I thought I knew what musical head banging was. I was wrong.
In 1995 I won a musical head banging contest at my niece’s bat mitzvah. As I recall the DJ played “Smells Like Teen Spirit” by Nirvana. I did what any student of 70’s hair band culture would have done. I planted my feet firmly in place, raised my right arm, saying “I Love You” in American Sign Language (cuz rock n’ roll is all about the love, dontcha know?) Then I proceeded to make like I was hammering finishing nails into a two-by-four. With my forehead. Brother Beavis will demonstrate.
I was so naive. That was NOT musical head banging.
Apparently, musical head banging has something to do with your baby’s sleep. It is claimed by some “experts” that if you play music to your baby as she falls asleep in the crib, she may develop musical head banging. And this is bad.
I learned this from illinoishomepage.net in an article entitled “Sleep Problems”
CHAMPAIGN COUNTY, Ill.
You might think letting your baby fall asleep to music is a good thing, but old habits sleep hard. It could actually negative affect their sleep.
It sounds harmless, but letting baby drift off listening to music might have a few consequences. Studies show constantly relying on certain sounds to go to sleep can create a need to listen to music.
So, if they’re away from home and don’t have access to that music, baby might not be able to sleep without listening to it first.
This could lead to musical head-banging. Music could make your child more likely to bang their head against solid objects.
If you think music isn’t the right choice for your child, experts suggest a white noise machine. It will drown out household sounds and provide a quiet environment for them to sleep in.
You can even find some apps for them on your smartphone.
A graphic in the accompanying video suggests that livestrong.com is the source of this information. I followed the lead and found this article from s2015. It states, in part,
[H]eadbanging (sic) is the habit some children have of banging their heads against solid objects. If you have a child who bangs his head, you may notice it’s more prevalent when falling asleep or when listening to music, notes the University of Michigan Health System. That means headbanging could be exacerbated when your little one listens to music to fall asleep.
I was floored. I’ve been a sleep consultant for a long time and I’ve never heard of this phenomenon before. According to her bio, the author of the piece, whom I will not name, “specializes in health, fitness and lifestyle topics. She is a support worker in the neonatal intensive care and antepartum units of her local hospital and recently became a certified group fitness instructor.” I wonder if she’s ever had a baby?
Not finished with my search, I checked the references at the bottom of the article. There was one piece that did indeed come from the University of Michigan Health System web site. The subject of the article was “Bad Habits/Annoying Behavior“. Here is what this piece had to say about head banging:
Body rocking is when (sic) a child rhythmically rocks while either sitting or resting on their knees or elbows. This behavior usually starts around age six months and disappears by age two. Most children rock for 15 minutes or less. Like head banging, it occurs while listening to music or falling asleep.
That’s it. How did we get from here to “Music could make your child more likely to bang their head against solid objects”?
I’m afraid what happened here is the internet version of a game of telephone. The message got so garbled by the last call that this television station in Illinois ended up giving some pretty dumb advice to parents.
What is Musical Head Banging, Really?
It’s one of two things. Babies rock and bang their heads sometimes when they are tired. It is a sort of self-soothing technique. It usually lasts no more than 15 minutes. Other babies bang their heads as a kind of what I call “Stupid Baby Trick”. Bonking her head makes the baby hear this hollow ‘thud’ sound that she didn’t expect. Any unexpected sensation is interesting to a baby. She’ll keep doing it because, well, it’s interesting. The same thing happens when she pulls her own hair (it HURTS!) or gags herself with her own fist.
Eventually the child gets bored and the behavior stops. But sometimes the baby keeps the behavior going if it gets a big reaction from a caregiver. It is as if the baby says to herself “I’m getting bored with this head banging thing, but look what a reaction I get from mom! I’m gonna keep this going!”
Can music become a negative sleep association?
Something else the Illinois article said caught my attention. It was the suggestion that that music at bedtime might interfere with sleep: “Studies show constantly relying on certain sounds to go to sleep can create a need to listen to music (emphasis added).” What were these studies?
I went to the online National Library of Medicine/National Institutes of Health, affectionately known as “PubMed“. I performed every search I could think of combining “music” and “sleep disturbance” or “sleep associations”. I could find none. There are no such studies. Playing music in the nursery does not interfere with the process of a baby falling asleep or staying asleep. In fact, one of the sources cited at the livestrong article actively recommended music to help a baby fall asleep.
Unless of course you decide to blast “Smells Like Teen Spirit” in the nursery.
In the age of the Fitbit, it is only a matter of time before devices designed for babies appear on the market. There are a whole bunch available now. There is a pacifier that doubles as a thermometer. You can buy a device to prevent heat stroke in your baby. There is even a GPS tracking devices for babies. The particular segment of the infant wearables market that concerns us here are the devices that measure infant blood oxygen levels. The unstated reason for buying such devices is the prevention of death by SIDS, or other sleep-related infant deaths.
Infant Wearables in the Age of Back-to-Sleep
These devices are based on a well-tested technology from the world of medicine called pulse oximetry. The “pulse ox” works by shining a red light onto the skin and simultaneously measuring the wave-length of the light that bounces back. The device then calculates the amount of oxygen in the bloodstream. Such devices have been used in even tiny babies for many years. Now, several companies are marketing these devices for parents worried about SIDS.
Do they work? Do infant wearables really prevent SIDS?
These are obviously two separate questions. We’ll tackle them one at a time.
To address the question of whether home pulse oximeters work, a few studies have been published. The study that best answers the question was published the the UK in 1991.
The British investigators focused on a group of babies that recently had been discharged from hospitals with apparent life-threatening events. Translated into English, the babies had turned blue at home, either because of choking or lung disease related to prematurity. This was a good population to study. The chance that these babies would actually need the alarm was greater than the general population of babies. Most of these babies had some kind of medical problem that made them more vulnerable to dropping their oxygen levels. This means the investigators were not measuring rare events and it would be unlikely that the number of events measured would be too small to give meaningful results.
The investigators also gave monitors to parents who had already lost a baby to SIDS.
The study looked at the number of events that the wearable devices picked up. Importantly, they also looked at false alarms, and measured side-effects of the devices, such as blisters and other skin burns.
A total of 201 babies were monitored for 30 months. Only 19 families withdrew from the study before it ended.
The pulse oximeters recorded 81 events, of which 52 were true episodes of blueness. No episodes were missed. In other words, the sensitivity of the device was 100%. Any time a test shows a 100% sensitivity (no true positives missed), there is going to be a substantial false positive rate. For these parents, that means an alarm going off for no reason. Sometimes the sensor would move out of position or fall off, activating the alarm. Sometimes it was a true false alarm. The device would go off when nothing was wrong. In the UK study, false alarms happened about once every 4 days.
Very few of the babies got skin redness from the red light source and none were burned.
