Webchat with Dr Helen Ball
In June 2010, sleep expert Dr Helen Ball offered her help and advice to Mums in a live webchat. Helen answered your questions on topics from overcoming co-sleeping difficulties and tackling insomnia to information on SIDS and her views on sleep training. Here are a selection of some of the most interesting questions and answers.
MrsJamin: When can you reasonably expect a baby to go longer than two or three hours without a feed in the night, ie "sleep through"? My second son is four months old.
Helen: If your baby is breastfed and nothing else is introduced until six months as recommended, then baby will keep needing to feed in the night most likely until six months or more. Babies digest breast-milk quite quickly and wake up when they need refuelling!
OopsDoneItAgain: My DS is nearly five years old, and wakes anything from once to five times a night for a wee or because of a bad dream or even for a chat We have tried reducing liquids, using a reward charts, being firm and so on but it doesn't stop him waking and calling us. He can be quite grumpy and is droopy in the afternoons, and I am a zombie. Any tips on how to deal with it?
Helen: If you can't think of an obvious explanation for frequent waking in a child of this age (e.g. being disturbed by something) then I think you should rule out a medical cause (such as apnoea). I suggest you talk to clinician. Reward charts and being firm won't stop a child from frequent waking – only discourage them from letting you know they are waking frequently. Sounds like he is getting poor quality sleep. Does he fall asleep at the beginning of the night on his own?
luciemule: My DS is 5 and still waking throughout the night and creeping into our bed - is this usual for a child of this age?
Helen: It's not common for this age group, but perfectly normal for some children of this age. Like everything else, night-waking and the need for parental presence in the night is distributed on a bell-shaped curve. Some kids grow out of it early, others late, and most in between. All are normal, some are just the outliers on the normal distribution. Yours sounds like one of them for this particular feature – with regards to other developmental features he'll be in other places on the curve.
If the night waking is frequent and every night you should probably talk to your doctor about whether there might be an underlying cause. Otherwise extended co-sleeping is not atypical cross-culturally – it only seems unusual in a western industrialised context where we 'expect' children to sleep alone. There is some research indicating that people who co-sleep as children are more independent and socially developed as young adults!
chinook: In your opinion will babies eventually learn to self settle without any kind of sleep training? And if so, when is this most likely to happen? I have a four-month-old who will sleep only when helped by feeding, or being pushed and so on, and I remember with a heavy heart the time I devoted to helping my older child learn to fall asleep by herself. Is it inevitable that I have to do this again?
Helen: Yes, babies don't need to be sleep trained to develop self settling. There is great variability in when it happens, partly to do with genetics, rates of development, and also what babies are fed. The idea that babies will self settle from three months of age comes from research on infant settling patterns done in the US in the late 50's when almost all babies were fed formula – so what it now considered 'gold standard' about settling and appears in lots of paediatric text books and popular literature, is abnormal settling for babies fed on cow's milk formula. Breastfed babies need to be fed frequently at night and night waking can continue for several more months – but breastfed babies do self settle at their own pace when left to their own devices! Remember also the clinical definition of 'settling' is uninterrupted sleep from midnight to 5am – which is not what most parents imagine when thinking of their baby 'sleeping through the night'!
GraceK: My elder daughter (now three and a half) always slept deeply on her side with one hand under her head - from birth, and still does so could, so we could transfer her relatively efficiently to her cot when she fell asleep. However, my eight-week-old younger daughter preferred deep-sleeping position is face down on my chest, after a feed. I know that sleeping face down is linked to SIDS and should be avoided. Are there any statistics for how dangerous this is when on a mother's chest, where she is not on a flat surface? I ask as it has happened quite a few times accidentally, when I have fallen asleep before her whilst feeding.
Helen: Nope, no statistics whatsoever, which suggests it has not happened very often if no-one has investigated it. No-one knows why the prone sleep position in a cot is a SIDS risk – only that the Back to Sleep campaign dramatically reduced deaths in cots. People have investigated re-breathing CO2 when face down on a mattress, inhaling noxious mattress chemicals, overheating in prone position, bacterial toxin accumulation in airways and many other theories.
Some, like toxic gas hypothesis, have been disproved. Others like bacterial toxins seem to hold some clues – but in all cases, sleeping prone on a mother's body is a very different scenario to sleeping prone alone in a cot, so I don't think we can necessarily assume the former is a SIDS risk just because the latter is.
ballstoit: Is it possible to provide some statistics on SIDS and co-sleeping which separate sofa and bed statistics? And statistics on co-sleeping just with breastfeeding mother versus other family members? I co-sleep with my DD who has just turned one, but have been heavily discouraged by my health visitor and family. However, as a deliberate co-sleeper whose baby sleeps on top of the covers and without any pillow, I'm unconvinced that this is really any less safe.
