Responses to Breastfeeding and Baby Friendly Hospitals

While we’re stoking the fires this week, here are two responses to my earlier breastfeeding article in The Federalist.

 

Slate: No, You Boob, Government Support For Breastfeeding Is Not a Threat to Our Freedom.

(Can I tell you how much I love this headline? Even though it’s directed at me? Snark for the win. There’s a reason I love Slate).

On a more serious note, upon reading this article, it seems as though Ms. Marcotte and I actually agree on a lot of things, and that she really didn’t take the time to read my article. We, of course, differ on the role of government, but that’s the main disconnect between both parties. I wish people would realize that.

Suzanne Barston responds: Of Nanny States and Nonesense

<begin self-conscious butt-covering>

I hesitated posted links here to my Federalist articles and the responses because I really really didn’t want to get all political here. I’m one of those people that think it’s totally okay to agree to disagree (and am non confrontational and want everyone to like me and am open minded and have changed my views often based on good arguments).  The articles have taken up a lot of my writing time, but I will try to go back to writing for this site as well.

</end self-conscious butt-covering>

Enough politics. Back to The Dreaded Sippy Cup Transition!

Okay, I still haven’t succeeded in moving 16 month old J to sippy cups, so maybe I can’t be the authority on that subject.

 

Advertisements

Controversy: Circumcision- The Cruellest Cut of All?

"You wouldn't..would you?"

“You wouldn’t..would you?”

Part One – Infections and Disease

To circumcise or not to circumcise? Some parents of baby boys don’t think twice about the routineness of circumcision, others are hell-bent against it, and still others agonize over the decision, a decision made harder by the contradictory information out there.  As with most of our controversies, there are multiple angles to the circumcision debate, a debate that is tied into moral arguments and religious freedom as well as hard data regarding health benefits and risks. Our goal will be to summarize all the arguments we can find, and to collate the medical information into plain language.  As there is a lot out there on circumcision, we’ll be breaking this research up into different parts.

Infection rates:

A 2009 meta analysis of studies on sexually active men in Africa found that circumcision reduces the infection rate of HIV among HIV among heterosexual men by 38-66% over a period of 24 months.  In addition, studies have concluded it is cost-effective against HIV in sub-saharan Africa.

A systematic review of interventions worldwide to prevent sexually transmitted infections, to include but not limited to circumcision, found that male circumcision protected against viral STIs and possibly trichomoniasis.  Specifically, male circumcision reduced the incidence of herpes HSV-2 infections by 28%.

Circumcision is also associated with reduced HPV prevalence. This means that a randomly selected circumcised man tested for HPV is less likely to be found to be infected with the virus than an uncircumcised man.  As a corollary to that, male circumcision also was associated with a reduced rate of transmission of HPV to the steady female partners of a circumcised man, leading also to lower cervical cancer rates.  Similar studies are found here, here, and here.

However, this study of course only shows correlation, not necessarily causation. Therefore, there may be other factors at play that lead to a reduced HPV prevalence that only appear to be related to circumcision.  In addition, no strong evidence (as explained in the studies above as well as the American Academy of Pediatrics’s task force on circumcision) indicates that circumcision reduces the rate of new infection.

Studies of its protective effects against other sexually transmitted infections have been inconclusive.

UTIs

Circumcision may also lead to a decreased risk of UTIs in male infants under 2 years old. However, most available data regarding the inverse relationship between UTIs and circumcision is from before 1995. There are two meta-analyses and one cohort study done after 1995 showing the inverse relationship, but data from randomized clinical trials are very limited.  In addition, there is only about a 1% risk of UTIs in boys under two years of age  (compared to a much higher number for girls) , and the majority of incidents occur in the first year of life.  Therefore, even a 10 fold reduction of risk is dealing with a very small number, and circumcision is most likely to benefit boys who have a high risk of UTIs due to anatomical defects.  Finally, a 1999 AAP article clearly states the studies on circumcision and male UTI do not look at potential confounder (such as prematurity, breastfeeding, and method of urine collection).  Some studies, for example, include premature infants, as they are less likely to be circumcised. However, their status as a premature infant itself may be a risk factor for UTIs.  I have also seen allegations on biased (anti-circ) sites that indicate many of the studies included pulling back the uncircumcised child’s foreskin to obtain samples – a method that may itself introduce infection.

Penile Cancer

There is indeed a correlation between decreased penile cancer rates and male circumcision.   However, penile cancer is rare, especially in the developed world (1 new case per 100,000/yr) and it appears to be declining among populations of both circumcised and uncircumcised males.  In addition, although there  appears is a slightly elevated risk in some cases of circumcised males and penile cancer,  in many instances the risk is not statistically significant. Finally, as two of the risk factors of penile cancer are 1.) cancerous HPV cells (which we have discussed at length above), and phimosis, which one would need a foreskin to even have, it is oversimplifying to state that circumcision prevents penile cancer.

