The truth about bedsharing risks – and why it may not be what you think

Welcome to the Safe Cosleeping Blog Carnival This post was written for inclusion in the Safe Cosleeping Blog Carnival hosted by Monkey Butt Junction . Our bloggers have written on so many different aspects of cosleeping. Please read to the end to find a list of links to the other carnival participants. ***

This post is an overview of the existing research into the safety of taking your baby into bed with you to sleep.  In it, I hope to explain why such different factions in the debate have reached such widely differing conclusions, and to clarify what the research actually shows.

A few quick notes, before starting:

1. It’s possible that you’re an exhausted new parent who stumbled on this when what you were actually Googling for was some easy-to-digest practical advice on how to bedshare as safely as possible, and that delving into the complications of the debate isn’t really what you’re after.  If so, I recommend the UNICEF BabyFriendly leaflet as the best resource I know of on the subject.

2. It’s also possible that you have personal reasons to find the topic of infant death particularly distressing.  If so, this is what’s generally known as a ‘trigger warning’, to tell you that this is a discussion of possible risk factors in infant smothering and SIDS deaths.

3. Terminology.  The term most often used for taking your baby into bed with you is ‘co-sleeping’ (which, of course, is also the one used in the title of the Carnival).  However, this technically covers any sleeping arrangement where your baby is within arm’s reach of you, including the usually-recommended one of a cot by the side of the bed.  Since the crux of the debate is how the safety of that arrangement compares to the safety of having your baby in the same bed as you, using a term that can refer to either arrangement does sometimes cause confusion; hence, I’ve gone for the term ‘bedsharing’ in this post.

4. Terminology, part 2: I’m from the UK, so I use the word ‘cot’ to refer to the kind of standard baby bed that goes by the name ‘crib’ in the US.  I’ve used that throughout this post simply because it’s the term that’s familiar to me.

5, added on reflection: As you can see, this post was submitted to a blogging carnival.  For anyone unfamiliar with how carnivals work, anyone who wants to submit a post on the topic can do so, taking whichever approach they wish, and everyone then links up to everyone else’s post at the end of theirs.  I’ve therefore included links to the posts of all other participants, but, of course, some of them will have different views from me on the subject.  For that reason, please do not take the inclusion of the links to other posts as implying that I agree with/endorse all the information contained therein.  Some of them I heartily do; some of them I emphatically don’t.

Right – that’s hopefully cleared all that up.  On with the post.

The controversy

Standard advice in most of the Western world is that you should NOT take your baby into bed with you to sleep as it’s much too dangerous.  I was originally planning to write something more sardonic about that view, but the public health department from Milwaukee has recently surpassed anything I could possibly come up with in the way of satire by, and I swear I am not making this up, publicity posters showing photos of a baby lying next to a meat cleaver with the caption ‘Sleeping with your baby can be just as dangerous’.  I really hope someone reports them to whichever organisation it is that’s supposed to ensure truth in advertising, because that would make a really interesting court case.

However, in recent decades, there has been an increasingly large pro-bedsharing contingent, chiefly the Attachment Parenting and Natural Parenting movements, claiming that the exact opposite is the case.  Not only is bedsharing quite safe given a few simple precautions, they say, but, if properly done, it actually reduces the risk of infant death.  And they will cite studies which they claim back up this viewpoint.

Caught in the middle of all this, as usual, are parents, and the amount of confusing and misleading information they’re getting on the subject isn’t helping anyone.  What makes this worse is that neither of the above two groups is actually right.

So, where are they both coming from on this?

Anti-bedsharing concerns

The concern over bedsharing comes largely from concerns that a baby might smother in an adult bed.  It’s not an unfounded concern; there have been many such tragedies in the past (1), with babies slipping down between the mattress and the wall, or the mattress and the headboard, or even the mattress and a safety rail designed to keep the baby in bed, and getting their heads trapped in such a way that they were unable to breathe.  Similar accidents can occur in cots too, of course – but cots are designed with infant occupants in mind, and manufacturers are held to safety standards which involve designing cots without any such gaps for a baby to get caught in.  Adult beds aren’t, and hence such deaths are considerably less rare in adult beds (2).

