Cry Baby

4th June, 2010 - Posted by Drboo - 5 Comments

There has been lots of media coverage recently on the “crying it out” technique – giving the impression that there are two camps: one of MeanMummies who leave their babies squealing in darkened rooms until they fall asleep, exhausted (parents and baby, I expect) and a second of distinctly crunchy Earth-Mamas who gather their little ones to their ample bosoms at the slightest squeak.
Let’s face it; most of us pitch our tents somewhere between these two. But the “research” is casting confusing light on the whole crying thing – does it harm our babies if we want to try and let them “self-settle” if it means they cry for a bit? Are we risking brain damaged offspring if we need to nip to the loo and have to leave our bundle of joy wailing in the next room?

“Crying it out”

Surprisingly few childcare experts actually advocate the “crying it out” (CIO) technique. Even Ferber1, with whose name CIO is often synonymous (it is sometimes called “Ferberising”) never used the term. “Extinction training” is the closest thing to CIO, where parents are instructed not to check on their children unless absolutely necessary. Most authors who suggest a “Ferber” type technique do allow for parental checking and sometimes a soothing pat or similar.

Ferber and others2 believe that crying, for some children, is an inevitable part of learning to sleep independently. Ferber suggested only letting your baby cry for 5 minutes before comforting him/her the first time, extending this to 15 minutes the second night and up to 25 minutes after several nights of trying his methods – usually with children from 5 months. So, basically a “timed soothing” approach which would teach your child to “self-soothe”.

Dr Spock suggests a similar, if a little harsher, routine:
The baby has to learn that there is nothing to be gained by waking and crying. This can usually be accomplished in two or three nights by letting her cry and not going to her at all. She is apt to cry for 20 or 30 minutes the first night (it may seem like much longer), 10 minutes the second night, not at all the third.”
Now, that’s more like CIO.

Ferber himself acknowledges that his approach does not “teach” a child to sleep. It simply denies them access to their parents’ soothing, so they work it out for themselves. And studies do suggest that children whose parents have used these techniques do throw less “bedtime tantrums”, sleep for longer periods of time, and settle more quickly. But why do they? One school of thought believes that babies stop crying eventually, not because they have learnt how to cope, but because they have simply “given up” and are in a state of either exhaustion or despair.

William Sears3 reckons that any method of getting your baby to sleep that involves leaving them to cry “desensitises” the mother (and father) to the baby’s needs and can mess with the attachment of baby to parent. Let’s face it, babies only have one way to communicate and it is instinctive to pick them up and comfort them when they do.

You are tired, Baby, GO TO SLEEP!

You are tired, Baby, GO TO SLEEP!

So, is any CIO or timed-soothing method going against parenting instincts? Not necessarily, I know many parents who, at the end of their tether would not immediately go to their baby when they cry for the tenth time in the night, book or no book. And, in fact, there are times when perhaps you shouldn’t go back to your screaming baby – hours after you started trying to get him/her to sleep, the end of your tether reached so long ago it is but a distant memory, and all you want to do is shake, fling, shout at this recalcitrant child who must know they are tired and need to sleep. Then, perhaps we are all best leaving the room and letting the baby cry alone. But are we still harming the baby doing this?

Evidence of the “dangers” of leaving a baby to cry

So, does it actually cause harm? Well, Gina Ford categorically states “I would like to reassure you that, providing your baby has been well fed, and that you have followed the routines … your baby will not suffer psychological damage” (pg 98). This may be true, but, while I have not found any research specifically investigating deliberately letting a child cry in an otherwise loving and nurturing household, and is no evidence of harm the same as evidence of no harm?

Studies4 have shown that crying raises Cortisol levels in babies. Concerns have been raised over the potential long-term neurological consequences of this, especially if it occurs on a regular basis. However, some experts have dismissed these worries – higher Cortisol may not be bad for a baby. In fact, research suggests that babies who are breastfed have higher Cortisol than formula-fed babies5, which may be related to the analgesic properties of breast milk – and no-one reckons breastfed babies are at risk because of this. In fact, some claim that higher levels of Cortisol in infancy is related to better performance in a number of areas including memory and executive functioning6,7.