Helen: First of all, SIDS-risk is greatest around two to three months of age. On average in the UK, the rate is one in 2000. For smokers the risk is increased five times, and SIDS-risk for sofa sharing is increased 20 times. Bed-sharing if you are a smoker, or smoked in pregnancy, has a risk increased 12 times, although different studies have produced different stats, but these are UK data. Bed-sharing if you are not a smoker carries no significant increased risk. Breastfed babies have a reduced risk of SIDS compared with non-breastfed babies. No one has studied the relative risks for breastfeeding related bedsharing, but they have been estimated as maybe one or two per 10,000, compared to one per 2000 generally.
LeninGoooaaalll: Do you think that once all common risk factors are eliminated, and indeed that all co-sleeping good practices are followed, co-sleeping might eventually be found to decrease the risk of SIDS?
Helen: I think SIDS is one of those things that will never be completely eliminated. I also don't think all SIDS result from the same 'cause' whatever that may turn out to be. I don't think SIDS is 'caused' by co-sleeping, but babies who are vulnerable may have their vulnerability increased by certain 'unsafe co-sleeping' practices. Trouble is, we have no way of knowing at present which babies are vulnerable. Safe co-sleeping may help protect some SIDS-vulnerable babies as McKenna originally hypothesised.
But I personally think co-sleeping is even more beneficial in terms of breastfeeding, attachment, and 'normal' neurological development, and the obsession with SIDS sometimes obscures these other important issues.
Hermya321: I'm currently pregnant and have been looking into the benefits of co-sleeping. I've seen things like bedside cots and the co-sleepers which sit near the bed. Do you feel that these sort of devices allow for the benefits of co-sleeping without the worry for the parent of squishing the child? If not, what do you feel is best to encourage good sleeping habits in babies?
Helen: Yes, bedside cots seem to be a good alternative to having the baby in the bed if you would prefer. We would like to look at breastfeeding outcomes with these cots to see if feed frequency is similar to bed-sharing, but we haven't got the funding to do so yet. When we looked at similar side-car cribs in hospital on the postnatal ward there was much more frequent feeding than with rooming-in which is good for breastfeeding initiation, but no difference in sleep for mother or baby.
Foxytocin: Do you think it is at all possible to have a national dialogue to normalise safe co-sleeping? Looking at how many parents co-sleep at least occasionally, is the health service doing us a disservice by allowing the taboo to continue?
Helen: There are lots of people (women mostly), working within the health service to change this situation, and I think it is slowly changing. But we are turning an ocean liner here, so it is very slow. Health service staff need evidence on which to justify changing practice and policy and it is very frustrating to them that a lot of current practice is not evidence based, but because it is 'the way things have always been done' it doesn't have to be rigorously justified, but anything seemingly 'new' is challenged every which way.
This is why I started doing clinical trials – they're certainly not the normal domain of an anthropologist – but they need doing so the 'right kinds' of evidence are available in the 'right kinds' of journals, and no-one else was getting on with them!
LindenAvery: If you are breastfeeding and wish to co-sleep in a bed, but your baby actually prefers to sleep alone in a cot, is this just one of those individual things or does it mean that there could be something wrong with your baby?
Helen: There is nothing wrong with your baby, they are all individual and have their own preferences. If he or she is happy, then just go with the flow!
Sparklingchampagne: My DD is five, and was always a fabulous sleeper. She first slept through at five weeks, and we never had any problems until last summer, when all of a sudden, she stopped going to sleep. We have a bedtime routine, with a bath, stories, warm milk, cuddles, and she goes to bed at 7pm. She will get up, come downstairs, go into the bathroom, jump around her bedroom until 9pm almost every night. I can't work out what to do - she has a black-out blind, we don't overstimulate her before bed, she's not eating sugary stuff. When we talk to her about it she just says sleep is 'boring.'
I've tried reward charts, taking things off her, taking her for very long walks, but can't find anything which works. She looks tired, and is really grumpy in the mornings, also when my SD (her half-sister) comes to stay they have to sleep in the same room, and it's not fair on SD, who ends up sleeping in our bed and having to be moved to hers when DD finally goes to sleep.
Helen: She has a long sleep latency – 90 minutes or more. Children on average fall asleep in around half an hour. Daytime activity has been found to reduce sleep latency in children, but it sounds like you've tried all the normal behavioural and sleep hygiene type stuff and she just doesn't sound ready for sleep at 7pm (or isn't allowing herself to be). Have you ruled out medical issues that might be keeping her awake? I've heard sleep paediatricians recommend temporarily making bedtime later to just before child normally falls asleep - and then when they are in the habit of going to bed and falling straight to sleep, start moving bedtime gradually forwards again. I don't know if that works, but sounds sensible!
