A time before smiles?

A time before smiles?

This is the first chapter from my book The Laughing Baby, coming soon from Unbound.

Illustration copyright Marian Medina Cuesta 2017

When the first baby laughed for the first time, its laugh broke into a thousand pieces and they all went skipping about and that was beginning of fairies 
— Peter Pan, JM Barrie

A baby’s first laugh is a magic moment. Parents have no trouble remembering it even years later. Happening anywhere from a few weeks old to four or five months, those early laughs will very likely be small and subtle, a light and breathy chuckle. A tiny baby cannot coordinate the rapid contractions of the intercostal chest muscles required to laugh properly but the sound is unmistakable nonetheless.

For Aristotle, the first time we laugh marks the instant when our soul enters our body and the moment we become truly human. He thought that laughter was what separates us from the animals. He was wrong, of course. Other animals can and do laugh and the boundary between us and other species is a matter of degree, a question of genes and culture. As for the soul, nowadays we would probably call that ‘consciousness’ and we understand that it dawns slowly.

But a baby’s first laugh is a very special event and one that feels transformative. Sometimes it is a spontaneous sound of wellbeing and satisfaction: “I am warm and happy and full of mother’s milk.” Occasionally it is a response to something the baby sees, like a shadow waving on the wall. Best of all is when it is the result of something a parent does — returning to the room or planting a ticklish kiss. However small that first laugh may be, parents will recognise in it the idea that “a laugh is a smile that burst”. It is the first time that a baby expresses their absolute delight with the world.

It is a memory that can stay with a parent forever. When I ran my baby laughter survey one parent, Mary, took the trouble to write and tell me about “the sound of the Angels” that burst forth when she kissed her tiny daughter’s tummy. It had happened forty-two years previously but it still echoed in her memory and made her “smile with JOY”. It was one of many similar stories. This is rather remarkable given that adult memory is usually very vague and non-specific. What did you have for lunch yesterday or do on your last birthday? Not many events in our grown up lives stick all that well. Even wedding days become hazy. But our children’s first laughs, first steps, first words remain with us and raise a smile decades later.

Memories of first smiles can be more elusive and uncertain. In my survey first smiles are reported anywhere from the first day to the sixth month, which is a relatively large range. On top of this, parents have a harder time pinpointing the very first smile and more difficulty recalling it. There are several things happening here. Not only are first smiles more subtle and fleeting but very often parents have been taught to doubt their own judgements.

There is a much-repeated myth that all smiles before about six weeks are actually responses to trapped wind or the sign of a baby filling their nappy rather than a true sign of pleasure or contentment. This myth is widespread and persistent. I’ve even seen it on popular midwifing websites. But it is one that I completely reject. It is true that babies do pull funny faces when burping or pooping. They also smile with genuine satisfaction. Many parents I’ve surveyed are convinced they have seen genuine smiles from very early on and I believe them. They are, no doubt, slightly biased but they are also studying their own baby far more intently than anyone else. We will see later in the chapter why there are excellent grounds for believing they are correct. For the moment, I think it is simple enough to let parents trust their own judgement on this.

Let’s take another look at those first smiles. Yes, babies can pull funny faces when burping up milk or filling nappies but they are equally capable of showing genuine emotion. No one doubts that first cries and first tears are real. A baby in distress is obvious to all. It seems strange, then, that experts would want to deny that early positive emotions are also valid; that first smiles aren’t “proper smiles”.

Worse yet, here we have new parents being told by experts that they are wrong about something so basic. Already uncertain of their own abilities, it is not a great way to reassure them. The main message of this book is that parents and their babies figure most things out for themselves. Nobody is ever properly prepared for a baby. But equally, parents know more than they realise and they will learn fast. It’s even more stressful and bewildering for the baby but their little laughs and smiles are a sign they are succeeding. No one should take that away from them.

