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“Attachment Parenting Medicine”, Part II

In Part I of this series, I pointed out a bit of magical thinking on the part of Susan Markel, M.D. who calls herself the “Attachment Parenting Doctor”. As I pointed out, she seems not very keen on vaccination (though she doesn’t quite take a stand against it). I find that odd on the part of the doctor, but she certainly has a right to her own opinions. I presume that, as the “AP doctor”, she has a none-too-small contingent of non-vaccinators whom she feels the need to cater to. However, medical opinions need to be based upon facts, and some of the things she says here clearly contradict known facts. It fact, the stuff on that webpage sounds much like the usual pseudoscientific mumbo-jumbo you find on AP webpages. Somehow, I expect better from someone with a medical degree and board certification in pediatrics.

(Just for full disclosure: I have a few families in my practice who don’t vaccinate, usually for all the common junk-science reasons. Working in a country with socialized medicine, I don’t know that I have the right to throw them out of my patient base, nor would I; however, I make very sure that they know exactly and in great detail how unwise I think their decision not to vaccinate is, and do my best to convince them to rethink their position. Nobody has left my care as a result – I don’t harass them about it nor do I get nasty, and I’ve even managed to change one mother’s mind, I’m happy to say).

Markel suggests that good alternatives to vaccination are:

Giving your children the “best diet possible” – i.e, whole grains, “organic” foods, avoiding corn syrup and the like.

While this is good advice in general (well, except the “organic” foods. Plain conventionally grown produce is every bit as healthy for you, and usually, you can afford more of it), and while malnourished children are certainly more at risk from infectious diseases, there is no evidence that unvaccinated children on this “holistic” diet are any more protected from vaccine-preventable diseases, or even from complications of such diseases, than a child on a conventional Western diet – McDonalds and all. In fact, there have been rather bad cases of disease among unvaccinated “natural-parented” children. Here’s a description of whooping cough cases among children on Vashon Island, WA, whose parents thought as Dr. Markel suggests:

From 1995 to 1999, said Ms. Packard, the school nurse, an epidemic here of whooping cough, which can be fatal in infants, hospitalized some infants and left some children with chronic asthma. Ms. Forest’s grandson Deven had whooping cough two years ago and, she conceded, probably passed the disease to 10 other children, including an infant.

”Yeah, that bothered me,” Ms. Forest said. ”But I called everybody and we studied up on what you can do to build up the immune system.”

The baby ”did just fine,” she said. ”On Vashon Island, you have middle-class people who eat healthy and keep warm. If everyone was poor-poor, not breast-fed, not eating right — that might be a reason to vaccinate.” But she and her daughter remain steadfastly opposed.

Meg White, 45, though, now somewhat regrets not vaccinating. Three years ago, her whole family, including her infant son Julian, had whooping cough ”really, really bad” for more than three months.

”My son would turn all shades of purple,” she said. ”He stopped breathing several times and we took him to the hospital. My daughter was terrified of going to sleep because then it got worse. She would vomit all over the place. My husband cracked ribs from coughing.”

Here’s another description of a measles epidemic in an affluent town in Germany, egged on by some homeopathic “doctors” and the local Waldorf school.

Breastfeeding as a panacea.

Claims Dr. Markel: “Breastfed babies are immunized; children who are injected with viruses and bacteria are vaccinated. An endorsed campaign by the government to increase Americans’ breastfeeding rate would prevent more childhood diseases -and deaths- than all of the vaccination programs currently endorsed.

As I’ve pointed out before, I’m all for breastfeeding and the immunological properties of breastmilk. But it takes a good deal of ignorance – or plain intellectual dishonesty – to claim that breastfeeding confers better protection against severe childhood diseases and death than vaccines do. Despite Dr. Markel’s wish to cater to her patient base, a doctor’s job is to advise her patients honestly and in a fact-based manner.

Putting aside for a moment the issue of passive vs. active vaccination (breastfeeding mostly confers antibodies which are gone not long after the baby stops breastfeeding, whereas a vaccine helps the child produce antibodies on his own which are much longer lasting), let’s compare the two – giving the breastfeeding side all the breaks possible – and see for ourselves which is the more effective health measure.

