Sleeping baby safely and enjoying nights as best you can: Dr Pamela Douglas in conversation with Durham University Professor Helen Ball | Possums for parents with babies ™ - Official Site

Sleeping baby safely and enjoying nights as best you can: Dr Pamela Douglas in conversation with Durham University Professor Helen Ball

Dr Pamela Douglas and Professor of Anthropology Helen Ball
Possums Baby sleep

This is a transcript of a conversation between Possums Medical Director, Dr Pamela Douglas, and Durham University Professor of Anthropology and Director of the Durham Infancy & Sleep Centre, Professor Helen Ball. The podcast is available through The 2020 Baby Podcast

Pam: 
Welcome to this next episode of 2020 Baby with me, Pamela Douglas, and with my dear colleague and friend from the Durham Infancy and Sleep Centre, Professor Helen Ball. Welcome to you, Helen, and thank you so much for being willing to talk with me today.

Helen:
You're very welcome, it's nice to chat.

Pam: 
Today we're going to talk about sleeping baby safely, and enjoying the night as best we can. I have had the privilege of knowing Helen for over seven years now, and Helen has done Possums the honor of presenting keynote talks at a number of conferences over that period of time. Then in more recent years, I've had the honor of collaborating with Helen and the team at the Durham Infancy and Sleep Centre on Sleep, Baby & You, which is an adaptation of the Possums Baby and Toddler Sleep Program for the UK context. It has been a great pleasure having the opportunity to get to know Helen, and indeed her family a little more recently in a trip in March 2018, to Durham, where Helen was holding an Infancy Sleep Conference. Helen, I wondered if you'd mind giving us a brief history of your professional life, and then talking to what matters to you most about your work. What is it that gets you fired up about your career as a researcher?

Helen:
Okay. Well, let's think about how I got started in this field then. I did my Undergraduate Degree in Biology, and then as a consequence of taking a few undergraduate modules in anthropology, I went to the States to pursue a Masters and a PhD in Biological Anthropology, and at the time I was interested in monkeys, primates. I did my PhD studying monkeys, rhesus macaques, on an island off of the coast of Puerto Rico which was fabulous. It was a great life to spend two years chasing monkeys around on a tropical island. But after I had written up my PhD, and then started applying for academic jobs and got hired to a permanent academic post at Durham back in the UK, and started at the same time having my own family; it became blatently clear that primatology and Puerto Rico, and motherhood, and academia in Durham, UK weren't that compatible, and that I was going to have to figure out a research career in something that I could do a little bit closer to home. That was when I decided to switch to studying mother-baby sleep.That switch was really inspired by Professor James McKenna, who had been a primatologist,and had started his own sleep lab in the United States studying mother-baby sleep. I looked at what he was doing, and I thought about the training that he had received, and that I had received, and I thought nobody is doing this in the UK, and I have all the skills that he has so I could do it too, and that would make my life so much easier. I was already of course interested in what was happening with mothers and babies because I have my own babies. So that was what propelled me into that space, the need to be able to combine family and career in the Northeast of England where there were no monkeys.

Pam: 
Well, and how fortunate we all are that you did this.

Helen:
I'm sure it involved a lot more angst, and soul-searching, and anxiety than it sounds like it did now looking back on it 28 years ago, but yes, it seemed like it, now it seems like it all makes sense, and it just fell into place. I think it was probably a much more difficult transition at the time, but I've blocked all of that from my memory now.

Pam: 
That's right.

Helen:
What I wanted to do in those early days, having looked at the research that Jim was doing, and seeing the sort of response from the medical establishments to Jim's involvement in infant sleep research, and what was an anthropologist studying all of these, was to demonstrate that there was something about what happens in families at night that the medical research world really wasn't accessing, and really didn't understand what was going on, but an anthropologist could unravel and unpick, and help to make sense of, and therefore contribute in some way to helping families get better support, better information, research that was a value to them for the issues that they were dealing with. That was what spurred me on into this area.

Pam: 
Thank you. I think it would be appropriate to say that over the years you've become the world's leading researcher in infant sleep, and I wonder if we look back over the years, before we look forward, what do you feel are the most important things that have come out of the work that you've been doing?