I am a huge fan of William Sears, but was deeply disappointed in his article on the dangers of leaving a baby to cry. On the face of it, it appears quite frightening – leaving a baby to cry causes hormonal imbalances in the brain, decreased emotional, social and intellectual development, and physiological changes including heart arrhythmias. However, a quick check through the references casts doubt on how some of these findings can be applied to children of loving families whose parents try a CIO approach: several papers about prolonged crying and later development are actually referring to children who cry excessively in infancy – not because they were left to do so. Other papers are about children growing in violent society, or abusive homes, or being separated from their parents. Further papers are about primates and rat pups being separated from their mothers. Some of these take too much of a leap for me to be happy applying their findings to using a CIO technique in an otherwise happy, stable home.

There is, however, firmer evidence that, along with the raised cortisol levels, babies left to cry have raised blood pressure, elevated heart rate, and reduced blood oxygen levels 10, 11. Sutherland18, who carried out a four year study of children’s brains using scans, concluded that leaving a child to cry “can cause serious damage to their brains on a level that can result in severe neurosis and emotional disorders later in life” and that the “blunt truth is that uncomforted distress may cause damage to the child’s developing brain”. So, contrary to Ford’s categorical assertion, there is some genuine concern that leaving a baby uncomforted could cause damage. And this is an area that has not been widely and well studied yet.

Some people also worry that sometimes babies are crying for other reasons rather than “just because they want attention”, and to ignore these cries could mean leaving your child in pain – teething, tummy ache…. I heard a story recently of an older gentleman who, many years ago, had left his baby to cry until he eventually gave up and found the baby had got their head stuck in the bars of their cot. Parenting is full of enough guilt – perhaps adding more like that is unnecessary. (He never told his wife).

One of my major concerns is around attachment. At around 6 months of age babies often start to experience anxiety around being separated

Cuddles - great for attachment

Cuddles - great for attachment

from their parents. It is often around this age that sleep problems start, and around the same age that CIO-type methods are recommended to be used. At this age babies need to learn that when their parents leave the room they will return and that they are safe. What we want is for our child to develop a “secure attachment” – be a bit upset if Mum or Dad leaves them, but settle down after a while and are happy when parents return, prefer parents above strangers, and go to parents if hurt – this type of attachment is best created when a parent responds to the child’s distress promptly, consistently, and appropriately.

Why do we think children should sleep better?

In most non-western cultures, babies are not expected to sleep independently and through the night. Research has shown that when parents do not expect their child to do these things, they report less sleep problems than parents who think their child should self-soothe to sleep and sleep without parental intervention.

Some feel that leaving a baby to cry violates our most basic parenting instincts. Back in the day we slept communally and shared parenting “watches” through the night to tend to waking babies13. So a baby that cried out was instantly soothed by a parent or parent figure. This makes sense – someone to watch out for dangers in the dark – and a baby uncontrollably crying would attract predators so would need shutting up as quickly as possible. In fact, our ancestors probably didn’t have one long period of sleep, but would sleep for a few hours, wake up for an hour or so, snooze again – so even the adults didn’t “sleep through”! OK, this is all a bit of a reach, perhaps, but it’s worth remembering that the way our children behave at night is totally normal and what we are trying to do is make them fit into our modern lifestyles. Knowing this may not change what you do, but it is worth bearing in mind when someone is telling you what they think you should do about your sleepless baby.