Four babies actually died during the study. One sibling of a SIDS victim died while the infant wearables were in calibration mode. That is to say they were not turned on correctly. The cause of death was ruled SIDS as well. The other three babies died of the severe congenital heart and lung problems that got them included in the study.
There are two important take-aways from this study. Pulse oximeters work well. They will catch every dip in a baby’s blood oxygen level. But the devices cannot prevent death in severely ill babies. As was demonstrated catastrophically in this study, the devices won’t work if they are not turned on.
Infant Wearables and SIDS
The second question we asked was whether these devices can prevent your baby from dying of SIDS. The honest answer is “nobody knows”. In the UK study, the only baby to die of SIDS was not wearing an alarm. One other sibling of a SIDS victim in the study had a substantial dip in her oxygen and was later found to have meningitis. The answer remains open. We simply do not know if infant wearables prevent SIDS.
But wait! Didn’t this study show that the alarm always goes off when the baby’s oxygen dips too low? If so, won’t any baby in danger of SIDS set off the alarm?
It’s a reasonable question. The answer is “yes, you are probably right”. And yet, we simply do not know because the studies have not proven the point to a degree of scientific certainty.
The Question You Didn’t Ask
It’s clear that pulse oximeters for use at home are very sensitive. They catch every event. This also means they “catch” events that are not events. Imagine how unbelievably frightening it must be to be awakened in the middle of the night by such an alarm. You cannot be sure if you are answering a false alarm or if you will be dialing 911. The question we didn’t ask at the outset was “do you think infant wearables make you more relaxed, or more anxious?”
The American Academy of Pediatrics has not taken a position on these devices for healthy infants. The organization’s silence probably reflects the absence of scientific evidence on SIDS prevention. Pediatricians disagree as to whether or not it’s a good idea for parents to buy such a device. My recommendation would be to discuss it with your pediatrician before buying.
I have argued before that no modern sleep expert recommends pure “cry-it-out” (CIO) sleep training. Here I want to explain in more depth where CIO stands currently. In order to simplify the discussion, I’ll call it by its more technical name, extinction. Some versions of this method are widely recommended today. One kind, unmodified extinction, has all but disappeared, or become extinct. That’s a shame, because it is highly effective, as I’ll explain below.
When it comes to any kind of human or animal behavior, “extinction” refers to the disappearance of a behavior in the presence of a stimulus. Pavlov famously could make his dogs salivate when he rang a bell (the stimulus). The dogs had learned that the bell meant Dr. Pavlov was about to feed them. That was only the first part of the experiment. In the second part, the dogs stopped salivating after a while. In other words, the salivating behavior “extinguished” with time.
Extinction in Sleep Training
When it comes to sleep training, the behavior we are trying to extinguish is crying. In sleep training, there are now three versions: Extinction with parental presence, graduated extinction, and unmodified extinction.
Extinction with parental presence is a version of CIO where the parent stays in the baby’s room, but does not respond to cries. With time, the caregiver moves farther away from the crib. Finally, the baby sleeps alone. This method has been championed by Kim West. She renamed the method “The Sleep Lady Shuffle”. The terms get even more confusing because West’s followers refer to her method as “bedtime fading”. This is very different from true fading techniques.
The graduated variety is today better known as “Ferberization“. The method involves answering the baby’s cries, but doing so at longer intervals every night until the baby goes to sleep on her own.
Finally, we come to the true dinosaur, the unmodified CIO technique, sometimes called “cold turkey”. The villain of the CIO story is a late-19th century pediatrician named Luther Emmett Holt. The first time we see the words “cry it out”, they appear in Holt’s 1894 catechism “The Care and Feeding of Children.”
Holt’s book is not a “sleep book”. In fact, there is no section on bedtime routines such as the kind we’ve grown used to. There is, however, a section on the types of infant cries and what to do about them. The section that follows is really about “problem crying”.
What should be done if a baby cries at night?
One should get up and see that the child is comfortable—the clothing smooth under the body, the hands and feet warm, and the napkin [diaper] not wet or soiled. If all these matters are properly adjusted and the child simply crying to be taken up, it should not be further interfered with. If the night cry is habitual some other cause should be sought.
How is an infant to be managed that cries from temper, habit, or to be indulged?
It should simply be allowed to “cry it out.” This often requires an hour, and in extreme cases, two or three hours. A second struggle will seldom last more than ten or fifteen minutes, and a third will rarely be necessary. Such discipline is not to be carried out unless one is sure as to the cause of the habitual crying.
Holt is describing a particular kind of crying here. This is crying born of habit. These are babies who have learned that crying can draw her parents’ attention. I suspect he is referring to babies who’ve acquired “object permanence“. That is, the baby knows that mom or dad is still there when they leave the room, and she can induce them to come back.
Dr. Holt is not describing a way to get a baby to fall asleep. He is describing a solution to a problem. That sleep problem is “bad sleep associations“. For example, the baby won’t sleep unless she has physical contact with a parent, or if she has a binky in her mouth. Likewise, sleep books that discuss “cold turkey” or any other CIO technique are aimed at families that already have developed bad sleep associations and want to reverse them.
The Moa is Extinct. So is the Cold Turkey
Of the three types of extinction methods, only unmodified extinction, or cold turkey, has disappeared. It has ceased to be (see video below). And yet, cold turkey has been tested experimentally and found to be extremely effective. Several arguments agains cold turkey have been raised, not least that the method stresses the baby and caregivers. These objections have also been tested and so far have proven to be false. Even the most-cited article arguing for the negative effects of CIO failed to show that the stress hormone cortisol goes up in crying babies!
The main reason cold turkey has gone extinct is that it is really difficult to listen to a child cry. Most parents can’t handle it. I know I couldn’t (the boys’ mother was the stronger partner). Listening to crying becomes even more difficult because of a thing called the “extinction burst”. This is an increase in crying as the sleep training process proceeds. Sometimes the burst happens after it appears that you’ve succeeded and the baby is sleeping through the night. In either case, the stress for parents becomes too much.
A second reason, perhaps more important, is that many parents believe cold turkey CIO will psychologically damage the baby. There is absolutely no evidence for this. To the contrary, the evidence suggests that babies sleep trained with unmodified extinction get good quality sleep. Parents report better sleep for themselves and their children. Overall there are only positive results for the family.
The reasons for the disappearance of a perfectly good sleep training method appear to be cultural, rather than scientific.
One more cultural factor deserves mention: consistency. Probably the number one reason why any of the extinction methods fails is that parents cannot or will not stick to the plan consistently. Consistency is the number one most important feature of any sleep training method, whether you are doing scheduled awakenings, bedtime fading, or the “Sleep Lady Shuffle” (which is, to repeat, extinction with parental presence).
To Extinguish This Line of Argument
The bottom line is that extinction methods are effective.
Extinction methods do not harm your baby or your bonding with her
Consistency, consistency, consistency. This is the essential piece of solving any sleep problem
Finally, let us explore the true meaning of life extinction with the help of our panel of experts, John Cleese and Michael Palin.
