Infant Crying and Sleeping in London, Copenhagen and When Parents Adopt a

"Proximal" Form of Care

Ian St James-Roberts, Marissa Alvarez, Emese Csipke, Tanya Abramsky, Jennifer
Goodwin and Esther Sorgenfrei
Pediatrics 2006;117;e1146-e1155
DOI: 10.1542/peds.2005-2387

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://www.pediatrics.org/cgi/content/full/117/6/e1146

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ARTICLE

Infant Crying and Sleeping in London, Copenhagen

and When Parents Adopt a Proximal Form of Care
Ian St James-Roberts, PhDa, Marissa Alvarez, PhDb, Emese Csipke, PhDa, Tanya Abramsky, MSca, Jennifer Goodwin, BAa,
Esther Sorgenfrei, MScb
aThomas Coram Research Unit, Institute of Education, University of London, London, United Kingdom; bDepartment of Psychology, University of Copenhagen,
Copenhagen, Denmark

The authors have indicated they have no nancial relationships relevant to this article to disclose.

ABSTRACT
OBJECTIVE. Western parents are given conflicting advice about whether to introduce
a scheduled approach to infant care or to follow their infants demands. Attempts to address this issue using randomized, controlled trials have been unsuccessful. This comparative study collected evidence about methods of parenting and
associated infant crying and sleeping in 2 communities with substantially different
approaches to infant care (London, United Kingdom, and Copenhagen, Denmark)
and in a proximal care group, where parents planned to hold their infants 80%
of the time between 8 AM and 8 PM, breastfeed frequently, and respond rapidly to
infant cries.
METHODS. Validated behavior diaries were used to measure parental behavior and

infant crying and night waking longitudinally at 8 to 14 days, 5 to 6 weeks, and 10

to 14 weeks of age. Feeding and sleeping practices were measured by questionnaire.
RESULTS. Proximal care parents held infants for 15 to 16 hours per 24 hours and

coslept with them through the night more often than other groups. London
parents had 50% less physical contact with their infants than proximal care
parents, including less contact when the infants were crying and when awake and
settled. London parents also abandoned breastfeeding earlier than other groups.
Copenhagen parents fell in between the other groups in measures of contact and
care. These differences in caregiving were associated with substantial differences in
several aspects of infant crying and settled behavior at night. London infants cried
50% more overall than infants in both other groups at 2 and 5 weeks of age.
However, bouts of unsoothable crying occurred in all 3 of the groups, and the
groups did not differ in unsoothable bouts or in colicky crying at 5 weeks of age.
Proximal care infants woke and cried at night most often at 12 weeks. Compared
with proximal care infants, Copenhagen infants cried as little per 24 hours, but
woke and cried at night less often at 12 weeks of age.

www.pediatrics.org/cgi/doi/10.1542/
peds.2005-2387
doi:10.1542/peds.2005-2387
Key Words
infant crying, colic, infant sleeping, care
giving, parental care
Abbreviation
ANOVAanalysis of variance
Accepted for publication Jan 12, 2006
Address correspondence to Ian St JamesRoberts, PhD, Thomas Coram Research Unit,
Institute of Education, University of London,
27/28 Woburn Square, London WC1H 0AA,
United Kingdom. E-mail: i.stjamesroberts@ioe.
ac.uk
PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright 2006 by the
American Academy of Pediatrics

CONCLUSIONS. Infant-demand care and conventional Western care, as practiced by

London parents, are associated with different benefits and costs. As used by

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ST JAMES-ROBERTS et al

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proximal care and Copenhagen parents, infant demand

parenting is associated with less overall crying per 24
hours. However, the proximal form of infant-demand
parenting is associated with more frequent night waking
and crying at 12 weeks of age. Copenhagen infants cry as
little per 24 hours as proximal care infants but are settled
at night like London infants at 12 weeks of age. Colicky
crying bouts at 5 weeks of age are unaffected by care.
The findings have implications for public health care
policy. First, they add to evidence that bouts of unsoothable crying, which are common in early infancy, are not
much affected by variations in parenting, providing reassurance that this aspect of infant crying is not parents
fault. Second, the findings provide information that professionals can give to parents to help them to make
choices about infant care. Third, the findings support
some experts concerns that many English parents are
adopting methods of care that lead to increased crying in
their infants. There is a need for informed debate among
professionals, policy makers, and parents about the social and cultural bases for the marked differences between London and Copenhagen parents approach to
care.

