How babies sleep: the view from anthropology. Video + transcript Professor Helen Ball 17 June 2025

Transcript

Pam I would like to start by acknowledging the traditional custodians of the lands upon which I live and work, the Turrbul and Jagera peoples, and pay my respect to Elders past, present, and emerging. So I'm Pam, and it's fabulous to see you all turning up. It really is such a great pleasure to welcome Professor Helen Ball who's joining us tonight as our guest speaker with the NDC Institute's guest speaker program. So Helen I think will be well known to most of you. Helen is a Professor of Anthropology and Director of the Durham Infancy Infant and Child Health and Sleep Center in the UK and world-leading infant sleep researcher. Amongst Helen's many recognitions, I can say that in 2018, Durham University was awarded the Queen's Anniversary Prize in recognition of Helen's research and her outreach on parent-infant sleep. But I'm excited to say that Helen has just launched here, her new book, which I consider to be an important book, How Babies Sleep. And Helen has kindly agreed to talk with us tonight about this book, How Babies Sleep: The View from Anthropology.

Helen So thanks very much, Pam. Thanks for inviting me. Thanks for giving me the chance to talk about this book. Some of you will be familiar with it already, I imagine, because you might have heard me talk about it at different conferences in the last few months as it was, as the publication date was kind of looming. But it's out now, and it really is a summary of what's happened in infant sleep research over the last 30 years, as well as an explanation of how babies sleep from a biological and anthropological perspective, because that's my training and background. I'm a biologist and anthropologist. Pam, I can't see— oh yes, it is recording. Okay, I was just checking that you were recording. Great. All right, so let's have a think then about what this might mean. And I'm just going to pull like 3 sections, 3 topics out of the book that I talk about. One is about why baby humans are helpless. And this is like, I find it very hard to talk about baby sleep without talking about the evolutionary biology of human babies.

I think it's fundamental to everything that we do when we're thinking and talking about baby sleep. So that's where I'll begin. Then I'm going to talk about my favorite topic, which of course is bed sharing, which is where my research started. And then I'm going to talk a little bit about how we understand what baby sleep problems are all about and whether babies have sleep problems. And this is part of the work that I've been involved in around sort of what you might call normal infant sleep, although I would argue that there is no single one-size-fits-all normal, but we'll talk about that when we get there. So I'm going to just for each section give you a little taste of something that I talk about in the book and then elaborate on that. So in Chapter 1, I talk about helpless babies and I say the unique suite of characteristics we have amassed over our evolutionary past has resulted in human babies being the most helpless of all primates at birth, completely dependent upon caregivers for warmth, safety, and food for the entire first year of life and beyond. So what does that mean? Well, that means that we're mammals, of course.

Evolutionary biology [00:05:19.19]

All humans, all primates are mammals, and we're mammal babies with a set of particular built-in needs. Or our babies are mammal babies with a set of particular built-in needs that come from kind of our evolutionary history as mammals, precocial mammals, primates, and humans. So if we think about kind of placental mammals, mammals who give birth to live young, there are two main types. They're known as altricial and precocial. An altricial baby is like these squirrels, stay in a nest that the mother has prepared for them that provides them with safety and warmth. They're born in an undeveloped state, they can't see, they can't hear, they're usually hairless. Staying together as a litter helps them to keep warm and mothers feed them infrequently. So mothers go off and forage for most of the day They produce milk that's very high in fat. They come back, they feed their babies. The highfat milk satiates them for a long time. Those babies basically just sleep and grow in the nest for a period of weeks, and by the time they emerge from the nest, they can see, they can hear, they can follow their mothers, and, you know, they're relatively well developed and able to start learning how to survive by themselves.

In contrast to that, the other group of mammals produce what are called precocial babies. Precocial babies have a much longer gestation period. When they're born, they can see, they can hear, they can call, they can pretty much stand and follow their mothers within a short period after birth, or they can cling to their mothers so they can maintain proximity. And because they can maintain proximity, they can feed frequently whenever they need to, and the mothers produce low-fat, high-energy content milk, high-sugar content milk. So babies need— those kinds of babies need energy because they're having to cling or follow, but they don't need satiating for long periods because they can feed frequently, so their mothers don't produce milk that's high in fat. So they stay with their mother for safety and warmth, and they feed often. So human babies then are precocial. We fit the precocial pattern like other monkeys and apes, but our babies are uniquely helpless at birth. They can't stand up and follow us, they can't cling to us. We have to maintain proximity, and they're not able to. So we know that we're precocial because we produce single babies that have well-developed internal and sensory organs, So our babies can see and can hear and can crawl, which fits the precocial pattern at birth.