There is another milestone for new mothers that it is often overlooked. When was the first time her baby made her laugh? This was earlier than you think. Of course there can be big smiles at the very beginning. Perhaps the time when she first suspected a baby was to be expected? Perhaps when it was confirmed by that second blue line on a pregnancy test? Or maybe a little later when seeing another mum with her new baby made the reality of her own future more concrete?

Secret Joy

But I am not talking about those moments. I like to think that the first time baby directly makes mother laugh is when something about their wriggling inside her makes her smile or starts her giggling. A good friend tells me of laughing when feeling that her unborn daughter had got the hiccups. But it doesn’t take something as comical as this to bring smiles to a mothers lips. Often it is just the knowledge that a new conversation has started.

In my favourite part of Expecting, Chitra Ramaswamy’s book-length memoir of her pregnancy. Chitra describes going out for dinner with friends to celebrate her birthday. Five months pregnant she can’t enjoy the adventurous food of the restaurant and is distracted from her friends as her baby wriggled inside:

I sat sipping champagne that tasted more like cider, pretending to follow the conversation while the baby fizzed in my belly. I said nothing about this furtive firework display. I had no desire to talk about it. There was nothing for anyone else to feel, nothing for anyone else to understand. This was my secret Morse code tapping out its message on my insides. I felt flushed with joy. It was one of the happiest moments of my life, one I can summon up whenever I want to, and often do. (p84–5, Expecting, Chitra Ramaswary 2016)

Just as that private joy became one of the happiest moments of her life. Chitra also relates how Tolstoy makes this secret moment a pivotal scene in his realist masterpiece, Anna Karenina. Anna is pregnant with the child of her lover, Vronsky, but huge obstacles face them because she is already married. Anna has dreamt that she will die in childbirth, and informs Vronsky of this prompting another a fraught discussion of their doomed affair, but in the middle of this Anna experiences the great fears for her situation giving way to a sense of bliss when she feels her baby stirring inside of her.

The first feeling of movement is known as the quickening. For thousands of years this was the major event of pregnancy. Before pregnancy tests and modern medicine this was the first time a woman could say with certainty that she was pregnant. Aristotle and the ancient Greeks and Romans thought this was the moment when the soul entered the body. That these movements indicated the moment when the foetus became “animated” with life, Animus and anima being the Latin words for mind and soul respectively; both having their roots in an even more ancient Proto Indo-European word for breath or breathing.

The legal system also recognised the quickening as the point that divided life from potential life as in the biblical phrase “the quick and the dead”. In English common law abortion was permissible before this point and assaults that caused a woman to miscarry after the quickening were treated as more serious. Until 1869 even the Catholic Church held this view, it accepted abortion before the quickening as the destruction of potential life not of life itself. Legal definitions are now based on viability of life outside the womb. English law recognises a foetus as being “capable of being born alive” from 24 weeks and a baby’s legal status as an individual commences from the point they draw their first breath.

In the private history of any individual pregnancy quickening is a big milestone. The very first flutters of movement are a tangible joy, literally a “touching” moment. From here onwards a mother has a new connection with her little passenger and can start to infer their personality. Comparing the patterns of activity with the experience of other mums to be. Is her little one more prone to wriggling late and night or early in the morning? How do they respond to music or their mother’s mood, to coffee or to cake?

For a first-time mum the first feelings of a baby moving typically occur between the 16th to 20th weeks of pregnancy. Second-time mums tend to notice these movements several weeks earlier because their uterus walls are thinner. This gives a big clue that a foetus is moving before the mother notices it. In fact, it is long before. The first movements are already possible between 4 & 8 weeks after conception. Although there is no way a mother will notice these as the foetus is still the size of a lentil. Though, of course, she will have known she is pregnant from near the beginning.

Even before the introduction of hormonal pregnancy tests in 1970s, few women failed to notice the massive changes that sweep through their bodies after a fertilized egg implants in the womb. The process is started by a flood of human chorinonic gonadortrophin (hCP to its friends) that gets released when the placenta first forms. This tells the ovaries that a pregnancy is taking place and prompts the ovaries to keep producing progesterone while the placenta takes over producing estrogen. The levels of both these two main female hormones will keep increasing throughout pregnancy. A third important hormone, oxytocin, makes its appearance later at the time of the birth.