Long before there was a “no-cry” solution to baby sleep training, there was a thing called “Scheduled Awakenings”.
What? You’ve never heard of scheduled awakenings? There’s a reason for that. It’s really really hard to do. Too bad, though: it appears to work.
Scheduled Awakenings: The Original No-Cry Method
In 1980, Rita J. McGarr was completing her Bachelor of Science in Nursing degree at Stanford. For her thesis, project, she performed a case study of a 3-month infant with frequent night awakenings. The objective of Ms. McGarr’s study was to test whether a mother could shape her baby’s waking pattern. Just prior to the time the baby would wake up naturally, the mom would wake the baby up at intervals using a music box. Then she would gradually move “music box time” later in the evening. The baby went from sleeping 5 hours straight to sleeping 7 hours sleep. Not great, but enough to get published. And a new sleep training method was born.
The method Rita McGarr tested came from Behavioral Learning Theory. Briefly, the theory says that all behavior can be learned. What’s going on inside the learner’s head is not as important. The idea that any behavior, including sleep, can be taught leads eventually to parent-led sleep training methods.
Other investigators would later test the method. The best of these compared scheduled awakenings to other methods such as “graduated extinction“. It turns out to work very well.
Here’s How it Works
First, you have to keep a log. Keeping records became a lot easier in the 21st century with the advent of smart phones. There was no more taking notes in crayon on toilet paper!
First, you put the baby down the same time every night. This is an important first step in any baby sleep method. You write down the hour the baby wakes up. When she wakes up, you do what you usually do to get her to go back to sleep: rock her, feed her, etc. You should do this every night for as many nights as it takes to see a pattern emerge. Obviously, one night is too few. A week may be to many. I usually settle on three days.
Once you have a schedule of the baby’s wake-up schedule, you set your alarm clock. Again, the smart phone comes in handy. You want to set the clock for 15 minutes prior to the time you’ve noted that the baby usually wakes up.
The waking up process should be as gentle as possible. I like Rita McGarr’s music box idea. When the baby is awake, you nurse or feed her as you usually do, and put her back down to sleep.
After about a week of this, you gradually increase the times you go in to wake the baby up. A good starting point is 15 minute increments. For example, if you had been waking her up at 1:00 AM, start waking her up at 1:15, etc. Do this three nights in a row.
Then start dropping the awakenings. If the baby had been waking up only once, great, drop the scheduled awakening and you are done. If she’s doing it more than once, start dropping them in order: Drop the first awakening first, then the second, etc.
Now you have a sleeping baby! You did an awful lot of work to get here. There is a good chance that you would have about the same success with scheduled awakenings as you would have had with one of the extinction techniques, only without the crying.
Problems with the Technique
Schedule awakening training is difficult. I mean, it’s really difficult. Of all the sleep training techniques, it is clearly the most labor-intensive. It asks of parents that they wake themselves up, rather than being awakened by the baby. It also requires more time than other techniques. Even if there are no set-backs along the way, the entire process will require a minimum of two weeks. This is something to consider in light of the following facts: all the extinction techniques, including old-school Holtian cry-it-out, require 3-5 days; Extinction is at worst equally effective as scheduled awakenings; Finally, there is no evidence that extinction techniques have any negative effects on babies or bonding with caregivers.
Scheduled awakenings remains a viable option, especially parents who absolutely cannot stand hearing a baby cry. I know how to train a baby this way, and I can help you do it. How many parents do I know who have tried it? I have that number memorized: it’s zero. For most parents, especially sleep-deprived, stressed out parents, the scheduled wake-ups are more stressful, not less.
Nevertheless, if you’ve “tried everything” to get the baby to sleep, and you haven’t tried scheduled awakenings, you have not in fact tried everything! Behavioral learning works. It requires strength and patience. You got this.
The so-called “cry it out” techniques for sleep training are getting a lot of attention. Meanwhile, there is another method that gets very little press, but which is highly effective. It’s called “bedtime fading”.
What is Bedtime Fading?
Bedtime fading is a method for teaching a child to fall asleep that is based on a simple principle: a child who is not tired will not go to sleep!
Babies and children are famous for “fighting” bedtime. Parents tell me that their child “fights” sleep. Or they tell me the child fights the parents at bedtime. The truth is that the child is fighting neither sleep nor the parents. She is fighting the time. She isn’t ready to sleep yet. Forcing the baby to bed earlier than she wants to is a recipe for conflict. Worse, the baby may develop negative associations surrounding sleep. This is never a good thing.
The Three Key Features of Bedtime Fading
One key feature of bedtime fading is finding the child’s “natural” time of sleep. This is presumably later than the perplexed parents want, but it’s what the baby wants. There are a couple of ways of finding out what the natural time of sleep is. See “The Bedtime Fading Technique” below.
Another key feature is “sleep onset latency“. This is nothing more than the amount of time it takes a person to fall asleep after getting into bed (or the crib in this case). Sleep experts agree that it’s never a good idea to have a long sleep onset latency, with a limit at about 20 minutes. Anything longer than that suggests the individual will not or cannot sleep. Ideally, you want the child to be falling asleep within 10 minutes. Less than 5 minutes, though ok, suggests that the child has a “severe sleep debt”. This is another way of saying “she’s totally exhausted”.
The third feature are good sleep associations. We want the child to associate going to sleep with calm and quiet. We want her to feel comfortable and safe. This step is essential to teaching the child to self-soothe, and to wind herself down to sleep on her own, without assistance from caregivers.
How to Do Bedtime Fading
The first step is to determine the baby’s natural sleep time. There are at least two ways to figure this out. The first is to keep a sleep diary. Parents or caregivers write down the times the child falls asleep every day. They should do this for every nap as well. Doing so provides useful information for them and for the sleep coach. The last time she falls asleep is probably the time she is “set” to fall asleep.
A second method for determining baby’s sleep time is called the “response cost” method.
[A Digression: The official name of this method is called “bedtime fading with response cost”. I never liked this expression. It’s high-tech expression for a truly low-tech idea.]
It works like this: you put the baby to bed at the time you want (the desired bedtime). If the child doesn’t fall asleep within 15 minutes, you remove the child from the crib or bed and allow her to play (quietly) and otherwise stay awake for 30-60 minutes. This is the “response cost” to the child. Then you try again. If the child still won’t fall asleep within 15 minutes, you repeat the procedure. You do this until the child falls asleep rapidly. Now you’ve found the child’s natural bed time.
For at least two days, you treat this later bedtime like the normal bedtime. This means establishing a steady, consistent bedtime ritual. You want to aim for any activity that promotes calm and quiet. I recommend starting the routine at dinner time, no matter how late. From then on the routine is completely predictable. It’s usually a mix of these activities: a warm bath, brushing teeth (if she has teeth), book reading, lullabies, prayer, etc.
