighttime care contexts. The answer is simple, though not informative. Yes, there is still a risk. Why? Because there are multiple risk factors that compromise infants’ capacity to breath and infants’ ability to arouse. Breastfeeding does not vaccinate against all risks (e.g., a pillow in the face).
The authors give lip service to breastfeeding, but suggest that any claim that bedsharing helps breastfeeding is ill-advised. The use of the Netherlands as a key example of how lowering bedsharing but increasing breastfeeding rates fails to make their point given the relatively low rates and low increases over the 10-year period discussed (a rise of 7% and 8% of any breastfeeding at 3 and 6 months respectively). It is unclear if the strong anti-bedsharing campaign inhibited greater growth in breastfeeding, something that should be of concern when examining the costs associated with infant health. In the U.S. alone, a cost-analysis found that if we could get 80% mothers to breastfeed exclusively for six months (the WHO recommendations), the U.S. would save $10.5 billion a year in health-related costs (Bartick & Reinhold, 2009).
Furthermore, it is misguided and dangerous to argue that if bedsharing were recognized as a means of supporting breastfeeding that we would see more SIDS events. Even more dangerous is to abandon support of breastfeeding in favor of supporting breastfeeding if it detoured bedsharing. Although the AOR in the current meta-analysis suggests that bottle-feeding is a lower risk factor than bed-sharing (the validity of which will be discussed below), it only concerns itself with SIDS events, not the more general protective benefits of breastfeeding on infant health. As previously mentioned, breastfeeding confers many health benefits, both immediate and long-term, to children (Horta et al., 2007; Ip et al., 2007; Martin et al., 2005; Owen et al., 2002). To only consider SIDS events ignores the effects of lower breastfeeding rates on myriad other diseases.
Risk Factors Not Included in the Analysis
The second issue pertains to the risk factors included and not included in the analysis. The authors have thankfully confirmed some of the major risk factors associated with SIDS, both independently and when interacting with sleep location, such as sleep position, parent smoking, alcohol use, drug use, birthweight, and infant age. The authors solidified many risks, as they were stated individually in the reports associated with each large data set. With this, researchers, practitioners, and parents now have a clear documentation of these specific risks. They clearly confirmed the known risks and quantification of those risks. For example, maternal smoking remains to be one of the most salient risks associated with SIDS—with paternal smoking contributing to risk as well. Similarly, infant sleep position (i.e., prone and side sleep), contribute significant risk of SIDS events.
Missing from the analysis are other known risk factors: specifically risk factors associated with the triple-risk model either through environmental context (bedding) or infant vulnerability (prematurity). Additionally, the authors fail to include data sets that do include these risk factors, and come to very different conclusions about the inherent risk of bedsharing on SIDS events (e.g., Blabey & Gessner, 2009). The authors argue that bedsharing is causally related to SIDS events via theories about infant breathing and arousability. Specifically, the authors state, “The proposition that bedsharing is causally related to SIDS is coherent with theories that respiratory obstruction, re-breathing expired gases, and thermal stress (or overheating),which may also give rise to the release of lethal toxins, are all mechanisms leading to SIDS, in the
absence of smoking, alcohol or drugs. Infants placed prone are exposed to similar hazards.”
Is the implication in the press release for this article verifiable? Are breastfed, bedsharing babies at inherent risk of SIDS events? The answer is equally as simple, but much more informative. No.
Again, factors that put infants’ breathing and arousability at risk also increase the risk of SIDS events. The elements of the sleep context that place infants’ breathing and arousability at risk are well defined:
Respiratory obstruction (e.g., bedding)
Rebreathing expired gases (i.e., from cover on face)
Thermal stress through overheating (e.g., too many covers)
Physiological vulnerability of arousal (e.g., deep sleep from formula usage)
These authors seem to be arguing that parenting behavior that can be associated with risk, even if the source of risk in not the behavior, should be stopped (i.e., bedsharing). This is problematic given that bedsharing is a universal, evolved practice, and is often preferred by parents. In fact, the absence of bedsharing does not eliminate risk of SIDS events. The diminishing of bedsharing however, is associated with decreases in other behaviors shown to provide protection against SIDS events, such as breastfeeding.
Certainly, without question, a nighttime care context that includes bedsharing and breastfeeding can include elements that compromise infants’ breathing and ability to arouse. Importantly, we know that breastfeeding not only does not contribute to the risk, but serves to help reduce these risks. See Table 1 whereby bottlefed infants are at a greater risk of a SIDS even regardless of sleep location.
What of Bedsharing?
The authors would have us believe bedsharing per se increases the risk of compromising infant breathing and arousability. However, they fail to acknowledge or discuss the fact that there are other factors that influence breathing and arousability, such as bedding, temperature, and premature status (which is correlated with birthweight, but carries with it unique risk factors that must be considered).
Data from Alaska between 1993 and 2004 examined the same question of bedsharing risk, only they also included other known risk factors such as sleep surface (not just sofa, but the type of bed) and sleeping with a non-caregiver, and compared the data not just to controls (Blabey & Gessner, 2009). Additionally, the comparison group was taken from a state-wide monitoring system that does not focus on answering one day of bedsharing habits, but rather asks parents about usual bedsharing habits. As such, they most likely had more accurate information on bedsharing than the studies included in the current review. What was found in Alaska? Of the SIDS events that took place while bedsharing, 99% included at least one risk factor, and thus the authors conclude that “infant bedsharing in the absence of other risk factors is not inherently dangerous.”
