Your Baby Week by Week - Consultant Paed Advocates Cry It Out?

Unless you've been living in a parenting cave the last few days, you can't have failed to see the image on the left which has been doing the social media rounds.

A baby book which appears to suggest that should a baby cry so hard they vomit, you can change the sheet half the cot at a time.  And resist any urge to comfort, cuddle or speak to baby as parents need to be strong minded.

I noticed when reading the discussions, some people claimed the snippet had been taken out of context. And they're right; the next line might read "don't ever do this!".  So I decided to take a look on Amazon at exactly what the book does and doesn't say.

Book Title: Your Baby Week by Week
Author: Dr Caroline Fertleman & Simone Cave
ISBN-13: 978-0091910556
Relevant Pages: 260+

Below you can find the sleep section in question:

My Amazon preview finished there, but a book owner copied the following conclusion to Facebook:

"and cry even harder. By all means try the popping-in technique, although you’ll probably find that it just seems as though you’re teasing him. Checking your baby will give you some reassurance that he’s still safe and well, despite being very upset, but leaving the room will be hard for both of you. So our advice is to check on your baby without him seeing you – perhaps through a crack in the door. The next day Your baby will wake up refreshed, be as cuddly and loving as ever and behave as though nothing happened. You’re bound to be feeling guilty, but see the programme through because you’ve made a decision to try controlled crying and it really won’t do your baby any harm.

What many first time parents reading this book may not be aware of, is that all the above is really rather controversial.  Whilst statements are written definitively ie "it really wont do your baby any harm", other specialists vehemently disagree with this opinion.

This makes it tricky.  A paediatrician, someone who many hold as the ultimate baby expert, is saying it absolutely won't do any harm to leave a baby crying so hard they vomit.

Firstly I would like to say that whilst the term "controlled crying" is used a lot, this book isn't advocating "controlled crying" (CC), but "cry it out" (CIO).  CC involves returning to the baby with ever extending gaps, CIO is basically just leaving them to cry, end of.

Let's start at paragraph one.

Five months is the recommended age to start.  I'm not sure why, ie who picked this date - it doesn't tie in with any research I've seen recently, and there are no references in the book to support the claims. According to all SIDS guidelines baby should still be in their parent's room at this stage right?

As a lactation consultant it's concerning, because many breastfed infants continue to need a night feed at 5 months - they haven't even started solids at this age.

Infants whose primary source of energy is breastmilk will often wake frequently to nurse, something that is essential for the breastfeeding relationship to continue (Ball, 2009).

The thing is, take the feeding out of the equation - and we know it's still biologically normal for infants of this age to wake regularly.  (Weinraub, Bender, Friedman, Susman, Knoke, Bradley, et al., 2012).  More about what is normal infant sleep here.

How can any parent of a 5 month old be sure their baby doesn't need milk, but that it's "just" a want?  To me it really highlights the formula feeding culture many health professionals live in.  That a bottle is simply calories and we can calculate whether they are deemed necessary.  It doesn't consider that the breast is a whole lot more than food.  Breastfeeding is recognised as an anaelgesic by the BMJ - therefore an infant in discomfort will often want to feed.  It releases relaxing, sleepy hormones to both mum and baby (often helping mothers themselves get back to sleep quickly after night wakings), helps baby pass any trapped wind (gas), and is the ultimate "comfort item".  It seems it's OK for babies to rely on bits of cloth or "loveys" as their comfort, but heaven forbid a baby derives comfort from its own mother.

We then have to warn the neighbours.  Seriously.  And apparently if you do this, they will be tolerant.   To be honest we clearly mix in different circles, as many of my friends would be horrified if their neighbours informed them of this, and would likely print off oodles of reading as to to the risks before dropping it round with an offer of babysitting!

You then basically need to book time off work, as you have to expect 4 nights of crying - right before they warn you will feel stressed as your baby howls.  

Dear readers this "stress" felt is called INSTINCT.  Many mothers can use their "stressed" feeling as an accurate gauge as to their baby's need.   There is the low pitched, almost moany non urgent cry, that many of us attend to - but we might pop to the loo en route calling out we are on our way.  It's the polar opposite of the high pitched scream that makes you want to sprint and stop that baby crying now.

"Don't stand unmoving outside the door of a crying baby whose only desire is to touch you. Go to your baby. Go to your baby a million times." - Peggy O'Mara

Next we check baby is well, presumably we're assuming onset of illness can't occur in the middle of the night.  We then have to add extra creams in case baby poops whilst crying.  Er why?  Are we seriously suggesting not changing the nappy if baby soils it?

