The latest parent-dividing headlines announce loudly that swaddling babies may cause them hip problems, according to a new report. Bad news for parents who have found that swaddling settles and soothes their little ones, and now have to decide whether to carry on and feel guilty, or stop and find some new coping strategy. Read More
Researchers from the department of human nutrition at the University of Glasgow have published a study on commercial baby foods, as reported in The Guardian today. Author Charlotte White then appeared on Radio 4’s Women’s Hour to talk about the findings of the study. The piece made good listening, with points made about not introducing solids too early and displacing milk, which is more nutrient dense than solid food; and there being no need at all for follow-on formula. It would have been nice to hear a bit more about baby-led weaning, which is a great option if parents want to take it very slowly and are relaxed about how much food baby actually takes.
Dr Mark Porter on Radio 4’s Inside Health last week had an interesting piece where a particular type of dental problem in children was attributed to extended breastfeeding.
Molar incisor hypomineralisation is described by Professor Monty Duggal, Head of Paediatric Dentistry at the Leeds Dental Institute as “pain and sensitivity in their back molars and also unsightly marks on [children’s] upper front teeth.” This appears to be a relatively new phenomenon, occurring in the last 15 years, and reportedly affects up to 16% of children in the north of England.
Importantly, Professor Duggal explains that this is a perinatal event; that is, something that happens around birth. He then goes on to suggest that new Swedish studies show a link with extended breastfeeding without introduction of solids. He defines extended breastfeeding as breastfeeding beyond six months, which of course is outside the perinatal period.
This raises a few questions for me. We know that in the UK, 23% of babies are still breastfed at six months, but fewer than 2% are exclusively breastfed. Current Department of Health guidelines are to introduce solids at around six months, and the vast majority of parents do it before this time. So I was curious to know where a large enough sample of babies who were exclusively breastfed beyond six months could be found, which perhaps is possible in Sweden where breastfeeding rates are higher, but even so that’s hard to tie up with the stated 16% Molar-incisor hypomineralisation figure for the UK. The Professor’s recommendation to introduce some solids by six months is hardly ground-breaking, but my concern would be that “by six months” would make parents feel they need to start earlier than that, which is not supported by the Department of Health.
With no reference to the Swedish study, it has been hard to follow this up; but I have found an interesting webpage that collates 40 studies of Molar-incisor hypomineralisation from different countries. Without PubMed access, I can only read the abstracts, but few of them mention breastfeeding at all, and this one from 2008 explicitly finds no link with breastfeeding. A 2012 study co-authored by Duggal doesn’t mention breastfeeding in the abstract, but does find a link with lower socio-economic status. Which is interesting in that we also know lower socio-economic status is correlated with shorter duration of breastfeeding. These figures don’t stack up.
On the basis of this interview and my subsequent reading, I cannot see a basis for Duggal’s claim that “they’re nutritionally not fully supported” in the context of dental issues; however it is well-established that breastmilk is a nutritionally complete diet until around the age of six months, when complementary foods are usually needed.
Finally I discovered that Dr Mark Porter is heavily involved with baby milk manufacturer Cow & Gate. Some cynics might feel that such a vested interest in not breastfeeding should be declared whenever there is an article about breastfeeding on the show.
The media week started well, with the heartwarming story about Finnish baby boxes, which I’ll write about later. And then it all went downhill with the release of an amazing report from The Royal College of Obstetricians and Gynaecologists on Chemical exposures during pregnancy.
The RCOG “encourages the study and advancement of the science and practice of obstetrics and gynaecology.” On this occasion, they have taken this to an extreme, by advising women to avoid any possible exposure to chemicals, which may or may not have a harmful effect on their developing baby. While they do explicitly state that none of these harmful effects are proven, this is not how it comes across in the media. Dr Michelle Bellingham, co-author of the report, goes a step further on Radio 4 by asking what harm it does to follow this advice, to err on the side of caution.
So what harm does it do, to tell women not to use cleaning products, shower gel, or make up; not to buy new furniture (presumably including cots and car seats); not to eat any processed or packaged food? Astonishingly, this is presented as “practical” advice. The message it sends is that women themselves are of little importance compared with the package they are carrying. Our job is to breed, and we had better do it well, and if this means no deodorant for nine months, suck it up. In a world where we are made to feel uncomfortable using our breasts for their original purpose and we are expected to glow throughout pregnancy; we are now expected not to wash.