They have a long gestation period too, that's another feature of precocial mammals. Our milk, the milk that humans produce, is low in fat and high in sugar like other precocial mammal mothers. And so our babies need to feed frequently. So again, that means they fit the precocial pattern. But human babies have got really poor neuromuscular control at birth. They're unable to follow or cling. They've got poor coordination, so they're more helpless than other precocial mammals when they're born. And that's because their brain is underdeveloped at birth. Human babies are born with about a quarter of their adult brain size, and this is a function of the fact that our adult brains are so huge. So human babies spend that first year of life growing that massive brain whereas other precocial mammals are kind of like most of the way there at the point of birth. So all of this means then being precocial mammal babies but helpless ones means that night waking and needing contact are normal for baby humans. So baby humans are finishing gestation outside the womb while their brains continue to grow rapidly, much more rapidly than any other precocial mammal species.

In other precocial mammals, brain growth is rapid in gestation and then it slows down at the point of birth, whereas humans is the same kind of like— is on the same growth trajectory throughout gestation and the first year of life and doesn't start to slow down until babies are a year old. So during this period then of extreme dependency, they need close contact with a caregiver for warmth and security. And for biological regulation. They need their caregivers during the day and during the night for many months, and they don't have a day-night rhythm. Their brains haven't developed that kind of circadian clock yet. They don't sleep for long periods. So frequent night waking and seeking contact are biological needs for human babies. So when we try and think about then what does that all mean for sleep, we can predict certain things about baby humans even if we'd never met a baby human. if we understood sort of what their evolutionary biology meant, we would understand that growing a big brain is energetically expensive. That is what human babies use the high-sugar-content milk for. They're not using it to expend energy like other precocial babies, they're using it to grow this brain, rapidly developing brain.

And brain growth happens during sleep. So we would expect human babies to need to sleep a lot. Babies were also— human babies would also be expected to wake and feed at night frequently because that's an important driver of their mother's milk supply and because they digest human milk quickly. So we should expect human babies to wake in the night and to wake us in the night. And like other precocial babies, Human babies expect close contact for warmth, safety, and for food day and night. So we should expect human babies to want to be in physical contact, to want to be held, to want to be close to us 24 hours a day. So all of those expectations then suggest that mother-baby contact is the norm 24 hours a day, and that's what we see all around the world in other societies. But Western societies are what has been called weird in that Western-educated, industrialized, rich, and democratic societies do something different with their babies. And particularly, they do something different with their babies at night. And that's happened over the course of about the last 100 to 200 years. So our cultural expectations in Western weird societies end up being unrealistic because they don't match baby's biology, and that makes caring for a new baby particularly challenging in Western societies.

So whereas most of the world's cultures will keep babies in close contact using a variety of different methods day and night, we tend to try to put our babies down by themselves for prolonged periods both during the day and particularly at night. And a lot of that came about during the era of industrialization when parents had to learn or come up with ways, devise different strategies to cope with their baby's helplessness and lack of day-night rhythm and night waking during a period when our own sleep was being compressed into an 8-hour window due to the demands of the kind of industrializing workplace. People were moving into the cities, they were working in factories and mills, they were required to work 12 hours a day. And babies somehow had to be fit into— and many women were going into the workplace during this time— babies somehow had to be fitted into this changing lifestyle. And the experts, the baby care experts that emerged sort of from this period were strongly advising mothers to manage their baby's sleep patterns by disregarding their needs at night, by showing babies who are in charge, showing them who's boss, that babies aren't in charge, not responding to them at night, making them learn to wake.

Lots of things that we hear still in the 21st century about how parents should treat babies came about during this period. So the whole picking babies up too often will spoil them, crying being good for their lungs, cuddling making them clingy, and not letting them feed to sleep are all sort of elements of ways of trying to help parents disentangle themselves from their babies so that they could fit into this 20th century industrialized sort of life. But one of the things that all of the evolutionary biology illustrates is that separating babies for sleep is not biologically predictable. It's not what you would expect to have happen. And bed sharing was, you know, keeping babies with you at night, was a topic that really fascinated me when I started doing this work in infant sleep. So it was really the first topic that I wanted to investigate. And I say in chapter 6 of the book, I wanted to lift the veil of stigma that was draped over the topic of bed sharing and explain to the critics and the uninformed why it was important for many families and why expectant parents needed to know about it, to have opportunities to discuss it with others, and to learn about its benefits, its hazards, and its nuances.