While it’s possible to adapt an adult bed in such a way as to minimise the risk, doing so properly can be a difficult matter involving some careful thought about the less obvious hazards and pitfalls.  For example, one of the ways often advocated is to push the bed flush against the wall so that the baby can’t either fall out or get trapped between bed and wall.  However, as one of the pro-bedsharing movement’s leading experts, Dr James McKenna, points out, this carries the risk that the bed will move just far enough away over time to create a dangerous gap, without the parents noticing.  What he suggests is to move the mattress off the bed frame altogether and putting it on the floor – a course of action which most people would probably find quite an extreme length to go to.    And given the difficulties in making an adult bed safe, it’s understandable that so many people take the attitude ‘Why take the risk in the first place?  Just put the baby in a cot.’

This approach to bedsharing risk has problems which I’ll discuss towards the end of the post.  First, there’s the other side of the bedsharing debate to consider.  In the face of possible smothering risks, why are so many people convinced that bedsharing actually reduces the risk to infants?  The answer lies in some of the research done into another, and less rare, cause of infant death: SIDS.

The pro-bedsharing case

SIDS is often confused with smothering in bedsharing discussions, but it’s important to understand that it is not the same thing.  SIDS – Sudden Infant Death Syndrome, also known as crib death or cot death – is the phenomenon of infant death for which no cause can be found.  (Smothering deaths are therefore, by definition, not SIDS deaths.)  SIDS, although every parents’ nightmare, is mercifully uncommon; but it is still substantially less rare a cause of death than getting trapped down the side of an adult bed and smothering there.  And research emerging in the 80s and 90s was raising a new and exciting possibility – that bedsharing might actually reduce the risk of dying of SIDS.

In 1990, James McKenna published the first of what would be several small studies looking at the physiology of infant sleep and how sleeping arrangements affect it.  His technique, in brief, was to monitor mother-baby pairs overnight in his laboratory, in each of two different arrangments – sharing a bed, and putting the baby in a cot in an adjacent room.  Each mother and baby would spend a night bedsharing and a night with the separate sleeping arrangements, and their measurements for the two nights would be compared.

Using this technique, McKenna was able to show some interesting differences in babies’ sleep behaviour according to their sleep arrangement.  On the nights that babies shared the bed with their mothers, they spent less time in deep sleep/surfaced from sleep more often (3), breastfed more often (4), and were more likely to have unexplained pauses in their breathing (5).

These results caused great excitement (the one about the increased risk of unexplained pauses in breathing was rather glossed over).  One plausible theory about SIDS is that it’s related to a baby slipping into too deep a sleep, with the normal arousal mechanisms not working properly.  And, of course, breastfeeding is already known to be beneficial.  Could these differences in sleep depth, arousal mechanisms, and breastfeeding frequency add up to a reduction in SIDS risk in babies who were bedsharing?  And, if so – since SIDS is a more frequent cause of death among babies than smothering as a result of sleeping in an adult bed, and since there were precautions that can reduce the risk of smothering during bedsharing to an extremely low level, could it be that bedsharing would prevent more deaths than it caused, and thus prove beneficial overall?

If so, this would be fantastic news.  Not only would any discovery of ways to reduce SIDS risk obviously be good news, but, as an extra bonus, this was the equivalent of someone coming up with a study that says that eating chocolate is really good for you.  Getting up for night feeds is one of the most horrible parts of being a parent.  Taking your baby into bed at night is one of the loveliest parts of being a parent.  Generations of exhausted mothers had struggled to deal with the first or opted in desperation for the second, facing the censure of baby experts for so doing.  You can imagine the enthusiasm with which they greeted the possibility that scientific evidence could now be vindicating them.

And other promising evidence was also emerging.  Acceptability and prevalence of bedsharing varies hugely from country to country (6).  When the rates of bedsharing in a number of different countries were compared with SIDS rates in those countries, an association showed up: not a cast-iron one, but there was certainly a tendency for cultures with higher rates of bedsharing to have lower SIDS rates.  Could that be cause and effect?

And, in Western cultures, as researchers compared the sleeping environments of babies who’d died of SIDS to those of living babies, it became apparent that the advice previously popular in the US and UK of putting your baby to bed in a separate room was actually not a good idea at all.  Sleeping in a different room  from the parents showed up as a strong risk factor.  If just having your baby in the same room as you could protect against SIDS, how much more effective might it be to have your baby in the same bed! The bedsharing case was looking better and better.

Unfortunately, this optimism would prove unfounded.

