Transcript for
Insights on infant sleep with Dr Pamela Douglas

Narrator [00:00:02] Welcome to the Emerging Minds podcast.

Sophie Guy [00:00:07] You’re with Sophie Guy and in today’s episode I’m joined by Dr Pamela Douglas to talk about infants and sleep. Dr Pamela Douglas is a GP and medical director of Possums & Co., a charity which educates health professionals in the evidence-based Neuroprotective Developmental Care, or Possums programs, which includes the Possums Baby and Toddler Sleep program. Pam is an adjunct associate professor with the Maternal, Newborn and Families Research Group at Griffith University and senior lecturer within the Primary Care Clinical Unit at the University of Queensland. She’s also the author of the discontented little baby book, All You Need to Know About Feeds, Sleep and Crying. In this episode, we discuss what the latest insights from neuroscience, anthropology and maternal and infant research tells us about infants’ needs around sleep, and how this can be made a more harmonious experience for families.

Sophie Guy [00:01:01] Welcome, Pam, to the Emerging Minds podcast series. Thank you very much for joining me today.

Pam Douglas [00:01:06] It’s my pleasure, Sophie.

Sophie Guy [00:01:08] We’re here today to talk about babies and sleep. And I was reading one of your articles the other day, and that’s on the Possums website, where it said that about one-third of parents, it’s known to seek help about their baby’s sleep and I imagine this is probably an underestimate of the number of parents who struggle with when they have a newborn and around sleep and, you know, I was thinking, you kind of only have to you only have to talk to the parents of a newborn to quickly understand that the topic of sleep consumes so much of their thinking and their concern. And I was also reflecting that it’s kind of telling, I think, that it’s really the norm, you know, you meet a parent who has a newborn and you kind of just know it’s automatic. You ask how it’s going. And I thought, you know, when you stop and think about that, it’s a question kind of holds this assumption that it is going to be something that the parent’s struggling with. So I’m really interested to hear from you, Pam, as someone who started their career in general practice and who now has a very specific focus around supporting mothers and fathers and caregivers and infants in the first year of a baby’s life. To start with, would you mind telling us a little bit about your background and how you came to establish Possums and Co.?

Pam Douglas [00:02:30] Yes, well, I’m a GP. I’ve been in general practice since 1987, so it goes back a while now. And it’s really just in the last two years that I’ve only focused on delivering clinical services in my area of special expertise to families with the baby in the first 12 months or into toddlerhood. So really for the whole of my career, I’ve both had a special interest in the care of parents with babies, but have also held that in the context of my generalism. From 2005, I began publishing in the research literature, the medical research literature, developing up a suite of programs that are now known as Neuroprotective Developmental Care or the Possums programs, as people in the community know them. So these programs reach across the domains of breastfeeding feeds, cry-fuss challenges, sleep challenges and then parent emotional wellbeing. So in 2011, a small and dedicated team of health professionals, I established the Brisbane Possums Clinic, and we are now practising out of Kindred, Obstetrics and Midwifery in East Brisbane. But apart from our, our physical Possums Clinic location in Brisbane, we now have a network of something like 55 NDC-accredited health professionals throughout Australia and some overseas, and well over 200 health professionals in our NDC accreditation pathway. So we have a whole suite of free resources and online programs for parents at possomsonline.com, and that’s also where health professionals can find out about our upskilling pathways. So that’s a little summary, really, of what I’ve, I’ve been up to.

Sophie Guy [00:04:43] I’d like to to ask a little bit, first of all, about the approach in the Neuroprotective Developmental Care Possums program to sleep, since we’re focusing this conversation around sleep. And so, yeah, I sort of wondered if you could tell us a bit about that, the approach and, and why yourself and your colleagues come to the view that this probably is most supportive of infant and parents wellbeing?