The only large study I know of which attempted to estimate how many excess deaths occur in babies due to their not breastfeeding is the infamous Chen and Rogan study from 2004. The study’s authors estimated that about 720 lives of children 1 month – 1 year old would be saved in the US each year if all children were breastfed. Unfortunately for them the only statistically significant association between lack of breastfeeding and increased incidence of death was in the category of “accidental injuries”, suggesting that the effect was probably the result of confounding variables not tested for (unless someone can suggest a plausible mechanism by which a breastfeeding baby is better protected from falling off a changing table, say, than a formula-fed one). But what the heck, I said we’re giving Dr. Markel every break possible. So let’s assume that breastfeeding can really prevent 720 infant deaths per year.

Now let’s look at vaccines and their health impact. The CDC has a great article on its website titled “What Would Happen If We Stopped Vaccinations?“. As I said I’m going to give the breastfeeding side all the breaks possible, I won’t include morbidity from nonfatal vaccine preventable diseases (mumps and rubella), nor mortality that usually manifests itself in adulthood from a disease acquired when the subject was a child (hepatitis B). That doesn’t mean those diseases are not worth vaccinating for, or do not save lives (again, I’m not counting fetuses that are aborted as a result of congenital rubella syndrome as deaths, but if you happen to be pro-life, you might want to).

Polio: Before vaccines, there were 13-20,000 cases of paralytic polio in the United States annually, mostly among children. According to the CDC, the death rate for paralytic polio among children (usually as a result of permanent paralysis of the breathing muscles) is 2-5%. 2% of 13,000 is 260 deaths per year. Remember that’s taking the minimum numbers.

Measles: Measles has a death rate of 1-3/1000 in the developed world (in the developing world, the rate is much higher due to nutritional deficiencies, particularly Vitamin A; but that’s not what we’re discussing). According to the article, “An average of 450 measles-associated deaths were reported each year between 1953 and 1963.” Measles vaccine was first introduced in 1963; you can see what happened to measles rates once vaccination was introduced here.

Hemophilus influenzae type b (Hib): ” Hib meningitis once killed 600 children each year and left many survivors with deafness, seizures, or mental retardation.”

Pertussis (whooping cough):“In the U.S., prior to pertussis immunization, between 150,000 and 260,000 cases of pertussis were reported each year, with up to 9,000 pertussis-related deaths.“. Even assuming that given better artificial respiration techniques, 95% of those 9000 children could have been saved (and I think I’m being optimistic here), that’s still some 450 deaths per year.

Penumococcus:“Before pneumococcal conjugate vaccine became available for children, pneumococcus caused 63,000 cases of invasive pneumococcal disease and 6,100 deaths in the U.S. each year. Many children who developed pneumococcal meningitis also developed long-term complications such as deafness or seizures. Since the vaccine was introduced, the incidence of invasive pneumococcal disease in children has been reduced by 75%.” That’s a reduction of 4575 cases/year.

Chickenpox: Caused mostly deaths in adults and vaccine uptake is relatively low. I would guess the vaccine prevented a few deaths in children from the previous level of 100-150 deaths per year overall, but it’s hard to estimate the exact number.

Diphtheria:“If we stopped immunization, the U.S. might experience a situation similar to the Newly Independent States of the former Soviet Union. With the breakdown of the public health services in this area, diphtheria epidemics began in 1990, fueled primarily by persons who were not properly vaccinated. From 1990-1999, more than 150,000 cases and 5,000 deaths were reported.” which makes some 500 deaths/year on average.

Tetanus:“From 1922-1926, there were an estimated 1,314 cases of tetanus per year in the U.S….approximately 20% of cases end in death”. Add another 260 fatalities per year.

I’ll leave you to do the adding-up, but it should be quite clear to anyone who can do basic math that vaccines are a far more effective health measure for children than breastfeeding is. There’s no reason you can’t do both, of course; but to pretend breastfeeding is in any way, shape or form as, or more, effective as vaccines in preventing severe childhood illness and/or death is something nobody, least of all someone with an MD, should contend.