N WESTERN SOCIETIES, infants who cry persistently or

wake at night are common concerns for parents13 and

costly problems for health services.4 More rarely, the
crying may lead a parent to smother, hit, or shake an
infant, sometimes resulting in infant brain damage or
death.5,6 These findings highlight the need for evidence
to guide parents about effective ways of managing infant
crying and sleeping.
In practice, the debate about infant care has been led
by expert opinion rather than scientific evidence. On
one hand, books like Fords The New Contented Little Baby
Book7 recommend introducing routines such as feeding
and sleeping schedules. In keeping with this, until recently the predominant form of infant care in London,
United Kingdom, and much of Europe and North America involved feeding approximately every 3 or 4 hours;
putting infants down in cots, seats, or strollers for much
of the daytime; delaying responding to crying on 40%
of occasions; and placing infants in separate cots to sleep
at night.811 Concern that Western parents are increasingly adopting scheduled forms of care for their own
convenience, where they encourage parents to leave
infants to cry, has fuelled a public debate.12
In contrast, Liedloffs book The Continuum Concept13
advocates an infant-demand approach to infant care.
More specifically, the anthropological term proximal
care refers to prolonged holding, frequent breastfeeding, rapid response to infant frets and cries, and cosleeping with infants at night.14 Studies in Africa of !Kung15
and Aka14 infants found that proximal care was associ-

ated with much lower amounts of crying than occur

among Western infants. However, a cautious interpretation is needed. One concern is that the !Kung study
sampled behavior briefly and infrequently, using different methods from Western studies. Standard methods
are required, because methodologic variations produce
large differences in the amounts of crying measured.16
Another proviso is that both studies measured infant
behavior only during the daytime, leaving open the
question of differences in infant waking and crying at
night. Third, African societies differ in climate, diet, and
other ways from Western cultures, making it unclear
whether differences in infant behavior reflect differences
between proximal and Western care.
Attempts to tackle these issues using randomized,
controlled trials have not produced a resolution. Hunziker and Barr17 found that increased holding and carrying by parents reduced infant crying at 5 to 6 weeks of
age, but this was not confirmed in 2 subsequent studies,18,19 and increased carrying was not an effective treatment when infants were already crying a lot.20 However,
all 4 of the studies were only moderately successful in
changing Western care. For example, holding/carrying
was increased in the London study, but only from the
community control group level of 2 to 4 hours per day
compared with 10 hours per day among !Kung parents,
who also cosleep with their infants at night. The London
study group that was asked to increase social interaction
and breastfeeding did not increase nonfeed parent-infant interaction. The number of feeds at 6 weeks was
increased, but to an average of just 8.7 feeds per 24
hours compared with 7.8 per 24 hours in the community
control group.
Because progress in comparing infant demand with
structured infant care has eluded randomized, controlled
trial methods, the present study compares the crying and
sleeping of 3 groups of infants whose parents elected to
adopt different forms of care. Copenhagen parents were
expected to be more responsive and to spend more time
holding their infants than London parents.21 The proximal care group was recruited through specialist networks. Proximal care was defined as parenting that involved holding infants 80% of the time between 8 AM
and 8 PM (shared between caregivers as preferred), frequent breastfeeding, and rapid response to infant cries.
We did not require cosleeping, but this often occurred.
Parents had to have elected to adopt proximal care before their infants birth.
Using standardized methods, the study aimed to confirm the group differences in caregiving and to assess
whether these were associated with differences in infant
crying in the day and night during the first 12 weeks of
age. This period was chosen because crying peaks at 4 to
6 weeks of age,22 and because most infants begin to
remain settled at night by 12 weeks of age,23,24 whereas
failure to do so in early infancy predicts long-term night
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waking and crying.25 Two hypotheses were tested. First,

recent studies have distinguished infant crying in general from bouts of unsoothable crying, which have been
attributed to neurodevelopmental changes at 6 weeks
of age.5 We, therefore, hypothesized that infants cared
for in Copenhagen and by proximal care would fuss and
cry less overall but would not differ from London infants
in bouts of unsoothable crying at 5 weeks of age. Second,
following evidence that structured behavior programs
help infants to learn to remain settled at night by 12
weeks of age,26 we hypothesized that infants who received proximal care would be more likely to wake and
cry at night at 12 weeks.