Progesterone increases the mother’s body temperature and metabolism, this requires extra energy, which is one reason she feels tired all the time. Progesterone also relaxes muscle tone which is useful in later stages of pregnancy but early on affects the stomach and intestine causing heartburn via acid reflux. Estrogen changes her senses of smell and taste and is thought to cause the nausea, vomiting and stomach cramps of morning sickness. On top of all that she has also just found out that you are pregnant. It is not unreasonable for her to be feeling a bit fragile. Fragile and largely in the dark. That first touch of the baby is reassuring.

But in the dark we can listen. Thanks to key medical inventions by maternity doctors René Laennec and Ian Donald eavesdropping on life in the womb has been an important part of obstetrics for nearly two hundred years. René Laennec was a doctor who worked at the Necker hospital for Sick Children in Paris, the world’s first paediatric hospital. In 1816 he invented the stethoscope. He used to get embarrassed having to put his ear to women’s chests to listen to their hearts so he made a listening tube. It was just a short straight wooden tube that he placed on their chest to let him keep a respectable distance. It turned out that this worked better than an ear directly on the chest.

It wasn’t long before Leannec and his colleagues realised that this new invention would let them listen to an unborn baby’s heart beat too. The first reports of foetal heart rates is from 1821 by Leannec’s pupil, Jean-Alexandre Le Jumeau (Wulf, 1985). The Y-shaped stethoscope appeared in 1851 and hasn’t really changed much since then. It is good enough to hear a baby’s heart beating from the 22nd week of pregnancy, though it can depend on the orientation of the baby in the womb (and how much mum’s stomach is gurgling). It could even confirm if there were going to be twins; although if the foetus is moving the heartbeat can be masked by the sound of it splashing around in the amniotic sack.

Measuring foetal heart rate and how much it varies can tell doctors about the health of the foetus. The heart rate is controlled by two complementary systems the sympathetic and parasympathetic nervous system. The sympathetic nervous system causes increase in heart rate and parasympathetic causes decreases. Normally they are in balance with each other and the heart rate gradually cycles up and down. A very fast or very slow heart rate or even a lack of variability can be a warning sign for doctors.

Interestingly, this very early research also led to an old wives’ tales that persists to this day. In 1860, a certain Dr Frankenhauser published a study in a German medical journal claiming that heart rate could predict the sex of baby. He believed that female foetuses had a heart rate of around 144 beats per minute (bpm) while male foetuses would average 124 bpm. This is not true but the myth has been very hard to shift. It still gets regularly repeated on many pregnancy websites.

Ian Donald was an obstetrician working at the Glasgow Royal Maternity Hospital. Always an original thinker and tinkerer, Donald had previously invented a respirator for newborn infants, unfairly gaining the nickname “Mad Donald”. In the late 1950’s he and his colleagues helped invent modern ultrasound equipment and pioneered its use in foetal medical imaging.

Ultrasound is technically described as an imaging technique but it is based on ordinary sound waves albeit beyond our range of hearing. Like the echolocation of bats, or the sonar of dolphins and submarines, it involves listening to the echoes of very high pitched squeaks and clicks. Sonar technologies had been around in rudimentary form since the first world war and ultrasound itself started life as means of inspecting the interior of metalwork.

Donald had heard of this and of previous attempts to use the same idea to peer into the body. In 1955 he visited the engineering firm Babcock & Wilcox who made large boilers for Glasgow’s shipbuilding industry and who had a metalwork ultrasound device. Donald turned up with two car-loads of medical specimens. Just as it detected flaws and weakness in welds and joints, the device was able to detect the anomalous signals coming from tumours and cysts in the samples. Donald and colleagues built their own version and started using it in their diagnostic work. They wrote up their findings for the medical journal The Lancet in 1958 (Donald, Macvicar, & Brown, 1958). That paper is widely credited for kick-starting medical ultrasound (Woo, 2002).