Helen:
Some of the things that I've been particularly pleased about, happy about, has been to understand how parents manage the conflict between their baby's sleep and their own sleep, and how they use bed sharing or sleep sharing as a tool to align their sleep needs with their baby's night time feeding needs. So revealing the close relationship, the really strong relationship that existed between breastfeeding and bed sharing was one of the first things that we did. That was in an era when bed sharing was really frowned upon, and parents were told not to do it at all. It was very important to me to document the reasons parents were engaging in bed sharing, and what benefits it was bringing them that they articulated. Then having understood from our conversations with parents about why they were bed sharing, to look at that in a objective way with videos and actigraphy, to understand what was going on for parents and for babies in terms of feed frequency and sustaining breastfeeding, and whether it was affecting their sleep in certain ways. To be able to properly understand the phenomenon of night time bed sharing, this led us to a series of randomized trials in the hospital that I very much thought that I would never end up doing, but which demonstrated how the proximity between mums and babies at night really affects the ways in which mums and babies communicate at night and mothers understand their baby's cues. Babies are able to alert their mums to their feeding needs, and it helps in the initiation of breastfeeding in a way that isn't possible even when babies are in stand-alone bassinets at the side of their mum's bed. That was all quite a real revelation and a learning journey for me.

Pam: 
Indeed, a profound contribution I'd argue to the well-being of women and their babies around the world really. So Helen, if we were to look into the future from here, what are the things that you are still hoping you might achieve in the years to come as an infant sleep researcher? Are there still particular issues that you're passionate about addressing that await us to hear about?

Helen:
Well, I think things are gradually moving in a direction that I would like to see things going in, but what I'm really keen to see before I retire is the conversation changing, and I think you share this sort of passion. To see the conversation around infant sleep changing, to normalizing the sleep of breastfed babies, for parents to be well-prepared to know what to expect, and for us to have moved away from this idea of the good comatose baby who sleeps full length periods. What I'd like to see is a changing expectation amongst the general public, and amongst practitioners about how we talk about infant sleep, about the information parents receive about infant sleep before they have a baby, and then while they're going through it all, and providing support for dealing with all of that.

Pam: 
Yes, absolutely. The whole issue around sleep and interrupted nights, but also sleep and safety is such a source of anxiety and distress for families. If we were to focus a little bit here now on the issue of sudden infant death syndrome (SIDS), sudden unexpected infant death, this is a kind of potential nightmare that parents find themselves really engaged in once they've had a baby. The fear of the baby dying in sleep is just a terrible thing for parents, and so the whole issue around how to sleep baby safely is so weighted isn't it, for families. I wonder if I could handover to you to talk to us about your thoughts as I address this area of great anxiety for families.

Helen:
No problem. The history of how SIDS has been tackled I suppose, or sudden unexpected death in infancy has been tackled over the course of the last 20 years is really interesting, but it has some legacies that we need to be aware of. If we go back 30 years, to the very early 90s, the SIDS rate all around the world were much, much, much higher than they are now, it was something like 1.5 to 2 babies in 1000 were dying. Nowadays, and certainly in the UK the rates are down to somewhere between 0.2 to 0.3 in 1000, so the rates have dropped dramatically, but the problem is that we still don't know what causes babies to die suddenly and unexpectedly. If we did, it would cease to be an unexplained death, we'd know what the cause was and we'd be able to explain it. So in order to try to reduce those deaths epidemiologists have had to try to work out what was associated with being a baby who died versus being a baby who didn't die. What were the things that parents were doing or what were the characteristics of the babies that made them vulnerable versus those babies who weren't. One of the first things that emerged from the case control studies was this issue of the sleep position. Babies who died were four times more likely to be on their front than they were on their back. The first real big initiative to reduce SIDS was putting babies on their backs, and the SIDS rates declined dramatically in the years after the Back to Sleep Campaigns. It was a simple intervention, parents didn't have a lot of reasons to say they didn't want to put their babies on their backs, it made sense, especially if it prevented their babies from dying. We still don't know why the supine position is safer, there are hypotheses about it but nobody has ever demonstrated one explanation. It's kind of a fundamental explanation for why. Then people started looking for other similar sorts of magic bullets, if you like. Things that they could tell parents to do that would eliminate the rest of the SIDS cases. Several things have emerged over the years, none quite as dramatic as the Back to Sleep, but this included keeping babies smoke-free, so cigarette smoke exposure during pregnancy, and afterwards was associated with an increased risk. Sleeping in the room alone is associated with an increased risk, not being breastfed is associated with an increased risk. Those all have clear data, not as many case control studies as the sleep position one, but multiple case control studies for each of those things. Then there are many things that are related to temperature and wrapping, and soft surfaces, that people have looked at in slightly different ways in different studies. It's difficult to say exactly what it is about some of these things, whether it's the external room temperature, whether it's too many layers on the baby, whether it's soft bedding that can insulate around the baby's head and stop it losing heat, all of these kinds of issues. But there's certainly something around temperature and soft bedding, and the wrapping so this is why babies are encouraged to sleep in a clear, flat space with nothing, no loose blankets that can cover their head, all these kinds of things. Then there was bed sharing, and bed sharing emerged during these case control studies as a potential risk, or being associated with an increased risk, and so people thought that the best way to tackle that was to then tell parents not to bed share, in the same way as they had told parents not to put their babies on their front. The difficulty arose with that when it became clear that parents didn't want to or weren't happy just trying to eliminate bed sharing. Just saying, "don't do it" didn't work, people didn't stop doing it. What became clear over time from my research and others, was that parents are invested in behaviors like bed sharing for lots of different reasons. The simple ''don't do something" approach wasn't working, it doesn't work. The bed sharing, it doesn't work for smoking, it doesn't work for encouraging people to breastfeed, so we had to think about the strategies to deal with it.