And as the report itself states, there is little or no evidence that any of these items actually do any harm, so this controlling advice is utterly spurious, and the idea that it is supposed to be in any way helpful to women is disingenuous.
Meanwhile any useful evidence-based guidelines are more likely to be ignored by women overwhelmed with conflicting and impractical instructions. On the one hand: good, we are grown-ups, we can make up our own minds. On the other hand, this is a real fail for those of us trying to provide evidence-based support during pregnancy and early parenthood.
Further Reading
The NHS’ excellent Behind The Headlines series takes the report apart here.
Sense About Science dismisses the usefulness of the report and the media coverage here.
Fran Yeoman responds as a new mother, in The Independent.
Risk Sense asks Is everything a risk when you’re pregnant?
This week a new study was published in the BMJ which gave rise to headlines regarding the dangers of sharing a bed with your baby: Bed sharing when parents do not smoke: is there a risk of SIDS? An individual level analysis of five major case–control studies.
The authors of this report combined the results of five studies done in different countries between 1987 and 1998. The amalgamation of these studies gave a sample size of 1472 babies who died, and a control group of 4679 babies who did not. Each individual study compares the conditions of the babies in the two groups. However the individual studies did not look at the same risk factors. The authors were able to draw out some significant factors, and show the level of risk for babies who were in their parents’ bed, compared with babies who were in their own bed in their parents’ room. The risk factors examined are whether the baby was breastfed or bottlefed, whether either parent smoked, the position the baby was put down in (front or back), whether the mother had had alcohol or illegal drugs in the previous 24 hours.
The report concludes that the lowest risk of cot death is where a breastfed baby of a non-smoking, non-drinking mother sleeps on his/her back in the parents’ room, but not in the bed. That is, in the absence of any of the risk factors studied here, the risk of cot death is 0.08 per 1,000 live births. When a baby with the same conditions shares his/her mother’s bed, the risk increases to 0.23 per 1,000 live births. This was reported in the popular press as “FIVE TIMES MORE LIKELY!!”
The Telegraph headline claims that this report “sheds new light on cot deaths”, which is interesting given that the studies in the meta-analysis are more than 15 years old. There are more recent studies the results of which do not support these conclusions. A number of known risk factors are missing from the meta-analysis, including smoking during pregnancy, use of legal drugs such as the strong painkillers often used in the early postnatal period, parental obesity, paternal alcohol use, prematurity, the conditions of the bed itself (was the baby between the parents or on mum’s side, was the baby on a pillow, were other siblings or pets also in the bed, etc). The authors are open about the fact that some of the drug/alcohol data was missing, so they “imputed” this. A cynical mind would define the verb “to impute” as meaning “to make stuff up.”
A huge flaw in the report, and in most studies of cot death risk, is the definition of a breastfed baby. In most cases “breastfed” includes partly formula fed babies. We know how fast the rate of breastfeeding falls in the UK (79% at five days; 58% at six weeks), so it is understandably hard to generate an appropriately large sample of exclusively breastfed babies. However all studies show a lower risk for breastfed babies compared with formula fed babies, therefore it makes sense to me that partly breastfed babies should be either a separate data set, or included with the formula fed babies. The report also implies that while bedsharing is associated with longer duration of breastfeeding, the risk of bedsharing is not cancelled out by breastfeeding and therefore this cannot be considered as a reasonable justification of bedsharing. This overlooks the fact that cot death is not the only thing that breastfeeding protects babies – and mothers – against. The long-term risks of not breastfeeding are well-documented, and may, for some parents, outweigh the 0.23 per 1,0000 risk of bedsharing.
Of course the media is generally more reticent in reporting the apparent protective effect of breastfeeding, lest we make mothers feel guilty. This delicacy does not appear to apply to parents who choose to share a bed with their baby* who appear to make up a similarly large group to the formula feeding parents. (This of course implies that huge numbers of bedsharing parents are also formula feeding parents, which is the higher risk). So here is the point at which I climb, with a sigh, on to my usual hobby horse of WHY ARE WE TRYING TO SET PARENTS ONE AGAINST ANOTHER? What is the use of demonising parenting decisions, banning common behaviours rather than informing about risk and how to reduce it?