METHODS
Participants
After joint training, researchers in London and Copenhagen used uniform procedures to approach breastfeeding mothers of 0- to 3-day-old newborns in community
hospital postnatal wards. We excluded multiple births,
infants with birth weight 2500 g, infants admitted to
special care or who medical staff considered unwell, and
cases where mothers had limited English/Danish or no
access to a telephone. Otherwise, mothers were approached consecutively, given an explanation of the
studys cross-cultural focus, and invited to allow a telephone call to explain the study fully after they returned
home. Mothers who agreed were asked whether they
planned to adopt infant care practices that were conventional in their community or proximal care and gave
written consent for the follow-up call. Seven mothers
approached in this way in Copenhagen and 1 in London
had decided before this infants birth to adopt proximal
infant care and were assigned to the proximal care
group. The study requirements were explained during
the telephone call, 1 week after the infants birth.
Written consent was obtained at a home visit when
infants were 6 to 11 days old. The study received Medical
Research Ethics Committee approval.
Most women planning to adopt proximal care were
approached via a private midwifery group in London
and others via National Childbirth Trust coordinators or
announcements on the Web sites of the Continuum
Concept, Natural Nurturing, and Natural Parenting networks. In Copenhagen, women were contacted via a
national organization for natural parenting and an attachment parenting Web site. The numbers contacted
are not known. Except for those recruited in postnatal
wards, proximal care cases were recruited during the
mothers pregnancy. Most (74%) were residents of
Southern England, 14 of Denmark, and 2 of the United
States. Exclusion criteria were as for the community
groups.
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ST JAMES-ROBERTS et al

Procedures
Behavior Diary
Data on parental behavior and infant crying were collected by parents using behavior diaries. These have
been validated against audio recordings and researcher
observations2729 and are the leading method for studies
of infant crying. The diary has four 6-hour time rulers,
printed on a single page, corresponding with the morning (6 AM and 12 PM), afternoon (12 PM and 6 PM),
evening (6 PM and 12 AM), and night (12 AM and 6 AM).
Parents shade in the onset and end time of successive
periods of behavior on the time rulers against a scale
showing 5-minute increments of time. Infant behaviors
are logged on the top section of the time ruler and
parental behaviors in the bottom section. Parents were
asked to log the caregiver and infant behaviors described
below.
Caregiver Behaviors
Caregiver behaviors included holding or carrying, playing or talking, soothing, and care (includes nappy changing, dressing, and bathing). Holding or carrying was
defined as any activity that involved body contact between parent and infant, including bed sharing, but
excluding where infants were in a cot or basket, even
nearby parents. Because parents reported during piloting
that soothing and play or talking could occur while
holding or carrying, 1 form of caregiving could be
recorded on the diary at any time. The combinations
were examined during data analysis.
Infant Behaviors
Infant behaviors included sleeping, being awake and
content, fussing, crying, unsoothable crying, and feeding. Fussy behavior was defined as your infant is awake
and irritable and may be vocalizing but not continuously
crying; crying was defined as periods of prolonged,
distressed vocalization; and unsoothable crying was defined as bouts of hard to soothe or unsoothable fussing
or crying.
The researchers explained diary completion during
the home visit. Copenhagen parents filled in a version
translated into Danish, back translated into English, and
checked by bilingual speakers. To improve the reliability
of each infants data, parents were asked to complete the
diary for 4 successive days when their infants were 10
(2) days and 5 to 6 weeks, of age. Less onerous diaries,
which measured only infant (not caregiver) behaviors,
and for 2 days (instead of 4), were completed at 12 (2)
weeks of age. The diaries were returned by post, and
contact was maintained by telephone.
Researchers entered the completed diaries in a computer program, RonNicLog,30 which calculates the duration and frequency of each infant and parental behavior.
Because infant and parental behaviors are entered