Pam: 
We're really dealing with is complex systems, aren't we?

Helen:
Yes, complex behaviors for which there are costs and benefits that play out in different ways in different families, in different contexts. It has become clearer over the years that the context in which bed sharing is happening makes a huge difference as to whether it's a benefit to the family or it's a potential risk to the baby. In some cases, of course it can be both, it can be a risk to the baby yet it's a benefit to the family as well, so they are willing to take the risk, so it's a difficult conversation to have with parents. It's been a difficult conversation to have at a national policy level as well, because of course different organizations have different interests in that conversation, and want the outcome to be in a different place.

Pam: 
Yes. In Australia, there has been a trend in my professional lifetime towards risk minimization when it comes to safe infant sleep advice. Could I ask you to talk to that, and to whether that has been the case in the UK, and perhaps the US? I'm interested to hear your perspectives on that.

Helen:
Yes, I think we began talking about the concept of risk minimization around the start of the 2000s when it began to become clear that what we call risk elimination wasn't working for things like bed sharing, particularly bed sharing was what I was focused on. I remember writing a paper with one of my colleagues, an American anthropologist called Lane Volpe, where we argued that from a bed sharing point of view risk minimization was going to be a more successful, effective strategy for dealing with bed sharing SIDS deaths than risk elimination has been. After that things changed fairly quickly in the UK, it was 2014 when I served on the National Institute for Health and Care Excellence (NICE) Panel that reviewed the evidence about co-sleeping and SIDS in the UK. It reviewed the evidence internationally, but made recommendations for how health professional should discuss bed sharing and co-sleeping with families in the UK. The recommendation was that we should follow a risk minimization approach, which meant discussing with families the pros and cons for their specific circumstances, and encouraging them to make an informed choice knowing all of the details about the pros and cons for that situation. So that has been the guidance to help professionals since 2014, but it wasn't being widely implemented until 2019. 

Pam: 
It's not so long ago.

Helen:
No, not really. My BASIS organization, which provides information to parents, was invited to collaborate with the Lullaby Trust, who are the UK SIDS organization, UNICEF Baby Friendly, who are the key breastfeeding support accreditation program in the UK maternity hospitals, and Public Health England. We all got together and created new national leaflets and guidance for health professionals and parents that explained what a risk minimization approach meant, that it involved discussing bed sharing, not just simply telling parents not to do it. It involved discussing how you might arrange your bed and yourselves in a way that minimizes the risk or hazards that we know about, and make sure that parents knew which things to avoid like the sofa sharing, etc., that were the most hazardous. That was very, very positively received, I have to say. We had lots of positive feedback from both health professionals and parents that this was a much more user-friendly approach I suppose, than the previous approach, which had just been to say never bed share. In Queensland, definitely you have a similar kind of strategy, but I think some parts of Australia still have a bit of a risk elimination tendency. I looked at the guidance from the different states earlier this year when I was doing a talk for the Academy of Breastfeeding Medicine, which was being held in Australia, and it seems South Australia is not happy with the risk minimization approach so they still take a risk elimination approach. That's what they do in the US, it's still a risk elimination approach, it still says never bed share. That's what pediatricians are recommended to tell parents, but I think they've softened a little bit in recent versions of their guidance, to say that they acknowledge that breastfeeders bed share, and that some parents choose to bed share, but they still say, "Our advice is not to." But I think they might be gradually realizing that they need to meet people where they are rather than having some unattainable ideal.

