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I'm pregnant through IVF. Should I have an induction? It is very common for women and people who became pregnant through IVF to be advised to have an induction of labour, usually around 38-40 weeks, if spontaneous labour hasn't started already.

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Does your baby like tummy time? Most don't, for good reason. Until infants are able to roll into the tummy position on their own, most of them find it uncomfortable, immobilizing, and no doubt highly discouraging.

But rather than listen to our babies, we are asked to put our faith in recent studies about plagiocephaly (flat-headedness), studies that don't take into account the fact that infants are now spending more time than ever in restrictive devices (like car seats, bouncy seats and carriers) that inhibit babies from doing what they are naturally inclined to do: round out the back of their heads by turning them from side to side.

Instead, the back position and rousingly successful "Back to Sleep" campaign (which has cut the SIDS rate in the US in half since it began in 1992) have been named as the culprits. So, rather than understand these studies as a reflection of the need for more free movement and floor time during the baby's waking hours, many experts have concluded that imposing tummy time is the answer.

In this insightful guest post, Irene Lyon, a Feldenkrais and Somatic Experiencing Practitioner (and producer/director of the world renowned "Baby Liv" video), sheds light on the valuable developmental processes hindered when tummy time is imposed early, and helps us see tummy time from our baby's point of view. Irene writes:
Have you ever had a local anesthetic for dental surgery?
Your gums, facial muscles, facial affect, smiling, talking, eating - it all just goes funny and you simply can't use your mouth area until the anesthesia wears off. You feel kind of silly and imbecile-like, yes?
Now imagine this.
You are on your stomach, lying on the ground. You want to lift your head up. But someone just injected your back extensor muscles (the ones that allow you to lift up off the ground and lift your head) with that same local anesthetic that dentists use. The very muscles that work to lift up your head and chest are simply deadened. It's even hard to engage your shoulders and arms to lift yourself up because, unfortunately, they too interact with your back extensors. You might say: "Darn it, this head feels so heavy. It's a struggle. I feel completely helpless!"

This last scenario is exactly what happens when infants are put on their stomachs for "tummy time." The only difference is that the infant can't speak yet to say: "Hey, what's going on, this sucks. I'm uncomfortable. HELP!"

Putting infants on their tummies without having them go through the process of getting to their tummy on their own is analogous to injecting their back extensor muscles with that local anesthetic. They are paralyzed and basically unable to access their back extensor muscles, mainly because the actual act of getting to their tummy from their back (something that takes months!) is what forms their spinal curves - the lumbar, thoracic and cervical - and in turn gives them strength in their back muscles.
Have you had a chance to watch "Baby Liv"?
Before you read on, give yourself the 3-minute pleasure of watching Baby Liv. Watch the video piece straight through. See the process of Baby Liv going from her back, to side, to tummy (and all the in-between's).

Then, I'd like to give you a recap of what she's doing from a functional and structural point of view. In essence: What is giving her the juice to get to her tummy and decide when she is ready for her own "Tummy Time".

Rolling - Feldenkrais with Baby Liv from Irene Lyon on Vimeo.

This footage was taken over a series of months.

@ 20 seconds: She's pretty still, but if you look at the eye movement, to the right and left, that is priming her spine for rotating. For now, she's doing tiny pieces of rotation. (Try this yourself, only move your eyes left and right. If you are attentive enough, you'll sense you neck and head wanting to move in the direction your eyes travel.)

She then looks at her fingertips. This gaze upwards is forming the curves in the upper part of her spine (the cervical area) - and in actuality, it is transmitting throughout her entire body. The support she finds from the ground under her - from foot to head - provides "juice" for this movement (and all movements, really).

@ 41 seconds: You can just see the increase in fluidity throughout her entire self and a greater availability for movement.

@ 1 min: She's moving her legs a lot, and this is putting a nice wave up her spine...think...snake like movement!

@1.15: She starts to do a roll. This seemingly innocent movement carries a lot of punch in the development world. That little push through her foot and the tiny rotation it brings is just the beginning of finding a teensy bit of spinal extension and use of her back muscles. Lifting both of her legs up tilts her pelvis and flattens her lower back into the ground. This flattening of her lower back is forming the opposite of her lumbar curve. It is lengthening her back muscles. This lengthening gives her 'energy' in her back muscles so that she has more ability to actually engage them.

@2.09: If you can catch it - it's quick - when she is going for giraffe Sophie, you see her little head pick up off the ground. BINGO! This little lift is happening because the rest of her body, below, has found the support surfaces and functionally to un-weight her head. All the pieces are falling into place.

@ 2.18: She's a pretty happy kid. She's got there HERSELF (think: self-reliance), and her head held high with absolute support coming from her pelvis, hands and legs. She's anchoring into the ground in numerous places and learning how to use her environment for movement. You see, in this moment of her lifting her body up, there is no impingement on her neck area, and clean spinal curves are being developed.

It isn't about the firing and strengthening of "muscles" per se, it's about functionally doing the movements that our nervous system wants to find, and then letting the muscles, and nature, just do their job.

@2.44-2.46: Now she is really showing off her ability to finely control her rotation and movement. She's got it dialed. It feels good. She's having fun!

Irene Gutteridge (now Irene Lyon) blogs at her virtual office, irenelyon.com. Her education is in the health sciences and she is a certified Feldenkrais and Somatic Experiencing Practitioner practicing in Whistler & Vancouver, British Columbia. You can reach her through her website, www.irenelyon.com, via Facebook: https://www.facebook.com/lyonirene, Twitter: @Irene_Lyon, or good old email: irene@irenelyon.com. She loves meeting new people!

For more about tummy time:

No Tummy Time Necessary and Tummy Time Baby's Way by child development specialist and RIE Associate Lisa Sunbury, Regarding Baby

Tummy Time May Not Be Needed by Nicholas Bakalar, The New York Times

Plagiocephaly?!? (or Why "Tummy Time" is not the answer) by Sarita Galvez, Moverse en Libertad

The Tummy Time Debate by Gill Connell, Little Treasures Magazine

For more thoughts on natural motor development and parenting with trust, I recommend Magda Gerber's books: Dear Parent: Caring For Infants With Respect and Your Self Confident Baby: How To Encourage Your Child's Natural Abilities From The Very Start

And my book, Elevating Child Care: A Guide to Respectful Parenting

(Photo by devinf on Flickr)

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The Case Against Tummy Time: Guest Post by Irene Lyon - Janet Lansbury

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Does your baby like tummy time? Most don't, for good reason. Until infants are able to roll into the tummy position on their own, most of them find it uncomfortable, immobilizing, and no doubt highly discouraging. But rather than listen to our babies, we are asked to put our faith in recent studies about plagiocephaly ...

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What really matters in caring for babies may be different than commonly thought, says Lehigh University researcher Susan S. Woodhouse, an expert on infant attachment. In new research, she finds that caregivers need only "get it right" 50 percent of the time when responding to babies' need for attachment to have a positive impact on a baby. Securely attached infants are more likely to have better outcomes in childhood and adulthood, and based on Woodhouse's potentially paradigm-shifting work, there is more than one way to get there, particularly for low socioeconomic-status families.

Woodhouse, an associate professor of counseling psychology, studied 83 low socioeconomic-status mothers and infants at ages 4.5 months, 7 months, 9 months and 12 months to observe and assess attachment. Infants and mothers in the study were racially and ethnically diverse, and infants were selected for high levels of temperamental irritability.

Her findings are detailed in "Secure Base Provision: A New Approach to Examining Links Between Maternal Caregiving and Infant Attachment," which appears in the journal Child Development, co-authored with Julie R. Scott of Pennsylvania State University, Allison D. Hepsworth of the University of the Maryland School of Social Work, and Jude Cassidy of the University of Maryland.

The study scored mother-baby pairs based on a mother's responses to the infant while the baby was crying and not crying to assess the qualities of "secure base provision." This framework focuses on aspects of caregiving that tell an infant about the caregiver's availability to serve as a secure base, such as soothing to cessation of crying and providing a present and safe base from which to explore.

Researchers found that this framework significantly predicted infant attachment, and that babies learned their mothers were providing a secure base when mothers responded properly at least 50 percent of the time.

"The findings provide evidence for the validity of a new way of conceptualizing the maternal caregiving quality that actually works for low-income families," Woodhouse said.
What is Infant Attachment and Secure Base Provision?
Infant attachment is the bond infants form with their primary caregiver. A secure attachment allows babies to feel safe, which gives them both comfort in times of distress and the ability to explore, knowing they can return to their secure base when needed. Attachment is an infant's first bond with important caregivers and a critical phase in development, with a major impact on emotional and social development.

Numerous studies have shown the importance of secure infant attachment to developmental outcomes. But, for the past 30 years, the actual building blocks leading to attachment have been unresolved. Caregiver "sensitivity" -- the ability to accurately interpret infant needs and to respond promptly and appropriately -- was shown to be a key predictor of attachment. But studies showed sensitivity accounts for a surprisingly low percentage of variation in attachment, and has an even lower impact among families with low socioeconomic status.

"That's a real problem, because low-income babies face the most amount of risk, toxic stress and other factors that go along with being low income," Woodhouse said. Data suggest secure attachment may serve a protective function in children's socio-emotional development when in a context of high risk. Secure attachment is associated with better mental health outcomes in both childhood and adulthood -- including less incidence of externalizing behaviors such as acting out and internalizing behaviors such as depression and anxiety -- as well as greater school readiness.

"If we want to give advice to parents about what they can do to give their baby the best start in life, it would be really good to know what helps a baby to be secure," Woodhouse said.

Woodhouse's study seeks to address this critical gap in understanding what leads to secure attachment, through examining whether a new conceptualization of caregiving behavior, "secure base provision" -- the degree to which a caregiver is able to meet an infant's needs on both sides of the attachment-exploration continuum -- predicts attachment security in infants. It is the first time this conceptualization has been tested separately from sensitivity and as a predictor of infant attachment. The new way of conceptualizing caregiving focuses on the aspects of caregiving that theoretically should be most important to building infant attachment because of what an infant can learn from them about a caregiver's availability to serve as a secure base for the infant -- both when the infant needs comforting and when the infant is focused on exploring.
Differences Between Secure Base Provision and Sensitivity
As frameworks, both sensitivity and secure base provision look at how caregivers perceive, interpret and appropriately respond to infant signals; and, in both, important infant signals occur at each end of the attachment-exploration continuum. But secure base provision looks only at certain key infant signals and more specific caregiver responses. It also focuses much less on prompt response and more on crying resolution (the ratio of infant crying episodes that end in chest-to-chest soothing until the infant is fully calmed, regardless of promptness).

Secure base provision also does not consider attunement to a baby's state and mood in a moment-by-moment manner, as the sensitivity framework does. "Attunement is not key because the focus is on what the infant learns about his or her ability to, in the end, recruit the caregiver when needed -- even in the context of a fair degree of insensitive behavior," such as not picking up the baby right away, or saying, "Come on, don't cry," to the baby, the researchers said. "It is this infant learning about the availability of the caregiver to be recruited to provide a secure base (more often than not) that is central to the construct."

Specifically, secure base provision looks at the degree to which a parent, on average, soothes a crying infant to a fully calm and regulated state while in chest-to-chest contact. "It is at the end of each crying episode that the infant learns about whether, on average, the caregiver can be counted on to be available as the infant achieves a calm state or whether the infant typically must stop crying alone," the researchers said.

During infant exploration and other times when the infant is not distressed, the secure base provision approach focuses on whether the caregiver allows exploration to occur without terminating or interrupting it -- for example, by making the baby cry through play that is too sudden or rough -- and on "calm connectedness," which communicates the mother's ongoing availability if needed for regulation or protection: "I am here if you need me, and you can count on me."

In addition, there are behaviors that caregivers must not do, either when the baby needs comfort or during exploration, in order for secure base provision to occur. Specifically, caregivers must not frighten the baby or fail to protect the baby when real hazards are present, such as another child who is too rough.
Secure Base Provision 8 Times More Effective at Predicting Attachment
The study scored mother-baby pairs based on maternal responses to the infant during episodes of infant crying and maternal responses outside of infant crying episodes. A separate group in another lab also scored for the commonly used sensitivity framework.

