A pediatric bonanza!

Wow. This coming month’s Pediatrics seems to have been written specially for this blog. The magazine is a treasure trove of studies about hot parenting topics, but the editorial staff seems to have outdone themselves this time. Let’s see:

In the “Yet another nail in the coffin” dept. we have an Italian study of over 1400 children, Tozzi et al, which demonstrated that the amount of thimerosal given to children in their pertussis vaccines (the children were randomly assigned to receive low or high-dose thinerosal, 62.5 vs. 137.5 mcg) made no difference in most (22/24) test of neuropsychological performance they were given 10 years later. In the two tests the high-thimerosal group did differ on (in girls only, the finger-tapping test and the Boston Naming test), though the difference was statistically significant, the absolute score difference between the two groups was low, and as the researchers point out, so many tests were given that it could very well be a matter of chance that some of the results came out statistically significant.

Keep in mind that this is not, per se, a refutation of the thimerosal/autism theory, but rather a corroboration of Thompson et al (2007), which also examined the purported link between thimerosal exposure and later neuropsychological outcomes…with very similar results. There was one child with autism…in the lower-dose group.

In the “Somebody desperately needs a shave with Occam’s Razor” dept. we’ve got Strathearn et al, which followed up an Australian cohort of prospective mothers presenting themselves for prenatal care at a large maternity hospital in Brisbane in 1981-84. Of the original 7223 maternity patients with liveborn, singleton babies delivered at the hospital, 92% (6621) of the mother-infant dyads were available for followup at 6 months with regard to breastfeeding info, various sociodemographic factors and government agency reports of child maltreatment if present. At 15 years later, records were collected on 81.5% of the original qualifying cohort (5890 dyads) with regard to later maltreatment. 512 of the children were reported to the authorities with at least one maltreatment episode (either neglect, emotional abuse, physical abuse, or a combination of same).

After adjusting for a veritable mountain of confounding factors (the table listing these variables takes a page and half of the article and covered age, marital status, substance abuse, whether the pregnancy was wanted and many other factors), the researchers found that the mothers who didn’t breastfeed had 2.6 times the odds (95% CI 1.7-3.9) for maltreating their children in any way as compared to mothers who breastfed 4 or more months. Of the various types of maltreatment, only child neglect was independently associated with breastfeeding duration, though all types of maternal maltreatment were associated with significantly lower incidence when not adjusted for other maltreatment types (in case more than one type of maltreatment occurred).

The authors’ conclusion? Breastfeeding (or rather, the oxytocin secreted from the mother’s pituitary while breastfeeding) prevents a child from being maltreated by her mother. Groan.

Let’s think about this for a minute: If one were the type of woman prone to abusing – or especially neglecting – one’s baby, what kind of feeding method would best enable Mom to pop out for a party overnight, or allow her to pursue her addictions with the minimum of hassle? Would such a woman be up to dealing with sore nipples, engorgement or low supply issues? What feeding method would she be likely to choose?

I wouldn’t say no such women would breastfeed, but it seems logical that many such women would not bother to, or quit at the first sign of trouble or inconvenience. In fact, a previous study (which the authors of the present one mention in the discussion, to their credit) demonstrates that breastfeeding doesn’t enhance maternal sensitivity and infant attachment; rather, the intent to breastfeed and subsequent infant attachment are both caused by the mother’s quality of sensitivity. Similarly, it makes sense that whatever quality (hormonal or otherwise) makes women want to breastfeed also prevents women from maltreating their children. Intent to breastfeed before giving birth, however, was not assessed in this cohort.

Does this study mean that if women at high risk of abusing their children are pressured to breastfeed, they’ll be less likely to maltreat their children? No, but it’s probably worth further study (you could also correlate national breastfeeding rates, which have risen in all socioeconomic strata since the early 80s, to the national rates of maternal child abuse, to help answer this question). Will Jane in Suburbia be more likely to abuse or neglect her children as a result of the fact that she bottle feeds? Not bloody likely.

(Kudos to Annie for not entirely falling for this one, BTW. The title of her post could use some work though, IMHO).