Other approaches

Gina Ford, in The Contented Little Baby Book, advocates settling babies with a cuddle but no eye contact or talking as “it could send confusing signals” and putting the baby down when they are still awake but about to fall asleep. She recommends leaving a baby to cry for a short time before he or she falls asleep: “Because I know they are well fed, burped, and ready to sleep, I am very strict. I would let them fuss and yell for 10-20 minutes until they have settled themselves..” (pg 98). She clearly states she does not advocate a genuine CIO approach.
Despite my previous quote, Spock was not all hard-hearted. He did suggest that parents of babies who cry because they are anxious about theparent leaving could try gradually moving away from the baby, talking and stroking one night, just stroking the next etc (Extinction with Parental Presence – I’ll look at that in a sec). He, however, goes on to say: “If the baby simply won’t go back to sleep this way, or if the waking continues for weeks, you can use the less tenderhearted method.” Hmm, to be tenderhearted towards your baby or not? Tough call.

Tracy Hogg, author of the Baby Whisperer Solves All Your Problems (oh, if only that were true!), suggests using the “Shush-Pat” method. This

© Denys Dolnikov | Dreamstime.com

approach accepts that a baby may need physical intervention to help them sleep – so you whisper “shh shh shh” into the baby’s ear – not directly, as you are meant to be doing this with the strength of a “faucet on full force” and you don’t want to perforate an eardrum – while patting them. She reckons this works on babies under three months. Hogg believes that parents who rock, feed, bounce or walk their babies to sleep are giving them a prop, and this will come back to haunt the parents in the end.

Nursing a baby to sleep - a rod for your own back?

Nursing a baby to sleep - a rod for your own back?

Personal interjection here – as you readers (if, in fact, anyone is reading this) will know, I firmly believe that you should do what works for you – and if it ain’t broke don’t fix it. I am pretty sure that, if you rock your baby to sleep, you won’t be doing this forever – how many 13 year olds do you know that need rocking to sleep? Hogg, however, does believe that leaving a baby to cry it out will destroy the trust they have in you.

After three months, Hogg recommends the “Pick Up, Put Down” method (PU/PD). Basically, you go to your child’s room when he or she cries. Try and comfort with words and a gentle hand on the back, or the “shush pat” (if they are up to 6 months old). If this doesn’t work you pick the baby up, and then the second the crying stops, you put him/her down (for us that would be a recipe for the crying to start again). Apparently, this usually takes 20 minutes, but can take up to an hour (as Tracey says (and there are so many things wrong in my opinion with this statement …. “if it takes 150 times, surely you’re prepared to do that in order to teach your baby to sleep and to get your own time back, aren’t you, luv?”). The difficulties with this, and any “sleep trainer” approach, is that they are based on a “one size fits all” theory.

It is worth remembering that we’ve always had one size fits all approaches, and, as generations go by they are discarded in favour of “better” approaches. And sometimes they come back. Should this tell us something? Like diets – if one diet worked for everyone there wouldn’t be a diet industry worth billions of pounds – so true with baby sleep training.

The American Academy of Sleep Medicine suggests that CIO, and similar approaches such as those above, do not have the best evidence base. The approach with the strongest empirical support is Extinction with Parental Presence5. This method does not involve leaving children alone, you put them down awake but snuggle them to sleep, gradually moving away each night, paying less and less attention to the baby who is drifting to sleep. Eventually the parent leaves the room, but returns before the baby cries, so he/she associates their parent leaving with their eventual return. The baby also learns self-soothing techniques with a parent present until he or she is ready to be left to soothe themselves alone.

Conclusions

Leaving your baby to cry on a regular basis is stressful for everyone involved. With little developing brains this could cause long-term damage, but the research base is kind of weak. Sometimes it may be the safer thing to do, and done on a few occasions – like when you’ve been trying to get him/her to sleep for hours and are about to burst a blood vessel, or you  desperately need to use the toilet  - doesn’t seem likely to cause any harm (especially if the alternative is you hurting the baby or wetting your pants).