Ultrasound and heart rate monitoring are the backbone of medical monitoring of foetal development. They have also been used by developmental scientists like myself to uncover what babies experience in the womb. Measurement of changes in foetal heart rate allow us to determine when a foetus is surprised by something. Ultrasound lets us see how a foetus moves in response to sounds, movements and other stimuli. Coupled with what it is known about the biology of the growing foetus, this lets us build a picture of what a foetus can learn in the womb.

Ultrasound shows that the clump of cells which become the heart is already beating by the sixth week after conception. As previously mentioned, at this point the embryo is the size of lentil but already the ears, mouth and nose are visible. The eyes and nostrils are two little black dots and arms and legs are still little stubs, the fingers and toes still webbed. A six-week-old embryo will already move in response to touches around the mouth and nose area. These are simple reflexive actions but show that the nervous system is already beginning to arrange itself. This gives a hint as to why mouthing is such an important exploratory skill for babies.

Fruit of the womb

Over the next two weeks, the embryo doubles to blueberry-sized and then doubles again to the size of a raspberry (according to the fruit and veg based measurement system that seems to be standard in all baby books ever written.) At around 10 or 11 weeks, your little strawberry has sleep and wake cycles. Changes in foetal heart rate indicate if the mummy’s passenger is sleeping or awake. Mostly, the womb is a bedroom. Throughout the pregnancy a foetus spends over 90% of his or her time asleep. Sleep cycles are about 40 minutes at a time punctuated by short bursts of activity. The amount of activity increasing as time goes by. At strawberry-sized the movements are minimal but are clearly exhausting as in-utero yawns have been seen as early as week 11 (Joseph, 2000).

Week 13 is peachy. This is the end of the first trimester, one third of the way through the pregnancy and the embryo has developed sufficiently that we start calling it a foetus. The first voluntary movements start to happen around 16 weeks when the foetus is around 4.5 inches long (11.5 cm) and the size of an avocado. Periods of activity are accompanied by foetal callisthenics. The foetus is recognisably human by now with a big round head and teeny tiny fingers and toes.

Foetal development is not simply a process of growth from blueberry-sized blob to bouncing baby. Throughout this time the constant metamorphosis is no less dramatic than from caterpillar to butterfly. Cells are not only dividing and their numbers multiplying but their functions change and they migrate within the body to different goals and different roles. That blueberry still has gill-like structures and tail which become jaw-bones and coccyx. Most internal organs are only fully formed by week 20 and neurons keep moving and connecting beyond birth.

As we already mentioned, the expectant mother will feel the first tickles of movement somewhere between here and week 20 (a small banana). This is typically when the midterm ultrasound takes place. The foetus is carefully examined to check that everything is developing as expected. On modern ultrasounds the sex of the baby can clearly be seen if you know what you are looking for.

Chances are the foetus will be asleep during this exam but if they are moving you might be in for a nice surprise. In March 2015, Jen Hazel and her husband went for their 14-week ultrasound scan with their doctor in Olympia, Washington. During the scan the foetus clapped her hands together. As Jen describes it:

We went in for an ultrasound and the baby clapped three times on screen. Not to the music, just clapped three times. So my doctor, he said, ‘Well, let’s sing a song.’ My husband grabbed his video and the doctor reran the ultrasound and played the claps and I sang and he sang with me ‘If you’re happy and you know it [clap your hands].’

Their singing isn’t great — Jen is laughing too much and her husband doesn’t seem to know all the words — but it’s a delightful video. And when it was uploaded to YouTube it understandably went viral. At the time of writing it has nearly 12 million views.

So could a 14-week-old foetus be happy? Here we get to the heart of this chapter. Is there really a time before smiles? Where does happiness and contentment begin? Are they present from the very start or do emotions only turn on sometime after birth? Jen’s daughter, Pip, was born safe and healthy. She is a happy, playful baby and she still likes music.