So, let’s stop going around in circles talking about secondary issues and focus on discussion on primary issue: decreasing the risk of SIDS events. If we want to decrease risk of SIDS events, then we must assure infants’ are in the best possible situation to support breathing and arousability.
How to do that?
Address Maternal and Infant Health that Reduces Risk
Reduce vulnerability by reducing elements that contribute to vulnerability prenatally, i.e., intrauterine exposure to cigarette smoke, premature birth, stressful pregnancy with increased cortisol in blood stream, low birthweight, etc.
Reduce vulnerability postnatally by increasing health through breastfeeding, increasing proximity to parent during sleep to protect arousability, increase supportive contexts for new parents to support breastfeeding, infant health, maternal health, etc. This level of support will decrease infant vulnerability, increase infant health a capacity to arouse.
Increase maternal nutrition during pregnancy.
Address Nighttime Care Practices to ENSURE Breathing and Arousability
Place infants on back to protect breathing.
Protect infants’ breathing and arousal by having infants sleep on firm, flat surface without pillows or toys or blankets.
Protect infants’ arousal response by having a cool sleep environment absent blankets.
Continue to Monitor Sleep Space
Keep infants in close proximity to parents to assure awareness of compromised breathing or arousal response that may be associated with unobservable variables, such as immature physiological responses.
Despite a long history of efforts to reduce bedsharing, this nighttime-care practice remains to be the preferred practice for many, is increasing in some areas, and provides many protective or health-benefiting outcomes for mothers and infants. Infants’ safety at night is compromised when discussions shift from the criteria above to admonitions to sleep separately. A focus on protection and a discussion of what underlies risk will be much more successful in reducing risk of SIDS—as well as improving the health context postnatally.
Ten Important Risk Factors That Are Not Included in Carpenter et al. (2013)
1. The researchers importantly did not consider whether the bedsharing was planned. Previous research from Venneman (2009) showed no increased risk in planned bedsharing (versus unplanned). This is an incredibly important omission.
2. The paper did not consider the effects of the mother smoking during pregnancy, only smoking post birth.
3. Breastfeeding information is too limited to draw conclusions. No difference has been drawn between frequency and percentage of breastfeeds versus formula feeds for those ‘partially feeding’.
4. The paper only considered ‘illegal drug use’. Many postnatal mothers (0-12weeks after the birth) are prescribed analgesic medication for related birth induced injuries including but not limited to Caesarean healing, known to have a sedative effect. This was not considered at all.
5. Prematurity was not considered at all.
6. Parental exhaustion was not considered at all. Some experts suggest this is considered to be less than 4-5 hours of sleep in the past 24-hour period, other experts advise parents to use their instincts. Parental exhaustion naturally impacts on responsive to infant cues.
7. The researchers did not examine the effect of maternal (and paternal) obesity.
8. No differentiation was made between having one or both parents in the bed and importantly the location of the baby. It is advisable that the mother sleeps in between the father and infant. Equally it was not noted if older siblings were also present in the bed.
9. The researchers did not consider fully the impact of alcohol consumption by the father when bedsharing.
10. No mention was made of whether parents were aware of the risks of bedsharing and how to minimize these before sharing a bed with their infant.
Sarah Ockwell-Smith, BabyCalming.com
Professor Wendy Middlemiss, University of North Texas
Tracy Cassels, University of British Columbia, EvolutionaryParenting.com
Helen Stevens, Safe Sleep Space
Professor Darcia Narvaez, University of Notre Dame
References
Blabey, M.H., & Gessner, B.D. (2009). Infant bed-sharing practices and associated risk factors among births and infant deaths in Alaska. Public Health Reports, 124, 527 -534.
Carpenter, R., McGarvey, C., Mitchell, E.A., Tappin, D.M., Vennemann, M.M., Smuk, M., & Carpenter, J.R. (2013). Bedsharing when parents do not smoke: Is there a risk of SIDS? An individual level analysis of five major case-control studies. British Medical Journal Open, BMJ Open 2013;3:e002299. doi:10.1136/bmjopen-2012-002299
Ford, R.P.K., Taylor. B.J., Mitchell, E.A., et al. (1993). Breastfeeding and the risk of sudden infant death syndrome. International Journal of Epidemiology, 22, 885- 890.
Horne, R.S., Parslow, P.M., Ferens, D., Watts, A.M., & Adamson, T.M. (2004). Comparison of evoked arousability in breast and formula-fed infants. Archives of Diseases of Childhood, 89(1), 22-25.
Horta, B.L., Bahl, R., Martinés, J.C., et al. (2007). Evidence on the long-term effects of breastfeeding: Systematic review and meta-analyses (pp. 1-57). Geneva: World Health Organization.
Ip, S., Chung, M., Raman, G., et al. (2007). Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess (FullRep), 153, 1-186.
Martin, R.M., Gunnell, D., & Smith, G.D. (2005). Breastfeeding in infancy and blood pressure in later life: Systematic review and meta-analysis. American Journal of Epidemiology, 161, 15-26.