When thinking about whether or not to use a CIO approach or something similar, I remind myself of what Kittie Franz wrote17: “Remember, you are not managing an inconvenience, you are raising a human being”. She cautions parents to consider, when looking at conflicting advice, consider whether you would put it in a “Good for the baby” basket or a “Good for the parent” basket – “Don’t talk yourself out of it by believing that some advice you read must be good because it was in a book, or the person giving the advice has five kids, or was a nurse.”

Yes, it is inconvenient to have to keep going up to my baby and rocking or nursing him to sleep, but that’s OK. Personally, I can cope with that

Sleeping like a baby - yeah, right

Sleeping like a baby - yeah, right

better than I’d be able to cope with him crying. But that is my choice – this is how X and my husband and I are happy to muddle along. It won’t work for everyone, because not all families are the same.

I would be very wary of following the advice of someone (who has never met you and your family) regarding what to do when your baby cries, especially if they are telling you to do something that goes against your instincts.

Further Reading

www.phdinparenting.com/2008/07/05/no-cry-it-out/
www.aaimhi.org/documents/position%20papers/controlled_crying.pdf
www.parentingscience.com/sleep-tips.html

References

1. Ferber, R. Solve your child’s sleep problems
2. Marc Weissbluth Healthy Sleep Habits, Happy Child
3. Levesque BM, Pollack P, Griffin BE and Nielsen HC. 2000. Pulse oximetry: What’s normal in the newborn nursery? Pediatric pulmonology 30(5): 406-412.
4. Luddington-Hoe SM, Cong X, and Hashemi F. 2002. Infant crying: nature, physiologic consequences, and select interventions. Neonatal Network 21(2): 29-36.
5. Skuladottir A and Thome M. 2003. Changes in infant sleep problems after a family-centered intervention. Pediatric Nursing 29(5):375-8
6. Cao, Y et al. 2009. Are breast-fed infants more resilient? Feeding method and cortisol in infants. J Pediatr. 154(3):452-4.
7. Haley, DW et al 2006. Cortisol, contingency learning, and memory in preterm and full-term infants. Psychoneuroendocrinology. 1(1):108-17.
8. Blair, C. Et al 2005. Cortisol reactivity is positively related to executive function in preschool children attending head start. Child Dev. 2005 May-Jun;76(3):554-67.
9. Sears http://askdrsears.com/html/10/handout2.asp
10. Levesque BM, Pollack P, Griffin BE and Nielsen HC. 2000. Pulse oximetry: What’s normal in the newborn nursery? Pediatric pulmonology 30(5): 406-412.
11. Luddington-Hoe SM, Cong X, and Hashemi F. 2002. Infant crying: nature, physiologic consequences, and select interventions. Neonatal Network 21(2): 29-36.
12. Ford, G. The Contented Little Baby Book.
13. Ekirch AR. 2005. At Day’s Close: Night in Times Past. New York: WW Norton.
14. Hogg, T The Baby Whisperer Solves All Your Problems.
15. C.M. Worthman and M. Melby. 2002. Toward a comparative developmental ecology of human sleep. In: Adolescent Sleep Patterns: Biological, Social, and Psychological Influences. M.A. Carskadon, ed. New York: Cambridge University Press, pp. 69-117.
16. Spock, B. http://www.drspock.com/article/0,1510,3975,00.html
17. Franz, K. 2005. Doesn’t the breast work anymore? Mothering Sept/Oct:132.
18. http://observer.guardian.co.uk/uk_news/story/0,6903,1345420,00.html

5 Comments

Lakshmi

June 6th, 2010 at 4:52 pm    


Hi. I was directed to your blog by a friend. This is a very interesting piece. I have a question for you with respect to the Sutherland study. Is it the crying itself that’s the problem? Or is it just leaving your baby alone to cry? I ask because my baby has had several extended periods of crying in her young life – starting with the fact that she was put in the NICU after birth and they wouldn’t let me “feed on demand.” Then she had blood taken every week and would cry for long periods after that. Then, I had her in the car seat on the highway and I couldn’t take her out of it so she cried for 20 mins. Etc. I have tried sleep training and the length of crying bouts have been shorter than those other times when I was in her presence and comforting her, so I wonder whether those issues later in life that Sutherland describes may be problems whether or not I was present and comforting her.