From here, you gradually fade bedtime earlier to your desired bedtime (hence “bedtime fading”). Experts differ as to the number of minutes to fade and the number of days to stay at each bedtime. Some recommend fading 30 minutes earlier every night until hitting the target. Others recommend moving in 15 minute increments. This is my preference. Half an hour is too big a jump for some children. I also recommend two days for each bedtime. This means the entire bedtime fading technique may require two weeks or more to complete. It is well worth the effort.
Setbacks can happen. Sometimes the child will revert to her previous “natural bedtime”. If so, I recommend repeating the fading technique, but this time taking it more slowly. Perhaps spend three days at each time point.
Other children might fall asleep well as a result of a successful bedtime fading campaign but will continue to wake up frequently at night. In this case, many experts recommend using an extinction method (since we don’t want to call it by its more infamous name. Okay, okay: cry it out.)
This is Great! How Come I’ve Never Heard of It?
Good question. Here’s a baseball analogy: Say your team has a power hitter batting in the clean-up spot (fourth in the order). He’s having a monster year. By the end of April he already has 12 home runs. People are already starting to compare him to Barry Bonds or even Babe Ruth. Camera crews follow him to every ballpark. He’s all they talk about during the sports segment on the evening news. Meanwhile, the guy hitting in front of him (the number three hitter) is quietly having a career year. He’s in the top 5 in just about every offensive statistical category. Why? Because pitchers don’t want to face the monster following him. So they throw strikes to the number three hitter, trying to get him out. And instead of getting him out, he’s getting hits. But no one pays attention because the monster sucks up all the headlines.
That’s kind of like what’s happened to bedtime fading. Extinction methods are like the home run hitter hitting clean-up. Bedtime fading is like the number three guy racking up all the amazing numbers that no one notices. Bedtime fading is an amazingly successful technique that is based on all the principles we know are essential for good sleep: a tired child, consistency, routine, and good sleep associations.
So keep this method in mind. If you need any help figuring out how to do it, that’s why I’m here.
Graduated extinction was criticized by proponents of “Attachment Parenting” styles of sleep training, particularly William Sears. In “The Baby Sleep Book”, Sears makes frequent reference to the relationship between baby crying and elevated levels of the stress hormone cortisol. Lots of crying leads to cortisol going up. Sears says this leads to all kinds of negative outcomes for baby. For example:
“Science (sic) tells us that when babies cry alone and unattended, they experience panic and anxiety. Their bodies and brains are flooded with adrenaline and cortisol stress hormones. Science has also found that when developing brain tissue is exposed to these hormones for prolonged periods, these nerves won’t form connections to other nerves and will degenerate. Is it therefore possible that infants who endure many nights or weeks of crying it out alone are actually suffering harmful neurological effects that may have permanent implications on the development of sections of their brain?”
It was a rhetorical question. Sears goes on to say that cortisol damages babies brains in all kinds of ways. In extreme cases, I will grant that chronic stress is bad for babies. But the “research” Sears cites has nothing to do with crying at bedtime. No one had ever measured levels of stress hormones at bedtime. Furthermore, no one had tested whether different sleep methods stressed out babies more than other sleep methods. No one had asked whether a particular sleep method damaged (or helped) develop a bond between baby and mother.
Investigators in Australia asked mothers in pediatric clinics if their babies had a sleep problem. The doctors recruited 43 babies between 6-16 months of age. They divided the babies randomly into three groups. One was assigned to try “graduated extinction” (AKA “cry-it-out”). Another group would try “bedtime fading“. This is a technique in which you move bedtime later in the evening to match the child’s “internal” bedtime clock, then gradually move bedtime back to your desired time. For example, if you want your baby to go to bed at 8:30, but she usually does not fall asleep until 10:30, choose 10:30 as his temporary bedtime. Then move bedtime gradually earlier.
A third group in the Australia study was handed a list of sleep instructions. This was the “control group” for comparison to the graduated extinction and the bedtime fading group.
During the study, investigators had the parents swipe a cotton swab on the inside of their babies’ mouths to measure the hormone cortisol. Motion sensors were given to parents in the study to measure baby’s wakefulness (actigraphy). The parents also filled out questionnaires to measure their own stress and anxiety. Finally, the mothers and babies took a standardized behavior test to measure their level of attachment.
Cry It Out is OK with Respect to Sleep
Compared with the control group, babies taught with graduated extinction and bedtime fading took less time to fall asleep (sleep latency, panel A). They also woke up at night less often (panels C). If these babies did wake up, they stayed awake fewer minutes than the control group (panel B).
You can see that the control group showed some improvements across the board. This suggests that sleep education helps. It also could mean simply that babies sleep better as they mature. This is why it is so important to include a control group. To study an intervention like a sleep method, you need to know what the “background” improvement is. Otherwise you’ll never really know if your intervention works.
Babies in the graduated extinction group got more hours of sleep in the early stages of the study. However, these gains appeared to disappear by the end (panel D).
Cry It Out is Ok? What About Stress?
The central issue in the Australian study was stress. Does graduated extinction really raise cortisol? Does the method damage the relationship between mother and baby? The answer was ‘no’.
Other researchers have shown that minor stressors can elevate cortisol levels in newborns; But this goes effect goes away at about 4 months of age. The Australian study only looked at babies older than 6 months. So you might think that this study misses an important point that Dr. Sears and others were trying to make.
However, the investigators did something clever to get around this limitation. Sears and others insinuate that cry-it-out sleep methods cause chronic increases in cortisol. These investigators measured cortisol twice, once in the morning and once in the afternoon. They saw no difference among groups. This suggests that cry it out is ok from the standpoint of stress as well.
So Cry It Out is OK for Baby: What About for Mom?
Mothers in both intervention groups reported less stress than mothers in the control group. You see this in panels C and D in the second figure I show here. The researchers also looked at mother-baby bonding one year after the study was over. They found no differences in the ability of moms and babies to bond with one another. The levels of attachment between the two appeared to be identical in all groups. Finally, the babies in the cry-it-out groups had no more emotional or behavior problems than the control babies.
This last finding was similar to a much larger study published in 2012. That study, also done in Australia, involved 326 children. These investigators found that sleep method had no effect on attachment, bonding, and behavior. This study was five years after the intervention, suggesting that there was nothing was messed up permanently by allowing your baby to cry at bedtime.
Limitations: Maybe Cry It Out is OK for Some, But Not for All?
The investigators acknowledge that their study has some problems. For one thing, it was relatively small. There were only 43 babies involved. With small studies like this, there’s a chance that you cannot generalize the results to all babies. This includes your own baby! That is why the investigators were careful to compare their results to other similar studies. We can believe in your conclusion more strongly if you do your study in a slightly different way, but come up with the same answers.