And, you know, throughout the last 30 years of researching baby sleep, this has always been an important topic. That parents need information around bed sharing because it's such a predictable thing for parents of human babies to do. So I wanted to make— it was an invisible topic and I wanted to kind of like make it more visible. Because adult bodies are where babies most want to be, and when I started studying parent-baby sleep in 1995, Some of my colleagues were quite bemused about studying this topic in the UK because the conventional wisdom was nobody in the UK does it. So one of them actually asked me, "How will you study that here? No one in the UK does it." And that was actually something that I read in various papers in the 1990s as well, that bed sharing was unfamiliar to the majority of the UK parenting population. And when I read that, I was like, that's rubbish actually, because I knew plenty of families who did bed share. I mean, I was talking about it all the time, so people would talk back to me about it, but they were frightened to talk to health professionals about it.

Bed sharing and breastfeeding[00:17:15.03]

So it was, it was an invisible topic to researchers and health professionals. Because parents felt that they would get told off if they spoke about it, and so they didn't talk about it, they just did it in private. And of course, they had no information about how to do it safely. So my goal was to make bed sharing visible, acknowledged, and understood in those first few research projects. So one of the things that we started out doing was interviewing parents about why they bed shared. Why did they bring their babies into bed? We actually started our research by talking to families who were expecting babies and asking them if they ever thought they would have their baby in bed with them. And they all said, almost all of them, unless they'd had a previous child, said no, they wouldn't have their baby in bed with them. But they very quickly after they had their baby realized that they would have their baby in bed with them. And when we asked them why they'd done that, a number of themes came out. And these themes sort of have come up again and again in the literature.

And there was a systematic review done in 2014 of 34 studies by that point that had looked at why parents bedshare with their babies. And the common themes, and these are the same themes that we came out with in our research, were first of all breastfeeding, second comforting, third more and better sleep, fourth being able to monitor your baby easily, and fifth bonding and attachment. And there were about 10 overall different reasons, but breastfeeding was always the most common reason cited in our studies and in 26 studies that were reviewed out of these 34. Breastfeeding was the primary motivation for bed sharing. It was described as easy and convenient for managing frequent nighttime feeding, and mothers who were trying to prioritize their sleep, preserving their sleep, especially when they were returning to work, found that bed sharing helped them to do that. So that led us to try to understand how breastfeeding mothers were bedsharing. We wanted to know what they were doing. They obviously weren't killing their babies by the thousand, which is what the kind of the narrative was at the time. That, you know, it was argued that parents pretty much felt that they were being told that the moment their baby's back touched their mattress, they would die.

However, it clearly wasn't happening, and we wanted to know what it was about breastfeeding mothers' bedsharing that actually was safe and convenient and should be shared with other people. So we did a number of video studies looking at the way in which breastfeeding mothers bedshared at home. So we videoed people in their own homes, we videoed them in our sleep lab, we videoed them on the postnatal ward of the maternity hospital. So they'd never— some of the mums that we videoed had never ever slept with a baby before, but they all did exactly the same thing. And this was so characteristically consistent that I thought that it was really worth recording and writing a paper about, which we did in 2006. And what we said was that breastfeeding bed-sharing mothers slept together in this very characteristic way where the baby's positioned flat on the mattress next to the mother's breasts, um, on their backs, and the mom puts her arm above the baby's head and puts her knees beneath the baby's feet and curls up around her baby and makes a space for the baby to sleep in. That stops the baby moving around the bed up to the pillows or under the covers.

It stops any bed partners from getting too close because the mum's knees and elbow are in the way. And it makes it easy for the baby to feed. So the baby will sort of, when they're small, they'll turn onto their side to get to the breast and then roll back again. But if they're bigger, they can often lie on their back and just turn their head and feed. And we also, as time went on, discovered that there was a very close relationship, not just between breastfeeding and bed sharing, but breastfeeding duration and bed sharing. So this is a graph from a study that we published in 2016. And in this article, what we did was take data from about 1,000 moms who had given birth in one of the hospitals where we were doing studies. And all of these moms had initiated breastfeeding on the postnatal ward. And then we asked them to report to us every week what their baby was being fed and where their baby was sleeping. And so this data shows if their baby received any breast milk each week between 0 and 6 months or 26 weeks. Whether they bed-shared at all during that time.