What further research has shown

Over the last two decades, a number of case-control studies have been done to look more directly at what risk factors might be involved in SIDS.  (Case-control studies are the type I described in the second part of the last paragraph – researchers look at the backgrounds of a group of babies who died of SIDS and a similar group of babies who haven’t, and compare the two to see whether any factors show up significantly more often in one group than the other.  The reason for doing things in this somewhat back-to-front way, in case you were wondering, is that SIDS is so rare.  As many people have pointed out, it would be better from the scientific point of view if we could start from the beginning and study groups of parents who do things in different ways, such as bedsharing vs. cot use, to compare the SIDS rates between the two – however, to get a large enough sample for there to be sufficient numbers of SIDS deaths in each group to compare and to look at different risk factors, you’d have to arrange for literally hundreds of thousands, if not millions, of families to be interviewed in detail to get all the information you needed, and that is just never going to be feasible.  Case-control studies, by starting with babies who’ve died of SIDS and finding comparison groups, allow researchers to gain a good approximation of this information by interviewing a few hundred families, which is manageable.)

The pro-bedsharing case took an initial wobble when the first case-control study to look at bedsharing announced that it increased SIDS risk (7).  However, things were still by no means that simple.  Research was also showing that some factors could make bedsharing particularly risky.   Bedsharing with a parent who smoked, for example, was associated with a far higher risk (smoking in a parent is associated with a major increase in SIDS risk anyway, but bedsharing with a smoker sent the risk up even further, possibly due to the higher rates of carbon monoxide and what-all else gunk that smokers normally have in their expired air compared to non-smokers).  Falling asleep with a baby on an armchair or sofa was also associated with a drastic increase in risk (this, of course, isn’t technically bedsharing, but it is a form of co-sleeping and thus gets categorised with bedsharing for research purposes.)  Other factors, which were risky under any circumstances (pillows, duvets, excessively soft mattresses), were more likely to be present in bedsharing situations but could potentially be removed if they were the only factors standing in the way of safe bedsharing.

(The above is not, by the way, intended by any means to be an exclusive list of the factors that might make bedsharing risky.  I’m just trying to mention some of the main ones to give a general idea.  Please do not take it as the final word on how to bedshare safely.  As I said above – if you want better advice, I think the UNICEF leaflet does the best job of covering different factors and giving realistic information.)

Analysing all bedsharing cases together without allowing for these factors could give an estimate of risk that wouldn’t apply across the board, and could obscure any potential benefit from bedsharing done in optimised, low-risk circumstances.  What would show up when further studies allowed for these excess risk factors in analysis?

Doing so did indeed eliminate the apparent extra SIDS risk that had initially showed up as associated with bedsharing (8).  When that study and several others (9 – 12) were analysed in such a way as to allow for higher-risk cases, the figures didn’t show any excess in SIDS risk for bedsharing with non-smoking parents who weren’t under the influence of anything (either prescribed or recreational) that might be making them excessively drowsy.  However…  they didn’t show any decreased risk, either.

No matter what other factors the studies controlled for that might be influencing risk, the best they showed was a similar risk for infants bedsharing in optimised conditions and infants cot-sleeping in optimised conditions.  The best hopes of the pro-bedsharing contingent hadn’t been borne out by the research.  And, given the increased risk of an infant smothering in a bed, if the SIDS risk was the same in either a bed or a cot then that still left bedsharing coming out as at least a bit more risky overall – and much more risky in any situations where best guidelines weren’t followed.

What was more, two more risk factors would emerge from further studies.  In 2004, the Lancet published the largest case-control study of SIDS ever done, in which the authors had looked at another risk factor: infant age.  Previous studies hadn’t made any differentiation between the youngest and oldest babies in the SIDS cases looked at.  However, when age was figured in as a factor, it turned out that bedsharing in the earliest months of a baby’s life was associated with an increased SIDS risk (13).  Several other studies have since confirmed this (14 – 16).  Bedsharing in the first few months is more risky.  The Lancet study showed that this age-associated risk is highest of all at birth, falling off steadily over subsequent months but taking a few months to drop to zero extra risk.

And in 2005, the CESDI SUDI research group did some further analysis on the figures from their 1999 study to look at how prematurity and low birth weight might affect bedsharing risk.  They found that, in the group of infants who were either premature or weighed less than five and a half pounds (2.5 kg) at birth, bedsharing with even a non-smoking parent was associated with a whopping 15 times the increase in risk, even when other risk factors were controlled for (17).  As far as I have been able to find, nobody else has looked into this particular risk factor, so I have no more information on this – however, it clearly bears taking into account.