McVea, K.L., Turner, P.D., & Peppler, D.K. (2000). The role of breastfeeding in sudden infant death syndrome. Journal of Human Lactation, 16, 13-20.
Mitchell, E.A., Taylor, B.J., Ford, R.P.K., et al. (1992). Four modifiable and other major risk factors for cot death: the New Zealand study. Journal of Paediatric of Child Health, 28(suppl 1), S3-S8.
Mosko, S., Richard, C., & McKenna, J. (1997). Infant arousals during mother-infant bed sharing: implications for infant sleep and sudden infant death syndrome research. Pediatrics, 100, 841- 849.
Owen, C.G., Whincup, P.H., Gilg, J.A., et al. (2003). Effect of breast feeding in infancy on blood pressure in later life: systematic review and meta-analysis. BMJ, 327, 1189-1195.
Owen, C.G., Whincup, P.H., Odoki, K., Gilg JA, Cook DG. (2002). Infant feeding and blood cholesterol: a study in adolescents and a systematic review. Pediatrics, 110, 597- 608.
Scragg, L.K., Mitchell, E.A., Tonkin, S.L., & Hassall, I.B. (1993). Evaluation of the cot death prevention programme in South Auckland. New Zealand Medical Journal, 106, 8-10.
New Gentle Sleep Help for Tired New Parents – Unique New Workshop Provides Alternatives to Controlled Crying
Forgive us for a small spot of advertising, we don’t usually advertise our wares on the blog, but we are SO super excited about our new baby sleep workshops launching later this month that we wanted to shout it from the rooftops!!!!
So, we are very proud to introduce you to the brand spanking new:
BabyCalm™ Sleep Workshop
This very special 3 hour baby sleep workshop is designed to help new parents who are struggling with their baby’s sleep, wondering if they will ever sleep through the night and battling sleep deprivation and exhaustion.
Our baby sleep workshop is however very different to most other baby sleep help (as you might expect!) that you may find. Our suggestions, tools and techniques are all based on sound scientific evidence and we guarantee that they will not cause any harm to your baby, nor will they result in tears – for your or your baby!
We promise to never teach you to use controlled crying, rapid return, gradual withdrawal, ‘pick up, put down’ or any other behavioural related technique. Why? Firstly because we only advocate gentle sleep techniques and secondly, because whilst these behavioural techniques may work in the short term research shows they may lead to far more problems, including poor sleep, in the long term.
Forget your Gina Ford, Tizzie Hall, Ferber, Ezzo, Supernanny and any other baby sleep trainer expert who focusses on behavioural modification techniques – our new workshop is all about understanding your baby’s nocturnal behaviour and working together to make the whole family happier.
What You will learn in a BabyCalm Sleep Workshop:
- What normal baby sleep looks like
- How to maximize the amount of sleep your baby – and you – will get
- The neuroscience of infant sleep
- The pros and cons of the most commonly used sleep training techniques
- Sleep safety and SIDS
- Gentle alternatives to help your baby sleep
- What to expect of your baby’s sleep in the future
- How to create good sleep habits – for life!
This is a great class for both mums and dads of babies aged 3 months to 12 months of age – all for the bargain price of £35 (in the UK, workshop prices in Canada, Ireland, Iceland, Australia, Hong Kong, New Zealand and Dubai will vary).
Plug over, we hope you can see why we are so excited! The first 30 locations offering our new sleep workshop will take bookings for early June, with our remaining locations taking bookings for September. To find and contact your nearest teacher to find out when their baby sleep workshops will launch please click HERE.
Does the UK Government Know Anything about the Needs of Children? A Guest Blog by Oliver James
Despite the posed pictures of her pushing a baby in a pram (I wonder if its hers?), Liz Truss, the minister for education and childcare, has made it abundantly clear that she knows bog all about small children.
Note – this isn’t Elizabeth Truss, we couldn’t find the image Oliver refers to!
Her starter for one was the proposal that ratios of minders and daycare to children should be increased. As Polly Toynbee amusingly pointed out, minders are supposed to take their charges out of the home once a day. Polly laid down a challenge to Truss: let’s see you take two babies and four under-threes out to the park.
Not satisfied with having put daycare nursery profits ahead of the needs of children, Truss then weighed in with a demand for our nurseries to be highly structured in their daily schedules. This would increase the educational value of the places (as is supposed to be the case in France, a country which has a negligent attitude to the needs of under-threes – mothers getting their figures back is put ahead of meeting the needs of neonates). Clearly, Truss has no idea that, for under-threes, play is the only really worthwhile activitiy. The words ‘structured’ and ‘play’ are as absurd when conjoined as the words ‘be spontaneous’. If an activity is structured externally, for a two year old, it ceases to be play.
Truss is a symptom of a much wider malaise. Very few, if any, of our present Ruling Elite have ever spent extended periods caring for under-threes. Speaking anecdotally, I would guess that very few of their partners have done so either – a high proportion of MPs or CEOs have partners who are also workaholic killer-drillers. They leave it to others to do the ‘boring’, ‘repetitive’ task of caring for small children. I have several times proposed that no MP should be admitted who has not spent at least one year looking after and under-three year old for at least one year. That would sort the negligent goats from the compassionate sheep.