The researchers found the new maternal caregiving concept of secure base provision correlated significantly with infant attachment security: mothers who had higher scores on secure base provision were more likely to have more securely attached infants, with an effect eight times larger than that of sensitivity, based on a meta-analysis of findings for low socioeconomic-status families. This was true, even after controlling for maternal sensitivity. They also found that "maternal sensitivity" did not significantly predict infant attachment security.

"What this paper tells us is that we need to change not only how we measure sensitivity, but how we are thinking about the caregiving behaviors that really matter," Woodhouse said. "What we found was that what really matters is not really so much that moment-to-moment matching between what the baby's cue is and how the parent responds. What really matters is in the end, does the parent get the job done -- both when a baby needs to connect, and when a baby needs to explore?"

Research suggests that infants demonstrate statistical learning to identify complex underlying patterns in stimuli, the researchers said. "Thus, we expected that infants whom caregivers soothed from crying to calm in a chest-to-chest position for at least half of the observed episodes of infant crying would learn that, on average, they could trust their caregivers to provide a secure base," they said, which they found to be true.

Woodhouse calls the findings "paradigm shifting."

"It really is a different way of looking at the quality of parenting," she said. "It's looking at this idea of does the job get done in the end, and it allows us to see strengths in low-income parents that our previous ideas about sensitivity don't let us see."
Additional Dos and Don'ts
Researchers also noted a number of problematic behaviors by mothers while their babies were crying that disrupted the process of comforting the infant. Such as: turning the baby away from their chests before crying ends; rough handling; harsh verbal tones; verbal instructions not to cry; and verbally attributing negative characteristics to the baby. They also documented presence or absence of frightening behavior, such as sudden looming into the baby's face or toward the baby, during crying episodes.

"If the mother did frightening things when the baby cried, like hard yelling or growling at the baby, or suddenly looming toward the baby's face while the baby was upset, even if it only happened one time, the baby would be insecure," Woodhouse said. "Similarly, if the mother did anything really frightening even when the baby wasn't in distress, like saying 'bye-bye' and pretending to leave, throwing the baby in the air to the point they would cry, failure to protect the baby, like walking away from the changing table or not protecting them from an aggressive sibling, or even what we call 'relentless play' -- insisting on play and getting the baby worked up when it is too much -- that also leads to insecurity."

Interestingly, overprotective-type behaviors, such as moms who don't let the baby explore more than an arm's length away, or interrupting or redirecting play (except for safety) also contributed to insecure baby attachment. "Some moms really had trouble allowing the baby to explore and were very insistent on the baby doing certain things or turning the baby's head to look at the mom," Woodhouse said. "In really intrusive parenting, if we saw that, the baby was insecure."
Applications for Parents and Practitioners, Across Cultures
One application of the findings is improving effectiveness of intervention programs that aim to increase secure infant attachment. The results indicate that low socioeconomic-status mothers who do a better job of providing a secure base increase their infants' chances of developing a secure attachment from about 30% to 71%; while low-SES mothers who fail to provide a secure base decrease their infants' chances of developing a secure relationship from about 71% to 30%.

Knowing this can help those leading interventions to view caregiving behavior in a new way. For example, this framework allows them to shift focus from urging mothers to respond as promptly as possible to working with mothers to focus on relenting and ultimately picking up and soothing a crying infant in a chest-to-chest position until calm.

"Because low socioeconomic-status parents juggle multiple challenges associated with low socioeconomic status, it may be helpful for them to know that holding a crying infant until fully soothed, even 50% of the time, promotes security," the researchers said. "Such a message could help parents increase positive caregiving without raising anxiety regarding 'perfect parenting' or setting the bar so high as to make change unattainable in families that face multiple stressors."

Methods of engaging an infant in calm, regulating connectedness, such as being available for eye contact without actively making eye contact and carrying an infant on the hip during daily tasks, also promote secure attachment in the baby, they said.

Focusing on the secure base also avoids emphasizing the importance of parenting practices that are often associated with white, middle-class populations, such as moment-to-moment attunement, prompt responses, sweet tone of voice and affectionate verbal comments. The new approach "captures strengths that can be present in parents who may be under economic strain or who ascribe to 'no-nonsense parenting,''' the researchers said. This also makes the secure base provision approach potentially more culturally sensitive and likely to be accepted across diverse low socioeconomic-status families.

"Across cultures, social class and race, parents want the best for their kids," Woodhouse said, "so parents are excited to know about this when I talk with them." Clinicians such as psychologists, counselors, social workers, home visitors, Head Start programs, early child care providers and pediatricians will also find it as a valuable lens, she said. "It has the potential to change intervention for agencies and practitioners, and I think that is really valuable," Woodhouse said.

The research isn't meant to contradict sensitivity as a framework, which remains useful, Woodhouse argues. The findings also aren't a challenge to attachment theory, which assumes that infants universally form attachments with familiar caregivers based on evolutionary pressures. "Attachment theory is a really important theory that has guided lots of research," she said. "(These findings) are about enriching, deepening and adding to the theory in ways that support applicability in diverse contexts."

Woodhouse clarifies that this is different from commonly understood tenets of "attachment parenting" in popular culture, such as co-sleeping, baby-wearing, breastfeeding or organic foods. "None of these things is inherently good or bad for attachment or a guarantee of having secure children -- it's about how they are done," she said. "Moms get secure children in different ways. It is more of an attachment-informed perspective, that biologically babies do have certain needs -- for safety, comfort and connection, exploration of their world -- and how do we meet these needs? There is more than one way to get there."

For Woodhouse, the takeaway is two-fold:

"The first message gets at the core of getting the job done -- supporting the baby in exploration and not interrupting it and welcoming babies in when they need us for comfort or protection," Woodhouse said. "The other part is that you don't have to do it 100 percent -- you have to get it right about half of the time, and babies are very forgiving and it's never too late. Keep trying. You don't have to be perfect, you just have to be good enough."

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infant's health; breastfeeding; pregnancy and childbirth; parenting; infant and preschool learning; child psychology; privacy issues; poverty and learning; public health

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'Good enough' parenting is good enough, study finds

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What really matters in caring for babies may be different than commonly thought, says Lehigh University researcher Susan S. Woodhouse, an expert on infant attachment. In new research, she finds that caregivers need only "get it right" 50 percent of the time when responding to babies' need for attachment to have a positive impact on a baby.

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By the time a child reaches five years old, 90% of their brain has already developed - which means the progression from birth to school is the most important time of their lives.

A child's brain develops in different stages. As part of Theirworld's #5for5 campaign on investment in early childhood development, we look at some of the changes going on inside the womb, from birth to three years old and from three to five.

In the womb

Just 16 days after conception - way before you know you are pregnant - your unborn baby's neural plate (the foundation of your baby's brain and spinal cord) is forming.

"At the same time, neural cells start travelling throughout the embryo to form the beginnings of nerves," says Heidi Murkoff, the author of What to Expect.

The nerve cells form but are not actually developed as a brain during the first 12 weeks.

"Impulses begin to fire without pattern or direction," explains the Developing Human Brain website. "Sensory organs and nerves are not developed at this point, so the foetus does not feel pain."

Over the next few months, the sensory organs and nerves begin to develop.

Research shows that outside influences can affect the unborn child's brain development - both positively and negatively.

In fact, the sounds made by dolphins can stimulate an unborn baby's brain even more than music or talking to your "bump"!

"The high-range sounds dolphins emit are registered by the baby. These sounds stimulate the nerves in the brain and the child's audible senses," said Elizabeth Yalan, dean of the Obstetrician College of Peru.

Neuroscientists can now identify patterns in brain activity that appear to be associated with some types of negative early experiences.

The long-term effects of early stress, poverty, neglect and maltreatment were well-documented and virtually uncontested years before scientists could "see" them with brain-scanning tools.

While most mothers in developed countries are given every opportunity to stimulate their unborn child, nourish it and protect it, it's often a very different story for pregnant women in the developing world.

Birth to age three

A child's brain undergoes a rapid period of development during these three years , producing 700 new neural connections every second. When a baby is born, 100 billion neurons - or brain cells - have already been produced.

The future of a child's developing brain is in our hands. Parents, caregivers and family members all have a part to play in helping to form a baby's brain.

Scientists are rapidly untangling how a child goes from seeing images when just born to being able to feed, talk, play and communicate by the age of three.

"Different stimuli and tasks, such as hearing a lullaby or reaching for a toy, help establish different neural networks," wrote Yudhijit Bhattacharjee in an article for National Geographic.

"Between the ages of one and five, the brain goes through cycles of growth and streamlining, with experience playing a key role in engraving the circuits that will endure."

Judit Gervain, a cognitive neuroscientist at Paris Descartes University, uses behavioural methods, optical brain imaging and electrophysiological measures to understand how babies learn their native language.

She says: "For a long time we had this linear view. First, babies are learning sounds, then they are understanding words, then many words together.

"From recent results, we know that almost everything starts to develop from the get-go. Babies are starting to learn grammatical rules from the beginning."

Researchers have shown that children around two and a half years old are savvy enough to correct grammatical mistakes made by puppets. By the age of three most children seem to master a considerable number of grammatical rules.

Despite coming prewired with huge capabilities and potential, the brain depends heavily on environmental input to keep "growing" and developing.

Scientists are now discovering precisely how that development is moulded by the interplay between nature and nurture.

Dr Alison Gopnik, a professor of psychology and affiliate professor of philosophy at UC Berkeley and author of Philosophical Baby, said: "One of the biggest changes I think that's happened most recently is how amazingly much babies know from the time they're born.

"So, far from being a blank slate, even the youngest babies already seem to have some basic ideas about other people, about language, about the physical world about the objects around them.

"And one of the evolutionary ideas is that early period ... is where we're just free to learn and explore without actually having to put all that learning to work. "The picture is that having a caregiver who's actually willing to invest in taking care of you is one of the prerequisites for being able to do all this amazing learning that we know babies are capable of."

Age three to age five

A five-year-old's brain uses twice as much glucose (the energy that fuels the brain) as that of a full-grown adult, researchers at Northwestern University anthropologists have discovered.

The study shows that because the brain needs so much, the body doesn't grow as rapidly.

"Our findings suggest that our bodies can't afford to grow faster during the toddler and childhood years because a huge quantity of resources is required to fuel the developing human brain," said Christopher Kuzawa, an IPR biological anthropologist and first author of the study.

"As humans we have so much to learn - and that learning requires a complex and energy-hungry brain.

"After a certain age it becomes difficult to guess a toddler or young child's age by their size. Instead you have to listen to their speech and watch their behaviour."

Kuzawa said the study suggests this is no accident. He added: "Body growth grinds nearly to a halt at the ages when brain development is happening at a lightning pace because the brain is sapping up the available resources."

And because the preschool years are a period of extremely rapid brain development, it is crucial that this age group receive proper stimulation and nutrition.

Children living in poverty, deprivation, abusive and war-torn environments are most at risk from not reaching their full potential because they are deprived of getting their most basic needs met.

Just by talking and interacting with a young child, you are increasing their brain development - and increasing their "usable" vocabulary. This period from age three to five is critical for language skills.

"On average, a child's vocabulary expands from 55 words at 16 months to 225 words at 23 months to 573 words at 30 months," according to Professor Usha Goswami, Director of the Centre for Neuroscience in Education at the University of Cambridge.

We are a global children's charity committed to ending the global education crisis and unleashing the potential of the next generation.

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How a child's brain develops from the womb to age five

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By the time a child reaches five years old, 90% of their brain has already developed - which means the progression from birth to school is the most important time of their lives. A child's brain develops in different stages.

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From Babycentre.co.uk

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Follow your baby's development from a tiny mass of cells through to a fully developed baby. Our illustrations show how your baby is growing inside your womb (uterus), while our Inside pregnancy videos take a 3D animated look at a baby from conception to labour and birth. And see the whole nine months in one timeline!

Conception

See what happens inside you during the conception process.

One month pregnant

Your baby is an embryo consisting of two layers of cells from which all her organs and body parts will develop.

Two months pregnant

Your baby is now about the size of a kidney bean and is constantly moving. He has distinct, slightly webbed fingers.

Three months pregnant

By now your baby is around 7 to 8 centimeters (3 inches) long and weighs about the same as a pea pod. Her tiny, unique fingerprints are now in place.

Nine months pregnant

Your baby is almost due. At birth, the average baby is more than 51cm (20.5in) long from head to toe and weighs approximately 3.4kg (7.5lb), but babies vary widely in size at this stage.