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against the same time scale, the program also computes

the amounts of time where target infant and parental
behaviors occur together. To confirm the reliability of
data coding, 100 diaries, selected uniformly across the
infant groups, were duplicate entered by separate researchers. statistics for agreement between the duplicate entries for infant and parental behavior ranged from
0.911 to 1.0.
Questionnaires
Danish versions of questionnaires were back translated
and checked against the English versions by bilingual
speakers. Demographic particulars about each family
were collected by questionnaire at 10 days. The mothers
completed summary questionnaires about infant feeding
and sleeping at 10 days, 5 weeks, and 12 weeks of age.
At each age, the mothers identified: (1) the method of
infant feeding being used (breast only, breast and expressed breast milk, breast and formula, formula only,
any other method); (2) where the infant usually slept (in
the parents bed, in a separate cot, or in a combination of
these); and (3) whether the infant slept in the parents
bed at all: (a) the number of nights in the last week this
had happened; and (b) whether this was all night or part
of the night. At 12 weeks, parents recorded the number
of nights in the last week that the infant had slept for 5
hours without waking and crying, a previously used
definition of sleeping through the night.26,31
RESULTS
Because behavior diaries are onerous for parents, studies
using them have substantial sample attrition, whereas
participants tend to be mature, well educated, and in
stable relationships.17,27,32 These features were reproduced here, and participating Copenhagen mothers
were more likely than London mothers to take part. In

Copenhagen, 197 women were approached in hospital;

174 (88%) agreed to be contacted by telephone; 3 could
not be reached. Of those approached in hospital, 87
(44%) signed consent forms. In London, 669 women
were approached; 540 (81%) agreed to be contacted; 90
could not be reached. Of those approached in hospital,
174 (26%) signed consent forms. The main reason for
declining was that taking part would be too demanding
when coping with a new infant.
Table 1 shows the resulting numbers of infants, their
ages at each measurement point, and demographic details for participants. The infant groups did not differ in
gender, birth order, or age, except that Copenhagen
infants were significantly younger than proximal care
infants at 12 weeks (but by just 3 days on average).
Parents in all 3 of the groups were well educated and in
stable relationships. Copenhagen mothers were
younger, but their age is representative of Danish childbearing women. Fewer partners in Copenhagen were in
full-time employment and more were in further or
higher education. The majority of parents in each group
were white-European in background (Danish community group: 92% mothers, 89% fathers of Danish national origins; London community group: 75% mothers,
71% fathers of white ethnicity; proximal care group:
92% mothers, 91% fathers of white/Danish national
origins). Notably, 29% of proximal care mothers were
employed before their infants birth compared with 57%
and 64%, respectively, of London and Copenhagen
community mothers.
Group Differences in Parental Behavior
Table 2 summarizes the number of minutes per 24 hours
that parents held and interacted with their infants and
the total number of infant feeds given at 10 days of
infant age. Proximal care parents spent an average of 16

TABLE 1 Descriptive Particulars of the 3 Groups

Variable
No. (%) of boys
No. (%) of rst borns
No. providing data at 10 d
No. providing data at 5 wk
No. providing data at 12 wk
Mean (SD) infant ages, d
10 d
5 wk
12 wk
Mothers mean (SD) age, y
Partners mean (SD) age, y
% mothers (partners) with college/university education
% partners employedfull-time
% mothers employed full-time before maternity leave
% parents living together

London
Community

Copenhagen
Community

Proximal
Care

59 (52)
66 (58)
111
81
75

32 (43)
58 (77)
70
64
63

27 (47)
28 (61)
56
54
55

10.7 (1.7)
36.3 (3.9)
86.5 (4.8)
33.8 (4.7)
35.8 (4.9)b
52 (49)
87
57
95

10.7 (0.8)
35.1 (3.5)
84.5 (3.6)b
29.9 (4.7)c
31.9 (5.8)b
83 (81)
73c
64
97

10.7 (1.9)
35.7 (3.3)
87.9 (6.6)b
32.3 (4.2)
34.0 (4.9)
93 (84)
85
29c
100

ANOVA or 2
Pa
NS
NS

NS
NS
.01
.001
.001
NS
.001
.001
NS

NS indictes not signicant.

a After ANOVA or 2, posthoc Tukey or 2 tests were used to identify signicant differences (P .05) between pairs of groups.
b Different from each other but not the third group gure.
c Different from both other group gures.

