The Fourth Trimester: Understanding, Protecting, and

Nurturing an Infant through the First Three Months

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The Fourth Trimester
Understanding, Protecting, and
Nurturing an Infant through
the First Three Months

Susan Brink

university of california press

Berkeley Los Angeles London
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© 2013 by Susan Brink
Library of Congress Cataloging-in-Publication Data
Brink, Susan (Susan Frances)
The fourth trimester : understanding, protecting, and nurturing an infant through
the fi rst three months / Susan Brink.
p. cm.
Includes bibliographical references and index.
isbn 978-0-520-26712-1 (cloth : alk. paper)
1. Infants—Development. 2. Infants—Care. 3. Newborn infants—
Development. 4. Newborn infants—Care. I. Title.
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To Max, Makayla, Maggie, Ariana, Carissa,
and Molly
And in loving memory of Nancy
This page intentionally left blank
 contents

Preface ix

Introduction: A Transition from the Comfort

of the Womb to the Reality of the World
1

1. Evolution and the Primitive Brain of a Newborn:

Why Infants Arrive Unfinished
15

2. Crying: The Wakeup Call That Says Everything

Has Changed
28

3. Sleeping: Irregular and Sporadic Sleep Is Normal

in the Fourth Trimester
50

4. Feeding: Breast Milk and Formula

71
 5. Sound: Laying the Foundation for Speech
92

6. Sight: From Forms to Faces

107

7. Touch: Pain and Pleasure

128

8. Physical Development: Getting Ready to Crawl,

Walk, and Run
142

9. Stimulation: Keep It Real, Keep It Simple

155

10. Mom and Dad: The Parents’ Fourth Trimester

166

Notes 185
Acknowledgments 203
Index 205
 pr eface

My commitment to write a book about the newborn’s first three

months comes from my own life. I married very young and
have two daughters and six grandchildren. Yet nothing from
my maternal experience or from my professional background
as a journalist specializing in science and medicine eased me
or my grown children through the sudden shock of being com-
pletely responsible for the life and development of a brand-new
human being.
On my desk I have photographs that tell the story. The
snapshots I took a few days before my daughters became
mothers show them proudly posing with their full-term preg-
nant bodies in profile, their smiles broad and genuine. Then
comes a shot of my daughter Jenny, triumphant with her new-
born Max, but her smile has become uncertain. The same
uncertainty is written on Rachel’s face in yet another snap-
shot, her eyes wary and full of doubt, posing with one-day-old
Makayla. As brand-new mothers, my daughters had had their
confidence seriously shaken.

ix
 x / Preface

I look at those photographs and recall my own shock

decades ago when nurses handed over my firstborn. How could
they be so reckless as to entrust a helpless new human being
to clueless me?
We all made it through, my daughters and I, as new parents
do. Yet I know that for the first three months we relied on trial
and error, intuition, dumb luck—and the passing of time.
Three months, said pediatricians, other mothers, friends, and
family. Just hang in there for three months, and the mysterious
and demanding infant will become more human, more like the
baby you imagined. Since embarking on the research for this
book, I understand in a deeper way why, during the fourth tri-
mester of development, an infant is not like the baby that people
imagine. I want others to be able to do more than just hang in
there while they anxiously wait for three months to pass. This
book is for parents, grandparents, friends, family members, phy-
sicians, and students, every single one of them eager to do the
right thing by each infant he or she encounters. I want every-
one who is in awe of and in love with a newborn to understand
exactly how to protect and nurture an infant during the first
three months of life—the critically important fourth trimester.
Susan Brink
 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 gath-
ered an extensive array of newborn equipment, read the rec-
ommended 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

1
 2 / Introduction

forty weeks of awkward discomfort, they find themselves fac-

ing 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 sud-
denly 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 scien-
tific 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 fol-
lows. 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 transi-
tion 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 tri-
mester to show how parents, caregivers, doctors, and stu-
dents might understand this period by looking at it through
a new lens.
Throughout, I talk about the essential bond between a lov-
ing, 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
 Introduction / 3

evolution, dependent on her milk, an infant bonds most quickly

with his mother.
But in our complex and ever-changing society, it’s impor-
tant 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 sim-
ply 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 medi-
cal 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 par-
ents, 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
 4 / Introduction

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. Cer-
tainly, 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 recog-
nize 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 sto-
ries 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
 Introduction / 5

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 care-
taker 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 care-
givers who want more than to be told how to care for a new-
born. 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.
 6 / Introduction

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 educa-
tion and into family homes. This report, From Neurons to Neigh-
borhoods: 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 devel-
opment, 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.
 Introduction / 7

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 sci-
ence 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. Acknowledg-
ing 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 developmen-
tal needs while remaining intimate, personal, and nonjudgmen-
tal. 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 mys-
tery 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.
 8 / Introduction

The book begins millions of years ago with the chapter

“Evolution and the Primitive Brain of a Newborn.” It is the nat-
ural 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 devel-
opment in the uterus. They will begin to see that all newborns
need another three months, a fourth trimester, of uncompro-
misingly close connection to their mothers or an equally loving
and attentive caretaker.
The remainder of the book is organized by first address-
ing 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 with-
out 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 com-
plete 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.
 Introduction / 9

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 nat-
ural 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 chap-
ters 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 iso-
lation, and these three senses are intimately connected to sooth-
ing, 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 adop-
tive parents or alternative caretakers, babies will soon recognize
a consistent new voice and will turn to the voice they’ve come
 10 / Introduction

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 fl icker of vision is setting up neu-
ral 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 swad-
dling, cuddling, and stroking. The last fifteen years have seen
a sea change in understanding touch, both painful and plea-
surable 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
 Introduction / 11

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 inter-
action 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 impor-
tant chapter on physical development shows why the “exercise”
begun in the womb must continue, with caretakers encourag-
ing infants to vary their positions during awake time. Hold-
ing 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 con-
fused about what course to follow. To put their minds at ease,
a chapter on stimulation summarizes appropriate sensory stim-
ulation. 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,
 12 / Introduction

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 exam-
ining 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 inter-
actions are reshaping maternal brains. Research into fathers’
health is fledgling, but science now knows that men, too, are sus-
ceptible 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, sim-
ple, 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 encour-
aged 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
 Introduction / 13

taken care of their own infants,” according to Dr. James Mc-

Kenna, director of the Mother-Baby Behavioral Sleep Labo-
ratory 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 de-
cades. 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 assump-
tion. 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 mys-
tery that has always surrounded the fourth trimester. It presents
an original perspective on the period following birth, identify-
ing 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.