How Do Human Infants Sleep And Feed Normally? James J. McKenna Ph.D

Edmund P. Joyce C.S.C. Professor of Biological AnthropologyUniversity of Notre Dame

Don’t sleep with your baby or put the baby down in an adult bed. The only safe place for a baby to sleep is in a crib that meets current safety standards and

has a firm tight-fitting mattress.”

Ann Brown September 29, 1999 to US Media Press Conference.

or“There is no such thing as a baby, there is a baby

and someone” D.Winnecott ?

“It’s not what we know that gets us into trouble….it’s what we know…that just ain’t so!

From: Everybody’s Friend (1874)

By Mark Twain

When it comes to how we study, promote and define western “normal, healthy infant sleep”………

“Never let an infant fall asleep at the breast” American Academy of Pediatrics

1999

Really? The very context within which an infant’s “falling asleep” evolved?

Until recent historic periods in the western industrialized world

• Until recent historic time no human (primate) infant (ancestral or modern) was ever separated from their caregivers…nocturnally, or any other time

– Most human infants know only social proximity and/or contact, with someone

– And nobody ever asked: where will my baby sleep, how will my baby feed, how will I lay my baby down for sleep (most still don’t)

– Any study which claims to understand human infant sleep absent of mother’s role, breastmilk metabolism and breastmilk delivery is at very least inaccurate, but most likely, incorrect.

Limitations…Sleep Science From An Anthropological Point of View

(there is no theory around which to interpret clinical events or research results, a

“snapshot- in- time” approach to infants )

non-evolutionary;

(a)theoretical..the infant is defined by and suspended in contemporary time and space and has no continuity to its unique evolutionary

past

scientific reductionism? Good?

NO! Not Suited for understanding the role of physiological regulatory effects

Limitations of Western Pediatric SIDS And Sleep Research From An Anthropological Point of View

Are adult- centric and ethnocentric..the “fallacy” of western medical normalcy..according to George

Williams…

not inclusive, holistic, no cross-cultural studies of human infants

Western “medical authoritative knowledge..” is hierarchical..it dismisses parental knowledge which is subordinated to “official” knowledge dispensed

my “medical authorities” or civil authorities (Bridget Jordan)

Model #1Zero to One year old babies.(Developmental age alone is all this physician needs.)

Model #2How did human evolution, the physician ponders, influence how this baby will respond to what I recommend?

Infant Sleep Development IS Determined By:Evolution of Infant Biology

Family Ecology size, SES,ethnicity,beliefs, Psychological-constellation

ExperimentalEcology..how is sleep

studied?(solitary, bottle fed)

infant needs/characteristics in relationshipto parental emotions, and breast feeding

Cultural Ecologyphysical settingvalues, ideologymedical viewsSocioeconomicsResources involved and rituals

**

**These data have never been includedin models of “normal infant sleep”

Cultural-Historical

Scientific

Public Health

Family

Factors/Processes Determining Where Baby Really Sleeps?

Where babies actually sleep is determined by…

Infant and Parental

Biology Including

Feeding Method

most relevant

least relevant

including economic status

References:

Ball 2007; Baddock et al.2007; McCoy et al. 2007; McKenna and Volpe 2006

Babyhood…….by Paul Reiser

“Getting your child to sleep becomes a blinding obsession. I myself would often loose sight of the larger picture.What is the actual goal here? Constant sleep? No awake time? Zero consciousness?

I mean, we must accept that at some point babies have to be awake.They did not come to the planet just to sleep. Are we determined to get them asleep just so we can get a taste of what life was like before we had a kid?

Because, if we are, then why did we have a kid? Just to lie there to look soft and fuzzy? We could have gotten, say, just a peach. A St Bernard? A narcoleptic houseguest?

Or why not just a chenille bathrobe? Chenille bathrobes are fuzzy and just lie there”?

With Respect To Infant Sleep Western Parents Remain …

the most exhaustedthe least satisfiedthe most obsessed

the most “well read”the most opinionatedthe most judgmental

Changing perceptions….of what’s good for baby…

“The constant handling of an infant is not good for him. The less he is lifted, held and passed from one pair of hands to

another, the better, as while he is young his bones are soft and constant handling does not tend to improve their development

nor the shapeliness of his little body. The newborn infant

should spend the greater portion of his life on the bed” FROM: THE BABY

MARIANNA WHEELER 1901HARPER BROS: NEW YPRK LONDON

CHANGING PERCEPTIONS OF WHAT INFANTS NEED...