And finally, in the “Makes you go Hmmm…” dept. we’ve got Shapiro-Mendoza et al. The authors, on behalf of the CDC, looked at the national infant mortality rates between the years 1984-2004, sorted according to cause of death. They found that there was a dramatic decrease in total causes of SUDI (sudden unexpected infant death) and SIDS during the early 90s as a result of the “back to sleep” campaign. More importantly,despite there being fairly stable rates of SUDI in the years after the campaign’s effect (1996-2004), there was a marked downward shift in SIDS rates, corresponding to an increase in deaths due to accidental suffocation and “unknown”. This strongly suggests that a diagnostic shift is occurring – namely, many deaths that would have been attributed to SIDS in past years are now thought to actually have been caused by suffocation.

The researchers examined the death certificates of accidental suffocation deaths from the years 2003-2004. Too many details were missing in too many certificates to come to a definite conclusion, but the information which can be gleaned, especially combined with prior knowledge about accidental suffocation (e.g. the CPSC’s Drago and Dannenberg) suggests a role for bedsharing as a cause of at least some of the deaths. A majority (51.2% of death certificates) of the infants were bedsharing at the time of death; the most common known cause (33.8% of death certificates) of death was by overlaying, which could not happen in a crib; and the largest known category of deaths occurred in adult beds (27.5%).

Most of the suffocated infants died in the first 3 months of life, which corresponds to the known additional risk for SIDS/SUDI seen in bedsharing infants, even in the absence of smoking as a risk factor.

Dr Amy disagrees; we’re having an interesting exchange in the comments of her blogpost.

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16 Responses

  1. Wow, how could the researchers on that breastfeeding study not see that they were missing the obvious conclusion? I think sometimes people need to pull back from the numbers and figure out if there can be motivational reasons for the difference.

  2. Oh, they considered it, all right. As an “alternative explanation”, apparently because they were so enamoured with the oxytocin explanation. But I would think the causality is more likely reversed.

  3. I’d agree that the breast-feeding/non-abuse would seem a correlation rather than a causation and not necessarily exclusively a biological one. Even if a mother has some innate quality which “makes women want to breastfeed [and] also prevents women from maltreating their children” she may not have the luxury to do so because of job or other external stress factors in her life, which may also increase the incidence of abuse. Not sure whether the study was normalized for these factors.

    However, it seems that your answer to your question whether “Jane in Suburbia [will] be more likely to abuse or neglect her children as a result of the fact that she bottle feeds” is not quite complete. You could say that “not BECAUSE she bottle feeds, but she WILL be 2.6 times as likely to abuse her kid as Sally in Suburbia who DOES breastfeed”. This is regardless of whether it’s because she’s missing out on some oxytocin high or because that’s the way she rolls for other reasons. Even if we don’t know the cause, that’s what the statistics imply, no?

  4. No, I’d say that IF Jane in Suburbia is a neglectful or abusive mother, then she is less likely to be breastfeeding than Sally.

  5. If there is a correlation between neglect and lack of breast feeding, then the statements “if Jane is a neglectful mother, she’s is less likely to be breastfeeding than the non-neglectful Sally” and “if Jane is not breast feeding, then she’s more likely to be a neglectful mother than the breastfeeding Sally” are corollaries. Which statement one uses to express this correlation is then a matter of spin or to imply causation.

    BTW, I happen to agree with you in suspecting that the causation is more likely from “neglectful inclination” to “not breast feeding” rather than vice versa. But it would be a fallacy to accept this as the causation just because if “seems logical” – apparently to the researchers it seemed logical that oxytocin would affect the rate of neglect.

  6. Did the breastfeeding/bottlefeeding study control for socioeconomic factors? That seems to be a potentially big confounding factor – that moms living in poverty would be facing significant stressors that could overwhelm their coping capacities and increase the potential for abuse and neglect – and that this population of moms would be less likely to breastfeed for a variety of reasons.

  7. Jen: “a Values were adjusted for maternal prenatal demographic factors (age,marital status, education, race, and employment), prenatal behaviors/attitudes (cigarette consumption and binge
    drinking during pregnancy, anxiety, and pregnancy ambivalence), infant factors (birth weight [as a continuous variable] and gender), and 6-month postpartum maternal behaviors and
    attitudes (mother-infant separation, employment, maternal stimulation/teaching of baby, maternal attitude of caregiving, and postpartum depression).”

