Breast-feed or else

In August, 2003, the U.S Department of Health and Human Services launched its Breast-Feeding Awareness Campaign to increase public understanding of the extraordinary benefits of human milk. (Details of this commendable effort here).

That's great. No one doubts that breast milk - refined by mother nature over a few million years of evolution - is the perfect food to nourish a human infant. The evidence is compelling: human milk lowers the risk of early infections and SIDS, and may provide long term benefits with reduced allergies, obesity and risk of various other diseases. Let's take "breast is best" as a given.

But how far should we go to encourage moms to breast-feed? Or, more precisely, how far should we go to discourage moms not to breast-feed. Here's where the controversy lies, fueled by a recent article in the New York Times (from which I shamelessly stole the title of this blog).

What controversy? Have a look at this spot which has been aired on TV.

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Hmmm... What do you think? Realistic, tough-love way to get across the risks of not breast-feeding? Justifiable scare tactics, given what we know? Isn't a little parental guilt-tripping a small price to promote infant health?

To help you better understand the benefits and risks, let's take a closer look at one of the many studies, in this case breast-feeding's protective effect on early respiratory infections.* This study showed (and the headlines trumpeted) that breast-feeding cut the incidence of respiratory infections in the vulnerable first month of life about in half.

Sounds impressive. It is impressive. But let's dig deeper and put the findings in perspective:

1. The protective effect, curiously, was true only for girls; breast-feeding didn't seem to provide protection for boys.
2. Breathing infections occurred in 241 of 13,224 (1.8%) infants in the first month of life. Put another way, 98% of the infants did not contract a respiratory infection, regardless of whether or not they breast-fed. So, yes, breast-feeding conferred an advantage, but the odds are great that an infant will be fine either way. An important benefit, to be sure (every little bit helps when it comes to prevention!), but not exactly the same as not riding a bucking bronco in the third trimester, is it?
   

On top of that, is it fair to scold those who decide not to breast-feed (or do so for a short time) when we as a society are unsupportive of breast-feeding moms? Very few companies, for example, have a designated area where a working mom can express her breast milk or have on-site child care. And, anyway, we weirdo Americans think it's obscene for a mom to breast-feed her infant in public. Perhaps working to change corporate America's practices and American attitudes towards openly breast-feeding would be a better use of our efforts.

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One of the scourges of 21st century pediatrics, in my view, is its incessant parent-bashing (anyway, most of you parents are plenty good at feeling guilty about your parental "shortcomings" without my help). Parenting is a tough and complicated business, almost all of you are conscientiously doing your best, and kids are resilient. Sure, breast-feeding is best and if you can do so, great. But if you don't, odds are still that your child will be just fine - unless, that is, you feel so anxious and guilty about it that it ruins your emotional well-being and undermines your relationship with your little one.

Promote the benefits of breast-feeding? By all means. Beat moms over the head who decide not to? It's not fair. It's not justified. It stinks.

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* Study cited
"Reduced risk of neonatal respiratory infections among breastfed girls but not boys." Pediatrics: Oct., 2003
http://pediatrics.aappublications.org/cgi/content/full/112/4/e303

Related Topics: Is Guilt Getting the Best of You?, Breastfeeding 101: A Mother's Guide

Technorati Tags: infant care, breastfeeding

Sibling relationships

Sibling relationships are a hot topic. The 7/10/06 cover of Time magazine reads "How your siblings make you who you are." Of course, for those of you with more than one child, it's likely to be high on your parenting agenda, media attention or not.

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When I was in training as a fellow in behavioral and developmental pediatrics with T. Berry Brazelton, I was asked to see parents who had been determined to prevent their two year old, Petunia, from resenting their new baby.

"We don't understand it," they confessed. "We've done everything the books advised to avoid sibling rivalry. We frequently talked about the new baby in mommy's belly, which we encouraged Petunia to lovingly stroke. We assured Petunia we would love her as much as ever and explained how wonderful it would for her to have a new playmate. Soon after delivery, we allowed her to hold her baby brother, Gregory. The doll she took home from the hospital was bigger than the baby! Petunia was allowed to help feed and diaper Gregory. When he was asleep, we gave her extra 'just you and me' quality time together."

Sound familiar?