Official Recommendations:

So what do the health organizations recommend?Anti-circumcision advocates often state that no health organization in the world recommends it.   This is partially true. The World Health Organization (WHO) does recommend circumcision in areas of high HIV prevalence to combat the rate of infection, although this is not applicable for American infants.  However, the CDC released a study in 2010 indicating that routine circumcision in American infants can be a cost-saving measure against HIV.  In addition, the American Academy of Pediatrics, while continuing to be ambivalent in its view of circumcision, has changed its language from a ambivalent slightly negative stance:

“At this time, there is insufficient data to recommend routine neonatal circumcision. Although there are potential benefits and risks, the procedure is usually not essential to the child’s well being.”

to an ambivalent, slightly positive stance:

“evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it.”

However, this is most commonly seen as a method to allow for circumcision to be covered by insurance carriers.  

As a summary? I wouldn’t circumcise based on a desire to protect from disease alone. However, there are other factors such as culture, religion, hygiene, and the desire to do it while young to prevent a possible need later, that parents need to weigh. We will discuss those issues (and counterarguments of infant pain and the morality of choice) in later articles.

Controversies: To Cry It Out or Not? There Might Not Be Much Research Either Way.

Look at this face. Could you let her cry?

Look at this face. Could you let her cry?

Few things elicit more controversy, advice, commiseration, and myths than infant sleep. Parents are asked early on if their babies have ‘slept through the night’ yet. Debates rage on regarding what exactly IS sleeping through the night and what we can expect at which age.  But by far the most controversial aspect of infant sleep is the concept of crying it out.

Let Me Sing You the Song of My People
First, what is crying it out? I will get into the how and when in the Basics portion of the site, but in general, it involves leaving a baby in the crib to put him or herself to sleep, after checking that they are clean, dry, healthy, and full.  For most people, crying it out involves a process of checking on the baby at intervals, to reassure him or her, and then leaving again, allowing the baby to ‘work it out’. Crying-it-out, especially in this form, is also referred to as ‘Feberizing’, after the work of Dr. Richard Ferber, who published his book, Solve Your Child’s Sleep Problems, in 1985. Some parents also refer to crying-it-out with the generic term “sleep training” although that of course can encompass no-cry methods as well.

Varieties abound. Intervals for checking on the baby can be shortened or lengthened. Some methods involve just a brief 30 second visit to the baby’s room with verbal reassurances, and some advocate picking the baby up until he or she is completely calm. There is also Attended CIO, which involve the parents staying by the baby’s crib until asleep, picking him or her up if hysterical crying ensues.  There are differences in opinion regarding what age to let a baby cry (Babywise by Gary Enzo seems to advocate it sooner than most).  Finally, there is the extinction method, best described by Dr. Marc Weissbluth in Healthy Sleep Habits, Happy Child, in which, in “extreme” cases, one just lets the baby cry to sleep, with no checks or reassurances.

As you can imagine, this is a deeply personal topic for many parents.  The attachment parenting philosophy, of course, is 100% against any sort of cry-to-sleep.  Dr. William Sears, the current guru of Attachment Parenting, states, “Baby loses trust in the signal value of his cry – and perhaps baby also loses trust in the responsiveness of his caregivers. Not only does something vital go “out” of baby, an important ingredient in the parent- child relationship goes “out” of parents: sensitivity. “  An essay I see commonly bandied about parenting forums is “Just Let Her Cry”, giving cry-it-out an adult perspective (“Sometimes,” she writes, “I’d be having a day where I felt I may be able to eat or drink something, and I would call out to him, asking for something.  Again, he would ignore me.  Sometimes he would poke his head in, but it was only to tell me that I needed to go to sleep and I was “fine”.  I had times where I grew very depressed.  On top of being sick and miserable, I missed my husband’s loving arms.  Sometimes I just needed to be held and comforted.  Still, he would ignore me.”).

On the other end, of course, are parents who state, first, that there was no other way to get the baby to sleep, that months of sleep deprivation were wearing on them, that this was as much for the baby’s health as theirs – babies need to sleep. “Walk a mile in my shoes,” they state.  The retort from the other side is often a mix of, “I did it, so can you,” “What did you expect? This is motherhood. Your baby needs you,” and “Your expectations were too high -babies are supposed to wake in the middle of the night, and we are supposed to comfort them.”

The fact that babies need sleep and the fact that babies do wake up at night are both valid, and I can get into that in more detail in the Basics section.  As you can see, just like with formula feeding vs. breastfeeding vs. who cares, there are so many variables in this discussion. Personal philosophy of the parent, disposition of the child, disposition of the parent, parental expectations, advice and comments from social circle, pediatrician advice, mental state of the parent, the extent of the child’s sleep issues (and related to expectations, whether or not the parent sees it as an issue), cosleep vs. not, nightwean vs. not, how much the parent thinks a child needing sleep trumps a child needing to not cry (and vice versa…), and on and on.