Pam Douglas [00:05:09] Well, you know, all the neuroscience is rapidly growing body of evidence points to the importance of cued care or responsive care of our babies if we’re to optimise developmental outcomes and that child’s capacity for secure attachment, for style of attachment relationally, that’s secure. So in the NDC programs, we think of cued care as a sensible pattern of responding to that baby over time. So, you know, acknowledging that we can’t always respond to a baby and that particularly becomes the case when we have other children and that responding to the baby doesn’t always dial the baby down the way we might hope. But that this pattern, this intentionality of developing up a consistent experience of being responded to, you know, enough of the time is very important, it’s foundational to our programs. So some of your listeners might understand this in terms of parent infant biobehavioral synchrony or neuro hormonal synchrony and will often use the phrase ‘getting in sync’ and talk about that as being a process of experimenting, then none of us know what our babies are communicating, really. But as parents, we engage in a process of experimenting with our responses to see what will dial that little one down. So this this is a second important concept, foundational concept to our programs. This is of the dial, which is referring to the sympathetic nervous system and the HPA axis, the hypothalamic pituitary adrenal axis. But we just talk to parents about the dial and how, you know, in sensible ways we’re aiming to keep that little one as, as dialled down as we can. So if we’re thinking responsivity, cued care, biobehavioral synchrony, it’s worth just reflecting for a moment on how in very early life this is very sensorimotor, a parent will be making sounds and speaking, but there’s a real physicality of the to and fro interaction with our new babies. And then of course these reciprocity chains, which importantly are initiated by the baby some of the time and at other times initiated by that loving adult or older sibling interacting. But these reciprocity chains grow in complexity and become increasingly verbal as well over that first year. But the physicality or the sensory motor component of reciprocity is really important, as well as the developing capacity for speech into, you know, through that second half, the first year.

Sophie Guy [00:08:13] Could you give an example of what you mean by the physicality?

Pam Douglas [00:08:17] There’s a video that we made that starts with a mother interacting with her baby and the baby responding with laughter and delight. And of course, it’s so physical. So the mum is saying things, but in fact, there’s just that real physicality of her smothering his little neck with kisses. And then he laughs and he’s looking for more and then she responds and then she waits till he’s signalling, oh, where did that go? And she starts again. So that watching and responding to the baby, initiating a communication, which may happen with little sounds, but often is a whole body communication or a facial expression. And then also initiating your own communications, which may involve sound and language, but are also very physical in the interaction.

Sophie Guy [00:09:12] Could you describe the approach to sleep that is taught through the Possums programs?

Pam Douglas [00:09:17] Yes. So what we have is the dominant approach to parent infant sleep at the moment is what would be technically known as a first wave behavioural approach to infant sleep. Parents might know it as a sleep training approach, and it’s so dominant that it’s right across all the information that parents are receiving about how to be a good parent, actually, and it might be useful just to run through the key tenets of this first wave behavioural approach.

Sophie Guy [00:09:56] Sure, yeah.