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TABLE 2 Mean (SD) Group Differences in Diary-Measured Caregiver and Caregiver-Infant Behavior per
24 Hours at 10 Days of Infant Age
Variable

London
Community

Copenhagen
Community

Proximal
Care

ANOVA
Pa

Min infants heldb

Min infant held while asleepb
No. infant feeds
Min feeding
Min interactiond
Min without any contacte
Min infant awake and settled without any contacte
Min infant fuss/cry without any contacte

509 (220)
152 (177)
11 (4)
244 (71)c
148 (73)
832 (214)
81 (53)f
38 (32)g

584 (187)
211 (173)
12 (3)
211 (66)c
148 (51)
768 (182)
60 (43)f
15 (12)

989 (321)g
571 (288)g
14 (4)g
240 (94)
133 (61)
377 (299)g
32 (30)f
10 (13)

.001
.001
.001
.015
NS
.001
.001
.001

NS indicates not signicant.

a After ANOVA, Tukey tests were used to identify signicant differences (P .05) between pairs of groups:
b Holding or carrying alone, in combination with any other parenting behavior, and holding while feeding.
c Different from each other, but not the third group gure.
d Time spent playing, talking, soothing, or caring, including combinations of these with each other and with holding (but not holding alone).
e Includes total time without holding, playing, talking, soothing, or caring.
f All 3 group gures are different.
g Different from both other group gures.

hours 29 minutes per 24 hours holding their 10-day-old

infants compared with 9 hours 44 minutes for Copenhagen parents and 8 hours 29 minutes for London parents. Proximal care parents held their infants while
asleep more than both other groups at 10 days (Table 2).
Table 2 also shows the amounts of time per 24 hours that
parents spent interacting with their infants, as well as
the time spent without any contact, when the infants
were 10 days old (definitions are in the Table 2 footnotes). Allowing for interaction that occurred while
holding, there were no significant group differences in
the time that parents spent interacting with infants.

However, as Table 2 shows, London parents spent much

less time in contact with their 10-day-old infants than
both other groups of parents, including when the infants
were crying and when they were awake and settled.
Proximal care parents fed more often than both other
groups at 10 days of age (Table 2). The groups differed in
the total number of feeds, but London parents did not
spend less time feeding (Table 2).
The 5-week diary findings were similar. At this age, as
Fig 1 illustrates, proximal care parents held their infants
more than Copenhagen parents, who did so more than
London parents (analysis of variance [ANOVA] P

FIGURE 1
Mean (SD) total minutes per 24 hours that infants were held by caregivers at 5 weeks of age. Lined box, held while asleep;

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ST JAMES-ROBERTS et al

, held while awake.

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.001; Tukey P .05). London parents spent an average

(SD) of 929 197 minutes per 24 hours without
contact, compared with 779 218 minutes and 441
330 minutes, respectively, in the Copenhagen and proximal care groups (ANOVA P .001; Tukey P .05 all
group pairs). Similarly, London parents left awake and
settled infants without contact for 125 65 minutes per
24 hours compared with 92 71 and 64 51 minutes,
respectively, in the Copenhagen and proximal care
groups (ANOVA P .001; Tukey P .05 all group
pairs). London parents left fussing/crying 5-week-old
infants without contact for 58 44 minutes per 24
hours compared with 17 15 minutes per 24 hours and
18 24 minutes per 24 hours, respectively, in the
Copenhagen and proximal care groups (ANOVA P
.001; Tukey P .05 between London and other groups
only). At 5 weeks, London, Copenhagen, and proximal
parents fed 10, 12, and 14 times per 24 hours, respectively (ANOVA P .001; Tukey P .05 between all
group pairs). There were no significant group differences
in the time parents spent feeding or interacting with
their infants at 5 weeks of age.
The questionnaire data showed that 85% of proximal
care and 70% of Copenhagen infants were still solely
breastfed at 12 weeks compared with only 37% of London infants (Table 3). At this age, both proximal and
Copenhagen parents coslept with their infants at least
part of the night during 5 nights per week compared
with London parents average of 1 night per week. Proximal care parents were more likely than other parents to
cosleep with their infants for the entire night: 70% of
proximal care parents did so for the whole night,
whereas just 16% of Copenhagen and 9% of London
parents did so.