So each week, did the— had the baby been in bed with mom? And what you can see in these two lines is that the ones who bed-shared in the first 13 weeks, so any bed-sharing up to this midpoint here, their breastfeeding kind of like carried on. About 60% of those who left the hospital breastfeeding were still breastfeeding at 6 months. And this group who didn't bed-share in that first 13 weeks you can see breastfeeding dropped off really quickly. And then sort of those who were going to carry on breastfeeding did carry on breastfeeding, but the overall percentage of the ones who didn't bedshare was about 30% compared to 60% of the ones who did bedshare. So this to us was evidence that there was a relationship between not just initiating breastfeeding and sort of getting milk production going with bedsharing, but also sustaining breastfeeding. And that might be because it helps maintain your milk supply, it might be because it's making nighttime breastfeeding easier and you feel more able to carry on breastfeeding for longer, or it might be that you have a very strong intention to breastfeed for 6 months and bed sharing is just one of the strategies that you use to get there.

But whatever the reason, there's a very strong relationship between the two. And that was important to know, and it was important to talk about, because it became one of the levers for changing attitudes about the importance of sharing safety information around bed sharing with parents, at least in the UK. So one of the things that happened over time here in the UK is, first of all, it became acknowledged and accepted that breastfeeding mothers needed information about bedsharing, and that started to be given out by different organizations like Baby Friendly and La Leche League. And then after some period of time and lots of conversations about the fact that there are other reasons why people bedshare and it's not only breastfeeding mothers who do it, and shouldn't we actually be sharing this information with everybody? That finally it became acknowledged and accepted that actually all parents are likely to fall asleep with their babies at some point. And if they're going to do it, they need to know how to do it as safely as possible. So we've now ended up in a situation in the UK where all parents are given information about bed sharing, and they're shown this picture of what safe bed sharing looks like, so that if they end up doing it by accident or unintentionally, or they're in a situation where they have choice, they at least have an idea what bed sharing safety looks like and they know what the contraindications are.

Cultural perceptions of baby sleep problems [00:25:43.04]

So lastly, I'm going to just quickly talk about this issue of baby sleep problems. This is what I talk about in Chapter 8 of the book where I say, although I'm an academic researcher and neither a medical doctor nor a wizard, people think I might have a magic wand or a potion with which I can fix their baby's sleep. Many questions I receive begin along the lines of, I don't think my baby's sleep is normal. And this idea about normal sleep and what normal baby sleep is has kind of like come up lots of times during the course of our research. And I traced back kind of where researchers had started talking about what normal sleep might be to 1957. When this research pair, Moore and Ucko, studied 160 babies, which they argued in their paper was to define what normal infant sleep was. And they talked about sleeping through the night occurring if parents reported no crying or fussing between midnight and 5 AM. And that sort of became entrenched in the parenting books in the UK that babies could do this by 3 months of age, therefore babies should be sleeping through the night from 3 months of age.

But what never got reported in the parenting books was that although 70% of the babies in their study did start sleeping for a 5-hour stretch from midnight to 5 AM, half of them reverted back to night waking after 3 months. And they also in this study said that 50% of 6-month-old English babies exhibited what they called problematic night waking. And this, I think, is one of the origins of the ideas that— the idea that babies have sleep problems is that in these studies there was a cultural ideal around what baby sleep should entail, and that was being able to get a baby to sleep for extended periods as early as possible. And that if they if babies weren't sleeping for the entire period of the night by a certain age, that was somehow a sleep problem. And what we find in our research is that new parents can be very ill-prepared for the amount of sleep disruption that they might experience when they've got a new baby, sort of how frequently babies will wake in their newborn period, but also how long they will continue to wake. And there's a strong link between this sleep disruption that parents experience and parental depression.