What is more, as was so graphically illustrated by the recent documentary featuring Boris Johnson, a great many of the Ruling Elite were severely deprived of responsive, loving care in their early years. Small wonder then, that they have so little understanding of under-threes’ needs. In fact, they are allergic to meeting those needs. I would go further: they think ‘nobody loved me, why should under-threes get the care I was deprived of?’ Put bluntly, deep down, it gives the Ruling Elite pleasure to see under-threes being deprived of love and responsive care.
By Oliver James
Oliver James is the author of Love Bombing – Reset your child’s emotional thermostat
(Karnac Books).
Oliver will be speaking at the forthcoming International Parenting Conference to be held at Cambridge University on July 20th and 21st. For more information about the conference, or to book a ticket to hear Oliver speak, please click HERE.
Why are the simplest solutions often kept hidden from us when we become mothers? With my firstborn (my son, Jackson) I did as I was told and have many regrets these days that I didn’t trust my instincts over the advice of health professionals, friends and family. In those days I had no one to tell me otherwise.
With Lola, things changed, although the journey was very tough. When she was two weeks old the babymoon ended abruptly and she became an unhappy baby. Unhappy, that is, when she wasn’t with me. Her latch became poor, she fed very very frequently, and she hated being laid down- I was either carrying her, or bouncing her to sleep in a bouncy chair- she couldn’t sleep in a basket etc. By 10 weeks old she was finally diagnosed as having Gastro Oesophageal Reflux (the “silent” type- not so-called because of a silent newborn, far from it. The silence refers to the fact that baby doesn’t actually vomit) and a posterior tongue-tie, and the medical advice I received (and took) was to give her infant Gaviscon for the reflux, and a tongue-tie release.
One dose of Gaviscon later, my poor baby was completely constipated and in distress. That was stopped immediately. I carried her about and rocked or fed her to sleep or just to calm her- all the stuff we’re not “meant” to do.
The tongue-tie release was done professionally and compassionately at a private hospital with a peaceful paediatric wing, on the NHS! Lolly fed immediately after, but I couldn’t say I noticed a difference in her latch. In fact, I think it “regrew” if anything- at nearly two (and still feeding) she still has it to a degree, even though the TTR was “successful”. I went to La Leche League, local breastfeeding counsellors and actually got great help from a couple of my peer supporter-trained Hypnobirthing clients, and so we continued- we plodded on, from one day to the next. I wasn’t going to quit whatever happened, but I wanted to try and make the whole thing easier on us both.
Lola was not that “good” baby people like to coo over and pat you on the back for. People called her “clingy” and “hard work”, unlike my “good” baby, Jackson- it made me very protective of her. She made my Hypnobirthing work a real trial, even though I worked from home! I had gone back to work a week after she was born, feeling fine in myself, but obviously knowing nothing about how to bed-in and set up good breastfeeding habits! At 11 weeks old we tried osteopathy- and for the first time, someone else calmed her. Sue, a wonderful osteo who I now refer all of my clients to, laid her hands gently and respectfully on Lola and did some gentle manipulation on her skull and diaphragm. It was truly miraculous, Sue explaining what she was doing (very refreshing after having various health professionals just manhandle my precious baby without a word of explanation) and Lola relaxing and sleeping on the treatment table- lying down! After one more treatment the reflux was vastly improved- Lola never liked traditional tummy time (BabyCalm have a solution for these babies!) but she could at least have her nappy changed without getting distressed!
And then, after finally cracking (my mother in law often commented on how patient she thought I was with Lola) and bursting into tears while on the phone to one of my previous Hypnobirthing clients who is also a peer supporter and a lovely friend, she suggested I brought Lola over to her house as she had an idea.
I’d heard about slings, but had no real idea what they would be used for other than maybe taking your baby hiking?! Chris had always wanted a carrier, so he’d bought a BabyBjorn when Jackson was a baby. I’d stopped him using it because I always thought it looked entirely wrong for a baby to be supported by his crotch! So I went to my friend’s house and she showed me her collection (a library in fact!) of wraps and soft carriers. I was worried I wouldn’t know how to put one on so she reassured me that a Close Carrier would be a good thing to try “babywearing” out with and wouldn’t get me in a muddle. So, feeling silly, I let her show me how to get myself into this odd, jersey cotton contraption with metal D-rings either side of my hips, and she showed me how to lower Lolly in (who was characteristically malhumoured by now) and tighten it. “That tight?”, “Yes, and close enough to kiss”…
The Close Caboo Carrier
Just as she did in the osteopathic clinic, Lola was calmed, instantly. I moved around a little, she nestled in, feeling closer to me than ever before (hence the product name I guess) and actually, she seemed happier than when actually being held. It’s like she should have been supplied with a sling at birth! It was honestly the missing ingredient! Since then we really turned a corner. I knew a marvellous way of helping her sleep, helping her stay calm so she fed more efficiently and therefore less frequently, keeping her safe and being able to get time to brush my teeth without listening to a screaming fit, not to mention being so much more mobile- I like to travel light, never been a handbag girl, so being able to go shopping without a pram (getting all of that “isn’t she a good baby!”, “oh how cute is she!” that she’d previously missed out on!) simply changed our lives. We used a couple of other types and still have a Connecta for the odd times I want to back carry her, and for all the carrying and feeling safe, secure and close to her mother, Lola is a very happy, sociable little girl- very much braver than her big brother too!