Two months later, following the appearance of inexplicable scratch marks on Gregory's face, Petunia was seen lobbing her Cabbage Patch doll into his crib and was quite adamant that the time had surely come for Gregory to go back the hospital, "where he belonged". That's when her distraught parents sought help from the great Dr. Brazelton (alas, they had to settle for a very green Dr. P).

As Petunia's parents learned, sibling rivalry is inevitable. To help her parents understand why this is so, I asked them to picture this scenario:

Without asking your permission, one day your husband/wife/partner comes home with a new man/women, saying: "Hi honey, this is Rachel/Freddie. S/he is going to live with you and me now. Sure, s/he'll be getting lots of my love and attention, but don't you worry: I love you just as much as always! This is just a wonderful addition to our family! Hey, why don't you look happy!?"

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Time magazine's certainty aside (to be fair and balanced, see their alternative viewpoint to mine), the importance of sibling relationships in "making us who we are" is still hotly debated.

Here's the key issue: Of course sibling relationships are important within the home. Do siblings get along? Who is dominant? Whom does mom love best? What behaviors get you more attention and energy and affection from your parents, compared to your siblings? All this is pretty obvious.

But think back to when you were a kid: how similar was the way you interacted with your siblings within the home, as opposed to how you interacted with others outside the home?

Most of us (thankfully) behave and feel very differently with our parents and siblings than we do in the "real world." It's called "code switching" - we adapt our behaviors to succeed in new circumstances. We toddle off to school and quickly learn, for example, that those behaviors that were so endearing to our parents and allowed us to get along with (or manipulate) our siblings may not be good ways to make and maintain friends outside the home. Maybe I am mean to my little sister, but that behavior isn't going to make me very popular with my peers. I may have been under my big brother's thumb at home, but I can be a leader among my new friends.

(Incidentally, you may have thought that Frank Sulloway's 1996 Born to Rebel proved being a first-born made you more likely to be ambitious, domineering, conservative and aggressive, while later borns are more likely to be rebellious, open to new ideas, and agreeable. If this were correct, then sibling relationships are indeed a major force in"making us who we are." Alas, the findings in his book - at least to my mind - have been debunked, decimated really (e.g., by Judith Rich Harris in her new book No Two Alike or here).

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There is one important reason the research in this area remains muddled: Genetic effects are rarely taken into account. Sure, you may be cooperative and positive with your brothers and sisters, and subsequently with your relationships outside the home. But is that because you had good early sibling relationships in the home or because you had the disposition to be a cooperative and cheerful person in any setting? If you are a peace-maker, is it because you were the middle child or because of your pacifistic nature? Correlation of child and adult relationships does not mean cause-and-effect. And there is plenty of data showing how different we are in our relationships inside and outside the home.

So it's still up for debate. I have to say, in thinking about my own history and having watched a ton of kids grow up in a ton of families, I'm more on the side of the "code-switching" hypothesis: that we often behave very differently in different settings to get our needs for status and affection and affiliation met. Yes, our siblings "make us who we are" inside the home and in our relationships with them, but their impact on us outside the home is much more limited than Time magazine implies.

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As I often ask: Is that good news or bad news for you parents, you who are conscientiously investing so much time and effort to teach your unruly kids how to get along with each other? Does this mean that your efforts don't matter?

I think it's good news and, yes, how you handle your kids' relationships with each other matters a lot - although perhaps not in the way you imagine.

Of course, as a parent, you make a huge difference in how things go in your home. You can try to be fair with your motley crew of kids as best you can, to show them pretty equal affection (even if you don't always feel that way), to teach them to generally work out their sibling conflicts on their own without your choosing sides, to treat and respect them as individuals, to recognize each one's strengths and weaknesses without constantly comparing them to one another.

These efforts will have been critical - once the early inevitable rivalries and disputes are past - in how they come to interact with and feel about each other. It will enable them to grow up with wonderful memories and stories and lessons and values from the positive family relationships you are working so hard to foster. And this will serve to enable them (hopefully) to establish close and enduring sibling relationships which, at their best, can be one of the deepest and most beautiful relationships of our adult lives. That's a lot of power and importance in my book.

