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Introduction

A Transition from the Comfort of the Womb to the Reality of the World

Like parents everywhere, David and Tammy DiGregorio were under the illusion that they were ready for the arrival of their firstborn child. They knew she was a girl and that they would name her Ava. The West Hollywood parents had carefully gathered an extensive array of newborn equipment, read the recommended books, taken Lamaze classes, practiced panting and breathing for her birth, and attended newborn classes offered by their hospital. And sure enough, the birth, delivery, and hospital stay went off without a hitch.

Then they brought Ava home, and all anxiety broke loose. “I was terrified,” says Tammy. “I was handed this little baby, and it was a complete shock. I was so tired and so scared; I felt like I was in a whole other world,” she continues. “And I was terrified of making a mistake.” As for baby Ava, well . . . “She was like a strange little alien.”¹

Such is the coming-home of many, alas most, newborns who are long awaited and eagerly welcomed. Before women even have time to complete a full sigh of relief signaling the end to forty weeks of awkward discomfort, they find themselves facing even greater challenges. Only now, with actual infants in their arms, they have far less control. Ava, like any newborn, was barely equipped to stay alive. Tammy and David were suddenly face to face with the most neurologically immature of all the earth's primates, born months before she was anywhere near ready to function in the world.

Parents around the world who welcome mysterious new life in this way encounter a significant void in up-to-date scientific information about the first days and weeks of infancy. With fingers crossed, they confront their uncertainty and fears.

This book presents a new paradigm of a baby's early life that shifts our focus and alters our priorities. It shows that this window of time, specifically the first three months of life, has more in common with what came before than with what follows. The fourth trimester is an outside-the-uterus period of intense development that is an extension of the work begun during the first nine months. A newborn human is not so much a baby as a final-phase fetus living through a time of transition as he gives up the comforts of the uterus and gradually adjusts to the wonders and challenges of the world. Further, during this period infants and mothers need to stay almost as tightly bound together as biology dictated during the first three trimesters. In this book, I use the model of a fourth trimester to show how parents, caregivers, doctors, and students might understand this period by looking at it through a new lens.

Throughout, I talk about the essential bond between a loving, committed, and attentive adult and a baby. Sometimes that attachment is biologically unique to birth mother and baby. Born recognizing her voice and her smell and, for most of human evolution, dependent on her milk, an infant bonds most quickly with his mother.

But in our complex and ever-changing society, it's important to think broadly and not give short shrift to any woman or man who “mothers” an infant. An adoptive parent—mother, father, married, single, gay, or straight—can read references to “mother” and “father” in these pages and know it speaks to them just as it does to biological parents. Be assured, this is not simply lip service. Though biology counts for a lot in favoring birth mothers, the book's importance to fathers and nonbiological parents represents more than an artifact of the past few decades of a changing culture. The bond between parents and non-biological offspring represents an evolutionary moral and medical breakthrough on parenting that no doubt is being, and will increasingly be, studied over generations.

Within this book, the advice and much of the science can apply to all who give birth to or adopt babies, as well as to those who watch over, nourish, nurture, and protect an infant in the first hours and days of life. Under that wide umbrella, I mean to give respectful due to all kinds of parents—birth mothers and fathers, adoptive parents, same-sex partners, single parents, grandmothers, grandfathers, and all manner of kith and kin. Any one person or pair or team of people responsible for the nurturance, care, and protection of a newborn is fully able to provide, and can be equally expert in providing, the love, diligence, and attention that every baby needs.

Infants are nothing if not flexible, ready to respond to love. Here's an analogy. I had a cat once, a calico, that loved me best. She curled up on my lap. She slept in my bed. She was as cozy with me as a cat can be. But once, she disappeared from the house for a few days. I put up posters, and soon a man was at my door holding my Irma. What surprised me was how quickly she had switched allegiance. She was curled up in this stranger's arms as though he were the love of her life. I almost hated to separate them as he handed her back to me.

This is not just the sentimental musing of a pet lover. Certainly, newborns are a lot more complicated, but in some ways they're a bit like my fickle cat. An infant will love the one she's with. And long before she can show love, she will respond to the one she's with. He can be fed with a tender touch, with locked-in eye contact from a birth father or mother. She can have her diaper changed to the accompaniment of chipper conversation by an adoptive parent and, in the blink of an eye, will recognize his voice above all others even though she didn't hear it in the womb. He can listen as a same-sex couple sings a lullaby duet. The mother who supplied the egg responsible for half his genetic makeup—but whose uterus did not house him—can soothe him. The father who devotes himself to the baby, regardless of whose sperm fertilized the egg all those months ago, can rock her to sleep. Newborns will thrive even as the definition of family changes to incorporate not only traditional marriages and adoptive parents but also gay marriages, single-parent families, combined families, grandparents raising second generations of children, and as many configurations as loving people can come up with to create the protective, nurturing nest that is a family.