The next paragraph about vomit, makes me feel like doing the same.  I have no words.

Whilst he's screaming we have to remind ourselves he isn't hungry or in pain.  Hmmm what about all the other emotions we humans have?  We are seriously limiting babies to two or three?

Oh no wait, it's ok because the next paragraph tells us he's probably not feeling abandoned or scared, because he isn't a teenager and only has basic needs.  Yep that's right, the basic need of a responsive caregiver.

If it all gets too much, watch a film, pop in some earplugs.  Forget your 5 month old is so desperate for you they're vomiting - because apparently whilst babies aren't mature enough to feel complex emotions, they're capable of a mastermind level of manipulation.

Wendy Middlemiss, Associate Professor of Educational Psychology at the University of North Texas decided to study exactly what does happen to babies who are left to cry.

"Saliva was sampled for mothers and infants at initiation of infants' nighttime sleep and following infants' falling to sleep on two program days and later assayed for cortisol. As expected on the first day of the program, mothers' and infants' cortisol levels were positively associated at initiation of nighttime sleep following a day of shared activities. Also, when infants expressed distress in response to the sleep transition, mother and infant cortisol responses were again positively associated. On the third day of the program, however, results showed that infants' physiological and behavioral responses were dissociated. They no longer expressed behavioral distress during the sleep transition but their cortisol levels were elevated. Without the infants' distress cue, mothers' cortisol levels decreased. The dissociation between infants' behavioral and physiological responses resulted in asynchrony in mothers' and infants' cortisol levels" here

What does this mean?  Basically it tells us that during the first two nights of sleep training, both mum and baby released increased levels of a hormone, indicating they were stressed at the "sleep training" taking place.  However by the third night, the baby stopped signalling this distress - the "result" that this book aims to achieve.

What is critical to note though, is that baby's saliva showed they were indeed still stressed - they just stopped signalling this distress to their caregiver.  Therefore mother's stress hormone dropped and for the first time during the study mother's and baby's cortisol was mismatched.

This also confirms that when mothers feel so incredibly stressed on nights one or two that they just want to go and retrieve their baby (which the authors acknowledge will happen) - he is feeling the exact same desperately overwhelming levels of stress too...

So what does cortisol, this stress hormone do to the brain when it's produced in excess? It has been linked to chemical and hormonal imbalances, a suppressed immune system, ADHD, and a negative impact on emotional development. Read full with references here

Darcia Narvaez is a Professor of Psychology at the University of Notre Dame and Executive Editor of the Journal of Moral Education agrees:

"With neuroscience, we can confirm what our ancestors took for granted---that letting babies get distressed is a practice that can damage children and their relational capacities in many ways for the long term."

She goes on to say:

When the baby is greatly distressed,it creates conditions for damage to synapses, the network construction which is ongoing in the infant brain. The hormone cortisol is released. In excess, it's a neuron killer but its consequences many not be apparent immediately (Thomas et al. 2007). A full-term baby (40-42 weeks), with only 25% of its brain developed, is undergoing rapid brain growth. The brain grows on average three times as large by the end of the first year (and head size growth in the first year is a sign of intelligence, e.g., Gale et al., 2006).

Darcia also believes there are other significant potential consequences, which are discussed fully in her article here.

Perhaps the most ironic thing, is that Penn State researchers recently suggested receptiveness is more important than routine.

Emotional availability of mothering at bedtime was significantly and inversely related to infant sleep disruption, and, although these links were stronger for younger infants, they were significant for older infants as well. 

These findings demonstrate that parents' emotional availability at bedtimes may be as important, if not more important, than bedtime practices in predicting infant sleep quality. Results support the theoretical premise that parents' emotional availability to children in sleep contexts promotes feelings of safety and security and, as a result, better-regulated child sleep.

The Australian Association for Infant Mental Health Inc (AAIMHI) in its 2002 position paper (revised in 2004) on controlled crying:

'AAIMHI is concerned that the widely practised technique of controlled crying is not consistent with what infants need for their optimal emotional and psychological health, and may have unintended negative consequences.' You can read the background to these concerns in a PDF document that can be downloaded from the AAIMHI's website .

I would like to conclude by thinking again about the advice to not interact, respond or communicate in anyway with baby when they are distressed.  I think this video clip highlights perfectly that whilst as non psychologists, emotional and psychological damage may not be easy to recognise - that doesn't mean it isn't happening.



Further reading:

Baby Taming, if it works does that make it right?

Evolutionary Parenting: Educating the Experts – Lesson One: Crying