Pam: 
Because of the risk of an unintended outcome?

Pam: 
Yes. So I wouldn't be surprised to see the US shifting its position a little more as the next round of guidance from the AAP comes out, which I think is towards the end of this year. We've just recently gone through another NICE review, and I saw the draft guidelines recently, and they haven't changed their position, they're still advocating for informed choice, so that was good to see.

Pam: 
It's the NHS's position?

Helen: 
The NHS, yes.

Pam: 
Well, I wanted to ask you, Helen, about a range of concerns that parents will often bring to us in the clinic. Maybe before I jump in to these particular questions, I should give you the opportunity just to talk a little bit more about BASIS, and also the fabulous website resource that BASIS offers online. Could you tell us just a little bit about that?

Helen: 
Sure. BASIS is the Baby Sleep Information Source. It's a project that the Durham Infancy and Sleep Centre run as a way to make our knowledge accessible to parents, and health professionals with a collation of all this academic research, and knowledge about the research that's done on infant sleep around the world. It felt as though it was important to make that available for other people, not keep it to ourselves, so that was what prompted us to create the website in the first place. We were getting lots of questions from both health professionals and parents when they found out what we did for research, that we thought should just be publicly available. We talked about normal infant sleep development. We talked about SIDS and sleep safety. We talked about the kind of anthropological explanations for why babies need contact and comfort, frequent feeding, and all of the things that we know new born babies expect to have happen to them, and then what the consequences of all of that means to parents in negotiating that first year of life, and what the research has said about different aspects of sleep and night time care that parents might want information on. So that's what we try to make available on BASIS. We received the funding to do it in 2010. We spent 2011 writing it all, and we launched it in 2012, so it's nearly 10 years old now, and we keep updating it periodically.

Pam: 
Yes, and it's an excellent resource that I refer parents to all the time. One part that I particularly enjoy in it, Helen, is the gallery of images of families bed sharing, and the myriad ways that families do, but more broadly it's a terrific resource for people to take a look at, and for health professionals to use with their parents.

Helen: 
Well, one of the reasons that we created that gallery was there was an article, actually it was when the new NICE Guidance came out. Around 2014 there was a commentary in the British Medical Journal about it, and they illustrated it with a picture of a mum and a baby bed sharing, and it was the most awful picture of bed sharing you could imagine because the baby was face down on a pillow. So I instantly wrote to the British Medical Journal and said, "If you are going to write a positive story about the new NICE Guidance around bed sharing and informed choice, could you please illustrate it with something that illustrates safe bed sharing or safer bed sharing than a baby face down on a pillow, because that seems to undermine the message that you're giving out." So they did, they changed the picture, but they actually didn't find it very easy to find a picture of a safer set-up for bed sharing. It made us realize that people might not see images of normal bed sharing very much, and how a mum and a baby arrange themselves in the bed, and how the mum makes this C position and curls around the baby, and puts the baby flat on the mattress, and away from the pillows. So we thought that having some images available for people to use in articles, and leaflets for parents, would be a good idea. One of our supporters knew a professional photographer, and persuaded them to come,and we had parents in the lab who were willing to be photographed, so he came and photographed them for free. So that was how that all came about.

Pam: 
Yes, fantastic, it's a wonderful gift to families. Thanks, Helen. I would like to put to you questions that I will commonly be asked in the clinic. Can we start with formula-fed babies? There is the predominantly formula-fed or exclusively formula-fed baby, or the baby who's receiving some formula. What about formula and bed sharing?

Helen: 
This is a really good question that we have tried to address, and we have some data about it, but I think we're the only research team that has ever looked at what's happening with formula-fed babies, and formula-feeding mums, and bed sharing. I'm not comfortable yet saying that there's a definitive answer to this question, I don't think there is enough robust evidence, but in the study that we did, and we need to remember that only this study included lots of breastfeeding mums, because breastfeeding mums bed share a lot, but formula-feeding mums tend not to volunteer for bed sharing studies for whatever reason. So we had 10 mums who were formula-feeding who came into the lab to take part in this particular study.

Pam:
Was that entirely formula or mixed feeding?