But if you hope by being the "perfect" parent (not that there has ever been one), you can avoid any sibling rivalry or conflicts, or that by enhancing sibling relationships you will have a major impact on your children's eventual personality and status and relationships outside the home, you may be disappointed. Khalil Gibran (1883-1931) the Persian poet said it best in his book The Prophet:

Your children are not your children.
They are the sons and daughters of Life's longing for itself.
They came through you but not from you.
And though they are with you yet they belong not to you.
You may give them your love but not your thoughts,
For they have their own thoughts.
You may house their bodies but not their souls,
For their souls dwell in the house of tomorrow, which you cannot visit,
not even in your dreams.
You may strive to be like them, but seek not to make them like you,
For life goes not backward nor tarries with yesterday.
You are the bows from which your children as living arrows are sent forth.

Related Topics: 6 Ways to De-Stress at the Dinner Table, Heart Disease in Sibling Doubles Your Risk

Technorati Tags: sibling rivalry, genetics, family relationships

"Helpful" safety tips from product warning labels

Once again the American legal system has done families a great service. OK,OK, so it's to avoid lawsuits, but now wary manufacturers are providing helpful warning labels so that we know how to use their products properly and safely.

Ever on the look-out for new safety tips, your Dr. P has scoured the internet for those warning labels containing important new advice to ensure your family is safe.

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On a baby stroller:
"Remove child before folding"

On a scooter for children:
"This product moves when used."

On a digital thermometer:
"Once used rectally, the thermometer should not be used orally."

On a pair of bicycle shin guards:
"Shin pads cannot protect any part of the body they do not cover."

On a dishwasher :
"Do not allow children to play in the dishwasher."

On a flushable toilet brush:
"Do not use for personal hygiene."

On a household iron:
"Never iron clothes while they are being worn."

On an electrical drill:
"This product not intended for use as a dental drill."

On a microwave oven:
"Do not use for drying pets."

On a box of rat poison:
"Warning: has been found to cause cancer in laboratory mice."

On a sign at a railroad station:
"Beware! To touch these wires is instant death. Anyone found doing so will be prosecuted."

On a child-sized Superman costume:
"Wearing this garment does not enable you to fly."

On a drain cleaner:
"If you do not understand or cannot read all directions, cautions and warnings, do not use this product."

On a snow sled for children:
"Beware: sled may develop high speed under certain snow."

On a bag of peanuts:
"Warning: This product contains nuts."

On a toilet bowl cleaner:
"Safe to use around pets and children, although it is not recommended that either be permitted to drink from the toilet."

On a hair coloring product:
"Do not use as an ice cream topping."

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I don't know about you, but I'm going to sleep a little easier knowing our children are safer because of these valuable tips for all you parents out there.

Related Topics: Childproof Your Home, Keeping Kids Safe

Technorati Tags: product warning, child safety, humor

Cervical cancer vaccine follow-up: The good and the good

In March, I wrote a blog called "Cervical Cancer Vaccine: The good, the bad and the ugly". In it I talked about an effective and safe new vaccine ("the good") to prevent contracting human papilloma virus (HPV), by far the leading cause of cervical cancer.

The "ugly" was my concern over mounting attacks on the HPV vaccine by those who inisisted it would encourage teens to have sex - to my mind a dubious and dangerous assertion (e.g., in a recent study of virgins, only 7-10% said "fear of a sexually transmitted disease" was a reason not to have sex).

Take a look at the blog and especially the fascinating, provocative debate that followed in the comments.

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Dr. P's fears were unfounded
I'm pleased to report my concerns of an effective opposition to this valuable new vaccine were unfounded. Yes, Dr. P was wrong (hey, it happens). In a tribute to good sense, on 6/29/06 the influential Advisory Committee on Immunization Practices (ACIP) unanimously endorsed the use of the HPV vaccine.

This is a very important step. The ACIP advises the Center for Disease Control (CDC), which in turn advises schools. Since the CDC has no enforcement powers, it will be up to insurers to agree to pay for the $125-a-dose, three dose vaccine. And it will be up to school districts and colleges to decide whether to require or just recommend it. (I hope it's required. We know that immunizations not required for school attendance are given much less frequently.)

Keep your ears open as to how this plays out and the debate that is sure to follow.

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Who should get the HPV vaccine?
The HPV vaccine is currently recommended for:

All girls ages 11 and 12 (although it can be given as early as 9 years).

All girls/women ages 13-26 who have not had the vaccine.

Women with abnormal pap smears, genital warts, or certain other conditions.