Infant Fussing and Crying

As Fig 2 indicates, London infants spent 50% more
time fussing and crying than both other groups at 10
days and 5 weeks of age (Table 4 contains the individual
figures). Resembling previous research, all 3 of the
groups reduced their fussing and crying by about one
third at 12 weeks of age. However, London infants still
fussed and cried significantly more at this age.
There was no group difference in the mean amount of
unsoothable crying at any age (Table 4). Table 5 identifies the number of infants in each group who exhibited
any bouts of unsoothable crying during the 4 days of
diary assessment. Up to 47% of infants did so, with the
highest number at 5 weeks and no difference between
the groups at any age.
The rule of threes by Wessel et al33 defines infants
whose fussing and crying exceeds 3 hours per day on 3
days per week as cases of infant colic. Because few
parents will keep diaries for 7 days, infants whose fussing and crying is 3 hours when averaged across diaries
are often regarded as colic cases.32,34 Table 5 shows the
proportion of infants in each group whose total fussing
plus crying plus unsoothable crying per 24 hours averaged 3 hours at each age. Just 1 proximal care and 1
Copenhagen infant met this definition at 10 days,
whereas 15 (17%) London infants did so. As expected,
the proportions of colic cases per group did not differ at
5 weeks of age. The proportion of colic cases declined in
each group and did not differ at 12 weeks of age.
At 12 weeks, parents recorded how many nights in
the last week their infant had spent a continuous period
of 5 hours asleep without waking and crying. London
and Copenhagen parents reported more such nights
than proximal care parents (mean SD: 5.0 2.3 and
4.6 2.6 vs 3.4 2.6 nights, respectively; ANOVA P

TABLE 3 Questionnaire Measures of Sleeping and Feeding Arrangements

Variable
No. (%) babies wholly breastfeda
10 d
5 wk
12 wk
No. (%) babies slept in parents bed whole nighta
10 d
5 wk
12 wk
No. (%) babies slept in own cot all or part of the nighta
10 d
5 wk
12 wk
Mean (SD) No. of nights in last week baby slept in parents bedb
10 d
5 wk
12 wk
aP
bP

London
Community

Copenhagen
Community

Proximal
Care

P (ANOVA or 2
Analysis)

78 (70.3)
35 (44.9)
27 (36.9)

65 (86.7)
52 (78.8)
44 (69.8)

56 (94.9)
47 (90.4)
46 (85.2)

.001
.001
.001

20 (18.0)
17 (21.2)
7 (9.5)

23 (30.7)
14 (21.2)
10 (15.9)

23 (72.9)
40 (76.9)
38 (70.4)

.001
.001
.001

91 (82.0)
63 (78.8)
65 (89.0)

52 (69.3)
52 (78.8)
53 (84.1)

16 (27.1)
12 (23.1)
16 (29.6)

.001
.001
.001

3.5 (3.3)
2.5 (3.1)
1.5 (2.6)

5.4 (2.3)
5.6 (2.4)
5.0 (2.9)

6.2 (2.1)
6.3 (1.8)
5.3 (2.8)

.001
.001
.001

value based on 2 analysis.

value based on ANOVA.

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FIGURE 2
Mean total minutes per 24 hours of infant distress (fuss
crying unsoothable crying) per group at each age. ,
London community group; , Copenhagen community
group; , proximal care group.