Pam Douglas [00:09:56] But it started in the 1950s and 1960s post Second World War. There’d been a real transformation in how women gave birth and this, this actually saved lives in terms of keeping women alive through the birth process, but also protecting them from injury and protecting our infant’s health. So we’ve had this tremendous transformation in the care of mothers and babies. But I’d argue that we’re in the final phase of that because to date, a health system hasn’t really taken on board the importance of this neuro hormonal biobehavioral synchrony between a parent and baby, between a mother and baby and breastfeeding. Feeding is just one part of that, the sleep that we’re going to talk about is also an important part. And so after this transformation had occurred and women were almost always giving birth in hospital, there was also a major societal disruption. And actually into that space came the first wave of behavioural psychology. So Skinner, Pavlov coming in from America, really, and it fitted well with the Nightingale approach to daily management that was happening in the hospitals and out of this in the 50s and 60s, the sleep training approach emerged and it was what I was taught in the 1970s in my compulsory mothercraft class in high school. You know, it really was this first wave behavioural sleep training approach. So let’s run through the basic strategies that belong to this philosophy is the belief that sleep breeds sleep. So at first, tired signs and parents are given a list of tired signs, which I’d argue is very disempowering. First tired signs, put the baby down. Don’t let the little one be awake for more than, you know, such and such a period of time during the day and parents are given algorithms around this. Try to make sure that the little one’s asleep for a certain block of time during the day, and that might involve teaching parents to try to get second sleep cycles. Try to get the little one down really nice and early at night. So you might hear 6:00 PM or 7:00 PM bedtime. Try to keep that little one sleeping in a bed situation for at least 12 hours overnight is often what parents are being taught, and then that it’s really important to teach that little one to self-settle. If you want to get good developmental and sleep outcomes in later childhood, parents are told, then it is really important to not develop bad sleep habits and to teach that little one to self-settle. And this is framed in terms of positive associations with the cot or perhaps other sleep aids, not letting the little one go to sleep at the breast or at the bottle, not letting the little one go to sleep in arms, but putting them down into the cot, drowsy but awake. And then the concepts of over-tiredness and overstimulation are very big in this philosophy of sleep training as well. So that’s the picture. And the truth is, Sophie, that it’s very disruptive of cued care and creates communication, confusion very often between a parent and that baby. So, for instance, a little one might be dialling up inside the house, which is a low sensory environment, because he or she has a powerful biological drive for rich and changing sensory stimulation for environmental complexity that’s hard to meet inside the house. (The) little one starts to dial up, but the parent is told to put on the sleep lens, it’s a tired sign.

Sophie Guy [00:13:52] And sorry, when you say dialling up, you mean the infant’s crying and fussing.

Pam Douglas [00:13:56] Yeah, starting to grizzle, starting to complain, you know, tends to start with sort of low level agitation, doesn’t it? And then just grizzling and builds up. And if a baby’s crying, the dial is, is up high. For babies screaming, the dial is as high as it can possibly be. And as parents, we’re aiming to keep that dial sensibly turned down as we can. So communication, confusion, so a little one’s sleep pressure may not be high enough for him or her to easily fall into sleep with the breastfeed, let’s say, or with rich sensory nourishment. And the parents advise to frame that as resisting sleep, when in fact, the little one’s sleep pressure isn’t high enough yet to make sleep easy, so there’s multiple ways in which the sleep training approaches actually disrupt that synchrony between a parent and baby and disrupt the parent’s capacity to experiment flexibly with responses to the bubby that make the days as easy and as enjoyable as possible, which means in part, keeping that little one as dialled down as we can, but also having days that, that are enjoyable for the primary carer. It’s important in our sleep program that we’re educating parents around developmentally normal night waking, which is essentially every couple of hours, I’m afraid to say, throughout the first year of life and even into toddlerhood, if we really look at the evidence, but everyone gets back to sleep quickly and developmentally, increasingly, that sleep will consolidate at night. So that’s developmentally normal night waking and we want to support parents to have the best possible quality of life which are full and meaningful life around developmentally normal night waking but many families are struggling with excessive night waking. So patterns of waking every hour, every 45 minutes, the baby takes forever to get back to sleep at night. You’re awake for big blocks of time in the night. You know, the baby seems to be ready to start the day from 4:00 AM. These are signs of disrupted sleep patterns and this is where in the Possums sleep program, we work with the two sleep regulators, the circadian clock and the sleep-wake homeostat over a couple of weeks to actually bring the baby sleep much better in sync with the parents’ sleep. There’s both supporting parents through developmentally normal night waking but there’s also picking up on any clinical problems, any excessive night waking or indeed the parent whose brain gets so busy as it can happen that even though the baby’s asleep, she finds it very difficult to quieten her mind.

Sophie Guy [00:17:00] You talked about sleep pressure, and I was wondering if you could talk a bit about that. And then you also just mentioned the circadian clock and the sleep-wake homeostat. Are those things all related? Could you talk a bit about what they are?