What about boys?
It obviously makes sense for boys to also get the vaccine, to lessen the incidence of genital warts, to lessen the rare associated risk of penile cancer, and to lessen the risk of sexual transmission of the HPV virus (males often have no symptoms and don't even know they carry - and therefore can spread - the virus).

Immunizing males is in the works but, unfortunately, efficacy and safety studies in boys won't be completed until 2008, so we'll have to wait until then.

How many lives will this save?
Every year about 4,000 women in the US (and 300,000 internationally) die from cervical cancer. These are heartbreaking statistics represent real people: our moms, some of you, our friends and, without this new vaccine, someday our daughters. Happily, we can expect to see these numbers plummet over the next decades, as fewer and fewer women contract HPV because of this vaccine.

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In my career I've seen the virtual elimination of some horrible viral and bacterial infections because of new immunizations. One fine day I anticipate gynecologists will give historical talks to their younger colleagues about the bad old forgotten days of cervical cancer, because it will be seen so rarely. Rare as hen's teeth. How great will that be?

Medical science and immunizations march on. This is such a wonderful development. Score another one for the good guys and for us all.

Related Topics: Adult Immunizations: Are You Protected?, WebMD Video: Cervical Cancer Vaccine: What Women Need To Know

Technorati Tags:HPV, Gardasil, cervical cancer vaccine

Thimerosal and autism: A cautionary tale

The latest issue of the journal Pediatrics has yet another study that does not support a link between thimerosal and autism. In case you are not familiar with this controversy, here's a quick update.

• Thimerosal (ethylmercury) was previously used as a stabilizing preservative agent in vaccines. (For more detailed information, see the FDA website: http://www.fda.gov/CBER/vaccine/thimerosal.htm)
• In 1999 it was wisely removed from almost all childhood vaccines in the U.S. as a "precautionary measure." Since no links with any neurological damage had been established, the National Academy of Science explained: "The effort to remove thimerosal from vaccines was a prudent measure in support of the public health goal to reduce the mercury exposure of infants and children as much as possible."
• That thimerosal might cause autism was a reasonable and "biologically plausible" hypothesis. Certainly mercury of any kind has the potential for toxicity to the nervous system, and kids were certainly getting many immunizations containing it. So, no one argued the need to study this potentially important issue.

Many studies now have been done. They are not rocket science: if thimerosal causes autism, then its removal from immunizations (1999 in the U.S, 1996 in Canada) should have led to a significant dip in autism. It has not, as this newest study demonstrates in a Canadian population of 27,749 children born between 1987 and 1998.

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Now, what if you happen to be the parent of an autistic child and you decide to research the link on the internet (Google "thimerosal autism" and you'll get 362,000 hits)? Here are some of the things you will read (my comments in italics):

• "There are now hundreds of studies that have identified thimerosal as the culprit responsible for the autism epidemic." (This is demonstrably false. Plus, note the absolute certainty.)
• "Mark my words, this is going to be the biggest man-made medical catastrophe in the history of this country, and probably the world. If we don't find a cure, we're talking $$ trillions for life-time care." (Scare us to death, why don't you, on the basis of...?)
• "Think about that for a minute. The children who received thimerosal were 27 times more likely to develop autism than children who received no thimerosal. Coincidence? 27 times? I think not."(A common tactic: the study is never cited, so it can't be reviewed. Since no one else has ever found this, it's either a bogus or a non-existent study.)
• "'The Institute of Medicine joined the pharmaceutical industry to gin up four European studies to 'exonerate thimerosal' because some IOM panelists had 'financial bonds' to the vaccine industry." "Not only do government and industry officials seem to be trying to downplay the possible harms of thimerosal; the media is also denying the issue coverage. ABC has been accused of suppressing the interviews because of its ties to the pharmaceutical industry." (If you disagree, it must be because you are one of the bad guys. There is always a vast conspiracy afoot to suppress the truth [read: the view the writer is touting]. Note the vague "has been accused." By whom? On what basis?)
• "Thousands of families say they can demonstrate with videotapes and photos that their children were normal prior to being vaccinated, reacted badly to the vaccines, and became autistic shortly thereafter." (Note the certainty of cause-and-effect for what we now know to be a coincidence: kids get many vaccines at the same time the symptoms of autism typically emerge).
• "The pertussis vaccine (DPT) may cause 45,000 cases of autism per year in America, affecting 15 cases out of 10,000 vaccinations; also caused by the measles-mumps-rubella vaccine (MMR) that causes mental impairment." (Great, scare me out of immunizing my kids with your spurious data.)
• And, inevitably: "If you have a loved one that has suffered the serious effects of thimerosal-containing vaccines we provide sound legal counsel. We encourage you to contact us regarding any questions you have so that we can inform you of your legal rights." (Need I even comment?)