Whether you choose to sleep with your baby in your bed, beside your bed, or in another room, it is important to be aware of safety guidelines. If you think you will NEVER sleep with your baby, it is still important to be aware of safety guidelines, as for a lot of parents this is not a planned thing, and that in itself increases the risk. Let us not make bedsharing a taboo subject, or a polarising argument. Let us accept that we all parent in different ways, and we are entitled to be well-informed, rather than dictated to, about risk.
In the last few days we have been hearing news of a shortage of Cow & Gate Comfort Milk and Aptamil Comfort Milk. Danone, the owner of both brands, is reported to have run out of an important ingredient, maize starch, which is a corn-based thickener.
Parents use Comfort Milk for babies who are colicky, have wind, or are prone to possetting (bringing up a little milk after feeds). These are also symptoms of lactose intolerance, as described on this NHS website.
Comfort Milk, according to their website, is “Specially developed with reduced lactose to assist with the dietary management of colic and constipation, keeping your baby more comfortable and giving you a helping hand when it comes to maintaining your little one’s health.” If your baby is constipated, it would be advisable to talk to your GP or Health Visitor.
Packets of Comfort Milk are currently going on eBay for huge sums, to parents desperate to give their baby their usual milk. If your baby usually has a Comfort Milk, and you are unable to get hold of it, you can give any other suitable formula milk instead; switching brands will not harm your baby. All infant formula is made to a set government standard, within very narrow guidelines, and therefore all brands have the same nutritional content. If your baby is under six months, it is important to give milk that is suitable for newborns. Follow-on milk can be used for babies over six months, but is nutritionally unnecessary, and you can continue giving first milk if you wish.
First Steps Nutrition has a good document about different types of milk.
NHS has a step-by-step guide to making up a bottle of formula safely and hygienically.
If you are worried about your baby, you can talk to an NCT Breastfeeding Counsellor on 0300 330 0700
Lots of supportive information about bottlefeeding can be found on our sister website.
As a confirmed skeptic, my title is deliberately provocative, but reflects the tail-chasing propensity I have to apply skepticism to skepticism. I absolutely have to be evidence-based in my work, and I’ve completed a BA module in understanding and using research, but I still worry that I’m as guilty as the next person of cherry-picking it to suit my own views.
When it comes to birth and parenting, the quality of evidence available is not great. Much of the subject matter is undefined or too complex to boil down to a testable hypothesis, and RCTs on babies are ethically difficult. On top of that, parents being such a super marketing demographic, there are an awful lot of vested interests.
Most people working in this area are emotionally invested in some way, and not all the organisations supporting parents have a rigorous reflective practice and supervision structure, allowing them to debrief to the extent that they don’t carry any value judgement at all into their work.
This muddies our use of evidence.
There is some research on how hard it is to adopt new learning, when prior knowledge is deeply embedded. Hence out of date practices and misinformation propagated through on the job learning. If new evidence is not a good fit with what we already ‘know’, it is difficult to re-align oneself. We see this with adherents to scientifically implausible theories for example within alternative therapies, where belief is very much stronger than evidence.
There is also research [pdf] suggesting that GPs often base their breastfeeding advice on their own experience or that of their partners. In fact this rule applies to most people: if it worked for you, you may well suggest it to someone else, especially since the urge to problem-solve may be overwhelming. One GP spoke to me at length about something that she called “yeast mastitis.” A yeast infection of the breast (thrush) and mastitis are two entirely separate conditions, with different (but sometimes related) causes and different treatments. This is fairly basic stuff.
Parents are certainly titled to evidence-based information, and there are some good sources such as NHS and NCT websites; but this should include information about the limitations of the evidence, and where professionals supporting parents are unsure, untrained, or inexperienced, they should be clear about their boundaries and limitations. More damage is done by the supportive making up of answers than by handing over a reputable helpline number.
Evidence can be used as a stick to beat parents with (perfect example: “breast is best”), and then on the other hand it really is overrated as a decision-making factor compared with pressing lifestyle issues and social influences. Science journalist Linda Geddes, a busy parent of two who knows the evidence behind exclusive breastfeeding to six months, still chooses formula milk for her four month old when it is more convenient to do so. She weighs the risk, according to the evidence, but also in the balance are the fact that her two children are “simultaneously clamouring for their dinner and I don’t have time to sit and breastfeed.”