CrawlDaddy: Does the actual bedtime have any effect on quality of sleep? For instance, would it matter if DS goes to bed at 8.30pm, say, as opposed to 7pm?
Helen: For toddlers and preschoolers it is the regularity that is more important than the actual bedtime - and being sure that the child gets enough sleep, so either sleeping later if they go to bed later, or having a regular daytime nap.
120: Is there a difference in the quality of sleep a child receives during the day and during the night? My three-year-old will either go to bed shattered at 7.30pm having been grumpy all afternoon, then sleep til 6.30, or nap for an hour during the day, be bright and breezy in the afternoon and then not go to bed until 8.30 then still awake at 6.30.
So the number of hours slept are the same, but I'm not sure which pattern is better for a three-year-old. I worry about them being a bit tired and accident prone in the afternoon, but would stick with it if it is better for them to have all the sleep at night!
Helen: An excellent question. I was discussing this with paediatric sleep researchers in US recently. The consensus currently is that the most important thing is total sleep time in 24 hours – it doesn't seem to matter if this sleep is achieved at night, or in combination with daytime naps so long as it is sufficient to alleviate sleep pressure. In the US three-year-old children routinely have afternoon naps, but it is not a routine custom in UK.
witchwithallthetrimmings: Most of my mother's generation insists that we slept loads more than my DCs. So, at 18 months, my DD sleeps 11 or so hours a night, and has a nap for about an hour and a half. At the same age I was sleeping 13 hours a night and napping for two hours. Is this true on average and if so why?
Helen: Yes, it's true that duration of child sleep has declined in recent decades. There are a host of reasons – parents working later and more varied schedules, children's TV programming 24 hours per day, less emphasis on daytime naps, early wake-up to be dropped at childminder – all sorts of reasons. Parents truncate their own sleep to gain time to fit everything in to busy lives, and children's sleep gets truncated also.
Druzhok: Is there any measure being taken of the physiological or psychological effect of sleep training that involves leaving a child to cry for any length of time? I can't bear to leave a young child to cry in the dark, but I can see that is does get results very quickly and it's certainly very popular.
Helen: This is a heavy topic! There is an increasing amount of neuropsychology research that indicates that children who experienced 'controlled crying' develop different behavioural-physiological profiles than those who are not exposed to this technique as research is now demonstrating that early infant experience drives neural and hormonal development.
Nils Bergman argues that in a very simplified scenario, controlled crying results in infant fear; the experience of fear results first in infant protest (crying), fear-terror (screaming) and then in despair/dissociation (shutting down).
Despair ultimately causes harm to the structural organisation of the brain. Immunological, hormonal and neurological functions are depressed. Controlled crying 'works' not because infants necessarily 'learn to sleep', but because they dissociate and shut down when abandoned. This is an adaptive response to the infant's perception that it has to survive in a malevolent environment.
We haven't researched this ourselves, but what I've read makes me think controlled crying is not an appropriate technique for use with infants – only for older children with the cognitive ability to understand what is being expected of them – and then only as a last resort. See Sue Gerhardt's book Why Love Matters for a synopsis of some of this research.
Adair: What's the most important thing we should try and teach or guide our babies to learn about sleep? Mine would be that sleep is a desirable, natural state and not to be feared.
Helen: I agree with your choices. For me the most important thing babies need with regards to sleep is security – to feel secure that they are safe while they are asleep, not abandoned, alone, afraid. If we think about the environment in which human infants have evolved, never, in thousands and millions of years would infants have been intentionally left alone for sleep by their carers (too dangerous). To wake alone would, for an infant, have been a life-threatening situation, and only the result of some very severe event, so it is predictable that they'd be fearful.
stealthpolarbear: Do you know of any evidence to back up the fact that is fairly regularly quoted about sleep being brain development time, the implication being that if you don't sleep train your child, you'll be harming their development?
Helen: This is an 'interesting' justification of sleep training! Yes, sleep is brain development time, particularly for infants. Newborns spend 20 hours or so a day asleep, and 50% of this is spent in REM sleep (so 10 hours a day). REM is when neural connections are made, when learning and memories are consolidated. Adults sleep for seven or eight hours on average, and 20% is spent in REM sleep (so an hour and a half). Babies brains grow rapidly in the first year, so they do need to sleep. HOWEVER – sleep training is a) inappropriate for babies because of the reasons mentioned and b) is often undertaken to try and modify when babies sleep, not to encourage them to get sufficient sleep.