Poor maternal sleep is significantly related to the increased severity of depressive symptoms if they're already depressed. And sleep disrupted and sleep depressed parents have been found to be more likely to think their baby has a sleep problem than parents who don't feel sleep disrupted and don't have depression symptoms. But when we look around the world, we see that what people think of as baby sleep problems is again hugely variable. In English-speaking countries, we have about 25 to 33% of babies reported as having sleep problems. But in places like Japan and Korea, parents only report about 7% of babies having a sleep problem. And sleep problems might involve night waking, difficulty settling, and short sleep duration. Some Japanese researchers have sort of tried to explore why this might be, what's going on, what's different in different cultures about baby sleep. And they came up with this notion of maternally acceptable sleep, that women in their Japanese study didn't perceive their sleep to be disturbed. Even though the amount of baby sleep disruption they were experiencing was similar to that of US women who did think their sleep was being disturbed. So the bottom line seems to be that parents in different places have got different expectations about baby sleep, and so they perceive their baby's sleep behavior differently.

And if parents are experiencing depression, that gets exacerbated. And we found this in our own studies that there was kind of like even within UK society, there were huge extremes in terms of what parents were expecting and what parents were prepared to live with. So, you know, we had some mums in our focus groups who said things like, "I've always had all of them in a routine. I believe a baby fits around your routine, you don't fit around theirs." And other mums who said the complete opposite, babies sleep when they need it and forget it. You've got to work around them and that's all there is to it. As often as she wakes is when she wakes. So this is one of the reasons why people end up having such huge arguments, I think, about what is right and what is wrong and what is normal and what is not normal, because there's such a wide spectrum of sort of attitudes and experiences. So one of the things that seems to happen is that we Overreport baby sleep problems. Parents' assessments of infant sleep don't align with objective assessments. So when we feel sleep deprived, when we feel as though our sleep has been disrupted, we often report that it's worse than it actually is.

And parents who are experiencing distress about sleep disruption tend to overreport infant sleep problems and seek more treatment for their babies. And that's been shown in a number of studies. So we end up thinking that we need to do something about this, that we somehow need to fix our baby's sleep. But I think one of the things that we have to recognize, and I'm sure this is kind of something that you've talked about as part of your NDC training, is that baby sleep problems are often artifacts of parental distress rather than something that's abnormal with baby sleep. But the baby's an easy target, and if you want to change something, trying to change what's happening with the baby often seems to be the obvious thing to do. So efforts to fix the baby might include giving the baby medication. In the past, it might have been gripe water. Well, in the Victorian era, it was things like laudanum. But nowadays it's sort of gripe water, painkillers, antihistamines, other products, herbal remedies, etc., that are marketed to help babies sleep, relieve reflux, relieve colic, all of those things. Sometimes parents medicalize their babies by seeking medical treatment for a sleep problem that isn't actually anything physiological to do with the baby.

It's defined entirely by its effect on the parent. Sometimes we're persuaded to buy magic solutions for a good night's sleep. So new parents are marketed all sorts of rubbish that might not be safe, that encourage parents to leave their babies alone for sleep, or just ineffective. And then of course we end up with sleep training as sort of the ultimate behavioral extinction techniques that will train babies or teach babies to stop signaling at night so that their parents can get some sleep. But I argue in the book, of course, that instead of fixing baby's sleep, what we should be doing is talking about how babies sleep, offering new parents support when things get difficult, talking about what helps us to cope by being there and sharing the load, and by changing baby sleep conversations not to be focused on what's wrong with the baby but on what you would expect the baby to be doing and how to help get through that period. So a few take-home thoughts then, since I think I'm probably well over time now. Human babies have got needs that don't fit easily with contemporary adult life, and this is sort of one of the big issues that we have to deal with in Western society.

The hormonal and neurological processes that regulate sleep develop slowly, And prolonged and deep sleep isn't normal in the first few months of life. Baby sleep is hugely variable into early childhood, and we need to expect this and help parents expect this. Comparisons with other people's babies aren't helpful. And many families, particularly breastfeeders, manage normal baby sleep disruption by bed sharing because it's one of the ways in which they manage to get the most sleep. Breastfeeding mothers cuddle curl to reduce the risks, and bed sharing helps mothers to breastfeed for longer. But all families need information on bed sharing safety and contraindications. And sleep disruption is difficult. A desire to fix the baby's sleep is often a sign of distress in new parents. So helping them develop realistic expectations is important. As is helping them seek support from family and friends, and of course, providing them with evidence-based information from professionals. Okay, I shall stop there and let Pam ask some questions.