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If thimerosal is pretty unlikely to cause autism - as current studies suggest - where does all this stuff come from? To help you become a more informed consumer of medical advice, note the tortuous logic and overblown rhetoric:

• If something can be true (e.g., the rise of immunizations and the rise of autism are cause-and-effect, and not a coincidence) it must be true, especially if it conforms to some pre-existing agenda (i.e., immunizations are bad).
• What starts as a guess soon morphs into absolute certainty ("thimerosal causes autism"), even in the absence of proof. But remember: extraordinary claims require extraordinary proof.
• Studies of dubious merit are cited (if any are cited at all), the preponderance of evidence from superior studies is conveniently ignored or trivialized, and anecdotes provide all the evidence anyone should need.
• Ad hominem attacks (questioning one's motives and integrity, rather than the merits of the argument) abound. Those who disagree are doing so because it is in their own financial interest or there is "hidden agenda" (like what? world domination?) or just because they are inveterate evil-doers. (I recall one disgruntled parent telling me I didn't want a cure for autism because it would lower my income.)
• A vast conspiracy is invoked to explain how and why the truth has been silenced, usually due to the pernicious influence of the rich, evil manufacturers of immunizations. We are all either on the take or merely unsuspecting pawns in their game.

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The whole field of autism, tragically, is especially susceptible to this sort of distortion by bogus gurus. After all, we don't really don't know which environmental factors may trigger autism in genetically susceptible children. We don't really know what the optimal treatment is. But at least we are honest about it.

Parents are understandably desperate for answers, ready to do anything for their beloved child, no matter how far-fetched, how unproved, and how expensive. If honest professionals have neither all the answers nor the cure, why not follow some guru who is unshakably certain about all of this, and who purports to know how to cure your afflicted child? (For starters: the added heartache of dashed hopes, the expense, the negative side-effects of unproved treatments, the time away from effective treatments, avoiding immunizations and getting sick...)

The good news? There is a ton of exciting and important research being done on autism. I'm optimistic that in the next decade we will have many of these answers, based on good science. So keep your wits about you when the next guru cries "Eureka!" and, as you watch this story unfold, work to sort out the wheat from the chaff. Don't miss it. It's going to be very exciting!

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Article cited:
Pervasive Developmental Disorders in Montreal, Quebec, Canada: Prevalence and Links With Immunizations
Fombonne E, et al. Pediatrics, July 2006, pp. e139-e150 http://pediatrics.aappublications.org/cgi/content/full/118/1/e139

Related Topics: WebMD Video: Junk DNA: Cause of Shyness, Autism?, Daydream Brain Activity: Autism Clue?

Technorati Tags: thimerosol, autism, MMR, DPT, vaccine, immunization

Are cell phones safe for kids?

A few days ago, two unrelated events converged for me.

First, I read of a newly published study, "Do cell phones 'excite' your brain?" (Answer: yes, but that doesn't mean they are harmful).

Next, I spent some time in a local mall and was blown away at the percentage of young people who were chatting, chatting, chatting away on cell phones as they rambled from Starbucks to Gap.

Cell phones - like the Internet, like e-mail - have become such an integral part of 21st century life that we often take their use for granted. But these two experiences made me wonder whether I had taken this new phenomenon seriously enough, whether I needed to become more educated about cell phone use, and whether doing so might affect my advice to parents.

It has. Here's what I've learned since then.

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Cell phone use and exposure
Cell phone usage has achieved unbelievable popularity. Consider that in the U.S. in 2005:

There were over 200 million cell phone subscribers.

Cell phones generated $113 billion in revenues.

113 trillion minutes of cell phone chat time was logged.

How do cell phones work?
A cell phone converts your voice into radiofrequency energy (RF or radio waves), which travel through the antenna/transmitter to the local base station of your cell phone provider. The base station then sends out these radio waves back to a receiver in the called phone, which converts it to the sound of a voice.