Month by month with ultrasound images

See our summary of how your baby is developing from two months. Within each month, 3D ultrasound images give you an idea of how your baby may look.

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Follow your baby's development from a tiny mass of cells through to a fully developed baby. Our illustrations show how your baby is growing inside your womb (uterus), while our Inside pregnancy videos take a 3D animated look at a baby from conception to labour and birth.

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A labelled anatomy diagram showing the changes in a pregnant woman's body

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A short animation that shows how the baby grows and develops over the course of the pregnancy

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Efficacy of pregnancy and labour massage

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Efficacy of pregnancy and labour massage

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Abstract

Massage therapy has been demonstrated to be effective during pregnancy. Women who received massage therapy reported decreased depression, anxiety, and leg and back pain. Cortisol levels decreased and, in turn, excessive fetal activity decreased, and the rate of prematurity was lower in the massage group. In a study of labor pain, women who received massage therapy experienced significantly less pain, and their labors were on average 3 h shorter with less need for medication. An underlying mechanism we have been exploring is that these effects are mediated by increased vagal activity. This likely occurs by the stimulation of pressure receptors that are innervated by vagal afferent fibers, which ultimately project to the limbic system, including hypothalamic structures involved in autonomic nervous system regulation and cortisol secretion.

Keywords: alternative therapy, labor pain, postpartum depression, pregnancy massage, prematurity

Complementary and alternative therapies have become increasingly popular for pregnant women and women in labor. In one survey, the majority of pregnant women who participated (62%) and 61% of providers of prenatal healthcare reported that they used complementary and alternative therapies during pregnancy [ 1]. The most common alternative therapies recommended during pregnancy were massage therapy (61%), acupuncture (45%), relaxation (43%), yoga (41%) and chiropractic therapies (37%).

Pregnancy massage

Massage therapy has been demonstrated to be effective during pregnancy in three studies by our group [ 2- 4]. In the first study, therapists provided massage therapy for 20 min per week for 5 weeks [ 4]. The women reported decreased depression, anxiety and leg and back pain. Cortisol levels decreased and, in turn, excessive fetal activity decreased, and the rate of prematurity was lower in the massage group.

In the second study, depressed pregnant women were massaged by their significant others over a 16-week period using the same protocol (20-min massages twice weekly) [ 2]. As in the first study, significant decreases were noted in depression and anxiety, as well as cortisol levels. In addition, like the results of the first study, pregnancy outcomes were improved, including a reduction in excessive fetal movement that has been noted in fetuses of depressed women (). The most important finding was the lower incidence of prematurity (0 vs 11% in the control group).

In the third study, pregnant women diagnosed with major depression were given 12 weeks of twice weekly massage therapy by their significant other, or only standard treatment as a control group [ 3]. The massage therapy group women versus the control group women not only had reduced depression by the end of the therapy period, but they also had reduced depression and cortisol levels during the postpartum period. Their newborns were also less likely to be born prematurely (4 vs 16%) and with low birthweight (2 vs 10%), and they had lower cortisol levels and performed better on the Brazelton Neonatal Behavioral Assessment habituation, orientation and motor scales.

The higher-than-national-average prematurity and low birthweight rates for the depressed mothers in this sample were not surprising given previous reports on a greater incidence of prematurity in depressed women [ 5, 6]. The decreased depression and low back pain in the massaged women and their fewer prenatal complications, including a 75% lower prematurity rate and an 80% lower incidence of low birthweight in the massaged depressed women, were also not surprising given our previous finding of a lower prematurity rate in depressed women given pregnancy massage [ 2].

These findings were unique in that post partum depression and cortisol levels were decreased in the massaged women. The decrease in depression by week 32 of gestation in the massaged women persisted through the duration of pregnancy and the postpartum period. To have mothers less depressed during the neonatal period would likely enhance their bonding with their infants. Having more mature and more interactive newborns would also certainly enhance that process [ 7]. The fact that the newborns of the massaged mothers also had lower cortisol levels than the newborns of the control mothers may relate to the mothers' lower cortisol levels and their decreasing depression across pregnancy.

Labor massage

It is interesting that while labor is an anxiety-provoking experience, and while massage therapy has been noted to reduce anxiety in many studies, the focus of massage therapy labor studies has been almost exclusively on the alleviation of pain. In one study, massage was noted to lessen the pain intensity during phase 1 and 2 dilation, but there were no significant differences between the massage and control groups at phase 3 dilation [ 8].

In a study we conducted on labor pain, the pregnant women's partners massaged them during the first 15 min of every hour of labor [ 9]. The partners were given instructions on massaging the back and the legs (the areas of greatest pain) of the pregnant women from a side-lying position. The women experienced significantly less pain, and their labors were on average 3 h shorter with less need for medication ().

Potential underlying mechanisms for massage therapy effects

Some suggest that massage effects can be explained by the 'gate theory' [ 10]. This is a kind of metaphor for the pain message traveling more slowly than the pressure message from massage (i.e., the stimulation of pressure receptors). Pressure messages travel more rapidly than pain messages, reaching the brain faster and closing the gate to the pain message. A more biological explanation of the gate theory is that cells in the dorsal horn of the spinal cord act like a switch between the nerve impulses from the different fibers. Pain is carried more slowly by the less insulated (unmyelinated) C neurons, whereas massage signals are carried more rapidly by the A neurons (myelinated) that close the gate to the C impulses and allow the A signals through. In this way, the massage stimulation (A fibers) closes the gate to the pain stimulus (C fibers).

An alternative underlying mechanism we have been exploring is that these effects are mediated by increased vagal activity. Vagal activity increases immediately after massage therapy sessions and across repeated sessions of massage therapy [ 11]. In these studies, significant increases in vagal activity occurred following massage therapy. This likely happens by the stimulation of pressure receptors that are innervated by vagal afferent fibers, which ultimately project to the limbic system, including hypothalamic structures involved in autonomic nervous system regulation and cortisol secretion.

These pathways are supported by several lines of evidence. First, anatomical studies indicate that baroreceptors, and to a lesser extent, mechanoreceptors under the skin (i.e., Pacinian corpuscles) are innervated by vagal afferent fibers projecting to the vagal nucleus of the solitary tract, the predominant source of afferent inputs to the efferent neurons of the nucleus ambiguous and the dorsal motor nucleus of the vagus [ 12]. Second, functional studies indicate that electrical vagal stimulation results in reduced cortisol responses in depressed patients [ 13]. Third, as already noted, we have recently shown that moderate pressure massage (but not light pressure massage) elicits a significant increase in vagal activity in both infants and adults [ 14]. Fourth, data collected across several studies by our group and others indicate that massage therapy decreases heart rate [ 15- 17], lowers blood pressure [ 17- 19] and reduces cortisol levels [ 20, 21]. Last, a functional MRI study revealed that massage therapy increased cerebral blood flow across several brain regions involved in depression and stress regulation, including the amygdala and the hypothalamus [ 22], suggesting that massage therapy involves hypothalamic regulation of autonomic nervous system activity, cortisol secretion and limbic activity associated with emotion regulation.

Inverse relationships between vagal activity and cortisol levels have also been reported [ 23]. In addition, psychological stressors that reduce vagal activity have been noted to increase cortisol levels [ 24]. Increased vagal activity results in a slowing of physiology (decreased heart rate and blood pressure) and downregulation of cortisol [ 25]. Others have interpreted this relationship as vagal activity playing an inhibitory role in the regulation of allostatic systems [ 23]. As Thayer and Sternberg noted, the prefrontal cortex and amygdala are important CNS structures linked to the regulation of emotion and allostatic systems, including hypothalamic-pituitary-adrenal axis function [ 23].

Expert commentary

Previous reports have found that depressed women have a greater incidence of prematurity and low birthweight rates [ 5, 6]. In our studies, massage therapy has been effective during pregnancy [ 2- 4]. Depressed women given massage therapy had fewer prenatal complications, including a 75% lower prematurity rate and an 80% lower incidence of low birthweight [ 2]. They also reported decreased depression, anxiety and back pain. Surprisingly, postpartum depression and cortisol levels decreased in the massaged women. Their newborns also had lower cortisol levels than the newborns of the control mothers, which may relate to their mothers' lower cortisol levels and their decreasing depression across pregnancy. In addition, the newborns performed better on the Brazelton Neonatal Behavioral Assessment habituation, orientation and motor scales. With mothers less depressed during the neonatal period along with more mature and interactive newborns, the bonding process between them is enhanced [ 7].

In many studies massage therapy has been known for reducing anxiety. In the study we conducted on labor pain, the pregnant women's partners massaged their back and legs from a side-lying position during the first 15 min of every hour of labor [ 9]. The women experienced less pain, and their labors were on average 3 h shorter with less need for medication.

Some credit the massage therapy effects with the gate theory [ 10]. This suggests that pressure messages travel more rapidly than pain messages, therefore reaching the brain faster and closing the gate to the pain message. Another underlying mechanism we have been exploring is that these massage therapy effects occur because vagal activity increases following massage therapy. In our previous studies, we have demonstrated that moderate-pressure massage and not light-pressure massage elicits a significant increase in vagal activity. According to a functional magnetic resonance imaging study, massage therapy increased cerebral flow in different brain regions involved in depression and stress regulation, including the amygdala and hypothalamus [ 22]. This implies that massage therapy engages hypothalamic regulation of autonomic nervous system activity, cortisol secretion and limbic activity related with emotional regulation. Psychological stressors that reduce vagal activity increase cortisol levels [ 24], but increased vagal activity decreases heart rate and blood pressure, as well as cortisol [ 25].

Five-year view

Like China, the USA may eventually have touch rooms in their hospitals where couples will learn the massage for both the pregnant women and the newborn. In time, the USA may come to have the low 1% rate of prematurity of China instead of the 14% rate it currently has. Additional research on underlying mechanisms for the massage effects will help to advance this field.

Key issues

Massage therapy is the most common alternative therapy recommended during pregnancy.

Massage therapy has been demonstrated to be effective during pregnancy. The women reported decreased depression, anxiety, and leg and back pain.

Depressed pregnant women given the pregnancy massage experienced fewer prenatal complications.

In our study on labor pain, the women receiving massage therapy experienced significantly less pain, and their labors were on average 3 h shorter with less need for medication.

The most important finding was the lower incidence of prematurity and low birthweight in the massaged depressed women.

Postpartum depression and cortisol levels were decreased in the massaged women. The newborns of the massaged mothers also had lower cortisol levels than the newborns of the control mothers, and performed better on the Brazelton Neonatal Behavioral Assessment habituation, orientation and motor scales. An underlying mechanism we have been exploring is that these effects are mediated by increased vagal activity.

Acknowledgements

Tiffany Field would like to thank her collaborators and Lissette Medina for assisting with this research, and the pregnant women who participated in her studies.

The studies discussed in this article were supported by NIH Senior Research Scientist Awards (MH 00331 and AT 01585) and an NIH Merit award (M 46586), NIH grants (AT1003 and HD 056036), and a March of Dimes grant (12-FY03-48) to Tiffany Field and funding from the Johnson & Johnson Pediatric Institute.

Footnotes

Financial & competing interests disclosure

The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

References

Papers of special note have been highlighted as:

** of considerable interest

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Massage therapy has been demonstrated to be effective during pregnancy. Women who received massage therapy reported decreased depression, anxiety, and leg and back pain. Cortisol levels decreased and, in turn, excessive fetal activity decreased, and the rate of prematurity was lower in the massage group.

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The last days of pregnancy are a distinct time of in-between. It's a tricky time for mothers, as these last few days are biological and psychological events.
She's curled up on the couch, waiting, a ball of baby and emotions. A scrambled pile of books on pregnancy, labor, baby names, breastfeeding &#8230; not one more word can be absorbed. The birth supplies are loaded in a laundry basket, ready for action. The freezer is filled with meals, the car seat installed, the camera charged. It's time to hurry up and wait. Not a comfortable place to be, but wholly necessary.

The last days of pregnancy - sometimes stretching to agonizing weeks - are a distinct place, time, event, stage. It is a time of in between. Neither here nor there. Your old self and your new self, balanced on the edge of a pregnancy. One foot in your old world, one foot in a new world.

Related: Pregnancy Week by Week

Shouldn't there be a word for this state of being, describing the time and place where mothers linger, waiting to be called forward?