Questions [00:35:27.07]

Pam Helen, thank you very much for talking to us from your book, telling us what's in your book in that way, and at the same time giving us a really good foundational overview actually of your work and of babies' sleep, how babies sleep. I've actually read every word now, I've sat in the local cafes and really enjoyed really enjoyed reading the book.

So if I can quote from page 153 of How Babies Sleep. You write, 30 years ago when I stood up at academic and medical conferences and told elderly male pediatricians that they were undermining efforts to improve breastfeeding in the UK by insisting babies should sleep alone and learn to selfsettle from an early age, you write, I met plenty of resistance. Changing attitudes about how and where babies sleep can be likened to turning an ocean liner. And then you write, but it has turned. So, you know, I have the view that you've driven profound change throughout the course of my professional lifetime, Helen, across the baby sleep sector. I know you would immediately say not single-handedly, you'd point to many others in this space. But the fact is you've been a very significant agent of change. Internationally, taking the lead in turning that ocean liner. There's many listening in this evening who have been engaged with NDC or the Possums programs and who themselves are disruptors in their own way, wanting to advocate for change in the way parents and their babies are cared for by our health systems. And I wondered if you'd speak to what advice you might have for us on being a disruptor 'in one's professional context.

What qualities in yourself would you say have been most useful? What's kept you going over the years? Where have you turned for nurturance?' I wonder if you'd mind just speaking to those questions, Helen.

Helen Interesting questions. No, very good questions actually. I don't think when I started all of this that I had any idea that it would go on for so long. And that it would end up being successful, really. I just thought it was profoundly important to me to sort of share the understanding that I gained from my research with people who could make a difference. And it, it seemed almost pointless, actually, to do research that found out things like this and to not share it. So, you know, I was one of those people for whom there were many sort of conversations around, "Well, are you a researcher or are you an advocate?" And there was sort of this idea that, you know, it's a bit of an inappropriate thing for a researcher to be doing, to be advocating as well as doing research, but to me that was the reason for doing the research was to demonstrate that there was a need for change and to provide the evidence that would help to bring about that change. And I think one of the things that— for anybody else who's trying to do a similar thing, I think, think about the questions that need to be answered and how you can find the evidence to support The need for change, because certainly in a— as a non-clinician working in what was really a clinical sort of setting, in, you know, all of those people who were making the decisions about things like what information should be given to parents about safer sleep and should they be told that they shouldn't bed share and all of this, they were all clinicians.

And I felt after a few years of just producing the sort of qualitative and descriptive and observational research that they'd always got, well, that's not really, you know, that you can't tell whether that's a causal difference, or, you know, that's not rigorous research, it's not a clinical trial, it's not a this, it's not a that. So in the end, I actually started doing randomized clinical trials. Because that was the only language that people would listen to. And once we had randomized clinical trial data on the fact that bed sharing and breastfeeding are closely related, and if you undermine bed sharing, you're going to undermine breastfeeding, people finally began to listen. But you had to sort of speak to them using the tools that they thought were valid. And I also think what was really important was finding my allies early on. And my allies early on were really the breastfeeding community, people working to support breastfeeding. Baby Friendly Initiative in the UK was hugely important in sort of disseminating the research that I did because it supported responsive parenting and values of the Baby Friendly Program. So, you know, those sorts of people gave me a platform to talk about my research from, and that enabled me to sort of get the message out much more effectively than I ever would have done all by myself.

So I think finding your allies, knowing who your supporters are when you go into any meeting to discuss policy change or practice change or whatever, It's really useful to know who's going to back you up if you say something, and to ask them in advance, "If I bring this up, will you back me up?" Because one voice alone in a meeting, a policy meeting like that, can be easily dismissed. But if there are multiple people sort of reinforcing what you're saying, it's a lot harder for people to dismiss it. So in terms of, you know, how to turn that ocean liner, those are some of the things that I found worked for me over the years. And the other thing you said, personal qualities, I think one of the things that I have always thought about myself is that I'm a plodder. I just keep plodding on. Doesn't matter, you know, how much, you know, the rain and the wind and blow in your face, you just get your head down and you keep going. And I think that's what I've always done. In my career is just kept plodding on. So it's taken a long time to see things change, but I think if you're a plodder, you get there.

Pam I think you've covered that well, but we want to be plodders. Thank you, Helen. Thank you. Well, I had another couple of questions up my sleeve, but I think really it's important to prioritize taking questions from our participants now.