They also noted that they didn’t measure cortisol continuously, or even at night when the crying was happening. It’s possible that cortisol does indeed go up in a crying baby. It would be surprising if it didn’t! But the study was looking at chronic elevations. That is, cortisol stays up over time. This, after all, is the accusation that Sears and others hurl at the Ferber method. Here, the investigators have a point: sleep method does not change cortisol long-term.
The investigators conclude from these data that sleep education alone may not be enough to get your baby to sleep. You may need an intervention if your baby has a sleep problem beyond 6 months of age. They propose an interesting combination of methods: Their results suggest that bedtime fading could be done first. Then graduated extinction could be used to reduce nighttime wakings.
Graduated extinction (cry it out) and bedtime fading are both effective.
Extinction-based methods do not stress out a baby chronically
These methods do no have long-term effects on a baby’s emotional life or her attachment to her mother.
My suggestion: find a sleep method that works for you and don’t worry about it. Show your baby a lot of love and attention and you don’t need to worry about bedtime. Above all, stay consistent: find a routine that works for you and stick with it!
As if parents don’t have enough to worry about these days: Now they are worried about swaddling and SIDS. I am sure that parents all across the world saw the news come across their Facebook feed and were sent into a panic.
Does swaddling your baby increase the rate of Sudden Infant Death Syndrome? You would think so, to read media accounts of a paper published recently in the journal Pediatrics. Here’s a link, and the reference for those who want to read it.
Pease AS, Fleming PJ, Hauck FR, et al. Swaddling and the Risk of Sudden Infant Death Syndrome: A Meta-analysis. Pediatrics. 2016;137(6):e20153275
Here are some headlines from some of our most respected media outlets. Almost all of them misunderstood the paper’s findings:
Washington Post: “Swaddling babies is tied to heightened risk of sudden infant death syndrome”
Yahoo! News: “New Research Suggests Swaddling Could Increase Risk Of SIDS”
Thank God for the Atlantic Monthly and to science writer Adrienne LaFrance. LaFrance is the only medical and science writer I’ve read so far who detected the flaws in the paper. Here’s the headline:
“About That Scary Swaddling Study: A new meta-analysis seems to link infant swaddling with a higher risk of SIDS. But there’s more to the data than that”
Indeed there is more to the story. Let’s get to the bottom of that study on swaddling and SIDS.
Why Even Study Swaddling and SIDS?
In the early 2000s, there was just as much uncertainty as there is today about the causes of SIDS. The famous Back-to-Sleep campaign in the US was already succeeding in dropping SIDS rates. Our success was similar to results seen in other countries. Researchers were stumped. Was it really as simple as all that? How could a silly little change like having the baby sleep on her back reduce the risk of SIDS? Many studies were performed looking at body functions like heart rate and breathing in babies. It was known that swaddled babies were generally calmer and less sensitive to waking up suddenly. The question was asked whether being quiet and less sensitive put a baby at risk for SIDS.
A Look at the Studies
Many studies were done, but most of them were lousy. Pease, et al., who wrote the paper that got all the headlines, decided to perform a “meta-analysis” of all the studies they could find on the subject of swaddling and SIDS. A meta-analysis is considered to be the highest form of scientific study. It looks at all scientific studies of a particular question and sort of pools the results. The idea is that many different groups looking at the same problem collectively get to the truth better than any one study does. It’s never a good idea to rely on only one study to answer a question. The more investigators who come up with the same result, the closer to the truth you are probably getting.
They looked at a lot of studies. Since the 1950’s there have been almost 400 studies asking the question: Is there a link between swaddling and SIDS? Of these studies, Dr. Pease and her colleagues could find only 4 that met a standard rigorous to be considered worthy. And one of these had never been published the data on swaddling. When they were done with their analysis the investigators discovered that they could not easily compare the results of all four studies. So to present their final results they needed to eliminate one study, leaving them with three. Out of 400.
What Did They Find?
After pooling all these data, the investigators found that swaddling increased the risk of SIDS very slightly if the baby was put down on her stomach or side. In other words, it was riskier to violate the “back-to-sleep” rule. It was also riskier to swaddle a baby older than 6 months of age. The most confusing part of the study showed that there was a slightly increased risk to swaddling if you lay the baby on her back. It’s confusing because even so, many more SIDS deaths occurred in un-swaddled babies than in swaddled babies. The so-called “increased risk” was only compared to the comparison (“control”) group.
There were other problems with the meta-analysis. The investigators could not be sure that all the studies used the same definition of “swaddling”. Swaddling means different things in different places. Some of the studies lumped together swaddled and “wrapped” babies. It isn’t entirely clear what was being compared. Perhaps more damaging, the pooled studies were so different from one another that it was impossible to eliminate all the features that could confound the results. In other words, they couldn’t really be sure that swaddling was the thing that increased the risk of SIDS!
The Bottom Line on Swaddling and SIDS
It’s okay to swaddle, but if you do, lay the baby on her back. Swaddling is only risky if the baby is face down or on her side.
Older babies probably shouldn’t be swaddled, but that’s okay, since it’s really difficult to swaddle a six-month old baby anyway. They fight out of the swaddle too easily.
Learn to swaddle a baby correctly. There are lots of terrific videos on YouTube that show you how. Here’s one:
You’re not alone. I know someone else who said that a few years back… ME.
Our first little one arrived 2 weeks early. But he fed well. He gained terrific weight. He hit all his milestones. There’s just one thing he didn’t do. LO did. not. sleep.
We tried everything (or rather, we thought we tried everything!) We rocked him in our laps for what seemed like days at a time. We walked the floor with him at 2 AM night after night. We tried leaving him to cry (against all recommendations). We used pacifiers, white noise machines, bouncy seats and baby swings. Everything worked… for about 10 minutes.
We asked friends with babies for advice. We even borrowed a copy of Ferber (and read it!)
Reading Ferber for me was the proverbial light at the end of the tunnel. In this book I first encountered the concept of “sleep associations“. It was a kind of epiphany for me. And my journey began. I started reading more about sleep and infant development. Then it all fell into place. I had planted the germ of and idea that was to evolve into my sleep coaching business.
I discovered that a powerful potential for normal sleep resides in every human being. The trick is to unlock it. There are no ‘sleep problems’ per se. There are only barriers that stand in the way of a baby or child and a restful night’s sleep!
Over the years, I’ve heard the cries of “Help! My baby won’t sleep!” hundreds, maybe thousands of times. Each story is unique. Each child and family has their own set of issues that contributes to a sleep problem.
But very often, each of these unique cases can be classified in its own group. I’ve made a catalog to share with you here. I’ll explain the broad sleep issue, then explain the elements of the fix. The key thing to remember is that each child is unique, so your story may be different, as will the remedy. The underlying elements, however, are the same.
Why Your Baby Won’t Sleep
1. She’s Not Tired
It’s 9:00 PM. You’ve been up since 4 AM with your 2-month old. You’ve fed and changed her what feels like a dozen times. You’ve gone shopping. You’ve done four loads of laundry. Oh yeah, and you cooked dinner for your husband, who strolls in at 6 PM looking fresh as a daisy. You look like you’ve been in a fight gone bad. You can barely keep your eyes open. So why is it the baby won’t sleep?