Germans have a word, zwischen, which means between. I've co-opted that word for my own obstetrical uses. When I sense the discomfort and tension of late pregnancy in my clients, I suggest that they are now in The Time of Zwischen. The time of in between, where the opening begins. Giving it a name gives it dimension, an experience closer to wonder than endurance.

I tell these beautiful, round, swollen, weepy women to go with it and be okay there. Feel it, think it, don't push it away. Write it down, sing really loudly when no one else is home, go commune with nature, or crawl into your own mama's lap so she can rub your head until you feel better. I tell their men to let go of their worry; this is an early sign of labor. I encourage them to sequester themselves if they need space, to go out if they need distraction, to enjoy the last hours of this life-as-they-now-know-it. I try to give them permission to follow the instinctual gravitational pulls that are at work within them, just as real and necessary as labor.

The discomforts of late pregnancy are easy to Google: painful pelvis, squished bladder, swollen ankles, leaky nipples, weight unevenly distributed in a girth that makes scratching an itch at ankle level a feat of flexibility. "You might find yourself teary and exhausted," says one website, "but your baby is coming soon!" Cheer up, sweetie, you're having a baby. More messaging that what is going on is incidental and insignificant.

Related: Use of Marijuana During Pregnancy

What we don't have is reverence or relevance - or even a working understanding of the vulnerability and openness a woman experiences at this time. Our language and culture fails us. This surely explains why many women find this time so complicated and tricky. But whether we recognize it or not, these last days of pregnancy are a distinct biologic and psychological event, essential to the birth of a mother.

We don't scientifically understand the complex hormones at play that loosen both her hips and her awareness. In fact, this uncomfortable time of aching is an early form of labor in which a woman begins opening her cervix and her soul. Someday, maybe we will be able to quantify this hormonal advance - the prolactin, oxytocin, cortisol, relaxin. But for now, it is still shrouded in mystery, and we know only how to measure thinning and dilation.

"You know that place between sleep and awake, the place where you can still remember dreaming? That's where I'll always love you, Peter Pan. That's where I'll be waiting." -Tinkerbell

I believe that this is more than biological. It is spiritual. To give birth, whether at home in a birth tub with candles and family or in a surgical suite with machines and a neonatal team, a woman must go to the place between this world and the next, to that thin membrane between here and there. To the place where life comes from, to the mystery, in order to reach over to bring forth the child that is hers. The heroic tales of Odysseus are with us, each ordinary day. This round woman is not going into battle, but she is going to the edge of her being where every resource she has will be called on to assist in this journey.

We need time and space to prepare for that journey. And somewhere, deep inside us, at a primal level, our cells and hormones and mind and soul know this, and begin the work with or without our awareness.

I call out Zwischen in prenatals as a way of offering comfort and, also, as a way of offering protection. I see how simple it is to exploit and abuse this time. A scheduled induction is seductive, promising a sense of control. Fearful and confused family can trigger a crisis of confidence. We are not a culture that waits for anything, nor are we believers in normal birth; waiting for a baby can feel like insanity. Giving this a name points her toward listening and developing her own intuition. That, in turn, is a powerful training ground for motherhood.

Today, I am waiting for a lovely new mother named Allison to call me, to announce that her Zwischen is ended and labor has begun. I am in my own in between place, waiting. My opportunity to grow and open is a lovely gift she gives me, in choosing me to attend her birth.

Jana Studelska CPM/LM, is a licensed midwife practicing in northern Minnesota and Wisconsin. She has been working with babies and mothers since 1998--as a La Leche leader, a certified doula, a childbirth educator, a regional birth network board member, and finally as a credentialed midwife. She is an author and writer, and has won several national awards for her work. Currently, she is the MANA Region 4 Representative for the Midwives Alliance, representing the upper midwest. She lives in Duluth, MN, with her husband, teen-aged boys, and a herd of dogs.

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The Last Days of Pregnancy: A Place of In-Between

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The last days of pregnancy are a distinct time of in-between. It's a tricky time for mothers, as these last few days are biological and psychological events. She's curled up on the couch, waiting, a ball of baby and emotions. A scrambled pile of books on pregnancy, labor, baby names...

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Practical advice based on personal experience and results of scientific research

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Bringing up a Bilingual / Trilingual child - Best working Languages Strategies.

You have a list of languages you would like your child to speak, but you do not know how to go about it and how to introduce the languages.

The typical questions of parents who are "freshmen" in the field :

Strategies:
There are two very successful and popular strategies in raising bilingual children, that with some modifications also apply to trilingual and multilingual children.

It is also called One Parent One Language or OPOL strategy.
One parent always speaks one language to the child and the other always speaks another.
For instance, the father always speaks Italian to the child and the mother always speaks Russian. The country language can be either one of the two, or the third one - English. You can read about my family strategy.

2. Minority Language at Home strategy (ML@H).

When both partners and family members speak one language at home, and the child learns the community or dominant language outside the house walls.

As an example, all family members (the household) speak English at home, when country language is Italian.

These strategies can be used with some modifications in raising multilingual children.

3. Time and Place strategy (T&P) for separating two and more languages.

In Time and Place (T&P) approach parents can assign a specific language to a day of the week (let's say every Sunday family speaks Spanish) or to an activity (speaking English while bathing or watching German news on TV). One parent can speak two languages to a child: one language in the morning and another language in the evening or take longer time for each language and switch them every other day or week. You would need to experiment and see what works best for you and your child. Many parents have reported that two week interval works best, because both child and the parents have enough time to adjust after the language switch. I provide some more tips in "Bilingualism and speech delay. How can you help?" article.

If families relocate and parents support child's new or previous language acquisitions, the child can become from bilingual to trilingual, quadrilingual and multilingual even if the parents speak only one language.

What language should I speak to my child?

Here there is no right or wrong answer. It is always best to speak the language you are more proficient in, which is normally your mother tongue.
From the mother's point of view, I suggest to stop your choice on your mother tongue, because all the lullabies and nursery songs you heard, when you were a baby yourself, were in that language.
When you have your child in the arms, the songs and the words you heard as a child naturally come out from you.
It might be hard to start speaking the language you have not used for a while. I had experienced it myself. You just need to start speaking to your child all the time, since he is born, using your mother tongue and eventually you will feel confident using that language.

You might speak a language in which you see no benefit for your child in learning. Please first ask yourself if your child needs that language knowledge to communicate with the grandparents or relatives? Do not take away this possible bound and enjoyment from your child!

If, after giving it a good thought, you still decide not to teach your child your mother tongue, know that you still can help your child dramatically by joining your spouse and speaking his or her mother tongue to the child ( this is the case when it is different from the community language). You can even benefit as a family from sticking to Minority language at home strategy. Having a normal conversation as a family, without interruptions for translation is a plus.

When should I start speaking to my child the targeted language?

I would say from the birth onwards. The earlier you start the better edge you will have over the dominant language. Start reading to your child early, when he is still a baby. The time is crucial here, as you need to create a language base in the minority language, before the majority language becomes stronger and starts taking over. The more time and energy you invest in your child, the better is the result.

What languages should speak other members of the family to the child?

Ask the ants, uncles, grandparents to support you in your task of raising a bilingual or multilingual child by speaking only the minority language.
If your relatives are fluent in some other minority language, you can ask them to always speak it to your child. Consistency is key even here. Decide together with the relatives what language they would speak to your child.

Do I need to do anything particular to reinforce the child's language knowledge?

Yes!
You would need to to your child. If possible, in the morning and in the afternoon.
Talk to your child in the targeted language all the time from the moment he was born or even during the pregnancy. According to the research published by Psychological Science journal, infants that were spoken to two different languages during the pregnancy were showing interest to both languages compare to monolinguals. It insures the attention and future learning of the languages he has already heard spoken.

You need to insure that your child receives enough language exposure. How much is enough? There is no scientifically proofed number. You just need to make sure that your input is consistent day after day and that your child learns the vocabulary from different life situations. Thus, if you are a working parent, you might think of hiring a nanny speaking less dominant language first, then to send your child to an immersion school. You need to develop a long run plan from the birth onwards, which you will modify as your child grows and according to your family situation.

My best wishes to you in your journey to a happy multilingual family!

Read my answers to other parents in the comments below and in the Question and Answer series.

Also you might have similar questions as the parents, who commented after the post Exposing your kids to languages.

9 Steps of Raising a Bilingual Child Successfully. How to Start So You Don't Feel Giving It Up Halfway Through.

Raising a Bilingual Child (Living Language Series) by Barbara Zurer Pearson

7 Steps to Raising a Bilingual Child by Naomi Steiner and Stephen Parker

Be Bilingual - Practical Ideas for Multilingual Families by Annika Bourgogne

Maximize Your Child's Bilingual Ability: Ideas and inspiration for even greater success and joy raising bilingual kids by Adam Beck

Language Strategies for Trilingual Families: Parents' Perspectives (Parents' and Teachers' Guides) by Andreas Braun and Tony Cline

Trilingual by Six: The sane way to raise intelligent, talented children by Lennis Dippel

Raising Multilingual Children (Parents' and Teachers' Guides) by Dr. Jean-Marc Dewaele and Julia Festman

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Bringing up a Bilingual / Trilingual child - Best working Languages Strategies. You have a list of languages you would like your child to speak, but you do not know how to go about it and how to introduce the languages.

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The Bilingual Family: A Handbook For Parents Paperback
by Edith Harding-Esch

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the bilingual family: a handbook for parents

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foreign language study / english as a second language

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foreign language study / english as a second language

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foreign language study/english as a second language

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The Bilingual Family: A Handbook For Parents

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A research and information centre about bilingualism and language learning, University of Edinburgh

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**Visit our new website www.bilingualism-matters.org for current information on the Bilingualism Matters network, including news and events.

Bilingualism Matters is a research and information centre at the University of Edinburgh, founded by Prof. Antonella Sorace in 2008. We study bilingualism and language learning, and communicate what we know to enable people to make informed decisions based on scientific evidence. We have partner branches run by international teams of researchers in many countries around the world. We think that everyone can enjoy the benefits of having more than one language.

We believe that real change happens through dialogue between researchers and the community. We work in partnership with parents, teachers, health professionals, policy makers and employers to help create impact in people's daily lives. There are now branches of Bilingualism Matters all over the world - check out our list of branches to find one near you.

Research has shown that bilingualism is beneficial for children's development and their future. Children exposed to different languages become more aware of different cultures, other people and other points of view. But they also tend to be better than monolinguals at 'multitasking' and focusing attention. They are often more precocious readers, and generally find it easier to learn other languages. Bilingualism gives children much more than two languages!

More recent research also suggests that learning another language may have benefits in later life, delaying the onset of dementia symptoms, and slowing cognitive aging. The good news is that these benefits seem to exist even when people learn a second language later in life. So it is never too late - see our resources page for classes and meet up groups around Edinburgh.

More information:

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Bilingualism Matters is a research and information centre at the University of Edinburgh, founded by Prof. Antonella Sorace in 2008. We study bilingualism and language learning, and communicate what we know to enable people to make informed decisions based on scientific evidence. We have partner branches run by international teams of researchers in many countries around the world.

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Use your languages - The more of your language(s) your baby hears, the more they will speak and understand. Give them the chance to listen to the languages that are important to you as often as possible.

Children can learn more than one language - Children can develop good language skills in any and every language that they hear - no matter what those languages are!

Speak in the languages you're most comfortable with - This will give your child the best chance at learning language. They will learn English from the community later.

Multilingualism is a positive - There are advantages for well-being, learning and thinking.

There is no one right way - Every family is unique. Do what works best for you!

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Use your languages - The more of your language(s) your baby hears, the more they will speak and understand. Give them the chance to listen to the languages that are important to you as often as possible.

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Babble to bilingual - advice on speaking multiple languages

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Babble to bilingual - advice on speaking multiple languages

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Bilingual babies and speaking multiple languages at home - BBC Tiny Happy People

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Will hearing me speak more than one language confuse my child? Is the speech of bilingual children delayed? What language should I use at home? Tips for parents on introducing children to more than one language.

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iCan the Childrens Communication charity

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iCan the Childrens Communication charity

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How can I help my child's speech and language development?