Given all this evidence, is it possible still to believe in completely safe bedsharing?  Well… maybe.  There’s always going to be some factor you can’t control for in studies, some ‘Yes, but what about if we…’ suggestion.  If, for example, you get rid of the bed altogether and just put a futon on the floor, find some bedding arrangement that eliminates the need for duvets, pillows, or anything that could go over the baby’s face, don’t smoke or drink, have a normal-weight full-term baby, don’t start bedsharing until after the riskier period in the early months, and don’t have any other factor I haven’t mentioned that might make bedsharing more risky, then it’s quite possible that your sleeping arrangement actually will be every bit as safe as having the baby in a cot by the side of your bed.  There’s still no evidence that it’ll be any safer, but you may well have achieved the lesser Holy Grail of reducing the excess risk to zero.  The thing is, there just aren’t ever going to be very many parents who want to, or even can, go to these sorts of lengths.

So – where does this leave us?

Firstly, although I have not as yet seen any case-controlled or epidemiological studies comparing the risks of bedsharing to the risks of putting your baby to sleep in the same bed as a meat cleaver, I do feel confident in saying that that one’s an exaggeration.  However, on a more serious note – what do we do with the fact that the overall evidence does seem to point towards there being some risks, however small, associated with bedsharing in any sort of form in which most parents in the Western world are going to be able to practice it?   Should we go with the ‘Just say no’ crowd on this subject?

I think there are two problems with that approach.  Firstly, for some parents it isn’t possible.  Some babies just don’t sleep in cots, and there are physical limits on how much sleep deprivation anyone can stand before their body will take a hand and fall asleep despite their best efforts.  If we dole out blanket advice against all bedsharing [aaaarrrrggghhhh - would you believe I've only just noticed the entirely unintentional pun there? Sorry], we do run a very real risk that some parents will become so utterly exhausted in their struggle not to bedshare that they’ll end up simply falling asleep with their baby under the duvet or, worse, on the sofa with them and putting the baby at far more risk than if they’d deliberately planned and created a minimal-risk bedsharing environment.

Secondly, we don’t, in other circumstances, expect parents to provide a zero-risk environment for their babies.  Nobody tells parents that because there is no such thing as risk-free driving, no matter how safely it’s done, they should never never never take their babies for a car ride or cross a road.  We accept other small risks as part of life.  Barring extremes, we let people make their own choices as to what level of risk they feel comfortable accepting – for themselves or their children.

There are circumstances where the risk associated with bedsharing is considerably higher, to the point where you probably should indeed be avoiding it – if anyone in the bed is a smoker, if your baby is premature/very small, if you’re taking anything (prescribed or recreational) that impairs your reactions to the point of putting you at potential risk of rolling over on your baby.  And I do think it’s worth doing whatever you can, within whatever sleep situation you feel it best for you and your family to try, to do whatever else you can to lower the risk of either SIDS or smothering.  But I think that, when we’re talking about a situation where the absolute risk is very low, it should ultimately be the job of parents to make their own informed decisions as to just what risk level they feel comfortable with.

However, to make informed decisions, people need accurate information. The problem with the pro-bedsharing contingent is that the message that they overwhelmingly put across – bedsharing protects your baby, everyone should do it, all it takes is a few simple precautions – isn’t very accurate.

Some sources leave parents with the impression that as long as they haven’t actually been drinking alcohol or taking drugs then there shouldn’t be a problem.  Most will give more detailed advice than this, but it’s still astonishing how rarely this includes the advice that babies are at much higher risk if they bedshare with a smoker, or if they’re premature and/or of low birth weight.  Parents are also getting inaccurate and contradictory advice – for example, Dr Sears, a famous pro-bedsharing advocate, advises that beds should be pushed flush against the wall, but James McKenna points out that this may actually increase risk.  The advice that babies should sleep between parents used to be popular, until the Chicago study showed that this, too, increased risk (11).  And if all this is in the context of a background that bedsharing is quite all right, even protective, how seriously are parents going to take the need to be careful about the risks anyway?  There’s a real risk that it’ll be seen as not that much of a big deal, since bedsharing’s so safe/beneficial anyway….