It could be that she’s already slept 16 hours in the last 24, and she just got up from a 3 hour nap at 7:00 PM! She’s just not tired enough to go to sleep yet!
Babies develop sleep-wake cycles just like we do. When they are very young, their stomachs usually set the clock. After a few weeks, they begin to respond to the structure imposed by the sun. That is, they learn that day is light and night is dark! They also respond to the structure imposed on the day by their parents: the day tends to start at the same time. She eats at the same time. She plays at the same time. And she naps at the same time.
For a baby like this, I first make sure she’s healthy and getting enough to eat. Then we talk about her sleep patterns. We talk about a typical day for her. In this case, when she’s just had a huge nap in the afternoon, I recommend some tinkering with the nap schedule. It may involve moving the afternoon nap earlier in small steps, say 15 minutes at a time. Again, the fix when the baby won’t sleep because of the recent long nap is only an example. There are always little tweaks that I recommend for families.
2. She’s Overstimulated
Overstimulation is a real thing. It really can rev a baby’s motor so high that she cannot calm down enough to go to sleep. Maybe there’s been too much activity. There was a party in the morning. You listened to a rock station on the radio on the way home. You played all afternoon when she wasn’t napping. By the end of the day the poor baby is wired up!
Newborns and some young babies are able to protect themselves from overstimulation. They do this by ‘shutting it down’, and going to sleep. I call this “The Tilt Function“. As they develop, babies lose the Tilt Function and expose themselves to the risk of overstimulation on those really busy days. Some babies can handle a lot of stimulation, but some cannot!
Sometimes the baby becomes overstimulated because she has lost one of her naps that she really needs. Sometimes this happens ‘accidentally’ and sometimes it happens by design – at day care.
The best way to fix overstimulation is to avoid it to begin with! If the baby’s day is too much for her senses, try cutting back on activities. If she needs that third nap and isn’t taking it, I can teach you some tricks to get that nap back!
On the day that the baby won’t sleep because she really is overstimulated, you may need to bend a few rules. That means, you may need to sit or rock with her for a while. Do this in a dark, calm place. You can run a white noise machine or hum quietly to her. It may be a bad night. But you’ll know how to avoid such nights in the future!
3. She’s Hungry
This one is more common than I thought it would be. Babies are growing faster in their first year of life than they will ever grow later. They need a lot of calories. Some exclusively breastfeeding moms worry that their babies aren’t eating enough. This is natural because it’s hard to know how much the baby is eating if you can’t measure it! But sometimes a baby won’t sleep who is exclusively bottle fed! Rarely, a baby who has started taking solids is still not getting enough calories during the day.
In all these cases, the baby won’t sleep because her stomach keeps her awake. It’s a good thing, in a way. A baby needs to grow!
The first step is to consult the pediatrician. You want to know if they baby is getting enough calories for her weight during the day. You want to know if she is gaining weight along her growth curve appropriately. If she is not getting enough calories, work with your pediatrician, or perhaps a nutritionist, to figure out ways to feed her up. A baby who eats well, sleeps well (and vice versa!)
4. She’s Over-Fed
This is the opposite of #3. Sometimes a baby won’t sleep at night because she’s eaten too much, not too little. Their stomachs are working double time to try and digest all the formula (and solids?). These babies are gassy and colicky. Often they are constipated. In that case, the baby won’t sleep because she needs to poop and cannot. Or sometimes she poops to much, and her full diaper won’t let her rest.
I see this a lot in babies who drink “spiked bottles”. These are bottles of formula or pumped breast milk that you’ve added cereal to. There is no reason to spike bottles, people (see below).
Just as in #3, the first step is to consult the pediatrician. You want to know if the baby has a good weight for her age. You want to count up the calories she’s eating per 24 hours. This number varies, but she should get around 50 calories per pound of body weight per day. If she’s eating substantially more than this, this could be the reason baby won’t sleep. You should discuss it with your pediatrician. He/She will probably recommend that you cut back on calories. One thing is pretty certain, however. The pediatrician will recommend you stop spiking the bottle if that is what you are doing! Formula or breast milk are perfect by themselves!
5. She’s Got Bad Sleep Associations
This is a major cause of “baby won’t sleep”. It may be the major reason. Sleep associations are, very simply, those things that your baby associates with going to sleep. Some typical ones are darkness, swaddling, sucking on a pacifier, being rocked.
What’s the difference between a “good” sleep association and a “bad” one? A good sleep association is something that will stay with the baby all night. Baby sleep cycles from shallow to deep, just like ours does. A bad sleep association is something that disappears, or is taken away, after we fall asleep. When we get to shallow sleep, we ‘take an inventory’ of all the things around us (our sleep associations), make sure they are all there, then we roll over and fall back asleep. We don’t even remember these partial awakenings.
A baby does this too. What if one of her sleep associations is being held by you? Unless you plan to hold her all night, she’s going to awaken partially at midnight and wonder where you went! That’s why being held is a bad sleep association.
Very often, the baby won’t sleep because the binky (pacifier) has become a bad sleep association for her. When the binky falls out of her mouth, as it surely will, she’ll ‘look around’ for it in the dark. Then she’ll get ticked off and become fully-awake. Then you have a crying baby!
Pay close attention to the events that surround the moment of sleep. Is she surrounded by all the things that will be there in 90-120 minutes when she partially wakes up? Do you hold her or rock her until she falls asleep? If so, she may associate holding and rocking with being asleep. No holding? No rocking? Baby won’t sleep!
Each case is different, but in general parents and I work on ways to put some time between the bad sleep association and the moment of sleep. First a few minutes, then more minutes. It’s essential to dis-associate these things in order to allow the baby to master her natural self-soothing technique.
6. She’s Got Colic
I call this the “C” word. I hate colic. Everybody hates colic. By definition, no one knows what colic really is. The incessant crying for hours at a time, every night, at the same time, is enough to drive any parent nuts! I’m talking about babies who eat well and nap perfectly throughout the day. Then they turn into little devil-babies at night. It begins at 3 weeks of age and continues until 12 weeks.
Colic is a “diagnosis of exclusion”. That means, once you exclude all the other reasons why baby won’t sleep, you can call it colic. Some of these reasons are reflux (see below), over-feeding (see above), or under-feeding (also above).
Parents hate this answer. You have to wait it out. If you and your pediatrician figure out that there’s no other reason why baby won’t sleep, then you have to wait. At 12 weeks of age, it will stop. These may be the longest 8 weeks of your life. But you will survive it. We all did.