Combining contemporary science with the personal stories of dozens of parents I interviewed—as well as a few of my own—I've attempted to write to all who nurture. Science has a lot to say to each and every one of them about the hows and whys of caring for a newborn. The word caretaker or caregiver is hardly sufficient to describe a person who changes diapers, is at the ready at all hours, sings, soothes, tries to project a calm front despite his own worry, plays, feeds, rocks, cradles, and would throw himself under a bus to protect a newborn. But loving caretaker and caregiver are convenient shorthand terms I sometimes use. Know that these are written with profound respect for all the people who love and tend to every need of a newborn throughout the fourth trimester.

The infant, amazingly competent yet totally dependent, needs all of them. The nine-month gestation prepared the fetus well, but incompletely. A newborn can hear, but cannot sort through the din. He can discern light, shadow, and contrast, but cannot “see” as we understand vision. She can feel, but the womb provided protection and warmth that she continues to need postpartum. In the uterus, taste and smell filtered through amniotic fluid, making him recognize the odor of colostrum and the taste of mother's milk. The newborn is prepared to begin learning the new world she's entered, but this period, which is closely linked to fetal life and is beginning to prepare her for real life, is one of transition during which she needs close, constant, and loving attention.

This book is primarily intended for new parents and caregivers who want more than to be told how to care for a newborn. They want to understand the reasons behind the advice. It will also be useful to anyone called upon to give guidance (doctors, nurses, teachers) and to those with a personal interest in understanding the well-being of a newborn (friends, relatives, grandparents). Each chapter of this book translates the most current science in a specific area of early infant development into a rationale for appropriate care. In a field where opinion and trendy advice are seldom connected to evidence, this book presents a clear and much-needed alternative.

Journalism skills, honed over a thirty-year career in medical reporting, helped me to arrive at this reasoned and evidence-based alternative. Journalists are adept at following all leads while pursuing a range of sources. They get an overview of an issue—not merely the pediatrician's view from the clinic, the scientist's view from the lab, the parent's view from the nursery, or the investigator's view from reading the latest research. The knowledge and wisdom of all those players inform the chapters, synthesized and interpreted for the curious new parents and caregivers eager for this information.

A report by the National Research Council and Institute of Medicine on children and brain development, published in 2000, became my starting point. The report's conclusions have rippled through every aspect of science, medicine, and education and into family homes. This report, From Neurons to Neighborhoods: The Science of Early Childhood Development, says, “Although there have been long-standing debates about how much the early years really matter in the larger scheme of lifelong development, our conclusion is unequivocal: What happens during the first months and years of life matters a lot, not because this period of development provides an indelible blueprint for adult well-being, but because it sets either a sturdy or fragile stage for what follows.”²

Readers will appreciate the distinction. Adhering to the best that science has to recommend during the fourth trimester does not present an “indelible blueprint,” since infants, babies, and children can and do overcome poor beginnings. But why start them out by giving them a lot to overcome? Rather, let's do our best to set the stage for “sturdy” development by treating the first three months of life as the biological continuation of fetal development that it is.

New research has begun to change thinking, establishing the fourth trimester as an especially vital time for laying down the very foundations of development. Yet this excellent science is not without controversy, as currently interpreted by the popular media and various advocacy groups. Two particularly inflamed hot-button issues are breast feeding versus formula feeding and cosleeping versus sleeping alone. Acknowledging a variety of opinions on these issues, the text sticks to the research while recognizing that science is a leading factor, but not the only factor, in parents’ decisions on feeding and sleeping arrangements. In this objective way, the book stands apart in providing a comprehensive survey of a newborn's developmental needs while remaining intimate, personal, and nonjudgmental. It can help new parents—biological or adoptive, as well as others who provide consistent love and attention to infants—make their own personal decisions within the parameters of best practices.

The need for loving attention is a constant theme of this book. Each chapter also draws on personal interviews with prominent researchers, practitioners, and parents. These resources are documented in the text in sufficient detail for a curious reader to pursue specific questions in the relevant literature.

The first three months of an infant's life need not be a mystery to bumble through. It's a common joke that infants don't come with an operating manual. This compilation of recent medical, biological, neurological, behavioral, developmental, and social science research from the past two decades provides the basis for just such an operating manual. New parents can comprehend much of what throughout human history has been inexplicable and, in the process, get their babies off to the best possible start.