There will always be parents who bedshare for practical reasons.  But increasing numbers of parents are making the choice to bedshare because attachment parenting/natural parenting groups are selling it to them as a wonderful, harmless, beneficial thing.  If these parents knew more about the risks, some would make the same choice.  Others might well choose not to bedshare, while still others might be more careful about precautions.  These families are being given incomplete and incorrect information, and hence are not being given the chance to make their own properly informed choices.

Simplistic anti-bedsharing campaigns are not the answer.  They aren’t providing parents with proper information either; they may increase the risk of very unsafe forms of bedsharing; and the more ridiculously over-the-top campaigns (coughMilwaukeemeatcleaveradscough) can backfire badly, by looking so ridiculous that it makes it easy for the pro-bedsharing campaign to step in with their much more plausible-sounding, attractive message of how safe and desirable bedsharing is.  Somehow, we have to find a way simultaneously to let parents know how to reduce bedsharing risk as much as possible and to make it clear to them that there is a risk.  I’m not under any illusions that it’ll be easy to find a sensible middle ground in which parents can be given clear, easy-to-follow information based on evidence rather than agendas.  But we have to try; because it’s what parents, and babies, deserve.

References

(Links are to the full study where this is available on line for free, and otherwise to the abstract.)

1. Nakamura S. et al. Review of Hazards Associated With Children Placed in Adult Beds. Arch Pediatr Adolesc Med 1999; 153: 1019 – 23.

2. Scheers NJ et al. Where Should Infants Sleep? A Comparison of Risk for Suffocation of Infants Sleeping in Cribs, Adult Beds, and Other Sleeping Locations. Pediatrics 2003; 112(4): 883 – 9.

3. Mosko S, Richard C, McKenna J. Infant arousals during mother-infant bed sharing: implications for infant sleep and sudden infant death syndrome research. Pediatrics 1997; 100(5): 841 – 9.

4. McKenna JJ, Mosko SS, Richard CA.  Bedsharing promotes breastfeeding.  Pediatrics 1997; 100(2 pt 1): 214 – 9.

5. Richard CA, Mosko SS, and McKenna JJ.  Apnea and periodic breathing in bed-sharing and solitary sleeping infants.  Journal of Applied Physiology 1998; 84(4): 1374 – 80.

6. Nelson EA et al. Early Human Development 2001; 62(1): 43 – 55.

7. Mitchell E et al. Four modifiable and other major risk factors for cot death: the New Zealand study. Journal of Paediatrics and Child Health 1992; 28(suppl 1): 53 – 8.

8. Scragg R. et al. Bed sharing, smoking, and alcohol in the sudden infant death syndrome. BMJ 1993; 307(6915): 1312 – 8.

9. Klonoff-Cohen H., Edelstein SL. Bed sharing and the sudden infant death syndrome. BMJ 1995; 311: 1269.

10. Blair PS, Fleming PJ et al.  Babies sleeping with parents: case-control study of factors influencing the risk of the sudden infant death syndrome.  BMJ 1999; 319: 1457 – 62.

11. Hauk SF et al. Sleep Environment and the Risk of Sudden Infant Death Syndrome in an Urban Population: The Chicago Infant Mortality Study. Pediatrics 2003; 111(5 pt 2): 1207 – 14.

12. Blair PS et al.  Hazardous cosleeping environments and risk factors amenable to change: case-control study of SIDS in south west England.  BMJ 2009;339:b3666

13. Carpenter RG et al.  Sudden unexplained infant death in 20 regions in Europe: case control study.  The Lancet 2004; 363: 185 – 91.

14. Tappin D, Ecob R., and Brooke H.  Bedsharing, roomsharing, and sudden infant death syndrome in Scotland: a case-control study.  Journal of Pediatrics 2005; 147: 32 – 7.

15. McGarvey C et al.  An 8-year study of risk factors for SIDS: bed-sharing versus non-bed-sharing.  Archives of Disease in Childhood 2006; 91(4): 318 – 23.

16. Vennemann MM et al.  Sleep Environment Risk Factors for Sudden Infant Death Syndrome: The German Sudden Infant Death Syndrome Study.  Pediatrics 2009; 123(4): 1162.

17. Blair PS et al.  Sudden infant death syndrome and sleeping position in pre-term and low birth weight infants: an opportunity for targeted intervention.  Arch Dis Child 2006; 91(2): 101 – 6.