I CAN's Talking Point gives parents/carers and practitioners the information they need to help children develop their speech, language and communication skills. If a child has difficulty with speaking, they may need help, or they may struggle in nursery or school. With the right help, they can develop the skills they need.

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How can I help my child's speech and language development? I CAN's Talking Point gives parents/carers and practitioners the information they need to help children develop their speech, language and communication skills. If a child has difficulty with speaking, they may need help, or they may struggle in nursery or school.

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Stages of Speech and Language Development

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Stages of Speech and Language Development

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0 to 6 months

Hold your baby close and look at them as you talk to them. Babies love faces and will watch you and respond as you talk.

Chat about what you're doing as you feed, change and bathe them.

Sing to your baby - this helps them tune in to the rhythm of language.

Repeat the sounds your baby makes back to them - this teaches your baby lessons about listening and taking turns in a conversation.

Talk in a sing-song voice - this helps to keep your baby's attention.

6 to 12 months

Name and point to things you can both see, for example, "Look, a cat". This will help your baby learn words and, in time, they'll start to copy you. As your baby gets older, add more detail, such as, "Look, a black cat".

Start looking at books with your baby - you do not have to read the words on the page, just talk about what you can see.

Only offer a dummy when it's time for sleep. It's hard to learn to talk with a dummy in your mouth. Aim to stop using dummies completely by 12 months.

Play games like "peek-a-boo" and "round and round the garden". This teaches your baby important skills like taking turns, paying attention and listening.

12 to 18 months

If your child is trying to say a word but gets it wrong, say the word properly. For example, if they point to a cat and say "Ca!" you should respond with, "Yes, it's a cat". Do not criticise or tell them off for getting the word wrong.

Increase your child's vocabulary by giving them choices, such as, "Do you want an apple or a banana?".

Toys and books that make a noise will help your child's listening skills.

Enjoy singing nursery rhymes and songs together as your baby grows, especially those with actions, such as "Pat-a-cake", "Row, row, row your boat" and "Wind the bobbin up". Doing the actions helps your child to remember the words.

18 to 24 months

Repeat words, for example, "Where are your shoes?", "Are you wearing blue shoes today?" and "Let's put your shoes on". Repetition helps your child to remember words.

Use simple instructions - your child will understand some instructions at this age, such as "Get your coat" or '"Shut the door". Keeping instructions short and simple will help your child understand.

Try asking "Where's your..." - ask your child to point to their ear, nose, foot, and so on.

Limit your child's daily TV time to no more than 30 minutes for children younger than 24 months. Playing and listening to stories is more helpful when they're learning to talk.

2 to 3 years

Help them build sentences - your child will start to put simple sentences together at around age 2. Try to reply using sentences that are a few words longer. For example, if they say, "sock off", respond with "yes, we're taking your sock off".

Get your child's attention by saying their name at the start of a sentence. If you ask a question, give them plenty of time to answer you.

Teach them about words that go together - for example, you could show them a ball, teddy and a rattle and then say the word 'toy'.

Start using sounds with meaning (symbolic sounds), like saying "whoops" or "uh-oh" when you drop something accidentally, or saying "meow" while showing them a picture of a cat.

Switch off the television and radio - background noise makes it harder for your child to listen to you.

Talk as you clean - children this age love to help. Chat about what you're doing as you do chores like shopping, cooking and cleaning together.

The I Can website has more information about stages of speech and language development at different ages.

Think your child may have a speech or language problem?

If you're worried about your child's speech or language development, talk to your GP or health visitor. If necessary, they will refer your child to your local speech and language therapy department.

If you prefer, you can refer your child to a speech and language therapist yourself.

The I Can website has answers to common questions about speech and language assessments and also information about the assessment services it offers.

How to help your bilingual child

Lots of children grow up in a family where more than one language is spoken. This can be an advantage to children in their learning. Knowing another language will help the development of their English.

The important thing is to talk to your child in whatever language feels comfortable to you. This may mean that one parent uses one language, while the other uses a different language. Children adapt to this very well.

Video: when will my child start talking? (12 to 30 months)

In this video, a health visitor talks about when you should expect your child to start talking.

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Hold your baby close and look at them as you talk to them. Babies love faces and will watch you and respond as you talk. Chat about what you're doing as you feed, change and bathe them. Sing to your baby - this helps them tune in to the rhythm of language.

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The first stop for information on children’s communication

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Welcome to I CAN’s Talking Point. Here you can find information to help you understand and support children and young people’s speech, language and communication

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Small Talk is a pilot project from the National Literacy Trust

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Words for Life | National Literacy Trust

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Activities and support for parents, children and young people to improve language, literacy and communication skills from home.

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As seen in class!

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Brain Development

The brain grows at an amazing rate during development. At times during brain development, 250,000 neurons are added every minute! At birth, a person's brain will have almost all the neurons that it will ever have. The brain continues to grow for a few years after a person is born and by the age of 2 years old, the brain is about 80% of the adult size.

You may wonder, "How does the brain continue to grow, if the brain has most of the neurons it will get when you are born?". The answer is in glial cells. Glia continues to divide and multiply. Glia carries out many important functions for normal brain function including insulating nerve cells with myelin. The neurons in the brain also make many new connections after birth.

The Brain During Development

The nervous system develops from embryonic tissue called the ectoderm. The first sign of the developing nervous system is the neural plate that can be seen at about the 16th day of development. Over the next few days, a "trench" is formed in the neural plate - this creates a neural groove. By the 21st day of development, a neural tube is formed when the edges of the neural groove meet. The rostral (front) part of the neural tubes goes on to develop into the brain and the rest of the neural tube develops into the spinal cord. Neural crest cells become the peripheral nervous system.

At the front end of the neural tube, three major brain areas are formed: the prosencephalon (forebrain), mesencepalon (midbrain) and rhombencephalon (hindbrain). By the 7th week of development, these three areas divide again. This process is called encephalization.

Average brain weights (BW)

AGE          BW - Male (grams)   BW - Female (grams)
--------     -----------------   -----------------
Newborn           380                  360
1 year            970                  940
2 years         1,120                1,040
3 years         1,270                1,090
10-12 years     1,440                1,260
19-21 years     1,450                1,310
56-60 years     1,370                1,250
81-85 years     1,310                1,170

(Data from Dekaban, A.S. and Sadowsky, D., Changes in brain weights during the span of human life: relation of brain weights to body heights and body weights, Ann. Neurology, 4:345-356, 1978)

Brain Weight

The top graph on the left shows the brain weights of males and females at different ages. The bottom graph shows the brain weight to total body weight ratio (expressed as a percentage). The adult brain makes up about 2% of the total body weight.
(Data from Dekaban, A.S. and Sadowsky, D., Changes in brain weights during the span of human life: relation of brain weights to body heights and body weights, Ann. Neurology, 4:345-356, 1978)

DID YOU KNOW? Touch is the first sense to develop. The developing fetus responds to touch of the lips and cheeks by 8 weeks and to other parts of its body at 14 week. The sense of taste may develop by 12 weeks and that of sound at 22-24 weeks. (Reference: Hepper, P., "Unraveling our beginnings", The Psychologist, 18:474-477, 2005.)

More about Brain Development

Copyright © 1996-2015, Eric H. Chudler, University of Washington

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The brain grows at an amazing rate during development. At times during brain development, 250,000 neurons are added every minute! At birth, a person's brain will have almost all the neurons that it will ever have.

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A baby's first smile is an exciting moment. But what can it tell us about their understanding of the world?

Boasting about the speed of childhood development is the sport of choice for many a doting parent.

From the 12-week scan right through the early years, monitoring the physical and mental progress of their pride and joy is a source of both excitement and concern.

Especially rewarding is the onset of smiles, squeals and laughter - the kind of milestones that make all the disturbed nights worth it.

Apparently not, as researchers now think that laughter and games like peek-a-boo could be telling us something more, and giving us a way to peer inside the workings of their minds.

"Laughter and smiles start incredibly early, just like tears," says Dr Caspar Addyman, a baby laughter researcher at Birkbeck College in London.

"So this leads us to think that it's a form of communication," he told the BBC.

Dr Addyman has collected nearly 700 questionnaires about baby smiles and laughter from around the world. He's still looking for more examples.

He found that babies are smiling in response to pleasant feelings much earlier than expected, which can be as young as one month old.

Soon after that, at between two to four months, social smiles develop that are used specifically to engage the parents.

He now hopes to take the research further and use laughter as a new way of tracking what it is that babies understand about the world around them.

The person who most greatly influenced our current view of childhood development was Swiss psychologist Jean Piaget.

Careful observations of children at different ages led him to identify four stages that everyone must go through to reach the cognitive abilities of an adult (see box).

In the earliest months of life, Piaget said that babies are only able to learn about the world by directly interacting with it through grasping, shaking and sucking.

With each experience, he concluded, children gradually build up a picture of how the world works - a kind of naïve physics.

But Dr Addyman thinks that studying babies' laughter can be just as effective at helping us pinpoint developments in the way their minds are expanding.

"You can't laugh at something until you get the joke, so what they laugh at really tells us about their understanding of the world," says Addyman.

As a result of having experienced so little, small children are for the most part quite content to accept the absurd as completely plausible.

Dr Addyman, who sports a crop of bright blue hair, sees this regularly with his young volunteers.

"Young babies would never laugh at my hair. But older children realise there's something wrong and that makes it funny."

The ability of children to suddenly see the funny side, Dr Addyman believes, acts to highlight much more profound developments going on deep inside their brains.

The Baby Laughter Project, which has surveyed parents from more than 20 countries, has shown that games like peek-a-boo are perfect for showing one such fundamental development - object permanence.

The term describes the understanding that an object still exists, even if you can't see it.

Very young children don't know this, which is why babies under around six months can look shocked and startled at peek-a-boo.

They think that not being able to see mum or dad's face means that they've actually disappeared, making their sudden reappearance come as quite a surprise.

However once a child understands (at around six- to eight-months old) that their parent is just hiding, then peek-a-boo becomes all about the anticipation of when they're going to come back.

Laughing as conversation

"Peek a boo is all the best things. It's mummy reappearing, but it's also about shared communication," says Dr Addyman.

"You can't help but smile and laugh when a baby starts laughing with you, which is really valuable for them developing their ability to interact with other people."

A potential link between laughter and language development suggests we've thus far underestimated babies' sense of humour.

Joking requires an element of taking turns as well as other skills needed for advanced interaction, like imitation and eye-contact.

"Children can pick up the rhythms of conversation through joking and playing games," says Dr Addyman.

In fact, smiles and laughter could be important communication tools for infants before they develop language.

Even primates seem to use laughter as a way of regulating social interaction.

"Laughter in chimps is predominantly used in play and it tends to be the youngest members of the group who have time for playing," says Dr Katie Slocombe, a primate cognition specialist at the University of York.

"It's been shown in chimps that laughter facilitates extended play, and we can't rule out that it has some sort of role in social bonding. When a chimp laughs, it seems to encourage their play partner to continue tickling or chasing them - just like a baby keeping an adult's attention for longer," she told the BBC.

So should we try harder to interpret the deeper meaning in those burbles and titters? Dr Addyman suggests a certain level of caution.

"Historically, we've certainly been guilty of projecting adult interpretations about what babies are laughing at, and it's a constant danger when doing this kind of research," he says.

"You really have to look at this scientifically and at a range of ages to really start to understand what's going on in their heads."

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A baby's first smile is an exciting moment. But what can it tell us about their understanding of the world? Boasting about the speed of childhood development is the sport of choice for many a doting parent.

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This article discusses the following subjects related to baby development, milestones, stages, communication and play:
Music and rhythm
Active play with your baby
Discovery play with your baby
Sensory play with your baby
Books and stories with your baby
Using different languages
Being together
Further information

Babies can learn a lot through play and all interaction between you both is valuable. During the first few months of life, your baby will be developing and learning to smile, look and laugh.

Although he may not be able to respond to you very early on, getting used to hearing your voice and learning to interact with you will always be stimulating. For instance, you can enjoy early 'conversations' with your baby where you talk or make a noise while you have eye contact with him and your baby may respond with a noise or movement themselves.

As your baby becomes older, he will be able to respond to you more and also start to become curious about the world around him. Baby play will become more sensory with him touching, banging and grabbing objects. He will develop emotionally too and you will see his playtime activities becoming more imaginative.