Speaker 3 Hi, Helen. Thank you so much. That was an amazing presentation, and I absolutely love both your and Pam's work. I support babies coming home from the NICU, and I have a question more so around the premature and lower birth rate babies and how we can support them with bed sharing or supporting them to support their babies who are craving a lot of that physical contact when we know there's an increased risk. So just, I guess, trying to think about how we can support them with the messaging and giving them that education on, you know, what's safe for babies who are at higher risk.

Helen Yep, yep. I think it's one of the most difficult areas that I'm asked to talk about because, you know, those, those babies do really want that contact and that contact's so important for them. Yet sleeping with those babies is more dangerous than sleeping with any other babies. So we have to help parents understand that, I think, understand why that's the case. I get asked probably every talk I give, somebody wants to know at what age is it safe for a baby who's been— was born prematurely to be able to bedshare. And there's, there's no answer that you can give them because there are so many variables that might go into that question. How premature the baby was, what gestational age they are now, whether the sort of arousal deficit that premature babies seem to have ever wears off, if they ever grow out of it, all of these kinds of things. So You know, one of the issues around bed sharing safety with premature babies is monitoring. So I think one of the things that we can do is encourage parents that if they think they might fall asleep with their premature baby on them, to make sure there's somebody around who can kind of keep an eye on them and is monitoring them.

And then another is about the use of sidecar cribs and sidecar bassinets and everything so that they can put their baby in a safe space. But ultimately, it's the parent's decision at the end of the day as to at what point they think their baby is sort of robust enough to be able to overcome some kind of challenge in a bedsharing environment. For instance, if the covers go over their face, Premature babies are less likely to push them away than term babies, but at some point presumably they will start doing that. I don't know, nobody's done that kind of longitudinal research, but parents often say, well, I'm sure he wouldn't kind of like lie there with the covers over his face now. Well, I suppose you know your baby best, and you at some point you're able to make that decision, but nobody else can can tell you whether you should do that or not. So if you're ultra-cautious, then I suppose you have to never bring them into bed. So it's not an easy conversation to have with parents who've had premature babies. There's a lot of nuance to it, and some people are kind of very anxious and other people really just want to go with it, and it's hard to give them advice.

Speaker 4 Thanks so much, Helen. I cannot wait for your book to arrive in my mailbox. I just wanted to ask a question around— you made a point about expecting babies to sleep a lot when it comes to brain development. And I was just wondering if you could speak to how that fits, because we know a baby's sleep needs are so variable, and to how do we kind of reconcile that sleep need with brain development and all the rhetoric around babies needing to sleep for X amount of time and the fearmongering around if they don't sleep for this length of time, they won't develop properly.

Helen Yeah, I think the research looking at sort of the cognitive outcomes associated with sleep in the first year of life isn't very robust, it isn't very clear that the absolute amount of sleep that a baby needs is linked to later cognitive outcomes. I think there's more evidence of that sort of in childhood than there is in infancy. I think in infancy, so long as a baby is allowed to take the sleep that they need, then that's sufficient for that baby's brain growth. So I don't think we need to encourage babies to sleep more than they automatically do, but we shouldn't be stopping them from sleeping. We should let them get the amount of sleep that they need. That will be what they need for their own particular brain growth. And, you know, some of, some of this stuff around how long babies need to sleep or how quickly after they've woken babies need to sleep again is related to kind of like what's happening to them during the time that they're awake and are they doing a lot of processing of information. If they're doing a lot of processing of information, then they're going to be using a lot of energy, so they're going to be building up adenosines in their brain more quickly.

So they're going to feel sleep pressure more quickly, their sleep pressure is going to rise more rapidly, so they're going to need to sleep sooner. But if they're not, if they're just staring at the white ceiling, then they're probably not going to be building up much sleep pressure, so they might not need to sleep as much. So I think, you know, trying to kind of convey to parents that their baby's sleep needs are all different and their baby's sleep needs might differ from one day to another as well, depending on sort of how much activity their brains are doing. And it's not— there's not this kind of easy equation that is kind of like, how much sleep do they need for optimal cognitive development over time? It's much more variable than that. There's not, yeah, a simple sort of equation that you can put together.