The book begins millions of years ago with the chapter “Evolution and the Primitive Brain of a Newborn.” It is the natural starting point in helping parents and caretakers understand that the reason human infants arrive so unfinished is deeply rooted in our common evolution—beginning with the moment our hominid ancestors first stood and walked on two legs. Readers will understand why forty weeks of gestation is both a biological imperative and insufficient for greater brain development in the uterus. They will begin to see that all newborns need another three months, a fourth trimester, of uncompromisingly close connection to their mothers or an equally loving and attentive caretaker.

The remainder of the book is organized by first addressing how such an immature brain influences infants’ most basic needs: crying, sleeping, and eating. These behaviors deserve three distinct chapters since they are the source of every parent's most urgent worries. These three concerns are linked to each other just as communication is linked to need. Every newborn cry of life reminds us that this human being isn't ready to be separated from the uterus. Food, warmth, soothing movement, and comfort once flowed to her without effort. Now, she must signal hunger, discomfort, and fear with a cry, at first her only tool of communication. Now, as she makes her transition from the womb to the world, each adult response to her wailing demands is helping to complete the neurological wiring vital for living. The comforting closeness so recently experienced by the fetus continues as chemicals released by physical contact or close proximity to a mother, father, or caring adult help the newborn regulate sleep and arousal.³ Food, passively received in the womb, now requires effort.

The best nutritional transition to the real world during the fourth trimester, as evolution and biology make clear, is breast milk. A clear understanding that breast feeding is the most natural extension of pregnancy is an important starting point for every birth mother as she makes her own decision. I balance that truth with the reality that some women cannot breast-feed or don't want to. Adoptive parents, foster parents, grandparents, and all manner of attentive caretakers cannot breast-feed. For them, formula is a perfectly adequate second-best choice as they, too, help their newborn with the transition to life in the world by holding the infant closely, making eye contact, and touching him. What he has received without asking for during nine months in the uterus—food, soothing comfort, sleeping on his own timetable—must continue during the time of transition via attentive response to his cries.

Even as the basic needs for soothing, sleep, and food are met, the senses are proving to be nature's first teachers. After addressing parents’ most urgent concerns, the book's next chapters delve deeply into sensory development—sound, sight, and touch. (Taste and smell, scientifically studied in far less depth in newborns and tightly linked to feeding, are discussed in the feeding chapter.) Nothing in infant development happens in isolation, and these three senses are intimately connected to soothing, sleeping, and eating. But these senses each deserve a closer look. Babies recognize their mothers’ voices at the moment of birth because they've heard them in the uterus. Hearing these voices again during the fourth trimester is an important part of the transition, and newborns turn to their mothers’ voices more readily than to any others. (Though, in the case of adoptive parents or alternative caretakers, babies will soon recognize a consistent new voice and will turn to the voice they've come to know.) From the moment of birth, infants are busy soaking up the acoustics of their surroundings.

Vision is less developed than hearing at birth, but newborns can already see shadows of eyes, edges of faces, and areas of high contrast. Newborns see better than once thought, but the concept of “seeing” is complex, since vision consists of multiple components—focus, contrast, three-dimensionality, color—all developing at varying rates. Furthermore, the areas of the brain that interpret what's coming through the eyes are not yet set up to register what's seen in the way adults understand vision. Yet astonishingly, the very act of seeing is exactly what babies need in order to sort it all out. Each flicker of vision is setting up neural connections that will eventually let babies see the full world around them. The relatively slowly developing sense of vision carries infants forward from a place of darkness in the womb into a world of light.

The sense of touch, influenced for forty weeks by the warmth of amniotic fluid and the secure confines of the uterus, continues during this time of transition through swaddling, cuddling, and stroking. The last fifteen years have seen a sea change in understanding touch, both painful and pleasurable types. Simple, human touch—comforting pats in response to tears, smiles in response to contented moments—releases brain chemicals that calm the infant. On the other hand, trauma and stress (abuse, neglect, pain) release a flood of neurochemicals, including cortisol, that can set a child up for future trouble.

There are coexisting truths about the development of the senses: infants come into the world highly immature and yet extremely capable of learning and communicating. Each sense, at its own stage of readiness at birth, interacts with all the others to mold a brain that is forming the likes, dislikes, and very personality of a new human being.