THE MOTHERHOOD BOOK (1935)

“Babies should be trained from their earliest days to sleep regularly and should never be woken in the night for feeding….”

“Baby should be given his own bedroom from the very beginning. He should never be brought into the living room at night”

Dr. Truby King ) Great Britain)……he offered value driven, moral –based recommendations without any empirical scientific data backing up these misguided recommendations

Sleep Like A Baby What Does It Really Mean?

Feed

Sleep

Wake

Feed

Sleep

Wake

Feed

Sleep

Wake

Feed

Sleep

Wake…all night long

Formula and cow’s milk made it possible to “Sleep Like This”

What explains “our” way of thinking about normal, healthy infant sleep ?

A little cultural history..,out of what historical context did present ways of thinking emerge

….culturally favored child care practices change

independent of, and much faster than,

infant biology….

(ideologies or goals that underlie recommendations are often

historical and ideological in origin but passed off as, if not confused for, scientific findings)

“Scientific” validation of

solitary infant sleep as “normal” and “healthy”

#1: Initial test condition—infant sleeps alone, is bottle fed, and has little or no parental contact

#2: Derive measuremen

ts of infant sleep under these

conditions

#3: Repeat measurements across ages, creating an “infant sleep model”

#4: Publish clinical model on what constitutes desirable, healthy infant sleep.

#5: To produce “healthy” infant sleep, replicate the test condition

Culture Producing Science Producing Culture: How A Folk Myth Achieved Scientific Validation

Solitary infant sleep becomes the “gold standard”

Socio-cultural and Historical Factors and Forces Leading to Erroneous Scientific Understandings (Slide from Hell)

• rise of child care experts using moral judgments as a basis of recommending what infants “need’..what is worth “investing in” as a practice..

• belief in superiority of technology, rather than on maternal bodies to stimulate, hold and nurture;• emphasis on “average expectable population outcomes” rather than on individual variability or

potential.. per any given behavioral parenting strategy;• emphasis on western social values and ideologies (not biology) to guide research and

conclusions..”fallacy of medical normalcy” (G.Williams)..ethnocentrism at its best?• improper medicalization of relational (caregiving) issues ..assumed to be best understood by

pediatricians (who generally have no training in human social development or human evolution…) • “Pathologizing” of normal behavior (crying when left alone) ..making infants into patients

(blaming the victim for the crime) in need of correction when they fail to follow cultural scripts..”Never let a baby fall asleep at the breast” AAP Guidelines For Infant Sleep

• social constructions of infancy, not /biological- evolutionary based (influences of Freud, Klein, Watson..psychology in general);

• “Science” of infant feeding (bottle-formula feeding) and sleep pediatrics became one and the same with… mutually reinforcing moral ideas about who infant should be, or become, rather than who they are…and how husbands and wives should relate vis a vis distance, authority and separation from children…also, ideologies about the bedroom as a “sexual place..”

• European history including “romantic love”, protection of the conjugal pair, Catholic Church bans bedsharing to help prevent infanticide, adoption of an infant original sin, slippage of medical and moral goods..as one and the same…

John Watson…the “father” of western behaviorist psychology believed “no child could get too

little affection”

“Never hug and kiss them…..Never let them sit in your lap. If you must, kiss them once on the forehead when they say goodnight. Shake hands with them in the morning. Give them a pat on the head if they have made and extremely good job of a difficult task”

(Watson, 1928, quoted by Hardyment, 1983, p. 175).

Watson’s Model ?

The dis-embodied infant?

future “caretaking” environments for our infants?

The cultural undermining of western maternal knowledge and confidence

Benjamin Spock writing to mothers in: Baby Care says…

“You know more than you think you do….don’t be afraid to trust your common sense. Bringing up baby won’t be a complicated job if you take it easy, trust your own instincts, and follow the directions your doctor

gives you!

cited by tina thenevin,1993, mothering and fathering

“…SLEEPING IN YOUR BED CAN MAKE an infant confused and anxious rather than relaxed and

reassured. Even a toddler may find this repeated experience overly stimulating”

R. FERBER (1886,1999..but not 2006) SOLVE YOUR CHILD’S SLEEP PROBLEMS

Dr. Richard Ferber “changes his mind”..?? But the larger and more important question is…What is it about our culture that makes us care so

much….

• “If you find that you actually prefer to to sleep with your baby you should consider your own feelings very carefully”.

• “Whatever you want to do , whatever you feel comfortable doing, is the right thing to do, as longs as it works….. most problems can be solved regardless of the philosophical approach chosen” (Ferber: 2006: 41)

1976

2006

But Dr. Richard Ferber…..?(Solve Your Child’s Sleep Problems)

“…changes his mind” i.e. cosleeping is ok!But shouldn’t we ask..