Here's the key point. These radio waves are a form of electromagnetic radiation, much like the energy that heats your microwave oven or is used for radar. Sounds worrisome, but the good news is that RF radiation is different ("non-ionizing") than the radiation from x-rays (which is "ionizing"). Unlike x-rays, non-ionizing radiation does not damage DNA and is not felt to harm living tissues at the levels of heat induced by a cell phone.

• To gauge the RF radiation emitted, each cell phone has a "specific absorption rate" (SAR), which is the amount of RF energy absorbed from the phone into the user's local tissues. The upper limit of SAR currently allowed is 1.6 watts per kilogram (W/kg) of body weight, which is felt to be safe. (You can find your phone's SAR at the FCC website.
  

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Are cell phones safe for kids?
The good news is that - at least at this early stage of imperfect research - the link between cell phone use and adverse health issues is inconsistent and weak, interpreted by most experts as non-existent. The U.S. Food and Drug Administration states: "The available scientific evidence does not show any health problems are associated with using wireless phones."

That's reassuring, but the safety issue is far from resolved. The FDA goes on to say, "There is no proof, however, that wireless phones are absolutely safe." No surprise that: cell phones haven't been around that long. It's possible that chronic exposure could cause a problem that won't show up for another decade or two. (Of course, it's possible - even likely - that nothing will show up. Who knows? No one. Therein lies our dilemma.)

Additionally, as a developmental pediatrician I'm paranoid about potential environmental risks to a child's developing brain. Although many scientists feel it doesn't matter in this case, the brains of children are more active, more changeable, and often more susceptible to toxins than are the sluggish brains of us adults. I have to wonder: could early and prolonged exposure starting in childhood have unanticipated consequences, not yet studied and not seen in those who started as adults?

Really, I have no idea. Alas, neither does anyone else. Certainly there is no cause for panic: even if there is a risk, it seems likely to be small, based on what we know so far. I encourage you to follow this research yourself and see what conclusions you draw, now and in the future.

• As always on the Internet, beware the inevitable conspiracy theorists who claim there is a huge risk knowingly being kept under wraps by the evil cell phone companies in cahoots with Uncle Sam. And beware the alarmists who, by the way, just happen to have a device that blocks the deadly radiation from melting your brain. (In case you're tempted, the FDA says these "do not work as advertised." Big surprise.)
  

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The dilemma
So here is my dilemma (and your dilemma): what should you do - if anything - when the early scientific data are reassuring, but the late returns are not in? Should I, as a pediatrician, recommend you change your child's cell phone behaviors to lessen an unknown, perhaps non-existent, risk? Should you as a parent do the same?

I vote yes. Even if there turns out to be no risk, the steps to lessen exposure to cell phone radiation are pretty easy and pretty simple - we're not talking major lifestyle changes or sacrifice here and, considering how many hours of exposure your chatty child will log in over his/her lifetime... :

• Use a "hands-free" device so the antenna/transmitter is far away from the brain. However, keeping it close to some other part of the body simply changes the area of exposure, so it's important to position the phone as far from the body as possible and to move it around [e.g., on the belt] to lessen exposure to any one area.
• In the car, use a cell phone with an outside antenna (of course, the real and present danger is talking on a cell phone while driving, which you should absolutely forbid your children to do. In fact, forget this advice. Just don't use a cell phone in a moving car, period.)
• Check the SAR in your phone and consider purchasing one with a lower number.
• Use a conventional phone whenever possible, especially for long conversations.
• Let your child pick the coolest, most rad, most socially acceptable hands-off device to be sure s/he will actually use it. Use bribery if necessary.

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I'm an old-fashioned guy and don't use my cell phone all that much. But I'm headed off to find an ear bud, "hands-free" thingie which, if it doesn't make me look cool (frankly, kind of hopeless at this stage), is the least dorky-looking for a middle-aged guy at the Mall as he answers his patients' calls. Better safe than sorry, eh?

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Resources cited:

American Cancer Society

CTIA - Cellular Telecommunications IndustryAssociation

National Cancer Institute

Related Topics: Driving + Cell Phones = Big Road Risk, No Cell Phones Outside in a Storm?

Technorati Tags: cell phones, children, cell phone danger