TABLE 4 Mean (SD) Group Differences in Diary-Measured Minutes per 24 Hours of Infant Fussing,
Crying, and Unsoothable Crying per 24 Hours at 10 Days, 5 Weeks, and 12 Weeks of Age
Variable
At 10 d
Fussing
Crying
Unsoothable crying
At 5 wk
Fussing
Crying
Unsoothable crying
At 12 wk
Fussing
Crying
Unsoothable crying

London
Community

Copenhagen
Community

Proximal
Care

ANOVA
Pa

82b (50)
32b (24)
6 (13)

61 (37)
15 (18)
4 (9)

56 (38)
15 (17)
3 (10)

.001
.001
NS

88b (42)
33b (30)
5 (12)

58 (40)
14 (16)
9 (21)

66 (43)
16 (18)
3 (8)

.001
.001
NS

62b (38)
16b (17)
2 (4)

40 (36)
7 (10)
5 (14)

45 (38)
13 (16)
3 (9)

.003
.001
NS

NS indicates not signicant.

a After ANOVA, Tukey tests were used to identify signicant differences (P .05) between pairs of groups.
b Figure is different from both other group gures.

.002). London and Copenhagen infants did not differ in

this respect.
DISCUSSION
By comparing groups that elected to adopt different
approaches to care, this study found much greater differences in parenting than have proved possible in randomized, controlled trials. Proximal care parents spent
16 hours per 24 hours holding or in body contact with
their infants at 10 days of age and similar amounts at 5
weeks. London parents spent about half as much time
holding their infants at both of these ages. Copenhagen
parents held less than proximal care parents but more
than London parents at 5 weeks. London infants were
also left without parental contact when fussing and crying and when awake and settled for much longer than
both other groups. These findings are consistent with
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ST JAMES-ROBERTS et al

earlier studies of typical Western care in London and

North America,810,17 so that the sample attrition, which
occurred particularly among London parents, has not
detracted from their representativeness.
Most proximal care parents coslept with their infants
for the entire night, whereas 16% of Copenhagen and
9% of London parents did this at 12 weeks. London
infants were predominantly put down to sleep in cots at
night, whereas Copenhagen parents mixed cot use with
taking their infants into their bed for part of the night.
Proximal care parents fed their infants more often (14
feeds per 24 hours on average) than both other groups.
Both Copenhagen and proximal care parents persisted
with breastfeeding longer than London parents: at 12
weeks, 70% of Copenhagen mothers and 85% of proximal care mothers were solely breastfeeding compared
with 37% of London mothers.

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TABLE 5 Percentages of Infants in Each Group Who Had Bouts of

Unsoothable Crying and Whose Total Distress (Fussing
Crying Unsoothable Crying) Averaged >3 Hours at Each
Age
Variable

London
Community, %

Copenhagen
Community, %

Proximal
Care, %

2 P

37
38
20

36
47
29

25
33
24

NS
NS
NS

17
14
4

1
5
2

2
9
4

.001
NS
NS

Unsoothable bouts
At 10 d
At 5 wk
At 12 wk
Distress 3 h
At 10 d
At 5 wk
At 12 wk
NS indicates not signicant.

These parenting differences were associated with substantial differences in infant fussing and crying, in the
predicted ways. First, London infants fussed and cried
50% more per 24 hours than both Copenhagen and
proximal care infants at both 10 days and 5 weeks of age.
The amounts of fussing and crying declined at 12 weeks
in each group but remained higher in London infants.
Second, bouts of unsoothable crying occurred in each
group and did not differ between the groups. Likewise,
infant colic occurred in 5% to 13% of infants at 5 weeks
and did not differ between the groups at this age. Third,
infant waking and crying at night was more common in
proximal care infants at 12 weeks of age. Infants who
continue to wake and cry at night are often described as
having sleeping problems, although they differ from
other infants by waking and crying at night, rather than
in biological sleeping.35 However, it is precisely because
the night waking is accompanied by crying that it disturbs many parents.35 Because their infants are next to
them in bed, it is possible that proximal care parents are
more aware of infant fussing and crying at night. Provisional analyses have indicated that most Proximal care
infants continue to wake their parents at night when 10
months of age.36
The lack of random assignment prevents certainty
that these group differences in infant crying were caused
by the measured differences in parental care. However,
features of the study suggest that this is likely. First, the
care approaches were adopted before birth, so that they
preceded infant crying rather than responding to it. Second, the reduced infant crying per 24 hours occurred
with 2 very different groups of parents: a general-community sample in Copenhagen and a nonconformist
sample of proximal care parents. This suggests that the
features of care they have in common, that is, high
amounts of holding and responsiveness, are responsible
for the similarities in their infants low overall amounts
of crying. Indeed, the more frequent feeding practiced by
proximal care parents did not impact on infant crying.
Third, the findings are consistent with evidence that