This is not a value judgement, but an excellent illustration of the way evidence is balanced and sometimes negated by parents’ lifestyle and needs, when making decisions. For me, it’s the evidence about sending a six month old to daycare that makes uncomfortable reading.
Working with parents is about providing evidenced information and decision making tools and confidence in themselves as parents. Evidence does not make something right or wrong when it comes to parenting, and we absolutely cannot use it either to dictate or to judge what parents do.
Most weeks, someone will tell me they ‘swear by’ some remedy for one of the many woes of early parenting, and assure me that it has worked wonders. And then they will turn and tell the mum sitting next to them, who [unless healthily sceptical] will unquestioningly accept the recommendation without asking two very important questions:
1. Is there any evidence that it works?
2. Is there any evidence that it does harm?
Infacol is a prime example of a medication recommended widely and unscientifically by mums everywhere, but more worryingly, by GPs and Health Visitors, who must surely know that there is no evidence that it works. Breastfeeding Network has a useful paper [pdf] on colic which discusses Infacol and other remedies, concluding the research is a bit thin on the ground and there are various things you can try; and particularly for the breastfed baby, getting some support with breastfeeding may be key.
Here’s another one: Lansinoh prevents nipple pain. It doesn’t. Its only function is to heal damaged tissue. Nipple pain is almost always prevented (and resolved) by good attachment, and no amount of lanolin cream will facilitate good attachment. In fact, large amounts of it, making the breast slippery, will make it harder for the baby to stay comfortably latched on. In addition, the heavy marketing of Lansinoh reinforces mums’ certainty that breastfeeding will hurt, and is therefore a barrier to doing it at all.
Blogger Scepticon takes a look at amber teething beads and basically demolishes them as a remedy for the pain of teething. Teething is a tough time for parents as well as babies, and parents may feel helpless to alleviate the pain and misery, so it’s no wonder there’s such a market in remedies that are only anecdotally effective.
And when we are talking about our babies’ health, anecdotal is just not good enough. There is an ethical obligation on health professionals not to recommend something just because they have no other answers, but the fact is that few health professionals have the time to sit with an anxious parent and help her to work through her worries and gain confidence in what she is doing. Hence the quick fix: a formula top-up, controlled crying, dummies, all of which can be shown to cause harm.
But the anecdotes of one mum to another seem to carry even more weight at this vulnerable time, and is an inevitable result of the peer-support that we encourage. It’s hard to take that away from new parents, but it’s equally important to encourage them to ask those questions rather than accept at face value the claim that something works.
Last week the British Medical Journal published an interesting study comparing outcomes for children who have experienced different styles of weaning, entitled Baby knows best? The impact of weaning style on food preferences and body mass index in early childhood in a case–controlled sample.
This sparked my interest for a number of reasons, one of which was a response on twitter complaining that research showing ‘pureed foods will make your babies overweight’ just makes parents feel guilty. This commenter went on to complain that the study, of 155 families, was an unrepresentative snapshot; and that was interesting too, because the study showed two main results: Baby-led weaning (BLW) babies were more likely to be underweight, AND puree-weaned babies were more likely to be obese in later childhood. So actually, you’re damned if you do and damned if you don’t, and guilt is once again a diversion from the actual information.
As I have written before, parents are entitled to information so that they can make decisions. The study is available in full on the BMJ website, so we really cannot get away with blaming the media for misrepresenting the facts. It’s quite easy to read, too.
I dusted off my memories of the ‘understanding research’ BA module I did last year, and had a good look at the article. I noticed that there were one or two flaws, but as far as preliminary research goes, it gives some interesting starting points. I thought that the sample size of 155 was not problematically small, but I noticed that the samples seemed to be drawn from quite different pools: mumsnet for the BLW families, and the local toddler lab for the puree families. However the researchers matched the samples for social status and all the usual factors.
The families self-reported on weaning styles, and the researchers acknowledge this as a weakness, since there is no strong definition of baby-led weaning, and it is not a discrete question. Many babies will experience some purees and some finger foods, in varying quantities. This could be addressed by a larger, prospective study following cohorts of children from birth well into childhood.