I passed this amazing knowledge on to my wonderful Hypnobirthing parents who come from all different walks of life, and like me, some of them never would have known about how the right sling can transform your everyday life. In time I read more, learned more, passed more knowledge on, to the point where I needed to make it official. Having spoken to Sarah a couple of times for professional advice before, the subject of BabyCalm came up, and Sarah suggested I train up as a teacher and help her and the other brilliant BabyCalm teachers rev up the Maternal Revolution. So I did! And amongst all of the amazing things that BabyCalm is, and does, I look at what we do and think, “if only it was around for my little Jackson and Lola, we could have had access to easier and simpler solutions to the problems we faced in those early days of their babyhood”.
By Melissa Wadey – Mother and BabyCalm & ToddlerCalm Teacher in Kent
Find out more about Melissa and her baby and toddler classes HERE.
Note: This is a collaborative post – please see author listing at the end of the piece.
Why do Toddlers Wake at Night?
The brain of a toddler is capable of complex processes and there may be many reasons a toddler wakes and signals, or calls/cries out. Reasons can include having bad dreams waking up and being uncomfortable with the dark, or just wanting comforting attention. A new experience a toddler has during the day can even cause additional waking and signalling overnight. Emotional and physical factors can cause wakefulness beyond what is normal.
Parents may worry that prolonged sleep without toddlers waking and calling or coming to the parent for attention will always continue. In the midst of wakeful nights, tiredness and the pressure of everyone around saying that toddlers should sleep through the night, it is easy for parent to fall into the trap of disciplining and harsh measures to ‘get the toddler to sleep through’.
The knowledge that the toddler needs comforting and kindness often slips to the background for tired families.
Helping Toddlers Sleep May Mean Knowing When They are Tired.
How can you know if a toddler is not sleeping because they aren’t tired enough to sleep… and when they are tired? Tired children will exhibit signs that they are sleepy. Toddlers may fight sleep and bedtime because there is so much that to do. But overtired toddlers will have more difficulty settling (cite). It is important then, to get toddlers to bed before they are overtired. Parents can watch for the signs of sleepiness…
Being Grumpy. When sleepy, toddlers become less tolerant of change and more emotionally reactive, easily bored and cannot hold interest in play and sometimes grizzling.
Being Jumpy. Toddlers, when tired, may become more reactive to sudden noises, even jerky movements may be seen.
Just Staring. Toddlers may begin to transition to sleep, just as infants had, with a change in alertness. With this they may have moments of fixed gaze, not focussed on anything, just staring. Sometimes briefly, sometimes longer.
Being Clumsy. As toddlers get more tired they may fall, tip from side to side, or drop things more readily.
Look Tired. When tired, some toddlers’ bright complexions become pale and dull and dark areas around the eyes develop.
Unusually Cuddly or not Cuddly at all. When very sleepy, toddlers may seek the comfort of more cuddles, or they may be less easily cuddled or comforted.
To help with toddlers’ transition to sleep and nighttime routine, it is good to get toddlers to bed before a parent sees these signs. This may help with toddlers’ being able to settle and toddlers sleeping peacefully. One of the most successful things parents can do is implement a bedtime routine that is catered to the specific child. It has been found that implementing a bedtime routine can decrease the time to sleep onset for toddlers while having the added benefit of improving mom’s mood (Mindell, Telofski, Wiegand, & Kurtz, 2009).
Practical Help for Parents of Toddlers with Sleep Issues.
ToddlerCalm offer a sleep workshop which focusses strongly on implementing a good bedtime routine for toddlers, as well as discussing the use of conditioned cues and helping parents to have realistic expectations and an understanding of the physiology of normal toddler sleep. Workshops are only £35 for 2 hours and are run nationwide. More information can be found HERE.
Co-Authors
Tracy Cassels, University of British Columbia,www.evolutionaryparenting.com
Sarah Ockwell-Smith, babycalming.com
Wendy Middlemiss, University of North Texas
John Hoffman, uncommonjohn.wordpress.com
Kathleen Kendall-Tackett, Texas Tech University,http://www.uppitysciencechick.com/sleep.html
Helen Stevens, Safe Sleep Space
James McKenna, Mother-Baby Behavioral Sleep Laboratory, University of Notre Dame, www.cosleeping.nd.edu
References
Alfano, C.A., Ginsberg, G.S., & Kingergy, J.N. (2007). Sleep-related problems among children and adolescents with anxiety disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 46, 224-232.
Barajas, R.G., Martin, A., Brooks-Gunn, J., & Hale, L. (2011). Mother-child bed-sharing in toddlerhood and cognitive and behavioral outcomes. Pediatrics, 128, e339-e347.
Cain, N. & Gradisar, M. (2010). Electronic media use and sleep in school-aged children and adolescents: a review. Sleep Medicine, 11, 735-742.
Cantor, J. (1998). “Mommy, I’m Scared”: How TV and Movies Frighten Children and What We Can Do to Protect Them. New York: Mariner.