    There’s no correction for income per se, but with plenty of correlates.

    Stepan: In a Venn diagram-ish kind of way, you’d probably be right. But one explanation assumes facts not in evidence (i.e., oxytocin production), and the other is easily divined from the facts present and what we know about human nature…hence the reference to Occam’s Razor.

    And this isn’t an idle distinction: the authors seem to want to spin this as yet another benefit of breastfeeding, implying: “Ooooh, if you don’t/can’t/won’t breastfeed, you’\re more likely to abuse or neglect your child later on”. That’s not what this study shows.

  8. It seems like both you and Dr. Amy are right… the study doesn’t prove anything, but it does give reason for concern, and when it comes to the lives of babies, why wait for definite proof when you can avoid the risk? Hence the warning being issued. The problem with that, from a pro-co-sleeper’s POV, is it assumes that the perceived benefits of co-sleeping are not enough. I’d wager many are willing to take a slightly increased risk of suffocation because they feel their child will end up more mentally stable, and since the risk isn’t yet quantified, they dsmiss it.

  9. For a lot of co-sleepers, I suspect it’s not so much about feeling their child will be more mentally stable, and more about just trying to get some damn sleep in any way possible. In my experience ideological cosleepers are far outnumbered by those of us who wind up cosleeping because it’s the only way we can get any sleep after 3 am.

  10. Lorry – I’m awaiting the authors’ response to the, IMO, very pertinent objection brought up here. The man obviously has far more experience with death certificate information than I have (thank God!). I do think, though, that whoever is filling out the death certificate wouldn’t write that the deaths were in the context of cosleeping or that they occurred in a specific location, or that there was overlying involved, absent some supporting evidence from the death scene. However, whether or not the deaths were, in fact, accidental strangulation, may not be possible to divine from a death certificate.

  11. I would agree with @Egrrl’s comment. Unfortunately, a lot of parents that end up cosleeping “by accident” (i.e. because their child won’t sleep any other way) aren’t necessarily prepared for it and may end up doing it unsafely.

  12. Do you have access to the full text of those articles Esther?

    I’m curious in the co-sleeping one, whether there was any mention of the use of alcohol, drugs, and smoking by the parents in the overlaying cases?

    You mention that 51.2% of the deaths involved bedsharing, but only 27.5% were in adult beds. So where were the other 48.8% of deaths? Were they in cribs or equivalent? If so, then as a proponent of SAFE co-sleeping, I would think it is more relevant to compare the 27.5% of deaths in adult beds to the 48.8% in cribs, since the other bedsharing environments would not be considered safe. Then if we look more closely at the crib deaths versus the adult bed deaths, I’m sure there are many factors that caused both of those environments to be unsafe (cigarette smoke, bedding, etc.) that could exist in either a crib or a bedsharing situation.

    Until someone comes up with a study that compares deaths in SAFE crib sleeping environments with deaths in SAFE co-sleeping environments, I don’t think it is possible to talk objectively or definitively about one being safer than the other. We know there are benefits and risks involved in both. We know that parents should (but do not) do everything in their power to make their infant’s sleep environment as safe as possible.

    There has been more discussion recently in studies on the effects of smoking, but very little discussion of the role that alcohol plays in co-sleeping deaths.

  13. Annie, I’ll be happy to email you the study if you wish.

    51.2% of the deaths were in the context of bedsharing. However, only 6.3% were known not to be w/bedsharing (the other categories were unknown/undetermined – 29.9% and pending – 12.7%. Similarly, 27.5% were in adult beds; 6.8% were in cribs, 10% sofa/couch/recliner, 1.1% other (e.g, beanbag, carseat, playpen), 42.6% unetermined, and 12 % pending. While we have no way of knowing how these categories overlap, it’s suggestive of the fact that there are more cosleeping deaths than are explicitly reported. However, as Dr. Gassner pointed out, there may be doubt from the death certificate info alone whether the death was from SIDS or accidental suffocation. Whether or not that makes much of a difference to my suspicions is another story, though (i.e, is cosleeping a risk factor for SIDS, suffocation, both?). There’s no way to prove anything from partial and possibly erroneous data; but it does raise a red flag.