On the disposition of the child front, the concept of the tension releaser vs. the tension escalator is relevant, as well as the concept of fuss-it-out vs. full blown CRY it out.  As Moxie points out, some children, the tension-releasers, need to exert energy by fussing or crying a bit before sleeping.  If those parents let the child fuss or cry to sleep, it’s considered cry-it-out – but it’s quite different than the experience of a parent with a very sensitive child, who may scream his or her head off the minute when placed in the crib. Those parents look at CIO parents completely askance.

…. Of course, with the fuss it out part, Mothering.com, known for its strict forum guidelines regarding certain positions contrary to peaceful parenting, takes issue even with discussion of a child fussing in his or her crib.

However, instead of the dramatics of this particular Mommy War, what I’m interested is is what the research shows.  Can cry it out damage a child? Conversely, can the lack of sleep training actually harm a child’s ability to sleep well (and all that comes with it – learning and development) down the road?

This Psychology Today article seems to give the ultimate verdict – crying it out damages the neurons in a child’s brains, leaving to a lifelong feeling of neglect.  But where are the studies that actually say that? Every study cited in this article talks about the effects of emotional distress, significant stress, and low-nurturing parents. We have here a common conflation – cry it out = emotional abuse, a child ‘left to cry’ in his or her bed is exhibiting significant distress.

We return back to Moxie’s “tension releasers” vs “tension increasers”, and the fact that most parents likely can tell when a baby is crying out of anger vs when a baby is truly distressed.

Now, in one of the first articles she writes, talks about a Harvard study that shows that CIO changes the baby’s nervous system, making the baby sensitive to future trauma.  So a smoking gun, correct?

Perhaps not.

It seems as though the Harvard study cited everywhere as showing for a fact that CIO causes long-term harm to babies is…just the personal opinion of the researchers?

There goes one of the major ‘evidence-based’ arguments against cry-it-out, one that I see over and over again.

So I’m for crying-it-out, right? Not necessarily. I try not to take a stand on either side of these types of arguments. If I seem pro-CIO here, it is simply because I just want to dissect the claims of anti-CIO people I see, and unfortunately, most of what I see doesn’t hold water.

Wait, there’s a new study that shows CIO has absolutely no ill effect?

Not exactly.   Major news organizations implied the study showed that a group of children who were subjected to CIO and a group of children that were not showed absolutely no difference years later.  But as AP champion Annie at PHD in Parenting points out:

“The only difference between the intervention group and the control group is that the nurses that in the intervention group were given formal training on sleep interventions. From what I can the parents were never asked which sleep interventions they used (if any).”

So, again, I’m not here to tell you to use one method or the other.  All I can tell you is that there isn’t much to scientifically give you an answer one way or the other.

Here are some more breakdowns on the research (or, that is to say, a lack thereof) on crying it out:

http://answers.google.com/answers/threadview/id/774928.html

http://www.infantsleep.org/cryingitoutresearch.html

The studies cited in the thread and in the article are below:

http://www.ncbi.nlm.nih.gov/pubmed/14989452?dopt=Abstract

http://www.ncbi.nlm.nih.gov/pubmed/1527680?dopt=Abstract

Controversies: Should You Redshirt Your Kindergartener?

Boy in Red ShirtThe practice of ‘redshirting’ kindergarten (holding kids back one year before they enter) has been the source of media histrionics over the last few years. Media reports usually presume parents redshirt so their children gain academic and leadership advantage over younger, less developed, more impulsive classmates. This theory developed after the popularity of Malcolm Gladwell’s Outliers, in which he discussed the landmark study indicating the power of age in Junior Hockey leagues in Canada.

Quite a few studies have been done regarding the impact of redshirting. A 2005 RAND study indicated the practice has benefit to reading skills in the first grade. However, a 2008 study by Harvard’s Dyanarski and Deming indicate there is not really a lasting, positive effect to redshirting – the benefits gap closes at about third grade. A 2000 study indicates there may even be some negative effect on behavior, especially for boys. A Canadian study even indicated benefit to “greenshirting” (starting school at a younger age). Finally, a study in Pediatrics journal of Icelandic middle schoolers indicated the practice may lead to higher ADHD prescription rates as the non-redshirted children seem hyperactive in comparison.

Important stuff, right? Maybe not. A March 2012 paper examining the practice found the incidences of redshirting nation-wide are much smaller than media reports seem to indicate (surprise surprise).

The exciting news is that another paper appears to be in the works.  We’ll keep our eyes peeled for the results.