What is it about our cultures that makes one persons opinion about where our baby

should sleep as being critical and important?Why are we willing to abdicate such social-relational decisions to external authorities who don’t even know us or our families, or

our baby’s unique needs

Current western infant sleep research paradigm: Prioritizes infant “sleep consolidation” at the expense

of nighttime breastfeeding!• One-size- must- fit- all approach (dismisses heterogeneity) • Devoid of relational-emotional aspects including unique infant

“intrinsic” factors – Infant sleep personality-temperament– How infant articulates with unique needs of parents– Devoid of underlying biology of emotions– Devoid of an evolutionary perspective;

• Current models either ignore altogether the critical relationship between nighttime breastfeeding and infant sleep;

• or minimize its significance of breastfeeding to infant-maternal health.. seeing anything that threatens early sleep consolidation as negative….too much breastfeeding is to be avoided or ”dealt with”

And “sleep training”??No human infant needs to be formally ‘’sleep trained’. Eventually, infants and children all follow the routines established by their families, individual sleep personalities, not withstanding. “Authorities” pushing a “one size MUST fit all” ideology involving fallacious warnings increasingly are used like weapons against parents…stressing and scaring them inappropriately.

Disregarding feeding method as an important factor in assessing sleep consolidation?

Recent paper published in Pediatrics, makes no mention the importance of night wakings in relationship to breastfeeding i.e.

the infant’s nutritional needs claims that even infants as young as one month of age can be trained to ‘sleep through the night’

See

Oct 25, 2010; Pediatrics Jacqueline M. T. Henderson, Karyn G. France, Joseph L. Owens and Neville M. Blampied . Sleeping Through the Night: The Consolidation of Self-regulated Sleep

Across the First Year of Life.

Crying

Chimps have….

..bad days, too!

Recent cultural ideologies place BOTH infants and parents at odds with their biology (emotions)

• Western Caregiving:– Child is not in contact with mother

most of the time (crib, stroller)– Baby is kept supine – Scheduled separated feedings– Social pressures not to respond to

infant crying for fear of “spoiling”– Separation, minimal feedings, is

thought to be “good for baby”

Function of Crying

• primary form of pre-verbal communication;

• evolved maximize chances of infant survival and parental reproductive success.

• signals infant distress, fear, hunger, pain and/or discomfort..

• crying ensures proximity to parent, protection from predators.. (Bowlby)

• Though crying is not the normal way by which infants receive breast milk…crying is a late sign of infant hunger signals …

Evolutionary Adaptedness• “A number of studies in human

infants have confirmed the potential importance of both contact and nutrients as regulators of infant behavioral state…increasing carrying from 3 to more than 4 hours a day reduces duration…of crying/fussing behavior by 43% at 6 weeks of age” (Ron Barr).

“Crying is a late indicator of hunger”

American Academy of Pediatrics Breast Feeding Task

Force..Gartner et.al 1997

From a biological perspective….

infants who protest by crying in attempts to ameliorate a life-threatening situation i.e. separation from the caregiver represent the most adapted infants of all!

These infants are vigorously adapted, mature,..they are responding properly to environmental cues and acting appropriately in response to their own emotions

(Not Bad!)

Traditional Pediatric and Clinical Approaches and assumptions to Infant Sleep:

• perpetuate the very environmental conditions that give rise to the parent-infant sleep problems they are asked to solve…

Controlled crying (or controlled comforting..or sleep training, “extinction”

1. a technique to manage infants and young children who do not settle alone or who wake at night, or who settle only if held or if permitted to sleep in proximity or contact with their parents….

2. involves leaving the infant to cry for increasingly longer periods of time before providing comfort…

3. the goal is to condition infants or young children to “sooth” themselves back to sleep and to stop them from crying or calling out during the night

Controlled crying techniques and philosophies …

reflect social ideologies not scientific findings about who infants are and what infants need based on empirically-based, scientific- biological studies;

techniques reflect who we want infants to be (convenient) or become or should become (autonomous/independent) as early in life as is possible;

Australian Association of Infant Mental Health

“The AAIMHI is concerned…

“controlled crying” is not consistent with what infants need for their optimal

emotional and psychological health, and may have unintended negative

consequences”

From “Controlled Crying: AAIMHI Position” Paper November 2002

First Question

What cultural assumptions about infants and their sleep and

developmental needs, lead to caregiving practices which induce

infants to cry in the first place, which in turn make “controlled crying”

techniques seemingly necessary?