Lowlybones: Why might my three-month-old be waking in the night for a feed, around 1am, but then staying awake for an hour and a half as though it's daytime? And what can I do about it? This happens once or twice a week. She sleeps well for daytime naps and other night, and I'm breastfeeding. I am a nervous wreck after the nights she stays awake, and she refuses more food, and has burped! I would just live with it if I knew it would end, but just don't know what to do at the time as she doesn't want food, or to be held , just wants to interact with me! Any advice gratefully received.
Helen: It will end! Babies start to get a circadian rhythm when they are about three months old (it happens later for breastfed than formula fed babies), but this is a gradual process. Over time sleep gets consolidated into night-time and waking into daytime. You might be able to help her achieve this sooner than later by providing cues for what is night and what is day (keep night-time dark, keep interactions quiet and calm etc).
You might just have to wait for her circadian rhythm to develop – there is individual variation in this, as in everything biological, of course! Another thing to consider is whether something different is happening on the nights she stays awake compared with those when she goes back to sleep? Something in her environment, in your diet, your behaviour? You might be able to figure out a trigger if you keep a diary of when it happens.
DidEinsteinsMum: I have had years of sleep disturbance due to child with sleep problems. Now that he has been medicated, his sleeping has improved over the last year, but mine is still really bad and I am constantly tired but unable to sleep. I'm reluctant to take medicine, as I still need to be able to wake up if he gets up in the night for safety reason - he's a five-year-old escapologist who can open doors and windows and has no fear. How long could it be before I am able to settle down to a sleep pattern that is closer to what I need rather then what my body had to become used to? What about letting him fall asleep at the breast, i.e. not self settling?
Helen: There are various treatments for poor sleep that don't involve medication - talk to your GP about referring you for CBT (cognitive behavioural therapy). It definitely helps some people. You'll eventually stop breastfeeding him to sleep and he'll fall asleep without it at some point. Why do we want to encourage babies to self-settle? Again this is a very culture-specific parenting requirement in our society and doesn't reflect babies evolved needs i.e. to ensure closeness with caregiver at vulnerable periods (such as the transition into sleep).
Suiledonne: It has been about four years since I have had a satisfactory night's sleep. Just wondering if there are consequences to one's health from ongoing sleep interruption or lack of sleep?
Helen: This all depends on what you want from a 'good night's sleep'. If you are not tired during the day and begin the day feeling refreshed, don't worry about it. Most people wake up during the night and go back to sleep. If you are suffering long periods of wakefulness and are tired in the morning or sleepy during the day then there are long term health consequences for things like heart disease, so in that case see a GP.
Thefoosa: Can you help me sleep through the night? I wake every night after an hour or two, then find it difficult to get back to sleep. I hit a brick wall of sheer exhaustion at about 6pm, which is probably the busiest part of the evening for me. What can I do to improve my sleep?
Helen: It depends what is keeping you awake! If it is anxiety, or mind-racing related, then there are various CBT techniques that can help. Consumption of alcohol before bed causes you to wake up after a couple of hours, as do certain types of food, and various illnesses. Modifying your 'sleep hygiene' might be all it takes. I'd suggest you consult a GP, and see NHS advice for insomnia.
hobbgoblin: Do you feel that too much emphasis is placed upon how we sleep and 'teach' our children to sleep and that an instinctive approach, that would be as varied as the individuals practising it, is better? Or, do you feel that there is a right or ideal way to sleep and learn how to achieve the state?
Helen: How we sleep and how much we sleep is as individual as everything else we do. So long as we get enough sleep to meet our individual needs (which are widely variable) then that is sufficient. The 'rules' we have created about how much sleep people 'need' (and the environments we 'need' to achieve 'good' sleep) are artificial. That being said, though, children need more sleep than adults, and infants need even more.
In our 24-hour artificially illuminated world children do need some amount of parental regulation to help them achieve sufficient sleep to meet their needs (previously we would be regulated by environmental cues) – but there is no 'right way' to accomplish this – there are lots of different ways that work for different families and circumstances.
Habbibu: My son, who is eight months old, seems to be a very light sleeper. Even cuddled in my arms he can take a long and very wriggly time to get into a deep sleep! Do you think that there are biological or physiological differences between babies and people in general that make them the kind of sleepers they are, or do you think it's mostly down to conditioning? I sleep badly when co-sleeping with DS, which is a bugger.
Helen: Interestingly, babies fall asleep differently from adults. While we fall straight into deep sleep, babies fall first into REM sleep and after 20 minutes or so (on average) fall into deep sleep. Babies can take variable amounts of time to get to deep sleep (floppy baby stage) however. And yes, there are biological differences in the kinds of sleepers we are, just as there is variation for all behavioural/physiological systems. Physiology can be regulated by conditioning to some degree but can't 'standardise' everything. So long as the amount of sleep he gets meets his needs (he's not constantly cranky etc) I wouldn't worry – his sleep is most likely normal for him.
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