proximal care in Africa14,15 and Copenhagen care21 are

associated with lower amounts of overall fussing and
crying than are typical in London infants. The figures for
crying amounts in London are similar to those from
previous studies of London and North American infants,16,17,37 indicating that they, too, are representative of
infants in these countries who are cared for in conventional Western ways. Based on recent evidence, our
prediction that unsoothable crying at 5 weeks of age
would not be affected by differences of care was confirmed. Similarly, rates of infant colic did not differ between the groups at 5 weeks of age, while the finding
that proximal care parents report infant night waking
and crying more often at 12 weeks is also consistent with
evidence and theory.26,38
Last, the findings may help to explain why the debate
about infant demand versus conventional Western infant care has persisted so long. Rather than one being
better, they are associated with different benefits and
costs. Infant demand care, as practiced by proximal care
and, to a lesser extent, Copenhagen parents, is associated
with less overall crying per 24 hours in the early weeks.
However, in the form adopted by proximal care parents,
infant demand care is associated with a higher amount
of reported waking and crying at night at 12 weeks of
age.
The question of causation will need to be resolved by
randomized, controlled trials. Toward this, it is striking
that Copenhagen parents care seems as effective as
proximal care in minimizing early crying and more effective than proximal care in helping infants to sleep
through the night at 12 weeks of age. Copenhagen
parents practice of placing their infant to sleep in cots
during part of the night meets current recommendations
for preventing infant cot death.13 London and other
Western parents may be willing to try Copenhagen parenting methods, allowing randomized trials.
Clinically, the substantial care differences between
London and Copenhagen parents are of interest in their
own right, particularly because these refer to well-educated parents who are motivated to participate in infant
research. Sample attrition was greater in London, but
the London/Copenhagen parenting differences would
probably have been at least as great if a more heterogeneous sample of London parents had been obtained.
The findings have 3 implications for public health
care policy. First, they add to evidence that bouts of
unsoothable crying, which are common in early infancy,
are not much affected by variations in parenting, providing reassurance that this aspect of infant crying is not
parents fault.39 Second, the findings provide information that professionals can give to parents to help them
to make choices about infant care. Third, the findings
support some experts concern that many English parents are adopting methods of care that lead to increased
crying in their infants.9 This issue is complex and unPEDIATRICS Volume 117, Number 6, June 2006

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e1153

likely to be productive if parents are given the blame.

There is a need for a broader debate among professionals, policy makers, and parents about the social and
cultural bases for these marked differences in parents
approach to care.
ACKNOWLEDGMENTS
This study was supported by Wellcome Trust Project
grant 065486 and by the Danish Research Council for
the Humanities.
Nicoletta Cavriani, Charlie Malyon, and Krista Manketo helped with data processing. Charlie Owen and
Antonia Simon assisted with data analysis. Support was
given by Neena Modi and colleagues at Queen Charlottes, Chelsea, and Westminster Hospitals and by the
Obstetrics and Gynecology Department at Hvidovre Hospital in Copenhagen. Proximal Care parents were recruited with support from: Caroline Flint, Pam Wild, and
colleagues at Caroline Flint Midwifery Services; Clare
Kanerick, Marie Coveney, Kate Williams, and colleagues
at the National Childbirth Trust; Elin Ross Pedersen, Scott
Noelle, and colleagues at www.continuum-concept.org:
Alex Stewart at www.natural-parenting.com; Julie Ridley
at www.naturalnurturing.org.uk; and the Foraeldre og
Foedsel Association. We are extremely grateful to all the
parents who took part together with their infants.
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PEDIATRICS Volume 117, Number 6, June 2006

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e1155

Infant Crying and Sleeping in London, Copenhagen and When Parents Adopt a
"Proximal" Form of Care
Ian St James-Roberts, Marissa Alvarez, Emese Csipke, Tanya Abramsky, Jennifer
Goodwin and Esther Sorgenfrei
Pediatrics 2006;117;e1146-e1155
DOI: 10.1542/peds.2005-2387
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