There are lots of ways to enjoy spending time with your baby and help him to develop his communication and understanding of the world. Fitting in some special quality time - switching off the television, phone and computer - and getting down to your baby's level to follow his lead and play a game, can be really enjoyable for you both.

It's important to remember that babies are also individuals - just like their parents - and what fascinates one, might not interest another. This is another aspect of their development and you will see this over time, as they start to have favourite games, books or activities at particular points in their early years.

Many things make different babies happy so it is a good idea to try out different ways of interacting with and playing with your child.

Music and rhythm

Rhymes and songs are wonderful sources of early learning and enjoyment which can encourage your baby's development. Rhymes help your baby to understand the importance of sounds, and repetition means the words are easily learnt. Older babies love action songs and rhymes with stronger beats and rhythms.

Look for new songs as he gets older but go back to the old ones too, especially if he is tired or not well. The familiarity is welcome and comforting.

Active play with your baby

From an early age, babies enjoy physical contact and movement. Discovering their hands and feet allows them to explore using their senses. They learn from physical interaction with you, watching and copying your facial expressions, and reacting to your touch and tickles.

Older babies enjoy more energetic play, such as bouncing on your lap, sitting on your shoulders and 'flying' in the air. As they become more mobile and start to roll, crawl, climb and reach, each of these activities will encourage the development of your baby's strength and agility.

Physical play also improves motor skills, keeping children fit and active.

Discovery play with your baby

Young babies are captivated by contrasting shapes and colours and will use their mouths to investigate different objects in their grasp. Enabling your baby to explore different, safe objects is key to helping their development.
A box with wooden spoons, different sized pots, cotton reels on string and bits of textured materials can be a useful and fun discovery tool for your baby.

Sensory play with your baby

Babies are fascinated by their home and the world outside. Young babies can enjoy lying outside underneath a tree, feeling the wind on their faces and watching the tree branches move. Some older babies will love to sit on the grass and feel different textures.

Exploring natural materials such as wood, sand, water and stones are all part of your baby's growing experiences of the world. This type of play stimulates their sense of touch and sound. It is here they begin to notice the different feel of things - wet, sticky, muddy - and hear how things make different sounds, the 'whoosh' noise of water, and clunk of pebbles, for instance.

In addition, when you begin to introduce solids into their diet, letting them 'play' with different types of food, allowing them to experience a variety of textures through touch and taste, can be fun and useful for them.

Books and stories with your baby

Looking at books and simple stories together is a great activity and you can begin reading to your baby as soon as you like. This can also be a signal that it is time to calm down and have a restful period, perhaps before bedtime or a daytime nap. Enjoy this opportunity to cuddle up and talk together.

Children's books are available in every shape, size and style. Some are deliberately chewable, or waterproof for taking in the bath. You may want to think about whether you'd like some books kept in good condition to be looked back at later.

Using different languages

Many families use more than one language. Consistency is important so agree with your partner and other family members who will speak in what language to help your child understand and separate the languages. It's best to talk in the early days in whichever language you are most comfortable and fluent. In this way, your child will learn a wide vocabulary and how to use language easily.

Later on it will be easier for him to learn another language because he has had the early experience of your fluent speech. Bilingual children in general benefit from their knowledge of two or more languages and learn others more easily.

Being together

It isn't always easy to find the time or energy to play with your baby - you may be trying to balance work and family life, and have domestic chores to get done. It can help to remember that one of the most important ways babies learn is simply by watching and listening to the people they love.

Parents can sometimes worry that they should be playing or communicating with their baby in certain ways to encourage their development. But if you focus on enjoying your time with your baby, and doing the things that you both like to do, his development should progress normally with no problems.

Further information

Our support line offers practical and emotional support with feeding your baby and general enquiries for parents, members and volunteers: 0300 330 0700.

You might find attending one of NCT's Early Days groups helpful as they give you the opportunity to explore different approaches to important parenting issues with a qualified group leader and other new parents in your area.

Make friends with other parents-to-be and new parents in your local area by seeing what NCT activities are happening nearby.

Words for Life, a dedicated website from the National Literacy Trust, provides clear information about early communication skills and is a great resource for ideas on bringing these skills into your baby's everyday life.

NHS Choices provides a guide to Learning and Playing with your child in its early years.

Playday organises the National day for play and has information on events nation wide.

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Your baby's development: communication and play | Baby & toddler articles & support | NCT

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Playtime has a significant role in your baby's development. Here we discuss baby play and communication and tips for interacting together.

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Your baby will reach milestones at a rate that's unique to them. They'll get to each development stage when they are ready so try not to compare them with others.

It's fascinating to see your baby grow and develop before your eyes. You will have plenty of exciting baby's firsts to look forward to in the coming months. The following are the baby development stages you can expect.

Grasping and grabbing

Your baby can grasp an object like your finger from the moment they are born. At birth it's a reflex and by the time they're around three months old, it's a skill they're keen to develop.

You'll notice your little one's increased hand-eye coordination, as they discover their hands are part of their body and start to gain control over them (Murray, 2014).

As your baby develops their arm and hand muscles they will start to reach for objects (Public Health Agency, 2018). It's a good idea to make sure hot drinks are out of their reach. Your little one will begin to reach accurately and quickly, not only with both hands but with their entire body.

By four months, your baby will probably have finally mastered this game and be able to get his thumb to his mouth and keep it there (Murray, 2014). Many people say this movement is one of the most important ways for your baby to self-sooth and calm down. So try not to cover your baby's hands or prevent them from sucking their thumb if they want to.

Kick, wriggle and roll

If your baby enjoys kicking, wriggling and rolling, let them have enough space to move around. Make sure they aren't constricted by clothing that's too big or too small.

At first your little one's movements may appear jerky and meaningless. If you observe your baby closely, you'll see they are communicating through limb movements and facial expressions (Kelly, 2014).

Babies sometimes prefer to feel contained, recreating the feeling of being in the womb. Some babies might fling out their arms or try to push themselves up to the sides of their cot or Moses basket. This is a short phase. To create that security, you could tuck your baby in, or carry them in a sling.

Rolling over is usually the next stage of baby movement. So be careful about putting your baby on a bed or a high surface in case they start demonstrating their new skill.

Tummy time

Giving your baby supervised tummy time will help them to strengthen their back, arm and neck muscles (Pin et al, 2007; Hewitt et al, 2017; NHS Choices, 2017a; Wittmeier and Mulder, 2017). It also encourages them to roll over and get a different view of the world.

You can practice 'tummy time' with your little one once or several times a day (Pin et al, 2007; Hewitt et al, 2017; NHS Choices, 2017a). It's best to do it when your baby is awake and alert.

Some babies don't like being put on their tummies. This is perfectly normal and may change as your baby develops week by week (Pin et al, 2007; Hewitt et al, 2017; NHS Choices, 2017a). Read more in our article about tips for tummy time.

Sitting, crawling and bottom shuffling

Babies learn to sit, first supported and then unsupported (Public Health Agency, 2018). Your little one might enjoy holding your hands and attempting to pull up to a sit.

Some babies find it difficult moving from sitting to crawling and they can hurt themselves. Your baby might get stuck, so it's a good idea for someone to be close by and keep an eye on them.

When your little one decides to crawl for the first time, it's likely to be towards something or someone that interests them. You can encourage them by putting a favourite toy just out of their reach, or by calling them from a few paces away.

Try to place your baby on a soft blanket or carpet and be prepared for them to wobble a little. As they may still be too young to support their own body weight on their arms.

Some babies crawl sideways, backwards, or even with one knee up. Others will shuffle around on their bottom instead of crawling, this is normal for some babies.

If your little one is a bottom-shuffler they may propel themselves using one hand and one leg or both hands and legs. They might even bounce themselves along.

Standing and cruising

Some babies will crawl for months before walking, others may move on quickly (Public Health Agency, 2018). You can encourage your little one to walk by supporting their underarms with your hands and bouncing them up and down. You might notice them stiffen then relax their legs, stand on their tip toes and sometimes resist being put down.

At this age your baby might stand up and not know how to get back down, so they may call out for help. You can teach them to lower themselves onto their bottom by pushing them down gently.

Once your little one has learned how to stand, it won't be long until they are cruising. This is when your baby starts grabbing onto furniture to pull themselves up and for support as they shuffle along a few steps (NHS Choices, 2017b). So always keep hot drinks out of reach.

Cruising is one of your baby's last steps to walking completely independently. Remember some slips and falls are inevitable and all part of learning.

In the beginning, your baby might walk with their feet at a slight angle; this can happen while the muscles in their legs get stronger (NHS Choices, 2017b). If this continues, seek advice from your GP.

It's a good idea to do another baby safety check around your house. You might need to move small items up another level out of your baby's reach or put them away. Make sure that any dangerous items like cleaning products are out of your baby's reach.

Walking

Some babies will spend plenty of time cruising as they gain confidence, while others quickly move on to walking. Learning to walk is a huge baby milestone.

Seeing your little one take their first steps on their own is an incredible feeling and they will be delighted too. Before you know it they will be running, jumping and skipping, and you will be chasing after them.

Baby milestones

Babies will choose when they feel comfortable rolling over, sitting, crawling, standing or walking.

If your little one is learning a new skill, it's better to leave them to master that stage of development rather than push them onto the next milestone (Plooij and van de Rijt, 2013).

Sometimes your baby may seem to lose a skill due to concentrating on gaining a new ability. Once they have mastered the new skill, you will see that the old ones are still present (WHO, 2006).

Similarly, if your little one is ill, they might temporarily regress with their movement. As soon as they're feeling well again, they'll have the energy to pick up where they left off (WHO, 2006).

There's no rush, most babies will do things when they're ready. You can help by making sure they can move around and practice their new abilities freely, easily and safely.
This page was last reviewed in October 2017.
Further information

Our support line offers practical and emotional support with feeding your baby and general enquiries for parents, members and volunteers: 0300 330 0700.

We also offer antenatal courses which are a great way to find out more about birth, labour and life with a new baby.

Make friends with other parents-to-be and new parents in your local area for support and friendship by seeing what NCT activities are happening nearby.

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Your baby's development: physical stages | Baby & toddler articles & support | NCT

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While babies develop at different rates here are the milestones you might expect. Get ready for rolling, crawling, cruising and more.

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Babies are born learning. Very young children are learning through play, the active exploration of their environment, and, most importantly, through interactions with the significant adults in their lives.

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Babies are born learning. Very young children are learning through play, the active exploration of their environment, and, most importantly, through interactions with the significant adults in their lives.

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By three months, your baby will have reached some exciting milestones. She will be making cooing noises, smiling, and even copying how your facial expressions sometimes.

Milestones

Babies like to look at faces and hear voices, so try to look at your baby when you speak to her. She will try to copy your sounds and expressions. When she does this, make the noise or expression back. This is how babies learn to communicate.

At this age, see if:

Your baby looks at you when you speak.

Your baby looks at your face when you speak.

Your baby coos or gurgles to themselves.

Your baby smiles or has different cries for how she feels.

By six months, your baby will be growing more curious about the world around them. They will try to copy you with babbles, facial expressions and movements. It's good to listen and respond to them at this age as they learn to communicate.

Milestones

By six months your baby will love spending time with you and hearing your voice. Being face-to-face with your baby helps them learn about expressions. This is also a great age to play games like peek-a-boo or sing songs to your baby.

At this age, see if:

Your baby laughs when they play.

Your baby makes sounds when somebody speaks to them.

Your baby makes different noises to show different feelings, like when they are happy, excited, hungry or tired.

Your baby smiles when someone smiles at them.

Concerns?

All babies are different, and your baby will develop in his own way. If you are worried about how your baby is getting on, speak to your Health Visitor or Children's Centre. They may suggest a hearing test or a visit to your GP.

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By three months, your baby will have reached some exciting milestones. She will be making cooing noises, smiling, and even copying how your facial expressions sometimes. Milestones Babies like to look at faces and hear voices, so try to look at your baby when you speak to her.

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Ideas to help your child play and learn

You can give your child lots of different opportunities to play, and it doesn't need to be difficult or expensive.

look at books and sing songs and nursery rhymes with your child. It's fun and will help them develop language and communication skills

use things that you've already got around the house. Try some of the ideas below

get involved yourself. Your child will learn more from you than they will from any toy

Play ideas at any age

Playing with water

Babies, toddlers and young children love playing with water - in the bath, paddling pool or just using the sink or a plastic bowl.