7. She’s Got an Inconsistent Schedule
Again, this reason why baby won’t sleep turns out to be a lot more common than I imagined. It turns out that some (many?) babies are creatures of habit. They like having a regular day. They like things predictable. They don’t like change. They don’t like inconsistency. Having said all that, there are many babies who don’t mind chaos at all! But if the baby won’t sleep because she needs consistency and her day is chaos, you may have a difficult problem on your hands!
Sometimes the schedule is fairly consistent except for one part of the day. I’ve had many clients who believe the baby won’t sleep because Dad comes home late and the baby wants to play with him! They’re right! She probably does want to play with him. The problem is her regular sleep-wake cycle wants her to be going to sleep at 9 PM, not to be playing with Dad.
Easier said than done. For many families, chaos is more or less a way of life. It would be great if every day were more or less the same, but the reality is that this just doesn’t happen for some families. But in every family, there are some ways that the day can be made as regular and as predictable as possible. For example, there may be a four-hour stretch at the beginning of the day when mom and baby are alone together. This is a good time to try and establish a routine of eating, playing, and sleeping. If you can succeed in introducing order in one part of the day, then you can work on other parts of the day as well.
8. She’s Got Reflux
Sometimes the baby won’t sleep because food comes up instead of going down. That’s reflux in a nutshell. Milk or food that is supposed to pass into the baby’s intestines comes back up toward her mouth instead. Sometimes acid from the stomach irritates the baby’s esophagus. These babies seem to be in pain. They make funny faces. Many, but not all, of these babies also spit up. Not every baby who spits up has the painful symptoms of reflux.
Some parents tell me that the baby won’t sleep unless she’s being held upright. Or she won’t sleep unless she’s in the bouncy chair. This is a clue. Other parents tell me that the baby always seems fussiest right after eating, especially if they put her down right away.
The first step, once again, is to discuss the possibility of reflux with your baby’s doctor. While you are doing this, there are some things you can try. I call these “anti-gravity methods”. The point here is to let gravity be the baby’s friend, not her enemy. If food is supposed to travel down, let gravity help it go down. I recommend keeping these babies up on an angle virtually all the time, except when changing their diapers. An angle of 30 degrees is possible, but you may have to buy more than one wedge at the baby store. When I say “angle” I mean the entire body, not just one part of it. You don’t want the baby to do an “abdominal crunch’; this might only make the reflux worse. You wan’t her entire body ‘planked’ up at an angle of 30 degrees.
Sometimes doing smaller feeds more frequently can cut down on reflux. If anti-gravity alone doesn’t work, I sometimes recommend adding this technique.
If neither trick works, your pediatrician and you can try some other methods. There may be dietary changes she can make. Sometimes medications can help. The good news is that practically every baby with symptomatic reflux gets better by her first birthday.
9. She’s Sick
Sometimes the baby won’t sleep because there’s something wrong. She’s coming down with something. Or she’s already caught something. Usually you can tell this reason from the other reasons because the baby won’t be right throughout the day, not only at sleep times. She may or may not have a fever. Sometimes, the best way to tell if a baby is sick or not is to ask how well she is feeding. A baby who is feeding well may be sick, but she’s not SICK, if you know what I mean. I worry a whole lot less about about when a baby won’t sleep but continues to eat well, than I do about a baby who won’t sleep and won’t eat!
If you have any concerns or question at all that the baby may have an illness, consult your pediatrician. The overwhelming majority of the time, when the medical problem is fixed, the baby will go back to sleeping well again!
10. She is Hypersensitive
Finally, the baby might be more sensitive to the sensations of her world than other babies. For example, the baby won’t sleep because she hears every toilet flush in the house and it wakes her up. Or if you go in her room to check on her and you ever-so-slightly jostle the crib and it wakes her up! Or the baby won’t sleep if there is too much light in the room.
These are real example from families I’ve helped. On further questioning, I often learn that one or both the parents were “just like this” when they were babies. Grandparents can be a helpful resource when trying to figure out why the baby won’t sleep.
Create a “sensory deprivation space” in the baby’s room. Install black-out shades and carpeting to muffle footsteps. The exception may be a white noise machine. Sometimes, but not always, these devices can help filter out noises from around the house that might wake the baby. It sounds gross, but sometimes I recommend that the parents wait until the baby is awake to flush the toilets. I’ve actually seen this work at least once.
Sleep, Baby! is Here for You
If these ideas don’t work for you, or if the reason your baby won’t sleep doesn’t appear on the list, contact me. I can help!
A: It’s a good question. The answer depends on a lot of factors.
First: What is Teething?
I define teething as the process involved in the eruption of baby teeth. Some people prefer to define teething as the one or two bad days a baby has while the teeth are actually breaking through the gums. This is a good definition, but anyone who has actually had children knows that the discomfort associated with teething starts long before the teeth actually break through.
How many of you have found that the only way to soothe your fussy baby has been to rub her gums with your finger? You can call it what you want to, but it sure seems like teething to me!
First teeth often appear between 4 and 6 months months. The earliest first tooth I’ve ever seen was in a 9-week old baby! But the first tooth can sometimes wait until a year of age to break through. After that, the process will continue until all 20 baby teeth have come through. This can take up to two years!
There’s a long history of teething being blamed for all kinds of nastiness. In the early part of the 20th century, teething was still appearing on infant death certificates! Also on the historical list of teething symptoms is “blinking eyes, vomiting, neuralgia, severe head cold, weight loss, toxemia, tonsillitis, paralysis, cholera, meningitis, tetanus, and insanity.” Fortunately, we’ve stopped believing teething was fatal, but we continue to think all kinds of symptoms are related to teething.
Fever is probably the most common. The latest evidence from the medical literature suggests that teething can lead to an increase in body temperature, but not to a level that could be characterized as a fever (100.4 F rectally).
This is a good time to emphasize a point. A true fever should never be brushed off as “only teething.” If the baby has a real fever, you should pay attention to it. Contact your pediatrician if you have any questions or concerns about a fever in your infant.
These days, teething is blamed for causing diarrhea, facial rashes, diaper rashes, runny noses, and sleeplessness (more on this below!) But the best evidence we have today suggests that teething causes really only two things: 1) Drooling, and … 2) Teeth.
Can the Baby Do Sleep Training While Teething?
But let’s face it: for many babies, teething hurts! These babies are fussy more often. They want to bite on anything that gets near their mouths. They try to insert both hands in their mouths simultaneously (anyone seen a baby try this?) They swat at their ears (anything to get at those painful gums!)
One thing teething should not do is interfere with sleep. Teething pain almost never wakes a baby from sleep, but a baby who does not yet know how to sleep on her own will not be helped out much by a mouth that bothers her!
The Answer is YES
Sleep training while teething is possible. Sleep training while teething is doable. And I recommend doing it! If you’ve started the process of allowing your baby to learn to self-soothe, there’s no reason why you should stop because of teething.
If the baby has already fallen into a daily routine (because you’ve paid attention to her cues and provided her with structure!) then small disruptions from night time teething should not cause you despair. There are many things you can do to try and make her more comfortable, and to continue with your routine.