Helen: 
No, and this is an issue. These were a combination of mums who had breastfed, but now were no longer breastfeeding, and mums who had never breastfed, and we saw a difference between these. There were probably about five of each, and we saw a difference between these two groups, in that the ones who had previously breastfed bed shared the way the breastfeeding moms bed shared. They had that instinctive behavior of curling up around their babies, putting their babies flat on the bed, etc. Where as for the moms who had never breastfed, they put their babies on the pillows or between the pillows, so if there were two parents in the bed they were between the parents, pillows at face-height, and if they were sleeping by themselves with the baby they were propped up on a pillow next to the mom. It seemed from that very small bit of data that they didn't have the same instinctive urge to put their baby flat on the mattress at their breast height. That's perfectly understandable because if they're not feeding their baby at the breast it wouldn't seem instinctive to put your baby down at breast height, so they put their babies up next to their faces. But because it's such a small number I don't know how generalized that is. I don't know whether all mums who have previously breastfed will automatically sleep like a breastfeeder, and I don't know whether all mums who have never breastfed will always put their baby up on a pillow or not think about putting the baby flat. One of the things that we wanted to do in producing this new leaflets that we produced with the Lullaby Trust and UNICEF was to illustrate what bed sharing looks like amongst those people who do it the most, as in the breastfeeding bed sharing mums. We illustrated this picture with a baby down at breast-height, in the hope that mums who don't know what that looks like will emulate that when they decide in the middle of the night that bed sharing is the only way they're going to settle this baby, and get some sleep. But what nobody can tell us at the moment, because nobody has done this piece of research, is whether you can teach a mum who's never breastfed to sleep with their baby like a breastfeeding mum does. We provide the information, we encourage formula-feeding mums who don't necessarily instinctively bed share in this way, we encourage them to do it, but I've never been able to do a study where we video mums that we have given that information to, to see if they sustain it in the same way that breastfeeding mums do, or whether in the middle of the night they move their baby or they turn their backs, or something happens that makes it less safe. I think for formula-feeding mums we can only raise their awareness really, I don't think we can tell them that it's difficult.

Pam:
Yes, because some advice of course is categorical to formula-fed babies, and it's not clear whether this is a baby who receives any formula, or a baby who is receiving only formula, but the advice is formula-fed babies should not share a sleep surface with the mother or with the parents. What do you think given that we don't have evidence to guide us? How do we manage this as clinicians? I can tell you what I do, but I'm interested to hear your thoughts.

Helen: 
I think if our goal is for parents to be able to make informed choices about these things, we have to explain to the parents what we know, and what we don't know, and then it's their choice, their decision. If they feel as though the bed sharing is providing them with a really important bonding opportunity with their baby, an opportunity to get to know their baby's cues, to be responsive in the night, and that outweighs for them any small chance of increased risk, I think that's completely their choice to make. Likewise, if they feel as though they don't have those breastfeeding hormones that make you aroused quite frequently because you feel the need to feed your baby, and you're attuned to your baby's movements because you sleep with it regularly, if they feel as though they're lacking that something that a breastfeeding mum might have, and don't feel as though it's safe to sleep with their baby then I think that's also their informed choice. We have to support them whichever decision they choose to make.

Pam:
So we've got the research to show that breastfeeding is protective against SIDS, but we don't actually have data, other than perhaps your team's work around instinctive positioning or lack thereof. We don't actually have data to show that bed sharing with a formula-fed baby is riskier than bed sharing with an exclusively breastfed baby. We have the overall data around breastfeeding being protective, but if we're breaking it down and looking at bed sharing, we have nothing to guide us. Have I got that right, Helen?

Helen: 
There was one publication in 2006, Bob Carpenter's publication where he tried to extrapolate, so it was a model, it wasn't actual data on numbers of bed sharing deaths amongst formula and breastfed babies. It was a model extrapolating from some data that he had, that produced a series of curves showing babies at different ages, and their risk of SIDS by whether they were breastfed and formula-fed, and bed shared or didn't bed share. My memory is that this model suggested that formula-fed babies bed sharing were at a ten-fold increased risk compared to the breastfed babies not bed sharing. I think for breastfed babies not bed sharing, and bed sharing it was twice the risk, but it was twice the risk for a very, very minute amount, like 1 in 10,000, but then for formula-fed babies not bed sharing it was five times, and for formula-fed babies bed sharing it was ten times. It was a difference between 2 in 10,000, and 10 in 10,000 for the comparison of breastfed and formula-fed. That's the only study that I am aware of that has attempted to quantify the difference in bed sharing risk for breastfed and formula-fed babies. But there are lots of questions around the data from that study because he imputed lots of missing variables, so it's one of those studies that gets picked apart quite a lot.