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Safe Cosleeping Blog Carnival

Thanks for reading a post in the Safe Cosleeping Blog Carnival. On Carnival day, please follow along on Twitter using the #CosleepCar hashtag.
Please take time to read the submissions by the other carnival participants:

***

Emotive Co-Sleeping Campaign – Miriam at Diary of an Unconscious Mother talks about her feelings on Milwaukee’s anti-cosleeping crusade and its latest advertising campaign.
Why Cosleeping has Always been the Right Choice for My Family – Patti at Jazzy Mama shares how lucky she feels to have the privilege of sleeping with her four children.
Cosleeping is a safe, natural and healthy solution parents need to feel good about. – See how Tilly at Silly Blatherings set up a side-car crib configuration to meet her and her families’ needs.
Black and White: Race and the Cosleeping Wars – Moorea at Mama Lady: Adventures in Queer Parenting points out the problem of race, class and health when addressing co-sleeping deaths and calls to action better sleep education and breastfeeding support in underprivileged communities.
Reflections on Cosleeping – Jenny at I’m a Full Time Mummy shares her thoughts on cosleeping and pictures of her cosleeping beauties.
Cosleeping and Transitioning to Own Bed – Isil at Smiling Like Sunshine shares her experiences in moving beyond the family bed.
What Works for One FamilyMomma Jorje shares why cosleeping is for her and why she feels it is the natural way to go. She also discusses the actual dangers and explores why it may not be for everyone.
Really High Beds, Co-Sleeping Safely, and the Humanity Family Sleeper – Jennifer at Hybrid Rasta Mama gives a quick view of Jennifer’s bed-sharing journey and highlights the Humanity Family Sleeper, something Jennifer could not imagine bed-sharing without.
Crying in Our Family Bed – With such a sweet newborn, why has adding Ailia to the family bed made Dionna at Code Name: Mama cry?
Dear Mama: – Zoie at TouchstoneZ shares a letter from the viewpoint of her youngest son about cosleeping.
Cuddle up, Buttercup! – Nada of The MiniMOMist and her husband Michael have enjoyed cosleeping with their daughter Naomi almost since birth. Nada shares why the phrase “Cuddle up, Buttercup!” has such special significance to her.
Co-Sleeping With A Baby, Toddler, and Preschooler – Kerry at City Kids Homeschooling shares how co-sleeping calls us to trust our inner maternal wisdom and embrace the safety and comfort of the family bed.
Fear instead of Facts: An Opportunity Squandered in Milwaukee – Jenn at Monkey Butt Junction discusses Milwaukee’s missed opportunity to educate on safe cosleeping

Cosleeping: A Mini-rant and a Lovely Picture – Siobhan at Res Ipsa Loquitor discusses her conversion to cosleeping and rants a little bit about the Milwaukee Health Department anti-cosleeping campaign.
Our Cosleeping Story – Adrienne at Mommying My Way shares her cosleeping story and the many bonus side effects of bedsharing.
Cosleeping can be safe and rewarding Christy at Mommy Outnumbered shares how her cosleeping experiences have been good for her family.
Adding one more to the family bed Lauren at Hobo Mama discusses the safety logistics of bed sharing with a new baby and a preschooler.
The Truth About Bedsharing – Dr. Sarah at Parenting Myths and Facts discusses the research into bedsharing and risk – and explains why it is so often misrepresented.
Cosleeping as a parenting survival tool – Melissa V. at Mothers of Change describes how she discovered cosleeping when her first baby was born. Melissa is the editor and a board member for the Canadian birth advocacy group, Mothers of Change.

Dear Delilah – Joella at Fine and Fair writes about her family bed and the process of finding the cosleeping arrangements that work best for her family.
CoSleeping ROCKS! – Melissa at White Noise talks about the evolution of cosleeping in her family.
Safe Sleep is a Choice – Tamara at Pea Wee Baby talks about safe sleep guidelines.
3 Babies Later: The Evolution of our Family Bed – Kat at Loving {Almost} Every Moment talks about how her family’s cosleeping arrangements evolved as her family grew.
Tender MomentsThe Accidental Natural Mama discusses tender cosleeping moments.
Cosleeping Experiences – Lindsey at An Unschooling Adventure describes how she ended up co-sleeping with her daughter through necessity, despite having no knowledge of the risks involved and how to minimise them, and wishes more information were made available to help parents co-sleep safely.
The early days of bedsharing – Luschka at Diary of a First Child shares her early memories of bedsharing with her then new born and gets excited as she plans including their new arrival into their sleeping arrangements.