Pam Douglas [00:17:14] So sleep, whether we’re a baby or a grown up, is under the control of two sleep regulators, two biological regulators. So one will be familiar to our listeners. That’s the circadian clock and the other is the sleep-wake homeostat. So the circadian clock is controlled by environmental cues, by the circadian cues of daylight noise activity during the day. And then even though we’re eye contacting and responding to our bubby in the night, that the background cues are, it’s dim, less activity and less noise. So this is a reason to have days outside the home that are very richly engaged with the outside world in a way that meets the carer’s needs. But then the sleep-wake homeostat is a system of neuro hormones that rises when we’re awake and drops off quite quickly, actually when we sleep. So for myself, let’s say when I wake in the morning, these neuro hormones are at a very low level that gradually rising all day and they’ll peak, let’s say, at 10 o’clock at night. That’s when my sleep pressure is really high and I feel sleepy. Then I’ll put my head down and sleep. So circadian clock and the sleep pressure are the two biological regulators of our baby’s sleep. Our bubby’s sleep pressure is rising much more quickly, but a daytime nap is just to take the edge off the rising sleep pressure so that that little one’s circadian clock and sleep pressure are well-aligned with the parent’s big sleep at night. But in our society, with the first wave behavioural approaches where there’s such a big focus on big blocks of sleep during the day, we very commonly see it might take two or three or four weeks to feed through but we very commonly see very disrupted circadian clocks that causes the excessive waking at night.

Sophie Guy [00:19:22] Okay. And so if I’m understanding what you’re saying correctly, is it that actually it’s a bit of a misunderstanding that babies need to sleep during the day or are you sort of saying it’s more around being quite regimented about trying to get them to sleep for long periods of time, heavy sleeps for long periods of time?

Pam Douglas [00:19:44] Yeah, well, the thing is, Sophie, if we’re trusting our baby’s sleep regulators and working with our baby’s communications, then in fact, sleep looks after itself. Our focus then is on a day that’s enjoyable for the primary carer, but also that meets the baby’s needs for rich and changing sensory input, which typically happens outside the house, whether it’s out walking, whether it’s parent groups, whether it’s visiting friends, dropping in on the workplace, getting tasks done, anything outside the house will just bathe that baby in rich and changing sensory input so that you don’t have to do all the hard work of meeting your baby’s needs inside the house, kind of one-on-one.

Sophie Guy [00:20:37] So you’re sort of saying that these are helpful, valuable things to focus on having rich, stimulating experiences during the day and sort of being able to offer feeding when the baby seems to be asking for that and that sleep will happen, baby will naturally go off to sleep where and when it just takes over. And so you’re sort of saying that that takes care of itself and it doesn’t need to be, we’ve perhaps gotten a bit off track with focusing so much on trying to make sleep happen. But actually, it’s not that baby isn’t going to sleep, they probably are, but they’ll do it when they want to do it throughout the course of the day.

Pam Douglas [00:21:13] That’s it. And, you know, in the Possums sleep program, we educate parents out of the science around sleep. And and one important aspect of this is that baby’s sleep needs are incredibly biologically variable. So it’s not meaningful to give parents any estimates around how much sleep their baby needs. In fact, again, that would undermine cued care or responsive care and cause communication confusion. We just want to work with your unique baby, understanding how the sleep regulators work and shifting the focus onto the most enjoyable and relaxed day you can possibly have, particularly in the early days. It means we have to sort out underlying clinical problems. You know, it’s hard to talk to parents who have a baby who’s screaming for hours a day about cued care. They just despair but it’s our role as health professionals to look at what’s happening there that might be causing this little one to dial up to the extent that he or she is, even though the first 16 weeks are a time of neurological sensitivity and bubbies are rather inclined to dial up, there’s actually a lot that we can do to help our little ones dial down and we want to sort all of that out.