But what about when Pip was still a lemon-size foetus of fourteen weeks? Was she happy and did she know it? Could she know it? A single fertilized egg, a zygote, cannot know or show happiness. Nor can the little ball of cells in the blastocyte or even the yawning strawberry sized embryo. Yet from my parental survey of infant laughter, I am confident that a baby of just a few weeks old can show genuine contentment. Many parents report this. So when do the lights come on? When can a smile really be a smile?

It’s hard to say. There is no way a 14-week-old foetus can feel pleasure or pain. Its nervous system isn’t developed enough. No real research exists on foetal pleasure. Indeed, it would be hard to know even know where to start. But foetal pain is a good guide to pleasure. Pleasure and pain are supported by similar circuits and evidence is accumulating that by end of the second trimester, at around 24–25 weeks post-conception, a foetus can feel rudimentary pain. The Royal College of Obstetricians and Gynecologists published a detailed report in 2010 reviewed the available evidence. They concluded that foetal awareness of pain is not possible for before 24 weeks (RCOG, 2010).

For anyone to experience pain, nerve signals from the unpleasant stimulus must reach a cortex capable of processing them. If the signal from some part of the body doesn’t reach the brain, all that we experience is numbness. This is how a local anaesthetic works. Additionally, if the signals reach the brainstem and thalamus but aren’t passed upwards to the cortex we won’t feel anything. This is how general anaesthetic works.

Before 24 weeks a foetus cannot experience pain because the brain is not fully connected. In particular, the thalamus which is a kind of junction box between brain and body, is not properly wired to the cortex (the wrinkly thinking bit). This is not too surprising when you appreciate how complicated the brain is, and how tangled the wiring. Every part needs to talk to every other part and those wires are long trailing tails of the brain cells, called axons. To connect one place to another, the cells must be born in one area and migrate to the other trailing the tail behind them.

As you can imagine this is complicated and the wiring cannot happen until there is somewhere to connect to. The thalamus and the cortex, initially known as the cortical plate, grow separately. A further group of cells develops in a “subplate zone” beneath the cortex. From 12 -18 weeks connections from thalamus arrive in the subplate zone and then wait as the cortical plate matures. At around 24 weeks they recommence their journey to connect to all areas of cortex. A process that continues to week 32. Also at 24 weeks, the neurons of the subplate themselves migrate into different areas of the cortex, effectively wiring these areas together.

Both these processes are important to an awareness of pain. An 18-week-old foetus moves away from a needle prick and even releases stress hormones but it doesn’t feel the pain. The signals can reach the thalamus and potentially the subplate zone but they can’t ascend any higher. The withdrawal reflex and hormone release come from the brainstem.

By 24 weeks nerve signals start to get through the cortex. Brain wave recordings performed with very premature infants show coordinated neural activity in response to a heel lance from 24 weeks of pregnancy. This sets the lower limit recommended by the Royal College. But, as they observe in their report, this is a necessary minimum but it might not be sufficient. EEG activity is not continuous at this point as it would be in an adult or a newborn. So it is not clear that the pain is being perceived as awareness or experience requires an experiencer.

From the 24th week the brain begins connecting itself up in earnest. The sensory inputs from hearing, vision, and touch pass through to the relevant areas of the cortex. Reciprocal connections downward from cortex to brainstem begin by week 26. Feedback loops start to form and the can begin to exert voluntary control over the world. The fetus is starting to hear, feel and even see things and it is starting to learn.

It is unlikely the fetus has any kind of experience before this. But in the third trimester he or she can absorb a surprising amount. Studies looking for changes in fetal heart rate have found that from 26 weeks onwards the fetus can respond and learn to ignore repetitive vibrations. They can respond to changes in levels of external illumination. And can respond to hearing their mother’s voice and feeling her touch through the walls of the womb (Marx & Nagy, 2015).

