Dear all:

In my experience, the majority of parents are pretty good about not overusing techniques such as the five S's in the early weeks of life and I've even found that they will make up their own S's.  The minority of parents who overuse these techniques are often responding to a feeding problem and most, but not all of the time, can be redirected towards more appropriate techniques for dealing with the underlying issue.  I find the sleep training books to be more problematic.  Jan actually made a comment about a book that recommends 12 hours of sleep by 12 weeks.  Here we have pediatricians recommending 12 hours at 8 weeks.  Really it is more extreme than the original Ezzo book and I have to say that this type of advice is the #1 cause of failure to thrive in my practice, followed closely by eating disorders.

I actually teach the "original swaddle"  in my prenatal classes.  What is the original swaddle?  Close skin-to-skin contact with the babies body plastered against mom  - with no gaps between the baby's and mother's skin.  In order to do this, you really do have to open up the arms around the breast, which when I tried this on myself, makes it easier for me to throw my head back and open my jaw than having my arms locked down by my sides.  So, I do have the parents try those body positions.  Long before Suzanne Colson's elegant research validated it, my classes included leaning back in my groups were always much more comfortable sitting on the floor with their knees up and back semireclined than they were at home and leaning back solves many of the gravitational problems caused by trying to lift the baby to the breast.  Her research gave me more ammunition to suggest leaning back as comfortable.  If you are recovering from a surgical delivery, it can be quite challenging to get up from a sitting position if you are leaning back.

I always talking about using the original swaddle to stimulate normal feeding reflexes and responding to those reflexes in the early weeks.  And how parent should assume hunger first until they start to understand their own baby's cues and how their own baby responds to their actions.

My tips for getting in sync with a baby's rhythm and figure out their cues starts with:

1) Proximity -- day and night
I explain how the American Academy of Pediatrics actually DOES recommend that the baby sleep in close proximity to the parents and that a multicountry study showed that the baby sleeping in a separate room increases the risk of SIDS by 36%.
I explain the risk factors for cobedding -- e.g. drug use, overconsumption of alcohol, morbid obesity, sleep apnea, smoking, etc  that are some of the components that contribute to the 16% higher risk when the baby sleeps on the same surface found in the same multicountry study (NOTE that the the risk of sleeping in a separate room is more than DOUBLE the risk of sleeping on the same surface -- why is the public health community not picking up on this?)  And how the risks factors for the surface (be it a stroller, a bed, a crib, a blanket on the floor, or anything the baby might sleep on or in) are the same -- shouldn't be soft and squishy or have any potential for blocking the baby's breathing whether it is the nose being blocked by an object or the airway collapsing.  

I also describe why its a pain in the butt to have your baby sleep in a separate room when you have to get up and feed your baby in the middle of the night and how the process is MORE likely to disrupt the parents own sleep rhythms.  

2) Skin to skin (which is fostered by 1) 
This is where we go over the original swaddle which puts mother and baby in the appropriate position to take advantage of the baby's innate reflexes and reward behaviors that lead to healthy infant feeding and the baby regulating the hunger satiety cues

and of course how they are calmer due to all the physiologic regulation offered by skin to skin

and of course how you also get oxytocin from skin to skin contact (which I mention later if any of the parents ask about daddy bonding through bottles --- how babies actually bond through skin contact and interaction while feeding rather than the object that gives the milk).

3) Frequently draining the breast
I first tell them that milk is not like the oil supply -- it doesn't run out. Then I talk about why the milk supply is like building muscle tissue.  If you lie on the couch conserving your muscle and expect anything other than your muscles whithering away.  You cannot expect to go to the gym once a month and build muscle either, you would only make your whithered muscles sore and then those muscles would continue to whither during the month you spent recovering from the muscle trauma.  Going to the gym and starting with frequent light repetitions (small amounts of milk) builds your muscles so that you can then move on to heavier repetitions (larger amounts of milk).  

Then I move on to hunger cues going from prefeeding behavior to active cues to ravenous (crying) and why avoiding crying is a self preservation strategy for mothers.  I imitate a screaming baby shaking her head lunging for the breast and they laugh.  

Then I move on to how to know that a baby gets enough
a) swallows because these are the most immediate sign
b) behavior which is the immediate response to the adequacy of the feed
c) diapers which are the output resulting from the feed and I do quote Laurie Nomsson-Rivers research which shows that diapers are not highly sensitive or specific in determining the adequacy of the feed without considering other indicators.  My interpretation is that diapers are a highly VISIBLE indicator, but should be taken with a grain of salt as a very rough guide.
d) weight gain which is the ultimate result of intake and energy expenditure -- and how if you focus on a) and b) you are more likely to be able to avoid worrying about d)

Throughout this discussion, I reinforce skin-to-skin contact and the original swaddle at every opportunity -- sticking it into strategies for eliciting and reinforcing feeding behaviors and strategies for calming the baby before feeding. 

To my recollection, I never have had a parent ask me about swaddling the baby by the time I'm done with my constant reiteration and demonstration of that original swaddle.  I do NOT teach newborn care classes ever because they always include how to swaddle your baby and I never learned how to do it with my son.  

Parents want methods because they need a framework.  When they bring up the latest greatest method, I always ask for specifics and then talk them through how that method has already been tried by parents and then take them through the particulars of their own situation and whether components of that method will be helpful or harmful as I work with them to develop their own individually tailored plan.  Perhaps now, I may start telling them that we're developing their own individually tailored "method".

Best, Susan Burger

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