Second Question (there is a choice) :

• What exactly needs to be changed? – should babies be changed… can they be

changed (biologically? -or-

– should the ideas and assumptions which underlie and justify recent western infant care

recommendations be changed ?– who gets to decide?

It’s one thing to ask if some infants can be conditioned or trained to sleep alone, unattended.. “through the night”

(unsupervised, unfed and unintended)

It’s altogether a different and more serious matter to ask if they should be,

or if it is not nice, dangerous or injurious in either the long or short run…

Misunderstandings by parents often motivate the use of “controlled crying” techniques….

infants will be cognitively or socially handicapped--no scientific studies support such predictions..

“

Evidence that crying is neither expectable nor beneficial, but deleterious..

• requires considerable physiological effort with…

• increase heart and lung activity (Rao et al. 1993; Lester et al 1985),

• increased energy loss through..• Heart rate increases (Pillai and Jane 1990);• Augmented plasma cortisol levels;• Decreased blood oxygenation (Anders et al.

1970;Levesque et al. 1994);

And , yet, from a western cultural medical (clinical) perspective

protesting infants are considered to be developmentally inferior, immature, or “spoiled” compared with infants who comply or acquiesce passively to the cultural model of separation-----which actually endangers infants…..

And parents of such infants assume either that their infants are deficient, or that they lack good parenting skills…

Evidence -Based Science:

Infants sleeping alone in a room by themselves are at least twice as likely to die from SIDS than are infants sleeping in the company (same

room) as a committed adult caregiver…

Sources: Great Britain (Blair et al 1999), New Zealand (Mitchell and Scragg 1995), and European Collaborative Study (Carpenter et.al.in press, Lancet)

Colic as a Condition Infants “Do”

• Difficult to define exactly what differentiates colic crying from normal crying

• Colic crying is continuous with what normal infants do, only for a longer duration and/or greater frequency

• Parental perceptions and interpretations of crying intensity range on a continuum

Colic: A Condition Infants “Do” Not “Have”

• 2 weeks to 5 months of age

• “paroxysmal,” or spontaneous bouts

• Rule of threes: >3hrs/day, >3days/week, >3weeks

With respect to crying …and smiling

• Both these “perceptuo-motor mechanisms” according to Bowlby…promotes maternal “attachment”..

• turning on , and turning off , of each--- become socially and psychologically mediated as the infant’s neocortex myelinates (baby decides whether or not or if, to cry or smile…and to whom or for whom…and when to do so….

• For the first 3-to 6 or more weeks neurological structures regulating initiation and termination capacities may not follow the same time course of development; an infant may be able to start to cry but unable to stop it, and the sensation of loss of control causes the baby to do more of what created the situation in the first place..cry (doing colic), crying inconsolably

Australian Association of Infant Mental Health Position Paper…

• “It is normal and healthy for infants and young children not to sleep through the night and to need attention from parents. This should not be labeled a disorder except where it is clearly outside the usual patterns”;

• “Parents should be reassured that attending to their infants needs/crying will not cause a lasting “habit”..Waking in older infants and young children may be due to separation anxiety, and in these cases sleeping with or next to a parent is a valid option. This often enables all to get a good nights sleep”

AAIMHI.. recommends that parents should be told….

• Controlled crying methods have not been assessed in terms of stress on the infant or the impact on the infant’s emotional development;

• A full professional assessment of the child’s health, and child and family relationships should be undertaken before initiating a controlled crying program…

• ….this should include an assessment of whether the infant’s crying is outside the normal levels

if...sleeping alone through the night is “good” for babies

then don’t “good” babies do so,?Controlled crying is a recent social invention having nothing

to do with what is in an infants best interest..Current research shows nothing more than how deeply social

ideologies and social agendas can masquerade as science.

Western parents often equate the infants (and parents) moral standing with infant sleep behavior i.e. confusing a perceived

medical “good” with a moral “good”, that is,

Clinical Application

• Inform parents that early infant crying is normal and “makes sense” from an evolutionary standpoint

• Possible “solution” to reduce the prolonged crying of colic: change “normative caregiving, rather than treating intrinsic or extrinsically induced pathology in the infant” (Barr 43). (remain physically close to baby, breastfeed more continuously, etc.)

Again..think about this..Who Controls Who?

• The only power medical authorities and their recommendations have over parents is what we (as citizens and parents) choose to give them;

• Its time to remove the locus of cultural/political control from these groups that dispense social judgments that masquerade as scientific truths, and relocate decision making to where it belongs… to informed parents!