The Joys of Cosleeping in Pictures – Charise of I Thought I Knew Mama shares pictures of some of her favorite cosleeping moments.
Symbiotic Sleep – Mandy at Living Peacefully With Children discusses how the symbiotic cosleeping relationship benefits not only children but also parents.
Co-sleeping Barriers: What’s Stopping You? – Kelly at Becoming Crunchy shares how she was almost prevented from gaining the benefits of co-sleeping her family currently enjoys.
Co-Sleeping with the Family Humanity Sleeper – Erica at ChildOrganics shares a way to make co-sleeping safe, comfortable and more convenient. Check out her post featuring the Humanity Organic Family Sleeper.
Why We CosleepThat Mama Gretchen’s husband chimes in on why cosleeping is a benefit to their family.
Adding to the Family Bed – Darah at A Girl Named Gus writes about her co-sleeping journey and what happens when a second child comes along.


A big thank you to all of the Safe Cosleeping Blog Carnival participants!

December 15, 2011 at 6:45 am 11 comments

Hello and welcome!

Hi there!  I’m Sarah, I’m a GP living and working in the UK, and I have two children.  If you want to read more about me and my life, do come check out my general blog, Good Enough Mum.

When I was pregnant with my first child, it didn’t take me long to learn that the age-old tradition of telling mothers how they should bring up their children has reached a whole new level in recent years.  At least a few decades ago it was just individuals making disparaging comments on what we should/shouldn’t be doing with that baby. These days, the do-it-this-way factions are organised into movements posting scads of articles on the Internet, complete with references to a half-dozen or more studies which (these authors claim) provide cast-iron, irrefutable proof of just how damaging and wrong parenting practice X is. And, while many of the dos and dont’s I read struck me as ridiculous enough for me to see through them, unfortunately I didn’t generalise that scepticism to the more convincing-sounding of the essays I was reading – I swallowed quite enough wholesale to spend my first child’s infancy as a nervous wreck over all the possible ways in which I could ruin him by failing to observe some all-important precept with sufficient accuracy.

Then – because my profession gives me the opportunity to get hold of journal articles to read for myself and the training to follow at least the basics of what they say and what their flaws are – I started actually looking up some of those references to research studies, and reading what they really said.  And, little by little, I discovered an astonishing amount of misleading information and downright misinformation.  A frightening number of these people giving their opinion as though it were gospel from on high were, in fact, downright misinterpreting research articles or ignoring contradictory results in order to make it look as though the evidence backed them up when it simply didn’t.  (For the most part, I don’t think these were deliberate attempts at deception – it’s an extremely natural human tendency to make the evidence fit our beliefs, rather than the other way around. We all tend to focus on that which supports our beliefs and gloss over that which doesn’t.  Unfortunately, the effect on bewildered new parents struggling to make sense of all the information out there and do the best thing for their babies is the same – they’re still being misled.)

I had the opportunity to learn that quite a lot of what I was reading just wasn’t correct – but what about other parents out there, who didn’t have access to the same information?  On my blog, I started to write the occasional post dealing with one parenting-related controversy or another, explaining what I knew on the subject and giving my take on it all.  Is sleep training really psychologically damaging for babies?  How much of a problem is it likely to be for a breastfed baby to get the occasional bottle of formula?  What did I think about the MMR?  I corrected erroneous claims I’d read, commented on logic that I found faulty, and generally did a bit of debunking of some of the myths out there.  Some people read them, and some people found them helpful.

After some years of this, my sister suggested, that instead of making them an occasional feature on a blog that was primarily filled with general ramblings about my own life, I should set up a separate blog specifically for posts about parenting.

“Won’t that be a bit of an empty blog?” I asked.  Posts like that take quite a lot of time to write and (see opening paragraph concerning existence of two children and job, above) I’d only actually written a handful of them over the years.

My sister thought I should go ahead anyway and add other posts as and when I got the chance.  So, I took her advice and here we are.

I’m copying the relevant posts from my other blog, with slight editing if appropriate, and posting them on here under the timestamp they were originally posted under (which is why it looks as though I’ve been posting here for years on a very occasional basis, in case you were wondering.  This is actually the first post written specifically for this blog.)  I’m not likely to have the chance to add more very often, but I’ll do what I can.  If you have any topics you’d like my views on, do please let me know.  Meanwhile, the most important piece of advice I’d give to any parent?  Don’t worry, don’t sweat the small stuff, and remember the old saying – the most important thing you can do for your kids is to enjoy them.