Feshbach, N.D. (1987). Parental empathy and child adjustment/maladjustment. In N. Eisenberg & J. Strayer (Eds.) Empathy and Its Development (pp. 271-291). Cambridge: Cambridge University Press.
Grusec, J.E. (2011). Socialization processes in the family: social and emotional development. Annual Review of Psychology, 62, 243-269.
Mindell, J.A., Telofski, L.S., Weigand, B., & Kurtz, E.S. (2009). A nightly bedtime routine: impact on sleep in young children and maternal mood. Sleep, 32, 599-606.
Owens, J., Maxim, R., McGuinn, M., Nobile, C., Msall, M., & Alario, A. (1999). Television-viewing habits and sleep disturbance in school children. Pediatrics, 104, e27.
Smith, H.A. (2006). Parenting for primates. Cambridge, MA: Harvard University Press.
Thompson, D.A. & Christakis, D.A. (2005). The association between television viewing and irregular sleep schedules among children less than 3 years of age. Pediatrics, 116, 851-856.
Weinraub, M., Bender, R. H., Friedman, S. L., Susman, E. J., Knoke, B., Bradley, R., Houts, R., & Williams, J. (2012). Patterns of developmental change in infants’ nighttime sleep awakenings from 6 through 36 months of age. Developmental Psychology, 48, 1511-1528.
Welles-Nystrom, B. (2005). Co-sleeping as a window into Swedish culture: considerations of gender and health care. Scandinavian Journal of Caring Science, 19, 354-360.
Understanding and Helping the Toddler Who Won’t Sleep
Please note this is a collaborative post – for a list of authors please see the end of the article.
Every parent has despaired of their toddler’s night waking, no matter where the toddler sleeps and no matter the circumstances surrounding the desperation. Although there is great disagreement regarding whether infants should be able to sleep through the night, the expectation that toddlers can and should sleep through the night without wakings parents is generally well accepted—with this expectation being what is presented as the “healthy” outcome by many health professionals.
Recent research however shows us how incorrect this expectation is as science tells us that it is normal for toddlers to wake at night well into their second year. Thus, to understand toddlers and what they need during nighttime care, we need to be sensitive to the “why” of their needs, abilities and experiences, and to look for “what” drives behaviours. The same concerns are important at bedtime. Knowing why a toddler is resistant to going to bed or unlikely to remain in bed when they wake at night is key to helping toddlers and parents create a healthy, happy sleep environment. Herein we offer some insight into the whys and whats of toddlerhood and then some practical suggestions about helping infants, and their parents, sleep.
Toddler Sleep Around the World
One of the primary concerns that parents raise, especially in many Western cultures, is that toddlerhood is the time when independence must be learned and parental responsiveness may hinder this development. Let us first assure you that the benefits of responsiveness to your child do not end in infancy, but rather that responsiveness to distress remains key to secure attachment and positive social and emotional outcomes for children (for a review, see Grusec, 2011).
If you have been bed-sharing or co-sleeping, often parents worry that continuing this practice into toddlerhood will lead to negative outcomes for the child. This is perpetuated by self-proclaimed “experts” who scare parents into believing they must take a hard line. But is this supported?
Around the world, toddlers regularly sleep with their parents, and not just out of necessity. In Bali, children regularly sleep with their mothers until the age of 3 (Diener, 2000). Mayan children also share their mothers’ bed and often nurse throughout the night until 2-3 years of age (Morelli et al., 1992). Among the Ifaluk of the South Pacific children sleep alongside their parents until about 3 years of age (Le, 2000). In Japan, family members traditionally sleep in the same room, with many children even sharing their parents’ bed (Fukumizu et al., 2005). In Sweden, approximately half of children aged 4-5 are bedsharing with their parents at least part of the time (Welles-Nystrom, 2005). In Japan, children traditionally sleep with some adult (e.g., grandmother) until adolescence.
Even in North America, long-term outcomes associated with bedsharing outside of infancy support normal, healthy development (Barajas, Martin, Brooks-Gunn, & Hale, 2011). Notably, at age 5 there were no cognitive or behavioural problems associated with bedsharing between the ages of 1 and 3 in a US sample of low-income families. Being responsive or even bedsharing will not inhibit and likely promote your child’s independence or emotional growth. Regardless of your sleep arrangements, the following sections should help you navigate your toddler’s sleep and help you all find solutions to any sleep problems you may encounter.
Knowing your Toddler
Toddlers are often misunderstood as they try to meet their own needs and the needs and expectations of family and society. Toddlerhood is a time of emotional, biological and social change as the transition from babyhood to a new level of independence and growth occurs. A time matched only by adolescence in level of challenging developmental changes for your child and necessary challenges in childrearing for parents.
Why Sleeping Can be Hard
For toddlers, energy abounds. Toddlers want to ‘do it’ themselves; they love to show you , tell you, direct you and ask you; and most of all, they love your company. So why would a toddler want to walk away from the excitement of being with you to go to sleep? Well, they often don’t! Thus, they do not make or maintain that transition without support and guidance. It is completely normal for toddlers to wake during the night.; they wake and may reach out for teddy, or something comforting with smells of mom; Toddlers may call out; termed “signalling”. Some toddlers signal once a week, others once a night or numerous times a night, or some not at all (Weinraub, Bender, Friedman, Susman, Knoke, Bradley, et al., 2012) .