Sophie Guy [00:22:32] OK, I don’t have children myself. And even though hearing you say that the focus could be on, how do I go out and enjoy myself with my baby each day rather than I need to get this done, this needs to happen at this time and I need to make sure the baby’s getting this much sleep. It feels like good news to hear that I can focus on enjoying myself and hoping that the both of us are going to enjoy ourselves and yeah, like you say, curious and experiment with what that looks like. And I feel relieved.

Pam Douglas [00:23:04] Good, good, I’m pleased, Sophie. Well, you know, it’s best for baby, best for that primary carer and really best for developmental outcomes. We want to be able to relax into and enjoy our baby.

Sophie Guy [00:23:16] Yeah.

Pam Douglas [00:23:17] The context of lovely, rich environmental experiences, social experiences.

Sophie Guy [00:23:21] Yeah. You’ve mentioned a couple of times and I picked this up on hearing you talk, this concept of a rich changing sensory environment. It’s sort of something I haven’t heard emphasised in thinking about day to day life with babies and their needs. Could you talk a bit about what that is?

Pam Douglas [00:23:40] Yes, because I think it is still very widely misunderstood in our world. But if we look at our infant’s environment of evolutionary adaptiveness, so if we use the, the frame of evolutionary biology, the human infant evolved in the context of very rich environmental experience, both social and typically multilateral social experience, not just the one-on-one that happens with our primary carers who feel locked in the house on their own, you know, so that very rich social engagement, but also very rich, non-social environmental experience. For instance, the outdoor world, a lot of unsettled baby behaviour happens inside the house because the little one’s biological need for rich and changing input across all of his or her senses, including kinaesthetic input, proprioceptive input, change of vestibular input, if you think, for instance, of long periods of time on the bubby’s back on a mattress, there’s very little vestibular stimulation in that and they thrive on the rich and changing vestibular stimulation that comes with, say, being in the carrier with the primary carer who’s out walking or, or even the pram. The motion is interesting, but the visual stimulation of the external world is wonderfully satisfying for babies and they just drink it up. Never put covers over our prams, for instance, unless we absolutely had to protect from the sun. But, you know, letting all of that change of air temperature and engagement with the incredible complexity of the outdoor world is so good for our babies. And this need comes out of our environment of evolutionary adaptiveness and it does optimise developmental outcomes.

Sophie Guy [00:25:39] Okay. I was also curious about I know that there’s a woman, Professor Helen Ball, that’s involved with the work as well. And she is an anthropologist and I was really curious to know what anthropology has been able to share and shed light on around babies and sleep across different cultures.

Pam Douglas [00:25:59] I think the important things that we learn from cross-cultural studies and from evolutionary biology that our infants were from an evolutionary point of view, primed for rich and changing sensory nourishment. And, you know, in an evolutionary context, often carried against the body of a loving adult, the baby slept on the same sleep surface as some parents, frequent, flexible access to the breast rich and changing sensory motor stimulation and and rich social engagement. And these needs are hardwired into the human baby even in the 21st century. And what we need to do and what we NDC or Possums programs aims to do is meet these hardwired evolutionary needs in a way that’s workable for families that actually makes the days easier rather than harder, that grows joy in early life. That’s our motto, Sophie, is growing joy in early life.

Sophie Guy [00:27:03] That’s beautiful.

Pam Douglas [00:27:05] Thank you, thank you. And probably talking anthropology just at the minute, it’s worth observing that there’s some common criticisms that are made by folks who really preference and promote the first way behavioural or sleep training approaches that come out of a very old fashioned understanding of anthropology. So one of the critiques that I’ve not uncommonly heard is that, oh, what you’re doing might meet the baby’s needs, but it doesn’t suit a woman who has to turn up to work and perform, for instance. Now, that’s actually a very 1950s, 1960s understanding of gendered roles. If we look across cultures, women were working very hard from the first weeks of life with their baby in tow, typically strapped to their cultures, women had to be very alert intellectually. So the idea that we can’t respond to our baby in a way that builds up this pattern of to and fro communication, because as women we’re needing to work is a really unhelpful and kind of outdated framing

Sophie Guy [00:28:21] I was sort of curious that we are you know, you’ve been talking about we are in this place where there’s a lot of information and there’s differing opinions. And it just seems so confusing, approaching a whole range of aspects of caring for a baby, but sort of wondering how do we get to this point and sort of why is it so complicated? And I wonder how we can move through and get to a place of greater clarity.