I also noticed that although the matched sample shows no significant difference between breastfeeding rates in the two groups, it is not clear whether or not the researchers controlled for duration of breastfeeding. The reason this interests me is that baby-led weaning does work well with (but isn’t restricted to) babies who continue to breastfeed well into toddlerhood. This is because if the baby is self-feeding, they are unlikely to consume very much for the first few months, and so will continue to rely on milk as an important source of nutrition probably until they are around a year old. I am just speculating here, but maybe the longer-term breastfeeding family can be a bit more relaxed about how much the baby eats; the researchers do state that BLW is is associated with reduced maternal anxiety about weaning and feeding and a maternal feeding style, which is low in control. I would posit that this is more likely to be the breastfeeding mother, but further research is certainly needed in that area!
I feel strongly that this is another area of parenting where the word ‘should’ does not apply. Many families need some support to find a style of introducing solids that works for them, and there are so many other complex factors, particularly relating to maternal control, that will affect the outcome for the child. As with breastfeeding, few people make the decision based solely on the publicised health outcomes: cost, expediency, social expectations and pressures will all play a part.
I’m starting to do a lot of Introducing Solids Workshops for parents over the next few months, and find the area really interesting. If you are interested in coming along to a workshop in Wokingham, Bracknell, Reading or Bagshot, get in touch.
Louise Timlin is a Health Economist and mother of two.
When I was pregnant with my first child I was often asked about baby-brain. A colleague or friend would smile indulgently and share a story about how they left their laptop on the train, or their wife put their socks in the fridge while pregnant. I smiled politely whilst I thought to myself, of course no non-pregnant person has ever made such a mistake. One day at work, when I was about 6 months pregnant I inadvertently sent out two invites for the same meeting to the same colleagues but for different days. Oops, I thought and shared my error with my boss who was one of the invitees. He laughed heartily and jokingly referred to my “baby-brain”. On my return to my desk I noticed that everyone invited had accepted both meetings without question, yet none of them were pregnant.
I am sure that baby-brain is simply another example of finding evidence for something if you look hard enough. For example I believe that some people are labelled “forgetful” who are probably no more forgetful than anyone else but every time they make a small mistake it is pounced on as evidence of their intractable forgetfulness.
And apparently I am right, according to a study conducted by Dr Helena Christensen from the Centre for Mental Health Research at the Australian National University. The study, published in the British Journal of Psychiatry, followed a representative cohort of women and measured cognition before, during and after pregnancy. No significant differences in cognition were found, leading to the conclusion that previous studies were flawed or biased.
Dr Helena Christensen said, “Part of the problem is that pregnancy manuals tell women they are likely to experience memory and concentration problems, so women and their partners are primed to attribute any memory lapse to the ‘hard to miss’ physical sign of pregnancy. Not so long ago, pregnancy was ‘confinement’ and motherhood meant the end of career aspirations.”
It may be that pregnancy shifts a woman’s focus away from work, and who wouldn’t forget where they’d left the remote control whilst chronically sleep deprived from looking after a new-born baby. But come on girls, give yourselves a break, you are not cognitively deficient and don’t let anyone tell you otherwise.
Having spent 12 years working in the highly regulated field of clinical research I am not a big fan of “alternative therapies”. Don’t get me wrong, I am a big fan of the placebo effect, just don’t kid yourself it is anything else. If it’s not backed up by evidence from a series of well designed, placebo controlled, regulatory and ethically approved clinical trials then you would do well to be sceptical.
The 1023 group concur. They staged a demonstration at 10.23am on 30th January in which more than 400 homeopathy sceptics took a “homeopathic overdose” in protest at Boots continued endorsement and sale of homeopathic remedies. Homeopathic remedies are hugely diluted substances. They are commonly sold at strengths labelled 6C. This means there is 0.0000000001% of the active substance in them.
There are people who are certain that homeopathy works for them. This is why the most rigorous clinical trials are placebo controlled. In clinical trials for antidepressants, up to 40% of patients taking placebo report a beneficial effect. A paper published in the Lancet in 2005 and the Cochrane Collaboration concluded that homeopathy is nothing more than a placebo effect. Proponents will claim that at worst it does no harm. However even this claim should be treated with scepticism. If patients delay seeking proper expert medical advice whilst using homeopathy to treat their condition, they could risk their condition degenerating. By all means go ahead and try it, but don’t forget, we have medicines that have actually been proven to work; why not give them a go at the same time?
Originally written for the Wokingham NCT Newsletter
Views expressed here are my own, and do not represent the views of NCT.