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“Attachment Parenting Medicine”, part I

I’ve recently come across a pediatrician on the Web who calls herself the Attachment Parenting Doctor, one Dr. Susan Markel. Dr. Markel is board-certified in pediatrics and has an M.D. from Tufts University, and is the medical associate for Attachment Parenting International. She also blogs on a group blog at Babycenter called Momformation. Looking over her entries on vaccines, one gets the impression that while she may not be anti-vaccines in general, she has an inordinate amount of sympathy towards parents who choose to opt out of vaccinating their children. Sometimes this is very subtle – for example, on a recent entry that discusses whether nonvaccinating parents should falsely claim religious exemptions for their children, a picture of a book dealing with legal vaccine exemptions is shown. Similarly, her comment on a study which demonstrated that parents who do not vaccinate are more likely to utilize woo*, have more distrust of the government’s motives, and display a good deal of ignorance and denial about vaccines and immunity, is:”Asking questions about the safety and effectiveness of your child’s health care and medical treatments is a positive parenting trait. It is important to get all the facts before making a major decision like forgoing childhood vaccinations.” …um, Doc? A few pointers about how not all sources of “facts” are equal might be in order, dontcha think?

Unfortunately, Dr. Markel doesn’t seem to vet her sources very carefully, either, that is when she chooses to reveal them. She seems to think a book by the late medical maverick, Robert Mendelsohn, M.D. , is a good source to quote. Never mind that the information being supported (feverphobia and the proper treatment of fever in children) is nothing original and is available from much more reliable sources.

Sometimes, all this flirting with woo and nature-worship causes Dr. Markel to cross over the line into outright misinformation. Let’s look at one of the more egregious examples I’ve found.

The Vitamin K birth dose “dilemma”

Markel states :

“If newborns are allowed to breastfeed soon after birth, the injection of Vitamin K is less necessary, since the colostrum that comes immediately from the mother’s breast before her milk lets down is usually rich in Vitamin K.”

Unfortunately, the amount of vitamin K obtained from colostrum is neither very large, nor is colostrum all that much richer in vitamin K than breastmilk. Either way, one must contend with the reality that exclusive breastfeeding (as opposed to formula feeding) is a risk factor for hemorrhagic disease of the newborn, which the vitamin K (given by injection or in several oral doses) is meant to prevent.

Dr. Markel muses:

It might be said that the standardization of the Vitamin K injection and indeed all the routine procedures performed on the newborn baby reinforce the messages to both baby and mother that nature is inadequate, that they are now dependent on the medical profession for their health.

Um, doc? Nature is inadequate. Nature is “looking” (assuming we accept the personification of this entity, of course) to keep the species going, but that doesn’t mean every human baby is guaranteed to survive under natural circumstances. To remind you, some 25% of fetuses are spontaneously aborted in the early weeks for pregnancy, most often because nature got it wrong and conceived a fetus with severe chromosomal abnormalities. There’s also that small issue of the 4% or so of babies born preterm. Nothing says “nature goofed up” better than a 24-weeker saved by the NICU staff.

Most babies will eventually overcome their vitamin K deficiency by acquiring vitamin K-producing gut bacteria in time (and one can argue that under more “natural”, less sanitary conditions, this happened sooner rather than later), but a minorty won’t. To most mothers, however, having one’s own baby die of an easily preventable cause is inexcusable. Therefore, we improve upon nature by this very simple intervention. Most mothers should be able to deal with the ‘unnaturalness’ of it.

Oh well. I suppose one should be thankful that Markel didn’t dredge up that old, long discredited canard about how vitamin K causes childhood cancer.

Next post, we’ll be dealing with another manifestation of Dr. Markel’s wishful thinking vs. the real facts of breastfeeding and vaccinations.

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*For the definition of woo, see here.

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Veronika ups the ante

If you’re a regular reader of this blog, you’ve already briefly met Veronika Robinson in this post; she’s the woman in the video who breastfed her two daughters until they were 7 and 8 years old. Robinson is also the editor of The Mother Magazine, which, judging by the articles on the website, is to Mothering Magazine as Mothering is to, say, Parents. Robinson is a True Literal Believer in (childless) Jean Liedloff’s The Continuum Concept and really truly believes that the worldwide average age of weaning is 4.2 years. Those facts alone should tell you great deal about her information-processing facilities.

Lately, I’ve been perusing her blog (which she seems to update even more infrequently than I do mine, hehe). The prose is stylish and flowing, and the pure…oddness of the content makes it an interesting read, but it’s sometimes hard not to cringe.