Always discuss dosing with your pediatrician before you give your baby Tylenol or Motrin. The doctor will probably tell you that you should not give Motrin to a baby less than 6 months of age. You should never give higher doses than recommended, and never more frequently than recommended. My own experience taught me that Tylenol is not anti-inflammatory enough to make any real difference to a baby who is dealing with gum inflammation from teething. So if she’s younger than 6 months old, you can try Tylenol, but rubbing her gums with your finger may be her only relief!
What you should not give is a topical anesthetic like Oragel or Anbesol. It’s true that the FDA has issued a warning that these medications should not be used in children younger than 2. But I have an even better reason to avoid these medications: they don’t work! The inflammation from teething occurs too deep below the surface of the gum to be touched by a topical anesthetic. It’s not worth it.
I confess I gave homeopathic teething tablets to both my boys when they were toddlers. Most teething tablets are made of Calcium Chloride, chalk basically. I knew these tablets would not actually treat teething pain. I also knew they were completely harmless. What they did do was convince my boys that their teeth would stop bothering them. The “placebo effect” worked. They would stand inside their cribs with their hands out waiting for the tablets every night. It became part of the bedtime ritual. Bedtime rituals are good! We stuck with it because it did no harm.
There are a ton of teething products on the market, but the truth is you don’t need to waste your money on them. If an item is clean and she can safely put it in her mouth, you can use it as a teether. We and other parents have tried the toothbrush. The frozen washcloth is always worth a try. But it my experience, nothing works better than the pad of a finger rubbing the baby’s gums. The problem of course is that you cannot keep your finger there all day.
Sleep Training While Teething Take-home Messages
By all means, the baby can continue sleep training while teething.
Consult your pediatrician about pain reliever doses and dosing intervals
Don’t give Oragel! It doesn’t work!
If you try all these things, and you need a sleep coach, I can help!
The good news is that flat head syndrome is a minor problem compared to SIDS. The better news is that it gets better with time. Here’s all you need to know about it:
What is “Flat Head Syndrome”?
Everything in medicine has to have a name carved out of Latin and Greek in order to confuse us. Flat head syndrome is no different. Doctors know it as “Positional Plagiocephaly“. Plagiocephaly means “oblique head”. Put together, the term refers to baby heads that are slanted on one side because of the way the baby lays down.
When babies lay on their backs for too long, particularly with their heads to one side, as shown, they have a tendency to get flat on that side. This is because the space between the bones of the baby’s skull allow for the head to change shape fairly easily. This is a good thing when a brain is growing fast! But it can also lead to flat head. The flatter a head gets on one side, the more likely it is that the baby will favor that side, because it’s harder for her to turn her head!
Premature babies are more likely than full-term babies to develop flat head, as the bones of their skulls are softer. Sometimes babies develop flat head before birth, particularly if conditions are cramped in mom’s uterus, as with twins, triplets, etc.
Other babies are born with a type of stiff neck called “torticollis“. This is another Latinate name for a simple concept, that is “twisted neck”. Before medicine got a hold of the condition, folks called it “wryneck”. Sometimes babies are born with tight neck muscles on one side, preventing them from turning their heads easily. This would cause the baby to lay on one side of her head, leading to flattening. Sometimes, it’s the other way around: the stiff neck comes as a result of flat head flattening!
Positional plagiocephaly will not affect your baby’s brain growth or damage her development in any way!
Not all strange baby skull shapes happen this way. Sometimes a baby is born with the bones of her skull already fused, prematurely as it were. This is called craniosynostosis (more dead languages here). It means “fused bones of the skull”, oddly enough. This is a condition that will have to be addressed by specialists in neurosurgery. If you have any concerns at all that this is what is going on with your baby, please ask your pediatrician!
What Started All This?
After years of study, researchers figured out that babies that sleep on their backs are less likely to die of SIDS than babies who sleep on their stomachs or sides. Several countries, including the UK and the US, have now instituted “Back-to-Sleep” campaigns, recommending that people lay their babies on their backs exclusively to sleep. It has been remarkably effective in reducing SIDS rates, and even better at increasing rates of positional plagiocephaly!
How Common is “Flat Head Syndrome”?
It’s becoming very common. Some studies suggest that, since 1992 when the American “Back-to-Sleep” campaign began, the rate of flat head may be approaching 50%. That is, half of all babies! Are we going to become a nation of people with weirdly shaped heads? Not so fast!
How to Prevent It
Because this is a fairly new condition, compared to the whole history of the human race, we’ve only very recently begun to figure out ways to prevent flat head from happening, while allowing babies to sleep in the safest position possible: on their backs. It cannot always be prevented, but some experts believe that there are several things parents and caregivers can do to reduce the chances of flat head.
One simple thing is to change the direction that you place the baby down in the crib every night. One night, place her head facing one end of the crib, the next night facing the other end of the crib. That way, if there is something interesting the baby likes to look at, she will turn her head the opposite direction every night. If there is not already something interesting for her to look at, put something interesting there! You can place a mobile or perch a doll she likes on the side of the crib.
Another good preventive method is “tummy time”, always supervised, 10-15 minutes, 2-3 times per day. Some experts believe that there are other benefits to tummy time, for example it will aid the development of your baby’s neck muscles, etc. I don’t believe this. These are the kinds of developmental milestones that will happen no matter how the baby sleeps. You can’t prevent these phases of development! You really don’t need to add other reasons for tummy time: prevention of flat head is good enough!
Experts also recommend limiting time in car seats and bouncy seats. They also recommend carrying the baby on your body in a front or back carrier. If you’ve got twins, you can do both (check out the Twingaroo!)
How to Treat It
What if, despite your best efforts, the baby develops flat head and/or wryneck anyway? If the baby has developed stiff neck, or torticollis, she’ll probably benefit most from a qualified physical therapist. I recommend discussing this with your pediatrician.
In the early days of positional plagiocephaly treatment, many babies were placed in molding helmets for up to 23 hours per day, over several months. The thought was that the molding could help the head form a more normal shape while the baby’s skull was growing. What researchers did not know was whether a baby’s head would become normal on its own, without the helmet…
…So They Did a Study
In 2014, researchers in the Netherlands published a study in the British Medical Journal looking at two groups of babies with flat head: one group treated with the helmet, and one group left alone. At the end of the study they found no differences between the groups. That means that the group left alone changed back to normal shape just as well as the group treated with helmets! This was true even for babies with severe flat head (Hat tip to Carey Goldberg). Not all insurances pay for the helmet, so this study could end up saving families a lot of money and inconvenience.
Sometimes the Law of Unintended Consequences gives us results that are neutral: neither good nor bad. In this case, the Back-to-Sleep Campaign has given us lower rates of SIDS, and a condition, flat head, that is not serious and goes away on its own. If you have any questions or concerns about this, consult your pediatrician!