As the senses are developing brand-new connections in the brain, the body is growing stronger. Neurological and physical developments are linked—these are similar to the mind-body connections science now recognizes in adults. Just as every interaction with the senses is building better abilities to see, hear, and feel, every kick is building muscles that will soon enable the baby to crawl, walk, and run. Biological mothers know that these early flailings begin during gestation, and many fathers have felt their force as they've laid a hand on a pregnant belly. An important chapter on physical development shows why the “exercise” begun in the womb must continue, with caretakers encouraging infants to vary their positions during awake time. Holding infants in various positions not only strengthens muscles, but it also gives infants a view of the world from more than one perspective, each view affecting the synapses being formed.

Almost universally, parents, regardless of their circumstances or limitations, want to do the best for their children. But with conflicting advice from the media, and with an array of books and toys promising smart and happy infants, parents can be confused about what course to follow. To put their minds at ease, a chapter on stimulation summarizes appropriate sensory stimulation. Loving attention to cries, along with soothing voices, comforting touches, eye contact, and closeness to the mother's body (or an equally loving caretaker's body) are the kinds of stimulation an infant needs. A view of a mother's face, a father's profile, the sound of live voices, the touch of skin or flannel or tweed, the smells of healthy foods cooking, and the taste of milk are preparing infants for the inimitable world that envelops them. For millions of years, trees, grass, voices, music, cuddling, constant proximity to mothers, and loving human interaction have provided all the stimulation infants need.

Finally, the book steps away from the newborn to delve into research on parents. Physical and psychological studies examining the postpartum months as experienced by mothers are extensive, and there are exciting new indications that, just as human interaction is sculpting infant brains, those same interactions are reshaping maternal brains. Research into fathers’ health is fledgling, but science now knows that men, too, are susceptible to postpartum depression and that welcoming a child into a family can be stressful for both parents.

The multiple lines of research upon which this book is based show that a well-equipped brain is grown from the normal, simple, and readily available seeds of playful activity and loving parents and adults. The chatter of everyday life, lullabies of love, and glimpses of blue sky through green branches surrounding a newborn are naturally programming language, art, music, math, dexterity on the playground, and lifelong social skills.

This book will help put to rest the remnants of a century of cultural misconceptions that still linger: infant independence, fixed IQ, and a substitution of quality time for quantity time.

Cultural norms, fading but not entirely gone, once encouraged parents to make their largely unformed infants partly independent from day one. Infants were expected to go it alone in their own rooms, to figure out how to soothe themselves by crying themselves to sleep, to wait through hunger pangs for an appointed feeding hour—or to eat more than they wanted, which, the parents could hope, would then cause them to sleep longer. About a hundred years ago, this approach was encouraged by “male physicians who not only had never changed a diaper, but had never—in any substantial way—associated with, or taken care of their own infants,” according to Dr. James McKenna, director of the Mother-Baby Behavioral Sleep Laboratory at the University of Notre Dame.⁴ Separating infants from their parents was supposed to foster independent toddlers, children, and adults, and this approach was practiced for decades. Current research shows that it has the opposite effect.

The mid-twentieth century was also a time when people believed intelligence was fixed, set in stone at birth. In the 1950s and 1960s, research began to cast doubt on that assumption. We now know that a child's IQ is influenced greatly by either environmental stimulation or environmental neglect.⁵ Science now sees the human brain in a kind of computer model: hardware delivered at birth, and software continually programmed by experience. The programming begins at birth at a breathtaking pace.

The 1970s introduced to popular culture the concept of “quality time.” Parents could be absent for long stretches of their infants’ days, the reasoning went, as long as they compensated for lost time by making every available moment of togetherness count with joyful, stimulating interaction. The trouble is, brain development doesn't take time off, and infants don't learn on a convenient schedule. When it comes to time, infants need both quality and sheer quantity. There are no shortcuts. A parent or a consistent, loving caretaker must be there when infants need them. During the fourth trimester, that's all the time.

This book goes a long way in removing the cloak of mystery that has always surrounded the fourth trimester. It presents an original perspective on the period following birth, identifying it as a continuation of the period of development within the uterus and, simultaneously, an interval that helps infants make the transition to the world.

This fresh way for parents, educators, and health care workers to understand newborns points to a difficult societal dilemma. Newborns require constant loving attention. That is a truth that must not be compromised by simple ignorance. Evolution and biology clearly prefer the bond to be between the newborn and the mother, though, as I've noted, infants can be well cared for by fathers, adoptive mothers and fathers, or other consistent, loving, attentive adults. This book points to the need to pay attention to infants twenty-four hours a day throughout the fourth trimester. Coming up with policy solutions that are truly family centered is beyond the scope of this book. But as a society, we need to come up with ways—paid parental leave for biological and adoptive mothers or fathers or both, for example—to support young families by ensuring that every infant is able to spend this crucial period of development held tightly in the arms of love.