One entry in particular caught my eye. It deals with a style of parenting I’d not previously heard about, but which sounds like a like a somewhat kinder, gentler version (on the parents, that is) of AP called Aware Parenting. While generally subscribing to the principles of AP, Aware Parenting recognizes that parents have needs and wants of their own, and cannot possibly anticipate their child’s every need. Or to quote the website:

Aware parents accept the entire range of emotions and listen non-judgmentally to children’s expressions of feelings. They realize that they cannot prevent all sadness, anger, or frustration, and they do not attempt to stop children from releasing painful feelings through crying or raging.

“Aware” parents, when faced with a crying, inconsolable baby, are encouraged to hold her while crying, after checking she has no needs that they, the parents, can address to relieve the crying jag. The philosophy views this type of crying as the baby’s method of letting go of internal tension. This, of course, does not sit well with Veronika. In her view,

What they don’t seem to acknowledge is that crying is virtually unheard of in indigenous cultures where babies’ needs are instantly met, if not anticipated first. Even if advocates of Aware Parenting don’t wish to admit it, they are in effect encouraging ‘controlled crying’. They do not encourage comforting of the baby through nursing, jiggling or rocking the baby ~ all actions which come instinctively to a NURTURING mother.

Though she parrots Jean Liedloff precisely, the notion that babies in hunter-gatherer societies nerver ever cry is, of course, unmitigated nonsense. All babies are hardwired to cry in their early weeks, some more than others. Just because Liedloff didn’t happen upon a colicky baby during her stay with the Yeqana Indians, or Verokina Robinson’s daughters didn’t exhibit such behavior to extremes, doesn’t mean it never happens or is related to inattentive parenting. I imagine “Aware” parenting is very much in favor of not just holding your crying child like a lump, but all the jiggling, rocking and nursing in the world may not soothe your baby if the crying is a result of colic, or conversely, an ear infection.

But that’s not good enough for the likes of Veronika Robinson: If you can’t read your baby’s mind and immediately alleviate (or would that be, alleviate in advance?) the source of her tension, you’re obviously a defective parent and not sufficiently “bonded” to your child. She actually says this in a more recent entry:”…when we’re bonded with our children, then we have an ESP-like quality which means we can meet their needs ahead of time. They don’t need to go into distress mode. When we’re bonded, we instinctively know what our children need, and equally, we know how to meet that need.”

I wish life were that simple.

My daughter is normally a delightful child with a sunny disposition. But between the ages of 1-3 years, she would often wake up from her night sleep or more frequently, from naps, crying hysterically. The crying jag would typically last about half an hour, during which she would reject any of mine or my husband’s attempts to physically comfort her. Inevitably, she’d accept a glass of water offered for the 4th or 5th time, calm down, and return to being her usual happy self. It made no difference if she was in bed with us when she woke, nor that I anticipated her need for water and offered it – she herself probably had no idea that was what she needed. I remember a cousin of mine having similar crying jags as a small child, and talking with friends and patients, it seems like a fairly common toddler ordeal. According to the likes of Veronika Robinson’s and based upon a sample of 2, though, we must all – even “aware” parents – be child abusers.

Oh, incidentally: that cousin of mine? She’s about to celebrate her 29th birthday, has a wonderful relationship with her parents, aced medical school and has just started her residency in oncology. And she has 3 darling children of her own, who are a joy to be around. Even if they were subjected to “controlled crying” of this, and the more conventional type…whereas Robinsons daughters, reading between the lines of her blog, are having a great deal of difficulty dealing with the world outside their home/cocoon.

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A refreshingly honest look…

at the realities of cosleeping with a 7-year-old. Apparently they don’t all leave the parental bed that fast. Note the little tyke is no stranger to emotional blackmail.

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Ewww…chemicals!

At NP/AP websites and messageboards, you’ll often read claims that society is being “poisoned with toxic chemicals” by Big Business, especially Big Pharma. These claims manifest themselves in myriad ways, such as how fluoride in our water and pesticides and preservatives in our food have caused cancer rates to skyrocket, how vaccines cause various diseases as the result of “toxins being injected into little babies”, or with false promises by snake-oil peddlers to rid your body of these toxins via herbal supplements, colonic irrigation or what not.