DrBoo

June 7th, 2010 at 8:55 am    


Hi Lakshmi
Thank you for reading!
Sorry to hear that your baby had to be in NICU and they wouldn’t let you feed on demand. That must have been very difficult for you both.
As for the baby crying in the car seat – I think we’ve all been there!
I think it’s worth bearing in mind that Sutherland is talking about babies in uncomforted distress. If you reassure your baby that you are there – by talking to them, stroking or holding them, even if it does not stop their crying, it is a world away from leaving your baby to cry alone.
In fact Sutherland goes on to advise:
* Do not try to persuade the child out of their emotions, however extreme or unreasonable you might feel those emotions to be.
* Do not minimise their emotions: show through touch, tone and facial expression that you understand the intensity and quality of what they are going through.
* Be their emotional rock: be kind and calm.
* Hold them – touch is vital to calm and soothe a child.
It is not prolonged periods of crying that is the problem, according to these studies – it is regular uncomforted distress.
So, in your case, you will have been soothing your baby (both when they were in NICU and in the car seat) either with words or touch, so your presence will mean that the negative long-terms effects will not apply to your baby.
I hope this makes sense. If you have any other questions or thoughts, do let me know!
DrBoo x

David

June 19th, 2010 at 10:53 am    


I read about this study on Infants’ Internal
Working Models of Attachment and was wondering if frequently leaving your baby to cry would impact the proposed internal working model. Just an idea (about an idea). Have you come across Johnson’s study?

http://www.google.co.uk/url?sa=t&source=web&cd=2&ved=0CBkQFjAB&url=https%3A%2F%2Fwww.stanford.edu%2Fdept%2Fpsychology%2Fcgi-bin%2Fdrupalm%2Fsystem%2Ffiles%2FEvidence%2520for%2520infants%2527%2520internal%2520working%2520models%2520of%2520attachment%2520attachment.pdf&rct=j&q=susan+johnson+insecure+attachment&ei=PJEcTLv9EZm80gS_isyzDQ&usg=AFQjCNEOsaBJPzlnEtSbgWxk4yTz-s6KfA

I wonder therefore what leaving your baby to cry might ultimately have on their theory of love.

DrBoo

June 20th, 2010 at 9:44 am    


Thanks for the article link, David!
The internal working model of attachment, for anyone reading this who doesn’t know, is the cornerstone of attachment theory. Basically, we develop internal representations (working models or “schemas”) of self and others and the relationship between the two. In order for a secure attachment to be formed between baby and caregiver the baby’s needs must be met promptly, consistently and appropriately. If they are not, the baby may form an insecure, disorganised or ambivalent attachment style to the parent. Our attachment styles follow us through life – it’s not just with our parents but with all relationships “from cradle to grave” as Bowlby said.
So, regularly leaving a baby to cry is highly likely to impact on attachment. However, I am concerned that sometimes we do not differentiate between leaving a baby in distress on a routine basis and letting a baby “Cry it out” at night for a few weeks. Perhaps, when the baby is left to cry like that it has a different impact than a baby left to cry regularly during the day? I don’t know.
As for their theory of love….Well, infant attachment can be considered the framework for love. How the attachment works out with the first person a baby feels love for – hopefully his/her parents – will influence romantic love in adult life. If you have anything other than secure attachment as a baby it is perhaps more likely that you will experience difficulties in adult relationships, fearing that you are not loved etc. Ainsworth talks more about this, I think.
Is this what you mean by their theory of love?

sophie

January 11th, 2011 at 12:56 am    


read ‘why love matters’ for lots of scientific evidence for how leaving a baby to cry DOES cause harm

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