Pam:
Well, thank you. So parents will also ask me often about the advice that they hear, that if they are going to share a sleep surface the baby should not be slept between the parents, and I must say that in that wonderful gallery of images on the BASIS site, of course we see many babies sleeping there between the parents, so could you share your thoughts about that?

Helen: 
Yes. So in the UK we don't give guidance about whether the baby should or shouldn't be between the parents, the guidance is mostly in terms of the kind of safe arrangement of the bed. Making sure that the bed is away from walls and furniture so that there are no gaps that the baby could slide down basically and hang themselves, because their bodies fit through gaps and their heads don't. So having the baby in the middle of the bed between two parents can be safer if the edges of the bed are a hazard, if there are things that the baby might slip between. People worry about dads, and whether dads sleep more deeply, and they're aware of where the babies are. I have to say from our videos there are some dads who are absolutely in tune with everything that goes on with the mum and the baby in the bed, so they arouse every time the mum and the baby do. They check out what's going on, sometimes they respond to the baby before the mum does, so not all dads are heavy sleepers, but there were some who turned their backs, zonked out and didn't interact with the mums and babies during the course of the night. So when parents ask me this question what I usually say is "you know whether your partner is a heavy sleeper or a light sleeper. You know whether he arouses and looks and checks out what's going on if you're awake with the baby or he doesn't. So if you are worried that he's a heavy sleeper and might not be aware of the baby, make sure you put yourself between him and the baby". But if you're happy that he is as attuned to the baby as you are, and some dads sleep with the baby by themselves, and let the mums go and have a night's sleep, or half a night sleep, so some dads are very competent bed sharers; then I think they have to make that decision themselves. I don't think there's a one-size-fits-all kind of answer to this one either. I think it depends on the parents.

Pam:
There's not really data to guide us is what you're saying, we don't have data to suggest that a heavy sleeper is going to increase the risk of SIDS really, do we?

Helen: 
No. No, or roll on the baby or anything like that.

Pam:
There are anecdotal stories, that's where a lot of these concerns come from, which may or may not include information that doesn't get passed on as part of those stories.Then, finally obesity, are you able to speak to that, Helen, with bed sharing?

Helen: 
There was one study done in the States many years ago that attempted to quantify the risk of bed sharing with an obese mother, and it found that there was an increased risk above a certain BMI. I'm afraid I can't remember what that BMI was off the top of my head, but the concept basically is if you're so obese that you're unaware of your body periphery, of whether your baby is pressed against your body, against the periphery of your body, you've not got sufficient sensation to know that your arm or your breast, or whatever it might be, is against your baby's face, then that's a good reason to avoid bed sharing. Again, there's only this one study, and otherwise it's anecdotal information.

Pam:
There have been many women who do fall into the category of obesity from a BMI perspective who wouldn't fit in to that category of having difficulty knowing the boundaries of their body. Well, Helen, thank you again. Is there anything else that you would like to add to wrap up our conversation here? 

Helen: 
Well, I think probably it would be a good idea to just reiterate what the known hazards are with bed sharing, that we should make sure that everybody is familiar with. The things that we always mention as being clear indicators of an increased risk for a baby when bed sharing or co-sleeping or sleeping with a baby on the sofa, sleeping with the baby if you're a smoker, sleeping with the baby if you've consumed drugs or alcohol, and sleeping with a low birthweight or premature baby. All of those have been shown in multiple studies to be associated with an increased risk, so those are the times when we need to be extra cautious and careful.

Pam:
Well, thank you so much, Helen, for your time. It has been wonderful to have this conversation with you. I think it's a conversation that will be highly valued by both the parents who are interested in Possums and the Neuroprotective Developmental Care (NDC) work, and also our health professionals, so thanks again, Helen.

Helen: 
You're very welcome. It has been lovely talking to you.
 

Dr Pamela Douglas is a GP and Medical Director of Possums & Co. www.possumsonline.com, a charity that educates health professionals in the evidence-based Neuroprotective Developmental Care (NDC) or Possums programs, including the Possums Baby and Toddler Sleep Program.  Please contribute to our movement for change in early life care by making a donation today. If you wish, you can refer to or upskill to become an NDC-accredited practitioner. There are lots of free videos and other resources for parents with babies here, and online parent peer support is available for a nominal fee. Pam is an Associate Professor Adjunct with the School of Nursing and Midwifery, Griffith University, and senior lecturer with the primary care clinical unit, The University of Queensland. She is author of The Discontented Little Baby Book: all you need to know about feeds, sleep and crying.

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