Unfortunately, even smart people sometimes fall for such scams – just look at the proliferation of “organic” produce*, or those scary emails about that horrible poison, aspartame. I hope to provide a few ground rules and reliable sources to separate the wheat from the (organic) chaff, so to speak.

Toxins are everywhere. There’s no getting away from the fact that everything (including us) is made of chemicals, and small dosages of frightening-sounding ones are prevalent in the air, water, soil and food. Humans aren’t to blame for much of it, either; elements such as mercury, aluminum and arsenic are all over the place and ingested by a variety of animals humans like to eat.

Not everything with a scary-sounding name is actually that scary. Keep that in mind next time you see an anti-vaccination website that claims vaccines contain “sodium chloride”, since you do too. And so does everyone who’s ever ingested…table salt. Next thing you know, you might be asked to sign a petition to ban that awful chemical, dihydrogen monoxide (chemical formula: H2O). Which brings us to

Rule #1 of toxicology: the dose makes the poison. As the DHMO website illustrates (all the information in it is 100% true, by the way), even necessities like water and oxygen can be highly toxic in the wrong doses. The rule holds for all chemicals, and the reverse is also true: minute doses of known poisons in our environment are generally harmless. In general, the EPA’s maximal allowed concentrations of different chemicals in water or air is much, much lower than doses known to cause toxic reactions. In fact, when the level of mercury via thimerosal in vaccines might have exceeded the EPA levels in very small infants, thimerosal was removed from vaccines, even though there was no evidence (and still isn’t) that the chemical caused any harm to babies, and in fact, the form of mercury in thimerosal (ethyl mercury) has since been shown to evacuate from the body in significantly less time than the mercury the EPA was referring to (methyl mercury), most probably making it even less toxic.

Nature is chock-full o’ toxins. No, I’m not referring to naturally derived drugs and poisons like curare, vinca alkaloids (used in chemotherapy) or digitalis, though those are certainly interesting. I’m talking about the formaldehyde in your apples, cyanide in your spinach…that sort of thing. Both are examples of naturally-occurring toxins in food (yes, even “organic” food) that we eat every day.

To quote Dr. Bruce Ames, developer of the Ames test to determine carcinogenicity of various toxins:

About 99.9% of the chemicals humans ingest are natural. The amounts of synthetic pesticide residues in plant foods are insignificant compared to the amount of natural pesticides produced by plants themselves. Of all dietary pesticides that humans eat, 99.99% are natural: they are chemicals produced by plants to defend themselves against fungi, insects, and other animal predators.

Each plant produces a different array of such chemicals. We have estimated that on average Americans ingest roughly 5000 to 10,000 different natural pesticides and their breakdown products. Americans eat about 1500 mg of natural pesticides per person per day, which is about 10,000 times more than the 0.09 mg they consume of synthetic pesticide residues. Even though only a small proportion of natural pesticides have been tested for carcinogenicity, 37 of the 71 tested are rodent carcinogens. Naturally occurring pesticides that are rodent carcinogens are ubiquitous in fruits, vegetables, herbs, and spices.

Humans are blessed with a great natural detox system which usually needs no outside help. Folks, meet your liver and kidneys. ;-)

Most cancer incidence rates (and even more so, cancer death rates) are actually decreasing. See here and the continuation of the trend, here

Some more useful reading: Health scares and the art of scaremongering.
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*Organic=carbon-based. In fact, almost all foods and all pesticides are organic.

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I guess there’s no such thing as bad publicity…

I’ve been expecting someone like this to come along sooner or later. No, she didn’t actually read any of the links. Why read information when your prejudices (excuse me, er, “instincts” ;) ) tell you otherwise? Hopefully, some of those she points here will bother to peruse the blog and the links contained within, and may find some value in it…or at least, emerge a bit less dogmatic.

So welcome, Livejournal folks. Feel free to look around and yes, click on the links. I promise none of them have cooties!

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Keep your agenda off my breasts, please!

A reader writes:

I’m due with my second child soon. I breastfed my first for only four months – I don’t beat myself up too much about it, but I do regret it because of the reasons I quit. We had no physical problems whatsoever, and she wasn’t an all-day comfort nurser. What sent me into a breastfeeding-related depression spiral was all the breastfeeding advice I was reading.
Even though we didn’t have problems, lots of times I’d want to know if something was normal, etc., so I’d look at kellymom or the LLL site or something. And as you know, those sites DON’T just give breastfeeding advice – it comes with a healthy side of Agenda. So by the time my daughter was a few months old, I was convinced that the only way to successfully breastfeed was if you also coslept, never left the baby’s side for a moment, fed at every single peep, were willing to forgo sleep for years on end, blah blah blah. And I just wasn’t willing to do all that stuff, so I stopped.