A Waking Toddler is a common concern for parents, with research showing that over half of children over one are waking regularly (Scher, 2001) and at least one-third of all parents of toddlers report having a ‘significant problem’ with their child’s sleep (Armstrong, Quinn, & Dadds, 1994). So, worrying or being concerned about your toddlers’ sleep is not unusual. However, just as in infancy, guiding them toward settling and providing comfort at night can help them return to sleep without negative consequences. Not responding can leave toddlers anxious or unsettled.
Most importantly to remember, is a waking toddler is NOT being naughty; they are trying to communicate something with their behaviour.
Many parents respond to toddlers’ waking with discipline (Armstrong et al., 1994)—yet there is no indication that this is helpful in promoting sleep or positive development. Sure, sometimes it is ‘in code’ but with gentle kindness and a sense of someone being there for them, toddlers can find sleep.
Co-Authors
Tracy Cassels, University of British Columbia,www.evolutionaryparenting.com
Sarah Ockwell-Smith, babycalming.com
Wendy Middlemiss, University of North Texas
John Hoffman, uncommonjohn.wordpress.com
Kathleen Kendall-Tackett, Texas Tech University,http://www.uppitysciencechick.com/sleep.html
Helen Stevens, Safe Sleep Space
James McKenna, Mother-Baby Behavioral Sleep Laboratory, University of Notre Dame, www.cosleeping.nd.edu
References
Alfano, C.A., Ginsberg, G.S., & Kingergy, J.N. (2007). Sleep-related problems among children and adolescents with anxiety disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 46, 224-232.
Barajas, R.G., Martin, A., Brooks-Gunn, J., & Hale, L. (2011). Mother-child bed-sharing in toddlerhood and cognitive and behavioral outcomes. Pediatrics, 128, e339-e347.
Cain, N. & Gradisar, M. (2010). Electronic media use and sleep in school-aged children and adolescents: a review. Sleep Medicine, 11, 735-742.
Cantor, J. (1998). “Mommy, I’m Scared”: How TV and Movies Frighten Children and What We Can Do to Protect Them. New York: Mariner.
Feshbach, N.D. (1987). Parental empathy and child adjustment/maladjustment. In N. Eisenberg & J. Strayer (Eds.) Empathy and Its Development (pp. 271-291). Cambridge: Cambridge University Press.
Mindell, J.A., Telofski, L.S., Weigand, B., & Kurtz, E.S. (2009). A nightly bedtime routine: impact on sleep in young children and maternal mood. Sleep, 32, 599-606.
Owens, J., Maxim, R., McGuinn, M., Nobile, C., Msall, M., & Alario, A. (1999). Television-viewing habits and sleep disturbance in school children. Pediatrics, 104, e27.
Smith, H.A. (2006). Parenting for primates. Cambridge, MA: Harvard University Press.
Thompson, D.A. & Christakis, D.A. (2005). The association between television viewing and irregular sleep schedules among children less than 3 years of age. Pediatrics, 116, 851-856.
Weinraub, M., Bender, R. H., Friedman, S. L., Susman, E. J., Knoke, B., Bradley, R., Houts, R., & Williams, J. (2012). Patterns of developmental change in infants’ nighttime sleep awakenings from 6 through 36 months of age. Developmental Psychology, 48, 1511-1528.
Welles-Nystrom, B. (2005). Co-sleeping as a window into Swedish culture: considerations of gender and health care. Scandinavian Journal of Caring Science, 19, 354-360.
Normal Baby Sleep – Do we have realistic expectations? (PART 2).
NOTE: This is a collaborative post – for an author listing please see the end of the post.
This is Part 2 of a 2 part post, to see part 1 click HERE.
“My child wakes up at 2am and is up for 1-2 hours!”
One of us remembers very clearly the first time her daughter ended up doing this. At around 14 months, she woke up in the middle of the night and simply wasn’t ready to fall back asleep. We nursed, we read, but nothing worked. She insisted upon getting up and going to play, which she did for 2 hours before being ready to get back to sleep. This continued regularly for a couple months. And then as quickly as it started, it stopped and hasn’t happened again in over The “why” of this is relatively unknown—although researchers are continuing to explore the physiological underpinnings of sleep—but we do know that extended night wakings like these are experienced by many children until around 3 years of age (Weinraub, Bender, Friedman, Susman, Knoke, Bradley, et al., 2012).
Many times the wakings are brief and the child settles quickly. Other times settling takes longer. In either case, these wakings do not readily suggest your child has a sleep “problem”. Increased night wakings, call-outs, and crying are common around 6 months of age or so, and again as infants near 2 years of age. These wakings may simply be one (of many) manifestations of separation anxiety experienced by the child—a normal change resulting from infants learning that they exist separately from their caregivers (for a review, see Middlemiss, 2004).Some argue that night wakings in toddlerhood are reflective of sleep problems, but these opinions are based on criteria that do not necessarily reflect the realities of infant sleep. Several studies found that night waking is relatively common between age 12 and 24 months (Richman, 1981; Goodlin-Jones, Burnham, Gaylor, & Anders 2005; Scher, 2000; Weinraub et al., 2013).