Use plastic bottles for pouring and squirting each other, plastic tubing, a sponge, a colander, straws, a funnel, spoons and anything else that's unbreakable.

Never leave a young child alone with water. A baby or young child can drown in just 5 centimetres (2 inches) of water.

Reading to your baby

You can start looking at books with your baby from an early age - it will help them with their future learning. The time spent sharing books with your baby also allows you to bond with them and is good for emotional wellbeing.

Even before babies learn to speak, they will enjoy hearing you read to them. Listening to you will give them a feel for the sounds, rhythms and rhymes of language. Even small babies like looking at picture books.

Local libraries usually have a good range of children's books. Some run story sessions for young children. Even if it's for just 10 minutes a day, looking at books with your child will help them build important skills and encourage their interest in reading.

Booktrust offers free Bookstart book packs to every child at 2 key ages before they start school. The aim is to help families enjoy reading together every day and get your child off to a flying start.

You will get a Bookstart Baby pack in your baby's first year, usually from your health visitor or other health professional. Your child will also get a Bookstart Treasure pack when they are 3 or 4 years old from their nursery, playgroup or other early years setting.

Visit the Bookstart website to enjoy interactive storybooks and games, and to find out about events at your local library. You'll also find plenty of other book recommendations.

You could also visit Words for Life for reading tips and ideas.

Play ideas from 4 months

Rattles

Wash out a plastic screw-top bottle and put dried lentils or beans inside. Shake it around in front of your child and they will learn how to make a noise with it.

Be sure to secure the lid so that it won't come off as some dried beans are poisonous and young children can choke on small objects.

Play ideas from 18 months

Pretend cooking

Use a bowl and spoons to measure small quantities of "real" ingredients (flour, lentils, rice, sugar, custard powder). You and your child can mix them up with water in bowls or egg cups.

Drawing and painting

Use crayons, felt tips or powder paint. You can make powder paint thicker by adding washing-up liquid and water.

Firstly, show your child how to hold the crayon or paintbrush. If you don't have paper, you can use the insides of cereal boxes or old envelopes that have been cut open.

Sock puppets

Use socks and envelopes to make hand puppets. Draw faces on them or stick things on to make your own characters. Get the puppets to "talk" to each other, or to you and your child.

Walking

Encourage your child to walk with you (you may want to use reins for safety) as soon as they are able to. It might slow you down, but it's a great way for both of you to get some exercise.

Play ideas from 24 months

Dressing up

Collect old hats, bags, gloves, scarves, nighties, lengths of material, tea towels and curtains. Ask friends and relatives or try jumble sales.

Make sure there are no loose cords, strings or ribbons that could wrap around your child's neck or trip them (or you) up.

Paper plates or cut-up cereal packets make good masks. Cut slits for the eyes and attach them to your face with string or elastic.

TV

It's best to limit your child's daily TV time to no more than half an hour for under-2s and an hour for 3- to 5-year-olds.

TV can entertain your child and give you a bit of time to do other things. Try not to have it on all the time, though. Always know what your child is watching. When possible, watch with your child, so that you can talk together about what you're watching.

Play ideas from 30 months

Junk modelling

Collect cardboard boxes, cartons, yoghurt pots, milk bottle tops and anything else you can think of. Buy some children's glue (the type that comes with a brush is easiest to use) and help them to make whatever they like.

Toy safety

When buying toys, look for the British Standard kitemark, lion mark or CE mark, which show that the toy meets safety standards.

Visit the Which? website to see the different safety symbols.

Take care when buying secondhand toys or toys from market stalls, as they may not meet safety standards and could be dangerous.

Toys usually have age warnings on them. If a toy is marked as "Not suitable for children under 36 months", don't give it to a baby or toddler under 3. Check toys for sharp edges or small parts that your child could swallow.

Button battery warning

Some electrical toys contain small, round batteries called button batteries. As well as being a choking hazard, these can cause severe internal burns if swallowed or lodged in your child's ear or nose.

Keep button batteries well away from your child and make sure that battery compartments on toys are properly secured with a screw.

If you think your child has swallowed a button battery, take them to A&E straight away or call 999.

Toys for children with special needs

Toys for children with special needs should match their developmental age and ability.

If your child is using a toy intended for a younger age group, make sure that it's strong enough and won't get broken.

Children with a visual impairment will need toys with different textures to explore with their hands and mouth.

Children with impaired hearing will need toys to stimulate language, such as puzzles that involve matching "finger-spelled" letters to appropriate pictures.

The Living made easy website has lots of play and leisure ideas and equipment for disabled children.

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You can give your child lots of different opportunities to play, and it doesn't need to be difficult or expensive. look at books and sing songs and nursery rhymes with your child. It's fun and will help them develop language and communication skills use things that you've already got around the house.

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WRITTEN BY CLAIRE BURGESS, FAMILY CONSULTANT

There have been thousands of babies born during 2020, a year when we have seen lockdowns and more social isolation than we have ever experienced before! This has brought about a great deal of concern for parents, often questioning if this isolation from friends, family, activity groups and classes will have an impact on their baby's development.
What is normal?
Our babies need to have primary care givers, these are one or two people who meet their every need from love, care and attention to food and shelter etc. Babies don't have to have lots of people around them, as the bond that is built with those very key people (typically their parents) is what makes them feel safe, secure and at ease. When our babies feel these things is when they are able to learn and develop to their full potential!

We often think is it vital that our baby sees and is held by different people from an early age so that they are not shy or reluctant to go to others, and so that they don't become over-reliant on their parents. Yes, our babies are social beings, as are we, but it is more about quality rather than quantity! The quality interactions that our babies have from those primary caregivers will help them to grow and develop into their own little personalities. Social interactions are valuable, but don't forget those interactions that your baby might be having when you go out for a walk or to the park, or even to the shops. On these outings they will see adults and other children which will start to build their understanding that there are other people in this world, not just their parents, and this can be enough.

In the first 2 years, our babies are in a stage of their development where they engage with solitary play, this means that they are focussed on the toys or activity that they are doing and do not have interest in what others are doing. If they are at nursery, or if you were attending a group or class, then they might have other babies or children around them, but this is not a requirement in order for them to be able to learn and develop.

What if they won't go to other people (family and friends) after all of this?
It is going to take your baby some time to adjust as it does for anyone when there is a change. The important part is how you approach it; if you feel confident and comfortable, then your baby will too.

Babies and children go through different stages of separation anxiety (see our blog for more on this https://www.bespokefamily.co.uk/blog/dontleaveme) and this is a completely normal and natural part of development. If you are with them your baby won't be experiencing separation anxiety as such, but the principles of socialising and introducing your baby to new people, or being held by people other than you, are the same as when your baby is going through separation anxiety (even though you are right there).

Don't just expect your baby to go to other people, remember that our babies have heightened senses to things such as sound, touch and smell. Someone who looks, sounds and smells different is going to take some getting used to. Let your baby sit on your lap (remember, you provide them with the security and comfort they need) and then let them adjust to the new person in front of them.
You may need to explain to the other adult that your baby is taking some time to adjust to seeing people and being held by them, so you are just giving them time to observe before handing them over for a cuddle. It will all work out much better if your baby has the time to adjust rather than handing them over straight away - they get upset and then come back to you - which will just make it an upsetting experience for you, your baby and the person who was hoping to have a cuddle.

Gently does it, is the way to go. It might mean that your baby sits with you for the first few meetings with new people - it might not be that after 10 minutes they are ready, and that is fine. Trust your instincts and you will know if your baby is feeling happy and comfortable to go to someone else.

Don't just leave them - when the time comes and you can leave your baby with others, make sure that it is done gradually. We can be tempted to just drop them off and leave them (and some people may suggest this) but this is going to be hard on your baby and on you. Your baby needs to be able to trust you and the person that they are getting to know, so having time with you both together, in an environment that they know etc will all help. Going 'cold turkey' is likely to cause your baby to be more apprehensive of going to others if they think you will just get up and leave.

Not being able to see people can be difficult, but having photos of family and friends which you look at with your baby can certainly help. Babies are very good at recognising faces, they are drawn to them, so having some photos in an album which you sit and go through with them - talk about the people, say their names, share funny stories or memories (yes, even with our smallest of babies this will help) and when they are a little bigger it can be in their book box so that they can take a look when they want to.

Technology is not something that we want to over-expose our babies to, but in the current circumstances this does provide a wonderful link to friends and family. Talking to a baby via video call can be tricky as they get distracted and are not always able to do respond, so perhaps suggest that family members read a story over a video call or record themselves reading a book which you can look at with your baby at the same time. This will help your baby to be able to recognise voices and faces - they might be in 2D but it all helps to create a greater understanding and familiarity for then they do see the person in 3D! Just try to avoid using screens around nap or bedtimes and try not to use a screen too much during the day particularly as your baby is still so little.

On the same theme of making good use of technology, having a shared photo stream on your phones or WhatsApp with a group of people where you can share photos and videos etc of your little one, will help you keep a connection with the family and friends in sharing your day to day with them.

Look at what online baby groups there are in your area, this can help with activity inspiration and can also help make connections with other parents. This might also mean that you are able to meet up for a walk somewhere or when groups or classes are running again there is some familiarity for both you and your baby.

Looking after you is just as important. How we are feeling can often have a significant impact on our babies as they are very attuned to their parent. Take time to look after you, do things that help you relax and feel happy and this will make a difference for you and your baby.

We can't change the situation and it will be ok
It is such a strange situation that we are in and we have to prioritise staying safe and well. At the moment I can't say for certain that this won't have any lasting negative effects on our children (or us!) as we simply don't know, but what we do know, from years and years of research, is that our babies need to have a safe, loving and secure family unit with 1 or 2 main carers who meet their needs in order to thrive. Our current situation has not taken this away - if anything it has only increased the opportunity for this bonding to take place.

If you are able to provide an environment at home which is stimulating and engaging, offering a variety of activities (there are SO many ideas for newborns through to older children on social media platforms where you can gain lots of inspiration) opportunities for getting out into the fresh air and time with you, your baby will be having all of their developmental needs met.

It is also important to remember that we are making relationships throughout our lives, they don't only happen when we are young. We are emotional beings and our brains are always adapting to the situation that we are in at the time. Your baby right now is learning what a loving and caring relationship feels like from you, they will take this learning forward and will use it to form their own relationships with family and friends.

Try to see this time now as you teaching them how to love, care and build relationships, which I would say is a pretty amazing thing to be doing! They will build and make relationships, they just might need some extra support, guidance and time.
While you are here, you might be interested in checking out our video guides which cover lots of different topics including welcoming and caring for newborns, breast-feeding, behaviour, sleep, toilet training and more! For more information - click here

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I'm worried my baby is missing out due to lockdown! - Bespoke Family

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There have been thousands of babies born during 2020, a year when we have seen lockdowns and more social isolation than we have ever experienced before! This has brought about a great deal of concern for parents, often questioning if this isolation from friends, family, activity groups and classes w

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An interactive timeline full of information on how and why your baby is growing

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From Babycentre.co.uk

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To give you the best experience, BabyCentre's website and emails use cookies and similar tracking systems to personalise the content and ads we provide to you. We use your health information to make our site even more helpful. By clicking the button, you agree to our policies and to get emails from us.

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To give you the best experience, BabyCentre's website and emails use cookies and similar tracking systems to personalise the content and ads we provide to you. We use your health information to make our site even more helpful. By clicking the button, you agree to our policies and to get emails from us.

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From thewonderweeks.com

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The Ten Leaps - What are the 10 Mental Leaps? - The Wonder Weeks

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All babies go though the same changes in the mental development at the same time. This is called a mental leap. In al 10 leaps your baby learn new things.

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A guide to milestones (use with caution - all babies are different!)

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Help us help you get the treatment you need

Because of coronavirus (COVID-19), it can be hard to know what to do if you're unwell. It's important to get medical help if you think you need it.

For help from a GP - use your GP surgery's website, use an online service or app, or call the surgery.

For urgent medical help - use the NHS 111 online service, or call 111 if you're unable to get help online.

For life-threatening emergencies - call 999 for an ambulance.

If you're advised to go to hospital, it's important to go.

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Help us help you get the treatment you need Because of coronavirus (COVID-19), it can be hard to know what to do if you're unwell. It's important to get medical help if you think you need it. For help from a GP - use your GP surgery's website, use an online service or app, or call the surgery.