I’ve since talked to a lot of other women about this and realized that it IS possible to breastfeed for a year or more without following the AP party line. Maybe you have to pump, maybe you have to give a formula bottle here and there, maybe you sleep train – but you can still breastfeed. At least that’s what they say. I’d like to believe that’s true, because I’d like to be able to go longer with my second child. Does “breastfeeding for the real world” sound like something you’d be interested in weighing in on?

Yes, I would. I think many breastfeeding resources, in print and online, “mix issues” far more often than they may realize, or at least are willing to admit. While a site like Kellymom is at least up front about being about “breastfeeding and parenting”, the La Leche League, which is supposed to be for the support of breastfeeding only and despite its protests to the contrary, recommends books and takes positions on diverse issues such as promoting “natural” birth, bedsharing and leaving work to SAH full-time, as ideals we women should strive for. While it could be argued that these practices promote breastfeeding, so do a lot of other things – like farming out your older kids for the first 6 weeks or having an LC live with you 24/7. But I can’t see The Womanly Art of Breastfeeding pushing that as ideal. The fact still remains that women overwhelmingly choose analgesia during birth, choose not to cosleep, return to work either out of desire or necessity, at some point expect their babies to sleep through the night…and they still should receive BF support without the dollop of judgement so favored by certain popular books and organizations. For many women, not working or having a “natural” birth is as practical as farming out your eldest in favor of the nursling.

Mind you, in the circles I work with (ultra-Orthodox Jews), women who’ve given birth to their 3rd, 4th or even 15th child often go with their babies to a few days at a “convalescent home” after they are discharged from hospital, to get some much-needed rest before they return to the demands of a large household. These women often refuse to “room in” at the hospital, and these facilities often have baby nurseries if Mom needs a break. Somehow, despite all the ‘detachment’, these women have the highest breastfeeding rates in Israel (which overall has higher BF rates that the US or the UK). These women could probably teach LLL a thing or two about breastfeeding…even without the AP trappings.

I’d like to suggest an alternative breastfeeding guide (no, I’m not getting paid for this and I don’t know the author from Adam, in case you were wondering) which doesn’t toe the AP party line, but still manages to be fairly comprehensive : Dr. Mom’s Guide to Breastfeeding By Dr. Marianne Neifert. While Dr. Neifert (a pediatrician and a lactation expert, who had a hand in composing the 1997 AAP policy statement on breastfeeding), is very pro-BF – and it shows – she also was in the proverbial BF trenches while a college student, intern and resident, and she can well appreciate the very real difficulties women run into while breastfeeding, as she herself needed to supplement with formula with 4 out of her 5 babies. The book covers insufficient milk supply in the most in-depth manner I’ve ever seen in a breastfeeding manual (ex. – did you know certain breast shapes can help predict if you might run into supply problems?), and how, and with what, to supplement if appropriate. Most importantly, the book is the least preachy of all the books of this kind: It discusses the different (as in equally valid) sleep arrangements of the family bed and sleep “training”, never once suggests that if you go back to work, your commitment to your baby is lacking, and gives various solutions to working and breastfeeding (some of which, believe it or not, may include mixed feeding with no guilt trip attached), and the section on weaning doesn’t make you feel like an evil selfish bitch for even considering it.

I would have liked to see an appendix about medicines and breastfeeding (instead of the few examples in a few paragraphs given), but this information can be found elsewhere and is subject to change as medical knowledge updates itself.

Neifert was a member of the Health Advisory Council of LLL, and is a lot more enthusiastic about them than I am. However, some of her advice, and her general approach to the subject, goes against what the “official” LLL is saying in the most unapologetic manner. While the book was published in 1998, I think she’d still be uncomfortable with LLL’s wimpy and confusing 2005 statement regarding HIV(+) women breastfeeding.

Anyway, the ideal is to breastfeed. AP Purism isn’t, and shouldn’t be, the goal.

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