Thus, a parent’s perceptions about what constitutes a sleep problem may be triggered by either a disconnect between expectations of uninterrupted sleep and a toddler sleep pattern that arguably falls within the range of normal, or by the impact that night waking has on the parent’s quality of sleep and daily functioning (Loutzenhiser, Ahlquist, & Hoffman 2012). However, although changes in sleep patterns may be inconvenient and frustrating, they are normal occurrences in the context of a healthy parent-child relationship. When viewed as indicating problematic, rather than normal, sleep patterns that will come and go, oarents can experience greater stress and worry (Middlemiss, 2004). As we have learned from many parents, understanding that these night wakings are normal can go a long way to making them more bearable.
“My child won’t go to sleep before 10 pm.”
It is not uncommon in our society to assume that infants and young children must be tired by 7 pm and asleep shortly thereafter. In a posted lecture on infant sleep, Dr. Wendy Hall, a researcher at the University of British Columbia, suggested that no child should be put to sleep later than 9 pm. Unfortunately, that’s just not the reality for many families and it’s not because parents are negligent in getting their infants to bed, but because some children simply have a different circadian rhythm or a later schedule may work for the family. Some children will continue this pattern into their toddler years and beyond.
Cross-cultural data on bedtimes for infants and toddlers shows that later bedtimes are actually quite frequent in predominantly Asian countries (Mindell, Sadeh, Wiegand, How, & Goh, 2010). Whereas the mean bedtime for children in predominantly Caucasian countries was found to be 8:42 pm, it was a full hour later for predominantly Asian countries (with a mean at 9:44 pm), with the latest mean bedtime being 10:17 pm in Hong Kong. Notably, the rising time was also significantly later in these countries. A concurrent finding was that the vast majority of children in predominantly Asian countries sleep either in the parent’s bed or room. Thus children who sleep with their parents may naturally have a sleep schedule closer to their parents owing to the sleeping arrangements.
What is important to remember is that a late bedtime in and of itself is not a problem. If it poses a problem for the family as a whole, then parents may want to adjust the bedtime routine (Mindell, Telofski, Weigand, & Kurtz, 2009) or start the routine earlier in small increments in order to gradually move to an earlier bedtime (Richman, 1981).
“My child sleeps less (or more) than the recommended amount no matter what I do!”
Most people have seen the “sleep guidelines” about how much sleep our children need at various stages. Parents are told that newborns should sleep around 16-18 hours, that at two years of age, children require a total of 13 hours sleep, and so on. When researchers explore questions of how long infants and children should sleep and what are healthy recommendations, the answers are not particularly clear and are often based on examining how much children are sleepingat different times in history (Matricciani, Olds, Blunden, Rigney, & Williams, 2012).
As parents it is important to remember that they arerecommendations.
Each child is different and the recommendations may not fit every child. Some will require much more sleep and some will require less. If a child is truly sleep deprived, there will be noticeable signs. Signs of sleep deprivation include rubbing eyes, looking dazed and not focusing on people or toys, becoming overly active late at night, and having a hard time waking up in the morning. By paying attention to your child and his or her cues and behaviours, you will be able to tell if your child is getting enough sleep, regardless of the exact number of hours your child sleeps. Sleep is important, but there are many ways to get it apart from one long, uninterrupted stretch.
*Interestingly, researchers are now telling us that waking in the middle of the night is common in adulthood and was viewed as normal in past eras—the “first sleep” lasted about 4 hours with an awake period in between followed by a “second sleep” of another four hours (for more details, see here and the book: At Day’s Close: Night in Times Past by Roger Ekirch (Norton 2005).
Co-Authors
Tracy Cassels, University of British Columbia,www.evolutionaryparenting.com
Sarah Ockwell-Smith, babycalming.com
Wendy Middlemiss, University of North Texas
John Hoffman, uncommonjohn.wordpress.com
Kathleen Kendall-Tackett, Texas Tech University,http://www.uppitysciencechick.com/sleep.html
Helen Stevens, Safe Sleep Space
James McKenna, Mother-Baby Behavioral Sleep Laboratory, University of Notre Dame, www.cosleeping.nd.edu
References:
Goodlin-Jones, B. L., Burnham, M. M., Gaylor, E. E., & Anders, T. F. (2001). Night waking, sleep-wake organization, and self-soothing in the first year of life. Journal of developmental and behavioral pediatrics: JDBP, 22(4), 226.
Loutzenhiser, L., Ahlquist, A., & Hoffman, J. (2011). Infant and maternal factors associated with maternal perceptions of infant sleep problems.Journal of Reproductive and Infant Psychology, 29(5), 460-471.
Matricciani, L. A., Olds, T. S., Blunden, S., Rigney, G., & Williams, M. T. (2012). Never enough sleep: a brief history of sleep recommendations for children. Pediatrics, 129, 548-556.
Middlemiss, W. (2004). Infant sleep: a review of normative and problematic sleep and interventions. Early Child Development and Care, 174, 99-122.
Mindell, J. A., Sadeh, A., Wiegand, B., How, T. H., & Goh, D. Y. T. (2010). Cross-cultural differences in infant and toddler sleep. Sleep Medicine, 11, 274-280.