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Video showing how much and how fast a baby changes over the first year.

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Information from the British Liver Trust

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ICP: Symptoms and Diagnosis

Symptoms

Itching is often the only symptom of ICP. The itching typically begins on the arms, legs, hands and soles of the feet. It may also occur on other parts of the body such as the face, back and breasts. It is usually worse at night, leading to sleeplessness and exhaustion.

Some women scratch themselves so frantically that they make themselves bleed. A few lose their appetite and feel generally unwell. A number of women (thought to be around one in ten) will develop jaundice in pregnancy. However, most women with ICP do not have jaundice.

Itching is not uncommon in normal pregnancy. However, some women may not be aware that they have ICP because they are told that itching is normal in pregnancy. This can be misleading.

Diagnosis

Your doctor should ask about your medical and family history to aid diagnosis. If close female family members have been affected by ICP then you may be at increased risk.

It is also important to exclude all other possible causes of your itching, such as allergies or eczema (but it is possible to have a skin condition and ICP). Other signs such as pale stools or dark urine may indicate a problem with your liver, including ICP.

Liver blood tests

Your doctor can diagnose ICP from blood tests called liver blood tests and a serum bile salt test. Liver blood tests are performed to gain an idea of how your liver is functioning. A number of separate properties of your blood will be examined. Your doctor should use pregnancy-specific reference ranges to interpret your blood test results.

In OC/ICP, doctors will be looking for abnormal levels of the liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Sometimes levels of another enzyme, gamma-glutamyl transferase (GGT), will also be raised. The most specific test involves measuring serum bile salts. In most UK hospitals raised levels would be a measurement of greater than 14µmol/L. However some hospitals may ask you to fast before the test. In this case a fasting level of greater than 10µmol/L would support the diagnosis of OC/ICP.

In most women with ICP, both ALT and bile salt levels will be raised, but just one may be raised at the first test. If the tests are within normal limits and you carry on itching, it is important that the tests are repeated. Unfortunately the serum bile salt test is not available in all hospitals. Your doctor may need to send a sample to another hospital for diagnosis

Hepatitis C and ICP

Women with hepatitis C are at increased risk of developing ICP during pregnancy. A small number of women with ICP may therefore have undiagnosed hepatitis C. If your test results do show that you have viral hepatitis, or another liver condition, you will then be able to be referred to a specialist in liver disease (hepatologist) and receive treatment.

ICP is only completely confirmed when symptoms disappear and liver tests go back to normal after delivery.

Pregnancy and itching
It is important that if you are pregnant and itching, you should check with your doctor or midwife. A simple blood test (see below) is required to diagnose ICP . It may be helpful to take a copy of the leaflet below with you.

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Intrahepatic Cholestasis of Pregnancy (ICP) - British Liver Trust

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Itching is often the only symptom of ICP. The itching typically begins on the arms, legs, hands and soles of the feet. It may also occur on other parts of the body such as the face, back and breasts. It is usually worse at night, leading to sleeplessness and exhaustion.

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Risk of unexplained stillbirth graph (2)

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Amniotic Fluid - what if the volume is to high or too low?

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Amniotic Fluid - what if the volume is to high or too low?

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This post is in response to readers asking me to cover the topic of induction for low amniotic fluid volume (AFV). Most of the content is available in textbooks and I have provided references/links for research where I have stepped outside textbook sources. I use the word 'may' quite a bit in this post because little is known about AFV, therefore a lot of the available information is theoretical. In fact, this post probably raises more questions than answers! Also note that I am focussing on AFV at term.

Amniotic Fluid Volume Regulation

Amniotic fluid is in a constant state of circulation. In the second half of pregnancy, the primary sources of fluid production are from the baby:

urine (700mls per day)

lung secretions (350ml/day)

And the main sources of fluid clearance are:

the baby swallowing fluid and passing it back into mother's blood stream

direct flow across the amnion (placental membrane) into placental blood vessels

The balancing act required to maintain a healthy AFV may be influenced by hormones (prolactin and prostaglandins), osmotic and hydrostatic forces, and the baby. Maternal hydration is also associated with AFV ( Patrielli et al. 2012). From day to day there is little change in AFV, however volume decreases towards term. This is normal. As the baby's kidneys mature, urine becomes more concentrated. Therefore, lower volumes of urine are excreted into the amniotic sac.

The amniotic sac and fluid play an important role during pregnancy and birth and you can read more about that in this post.

Abnormalities in AFV occur when there is an imbalance between fluid production and clearance. Too much fluid is called 'polyhydramnios' and too little fluid is called 'oligohydramnios'. However, measurement and thresholds of normal/abnormal are not clear.

Accurate Measurement?

Here is the first problem... there is no accurate method for measuring AFV. There are two types of ultrasound tests aimed at assessing AFV:

Amniotic Fluid Index (AFI): four 'pockets' of fluid are measured by ultrasound and added up.

Maximum Vertical Pool (MVP): The 'single deepest vertical pocket' of fluid is identified and measured.

Both tests measure amniotic fluid in cms amniotic fluid with 'normal' values considered to be 5cm to 25cm. Studies comparing the two methods conclude that the 'maximum pool' measurement is the 'better choice' ( Coombe-Patterson et al. 2017; Nebhan & Abdelmoula 2008; Magann et al. 2011). The reasoning for this is because AFI increases the detection of oligohydramnios, resulting in increased rates of induction without improving outcomes for babies.

Measurement of AFV by AFI or 'maximum pool' is part of the Biophysical Profile assessment, which aims to identify babies with inadequate oxygenation via the placenta. However, it is unclear whether there is any benefit to this test. Indeed, an umbilical artery Doppler test may provide a better assessment of placental function, and therefore how well oxygenated the baby is ( Alfirevic, Stampalija & Gyte 2017).

There is of course the old fashioned method of assessment, also not well researched. Abdominal palpation is usually carried out during antenatal visits. In addition to working out what position the baby is in, a midwife assesses the amniotic fluid volume. When you have palpated lots of pregnant bellies, 'real' polyhydramnios and oligohydramnios are usually pretty obvious. Mothers are also experts regarding their own body/baby and notice differences themselves - particularly if they have been pregnant before and can compare pregnancies. What you may find:

Oligohydramnios: baby is very easy to feel - in some cases you can see limbs; the uterus is smaller than expected; the mother may notice reduced movements.

Polyhydramnios: baby is difficult to palpate and floats away as you apply pressure; the uterus is bigger than expected; the baby's heart rate may sound muffled; the mother may notice breathlessness, vulval varicosities, oedema and gastric problems.

When you are working as a midwife in a continuity of care situation you get familiar with the individual woman's bump over time, and it is easier to notice changes. Measuring (with a tape measure) is often used to assess uterine growth, particularly when care is spread between a number of practitioners. Whilst measuring can assist with identifying polyhydramnios, it is unreliable in identifying oligohydramnios ( Freire et al. 2013).

Here is the second problem... there is currently no agreement about what constitutes 'high' or 'low' levels of AFV. Megann et al. (2011) conclude that: 'high and low levels [of amniotic fluid] have yet to be established in the literature and are difficult to directly link to adverse pregnancy outcomes.' So, we are busy finding measurements that we don't really understand the implications of.

Most of the time there is no known cause for the 'high' or 'low' volume of fluid, and there are no complications caused by it. However, there are some factors worth considering if you are labelled with oligohydramnios or polyhydramnios.

Oligoydramnios - too little

The definition of oligohydramnios is usually less than 500mls of fluid; <2cm maximum pool; or AFI <5. Around 3-5% of pregnant women are diagnosed as having too little fluid. Because of the complexities of measurement and the diagnosis of oligohydramnios, I have differentiated between the two types:

Uncomplicated oligohydramnios

This is mild oligohydramnios and occurs in an uncomplicated pregnancy. This is often associated with post-dates pregnancy and is caused by two factors:

1. The normal physiological changes that occur to AFV as term approaches (see chart above) and/or the 'normal' level for the individual mother/baby are comparatively low to the general 'norm'.

2. Routine scans for post-dates pregnancy which then identify this normal AFV as 'low'.

There is a lack of evidence to support induction for oligohydramnios in uncomplicated pregnancies ie. when there is nothing else 'abnormal' going on with mother or baby ( Quiñones et al 2012). Driggers et al. 2004).

A review of the literature ( Rossi & Prefumo 2013) found that in term or post-term pregnancies, oligohydramnios (with an otherwise healthy pregnancy/baby) was not associated with poor outcomes. However, it was associated with increased risk of obstetric interventions. Probably because the diagnosis often leads to interventions such as induction.

Complicated oligohydramnios

Complicated oligohydramnios is generally a consequence of reduced urine output (baby) caused by reduced oxygenation. If the placenta is not providing adequate oxygenation, the baby attempts to compensate by redirecting blood flow away from the kidneys to the heart and brain. Therefore the oligohydramnios is a symptom of pregnancy complication such as pre-eclampsia or fetal growth restriction. It can also be caused by underlying congenital abnormalities of the baby. These babies often have very low AFV (easily identified by palpation), and are at significant risk. Further assessment and intervention should be offered.

Induction of labour is the usual recommendation for complicated oligohydramnios. However, induction needs to be considered carefully when the baby is already compromised by reduced oxygenation and limited glycogen stores. The induction procedure itself is associated with reducing placental circulation and causing hypoxia and fetal distress. Therefore, it is very likely that the baby will become distressed during labour before birth occurs. So, the mother must be prepared for, and informed of the likelihood of c-section. The other alternatives are awaiting spontaneous labour or a planned c-section. Whilst spontaneous labour is more gentle on the baby than an induction, waiting for labour with a baby who is not being well supported by their placenta requires serious consideration (and nerve) because time will not improve the situation, only worsen it. Even spontaneous labour is likely to result in fetal distress once contractions start because these babies are already struggling. Complicated oligohydraminios is a serious complication. I know a few women who have opted for a planned c-section rather than put their compromised baby through induced contractions.

Polyhydramnios - too much

The definition of polyhydramnios is usually around 2000mls of fluid; >8cm maximum pool; or AFI >25cm. Around 1-3% of pregnant women are diagnosed with having too much amniotic fluid. In 60% of cases there is no known cause, but factors that increase fluid volume include:

The baby producing too much urine

Decreased fetal swallowing (baby)

Increased water transfer across the placenta by the mother

These factors may be influenced by the general well being of mother and baby ie. may occur if there are complications present such as diabetes, rhesus isoimmunisation, congential abnormalities, infection, etc. But, usually no complication is present.

Complications associated with polyhydramnios

Most cases of polyhdramnios are mild and do not result in any complications. However, severe polyhydramnio can result in:

Preterm birth - as the uterus become over stretched with fluid.

'Unstable' position of the baby - the baby can float about into helpful and not so helpful positions.

Cord presentation or prolapse - because the baby is floating about the cord can get between his head and the cervix.

Placental abruption - may occur with a sudden change in fluid volume and therefore size of uterus/placental site.

Management of polyhydramnios?

Tests may be suggested to see if a cause can be identified (although nothing can be done at this point). Mild polyhydramnios is best left alone because it is unlikely to result in any complications. When polydyramnios is severe, induction of labour with a 'controlled' artificial rupture of membranes may be suggested to manage the risk of an unstable lie and/or cord prolapse. This involves breaking the waters whilst holding the baby in place, and with quick access to theatre as the procedure can result in a cord prolapse. Alternatively, the woman may choose to wait until labour begins, and assess her baby's position once contractions have started. Either way, the risk is the woman's therefore she must be the person to decide which risks are best for her - induction or waiting.

In Summary

The exact mechanisms involved in regulating AFV are still unknown.

AFV reduces significantly after 37 weeks - this is normal.

There are no accurate methods of measuring amniotic fluid.

There is no agreement about what measurements indicate 'high' or 'low' AFV.

The intervention used to manage polyhydramnios or oligohydramnios ie. induction also carries risks that need to be taken into consideration.

Further Resources

If you enjoyed this post, you can find more of my work in the following resources:

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Amniotic Fluid Volume: too much, too little, or who knows?

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Updated: May 2023 This post is in response to readers asking me to cover the topic of induction for low amniotic fluid volume (AFV). Most of the content is available in textbooks and I have provided references/links for research where I have stepped outside textbook sources.