    And I’ve demonstrated before that just because parents cosleep for ideological reasons doesn’t mean they necessarily follow all the “safe cosleeping” rules all of the time – some of the websites don’t even mention smoking as a major risk factor, and some suggest putting a baby between a parent and a wall, even though wedging between mattress and wall is a common method of infant suffocation. Some also, apparently, believe that cosleeping and breastfeeding are protective against SIDS (as too many AP advocacy websites claim; both are unproven), and may feel that their slack on other safety rules is counterbalanced by those ‘benefits’. And all the ‘benefits’ of cosleeping (which are a good deal more meager than some would have you believe) can be had with a sidecar or separate sleeping surface that you put in the bed.

    It simply doesn’t follow that reactive cosleeping=dangerous, whereas ideological cosleeping=perfectly safe.

    And I think it’s a wee bit hypocritical of you to claim that because CIO hasn’t been proven to be absolutely 100% safe by randomized, controlled studies or whatnot, that it’s too dangerous to even contemplate, but cosleeping – despite studies that clearly suggest excess risk – is perfectly safe until proven otherwise.

  14. I would love it if you could e-mail me the study (phdinparenting at gmail dot com).

    I agree that “It simply doesn’t follow that reactive cosleeping=dangerous, whereas ideological cosleeping=perfectly safe.” I do unfortunately know plenty of ideological cosleepers that are not safe about it. However, I still think it is fair to say that many people that do reactive co-sleeping are not prepared for it and end up doing it unsafely. I think if public health agencies focused more on telling people how to co-sleep safely (instead of just saying don’t do it), then maybe lives could be saved.

    With regards to putting an infant between a breastfeeding mother and a wall or between a breastfeeding mother and a bedrail, I do think this is safer if done properly (i.e. ensuring there is no space the baby could get wedged into) than having the baby sleep between the mother and the father (or other person in the bed). The breastfeeding mother has a very good sense of her baby’s wherabouts in the bed and is also hopefully not drunk. The same cannot necessarily be said about the father or other person in the bed.

  15. “The authors’ conclusion? Breastfeeding (or rather, the oxytocin secreted from the mother’s pituitary while breastfeeding) prevents a child from being maltreated by her mother. Groan. ”

    The problem with this study is that historically beating one’s children was a sign of being a good parent.

    Back in the Middle Ages and other premodern times, before things like police existed, people were expected to and to be able to defend themselves. So parents were beaten by their children in what Lonnie Athens would call the process of violentization. Children would learn the world is a cold and harsh place where you need to man up and every so often stab someone. Then they would deploy violence against others.

    It’s seen in modified ways in military boot camps, police academies, in the ghetto, third world, and any other places where the need for individuals to frequently deploy violence is required.

  16. The problem with “co-sleeping safely” is that there is no such thing – not when it comes to infants and sleep related deaths. Even if you remove all possible confounders of adult behavior impacting the sleep enviroment, (& those are mind boggling) you still have an infant on a surface never made for or intended for infant sleep. All adult mattresses have quilting on the surface and are compressible – they are very, very different from safety approved crib mattresses. Then you have that pesky little thing known as an adult body. What happens to a surface that is supposed to be flat and firm when you place 150lbs on it? How many parents will actually give up their pillows and blankets? Hardly any, in my experience. They take all these things and they rationalize, mollify, adulterate and do whatever necessary to allow them to get what they want while proclaiming to be safe. It’s an illusion only maintained by luck.

    No doubt, there are “safer” co-sleeping environments, but they will never equal a baby alongside in their own, protected space, designed and made for infant sleep.

    We often hear or read the accusatory mantra, “Instead of condemning, why aren’t they teaching mothers to co-sleep safely!?” Studies have demonstrated that a nursing dyad can maintain the same benefits with the baby alongside. A better question might be – Why isn’t LLLI and API teaching co-sleeping mothers that it’s possible to successful nurse and have your baby sleep alongside?

    What’s more important? Defending a parenting practice at all costs? Or a healthy, live baby?

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