My favourite study of this kind was done by Peter Hepper of Queen’s University Belfast (Hepper, 1991). He tested newborn infants at just 2–4 days old to see how they responded to music they had heard in the womb. To do this he took advantage of the fact that many mothers watched soap operas. Half of his sample were fans of the show Neighbours and half weren’t. This meant that half babies had heard its catchy theme tune many times while in the womb. When he played it to the two groups in the maternity ward, the movements and heart rates of the Neighbours babies dropped relative to the control group as they seemed to drop into an alert listening state. To double check they were not just more likely to respond to music he tried the Coronation Street theme and got no response. A second experiment got similar results but this time playing the theme tunes to babies still in the womb through headphones on the mummies’ tummies. Hepper argues that the babies were learning not just the music but were associating it with the calm and relaxed state the mother went into as she sat down to enjoy the soap.

One curious feature of most of these studies is that doesn’t seem to matter if the foetus active or ‘asleep’. Recall that foetuses are only active about 10% of the time and the periods of activity in the womb are a dreamlike state not easily comparable to the wakeful attention of a newborn baby is capable of. In fact, some researchers go further and say the whole pregnancy is spent in a deep sleep. Consciousness expert Chirstof Koch writing in Scientific American:

I wager that the foetus experiences nothing in utero; that it feels the way we do when we are in a deep, dreamless sleep. The dramatic events attending delivery by natural (vaginal) means cause the brain to abruptly wake up, however. The foetus is forced from its paradisic existence in the protected, aqueous and warm womb into a hostile, aerial and cold world that assaults its senses with utterly foreign sounds, smells and sights, a highly stressful event. 
 (Koch, 2009)

It is a vivid image but I disagree that life in the womb is spent in such a sedated state. The changes in infant heart rate in various studies suggest they are responsive to events around them and I think these experiences can even be pleasant for the foetus. Anecdotal reports of babies pictured smiling in ultrasounds have been around since 2000, when the resolution of scans became good enough to show facial expressions. Looking at this evidence systematically, the psychologist Nadja Reissland at the University of Durham and colleagues have identified seven foetal facial expressions and confirmed that both crying and laughing are ‘practiced’ in the womb (Reissland, Francis, Mason, & Lincoln, 2011).

Using modern ‘4D’ ultrasound, which has good spatial and depth resolution in real-time, Nadja’s team scanned two foetuses on multiple occasions between 24 and 35 weeks. They recorded 10 minutes of facial expressions on each occasion and used a standard coding scheme to objectively classify what they saw. Facial expressions can be broken down into their component micro-expressions (pursed lips or raised cheeks). The coding scheme designed for very young babies was adapted to define sets of expressions that went together to form a ‘cry face gestalt’ and a ‘laughter face gestalt.’ Some, like a wrinkling of the nose, were common to both. Others defined just laughter (tongue sticking out & lips pulling back) or crying (pulled down lower lip and furrowed brow). Combining data both foetuses (both girls), they found that the crying expression increased from 0 to 42% occurrence while laughing faces increased from 0 to 35% between the 24th and 35th week respectively.

Pleasant expressions were as common as expressions of distress, and both gradually appear as the foetus itself gradually gains awareness. From the baby’s personal point of view, there really is no time before smiles.

When asked I say the grimaces and smiles of infants in utero reflect something genuine from around week 25. I believe this is the start of foetal awareness of pleasure and pain. This not too different from the 24 week mark recommended in the Royal College report. But, for idiosyncratic reasons, I prefer week 25, when the universal fruit and veg scale says the foetus has reached the size of an aubergine.

A former girlfriend of mine, Belinda, always used to say that springy aesthetic pleasures of aubergines reminded her of the chubby arms, legs and tummies of young babies. In the supermarket she couldn’t resist giving the aubergines a playful squeeze. When I started work with babies she would ask often me “How are the aubergines?” It became our secret synonym.

And then a few years ago, while Belinda was pregnant with her daughter Rose, I got a delighted text message letting me know the pregnancy app on her phone had informed that, after 25 weeks, her blueberry had graduated and she was now the proud possessor of a little aubergine of her own.

For more like this, please look out for my book The Laughing Baby. It is being crowdfunded by Unbound Books. So it needs your support to make it a reality. Please pre-order your copy or tell your friends with babies