Speaker 5 Thank you very much, Helen. It's a fascinating subject, sleep. I'm just thinking about what studies there are. The quality of sleep. So does, for example, a breastfed baby would generally feed more frequently, so wake— awakens, wakes up more frequently, yeah, compared to a bottle-fed baby or formula-fed baby. Oh, formula-fed, not bottle-fed, but yeah, formula-fed baby. I'm just talking about the quality of sleep because then I'm just wondering is breastfeeding a protector of SUDI? Because babies sleep— babies wake more frequently on what their sleep quality might be in versus— do you know, am I making sense? Versus a formula-fed baby.

Helen yeah, so the difference in sleep between breastfed babies and formula-fed babies, they don't seem to get any different amount of sleep in recent studies, but formula-fed babies seem to spend a bit more time in deeper sleep, and breastfed babies spend more time in, in lighter sleep and REM sleep. And REM sleep is when they're growing their brains and they're processing stuff. So babies spend more time in REM sleep than they ever do— or we spend more time in REM sleep as babies than we ever do at any point in our lives afterwards. So, and, and it's, and it's that REM sleep, it's the light sleep that is actually important. For brain growth. So when babies— so we, when we talk about sleep quality, what is desirable in adults is different from what is desirable in babies. So we think, for our purposes, we think good sleep quality is like a good long block of deep sleep at the beginning of the night, which is that restorative sleep. But for babies, they don't need that much deep sleep. Having more REM sleep and quiet sleep that allows them to arouse easily, as you say, which is protective for SIDS, but also is the period when their brains are sort of consolidating all of that information and growing neurons and stuff.

Helen The bed sharing image looks rather chilly. Mom and dad need some bed covering. So, and having the doona and blankets over your back and diagonally round down over the baby. I think that could well be what we would, you know, when we were talking at the beginning, Pam, about sort of not having central heating in your houses in Australia. Yes, that's right. That's probably the difference between Australia and the UK. So, you know, here houses are centrally heated, and so people wouldn't feel as cold probably during the night. But the other thing that we encourage mums to do is wear longsleeved cardigans or long-sleeved shirts in bed if they need their arms warm, rather than pulling the covers up over the baby. And that's because of, you know, the baby suffocating and overheating with big heavy duvets and comforters and doonas and what have you over them. So yeah, I think if you know that, if you're comfortable that you can keep sort of your blankets under control and not covering your baby, then fine. But I think for general consumption, the guidance to kind of like keep them down low is probably the best, because if people aren't thinking about where they are, they can end up over the baby's head pretty easily.

Speaker 3 Did you have to find in your studies, did you have mums who formula fed and then still brought the baby in for bed sharing to when— if they were craving that physical contact?

Helen Yeah. Yeah, and they didn't bed share necessarily in the same way if they'd never breastfed. So there was a bit of a difference between mums who were giving the babies formula at the time we studied them and whether they were never breastfeeders or they had previously breastfed either this baby or another baby. And if they'd previously breastfed at all, they tended to sleep like breastfeeding mums. They had that sort of instinctive putting the baby at breast height on their back below the pillows. But the ones who had never ever breastfed put the baby sort of up by their faces. They either put the baby on their pillow or they put the baby in between the parents' pillows, which was quite an interesting difference. They didn't They didn't have that instinct to sort of curl up around the baby. It was more like this face-to-face relationship, and they sometimes turned away, they sometimes turned their backs. So I think one of the things that I always felt it was really important was for mothers who'd never breastfeed to know how to bedshare like a breastfeeding mom if they didn't know how to do it instinctively. Because those pillow situations, putting the baby on the pillow or between the pillow or turning away from the baby, seemed to me to increase the baby's risk, you know, much more. So I thought, yeah, so that was one of the arguments for giving everybody really bad sharing information, was to make sure that everybody knew. If it's not instinctive that you know, you can try to learn what you should do.

Pam Well, I think we'll leave it there. We've just get into a gallery view. So Helen, thank you so much for giving up your time to speak with us today. It's a real honor to have you here to talk. I'm excited to see this book, which really does speak to your life work, out and available for all of us now. And I suppose to just to thank you again for the the way you've managed our collaboration with Sleep Baby and You over these years, always with impeccable ethics, but just so much kindness and goodwill and tolerance of the sort of bumpy journey of a sort of primary care initiative here in Australia. So thank you very much, Helen, for everything really that you're giving to us as health professionals, but to families. We're very grateful to you.