Pam Douglas [00:28:48] Well, I suppose to sort of encapsulate, again, the reasons why we might be in this place where there’s such huge amounts of conflicting advice, where we can send a rocket to land on Mars, but we can’t actually offer an integrated and coherent approach to support parents in that critically neurosensitive first 100 days of life or indeed first year of the baby’s life. I think we’re at the tail end of a real revolution in the care of mothers and babies. And the biobehavioral synchrony of a parent and baby has not yet been prioritised within the health system, even though there’s a big understanding rising up around all the neuroscience to do with attachment and responsivity. I also think, to be frank, Sophie, that there’s been a historical devaluing of research into the care of of mothers and babies, so it’s just not been a research priority. And that’s complicated by the fact that primary care itself has not really been a research priority. So that’s how I make sense of it. So we’ve got people across different health disciplines applying different lenses, trained in different ways, often a huge gap between what the evidence is telling us and what’s being practised out there. And I guess it’s into that gap, really, that I’ve aimed to come with the NDC evidence-based programs. So it’s really moving to see so many health professionals now really interested in being a part of the NDC accreditation and wanting to identify with what we call a movement for change, really, in the way health professionals approach these problems in the clinic.

Sophie Guy [00:30:44] Lovely. Thank you. And I’d like to touch on before we wind up for practitioners listening to this who who do work from time to time with parents and babies, but perhaps don’t have a lot of knowledge around helping practical suggestions for supporting sleep. What would be one or two key principles or takeaways that they could take away from this and start to implement by, by just sharing information with parents or helping them with some practical strategies

Pam Douglas [00:31:17] Well possibly one of the most useful things for parents to know, is that baby sleep needs are incredibly biologically variable. One baby, look at a newborn can have a low sleep need newborn, perfectly normal, normal developmental outcomes only needs 9 hours total in a 24-hour period, maybe half an hour total during the day here at the low end of that bell curve. And then we can have another newborn who needs 18 hours total, both normal little ones with normal developmental outcomes. Parents can find that incredibly powerful to know. The second thing would be set aside the sleep lens, because we can trust those sleep regulators and focus on getting out of the house because that brings lovely, rich sensory nourishment to your bubby’s little developing brain. But create a day that you’re going to enjoy with the physical activity, which is typically walking at that time of life, isn’t it, with the bubby, but socially engaged, visiting your workplace, getting tasks done, highly social, going to lunches, you know, going for walks with friends and having a life that’s as rich and enjoyable for you as you possibly can.

Sophie Guy [00:32:31] Yeah, absolutely. Unfortunately, it’s quite often missing isn’t in our live. And for that stage as well, often for parents of newborns or for a first child, it can be very, very stressful. So it’s kind of a simple message but I think often when we unpack these things, it does come down to quite simple strategies. At the end, I think we’ve made life quite complicated, but actually our needs, when you boil them down, are rather simple.

Pam Douglas [00:32:59] Mm hmm. I think we’ve had quite a wide-ranging conversation there, really.

Sophie Guy [00:33:05] Well, I’ve really enjoyed it, too. And so thank you very much, Pam, for your time today.

Pam Douglas [00:33:09] It’s my great pleasure. Thank you, Sophie, for the opportunity.

Narrator [00:33:14] Visit our website at www.emergingminds.com.au to access a range of resources to assist your practice. Brought to you by the National Workforce Centre for Child Mental Health, led by Emerging Minds, the National Workforce Centre for Child Mental Health is funded by the Australian Government Department of Health under the National Support for Child and Youth Mental Health Program.