November 5, 2011 at 7:08 pm 7 comments

Accentuate the negative, eliminate the positive? The problems with Wiessinger’s ‘Watch Your Language’

(This post was first posted on the Good Enough Mum blog, here.)

Fifteen years ago, Diane Wiessinger, a breastfeeding counsellor and activist, wrote an article about breastfeeding promotion for the Journal of Human Lactation, entitled ‘Watch Your Language‘.  In it, she claimed to have the answer to the thorny question of why lactation consultants and the health care profession have such poor results when it comes to persuading women in the US to breastfeed.  I find this article, and the huge following it has received, to be of great concern; not only do I see no evidence for her theory, but I see a number of reasons to believe it is likely to do the cause of breastfeeding promotion far more harm than good.

Wiessinger’s key premise is that, when we talk about the benefits of breastfeeding, we have it backwards.  Instead, we should talk as though breastfeeding is the norm, and frame all our discussions of the differences between the two in terms of drawbacks and harms of formula-feeding.  And we shouldn’t mince words while doing so.  In Wiessinger’s opinion, we should be trying to catch our flies with vinegar rather than honey, and particularly bitter vinegar at that.  For example, Wiessinger advocates telling women that ‘artificial feeding results in an abnormal and unpleasant odor that reflects problems in an infant’s gut’, and describes formula-feeding as ‘deficient, incomplete, and inferior’.  ‘Those are difficult words,’ Wiessinger writes, ‘but they have an appropriate place in our vocabulary.’

Of course they do; however, that place is not in the speech of those wishing to describe the behaviour of those whose hearts and minds they wish to win over.

I’ve had a hard time writing this post, simply because I genuinely haven’t known where to start – there are just so many things wrong with the article.  But I’ve also known that this post needs to be written.  Wiessinger’s claims are hugely influential in the world of breastfeeding activism.  Google that title and Wiessinger’s name, and you’ll find her original article posted in its entirety in multiple places on the Net.  Lactivist website after lactivist website tells us that we should refer to breastfeeding as the norm and talk about the harms of formula-feeding instead of the benefits of breastfeeding.  I’ve even seen one blog describe the approach of talking about the benefits of breastfeeding as ‘anti-breastfeeding’.  I think that a post pointing out the fundamental problems with this approach is long overdue and very necessary.  So, here are the many reasons why I disagree with what Wiessinger has to say.

It’s counter to the evidence.  One of the principles on which behavioural psychology is extremely clear is that, if you want to change people’s behaviour, the carrot is mightier than the stick.  Research in this field established decades ago that potential benefits are much better motivators for change than potential avoidance of harm.  This really is the kind of thing that gets taught in introductory psychology classes.  Which, of course, is why advertising campaigns are not generally framed around the idea that you should buy product X because the alternatives are worse – they’re framed around the many benefits product X can offer you.

Oddly enough, Wiessinger herself touches on this when she writes that the phrasing of lactation consultants pushing breastfeeding ‘could just as easily have come from a commercial baby milk pamphlet’… and then comes to the rather bizarre conclusion that ‘[w]hen our phrasing and that of the baby milk industry are interchangeable, one of us is going about it wrong’.  Logically, if two groups of people are going about something the same way, they’re either both right or both wrong.  If companies with millions to spend on employing the best advertisers are taking the approach of advertising their product’s benefits, shouldn’t we be considering the likelihood that they’re doing this because they know it to be the most effective way of convincing people?

Yet Wiessinger shows an astonishing disregard for what the evidence in psychological research has to say.  And, given that she gives nothing to back up her opinions on this point, isn’t the most likely conclusion that the psychologists all have it right and Wiessinger has it wrong?

Most people aren’t that masochistic.  People generally just aren’t that keen to listen to criticism.  Think for a minute about how Wiessinger’s words might sound to a woman who’s happily formula-fed her first child and is now expecting another.  Talk to her about the benefits of breastfeeding, and maybe she’ll be open to listening and perhaps having a shot at another way of doing things.  Tell her how deficient, incomplete, and inferior her way of feeding her first child was – letting her know, while you’re at it, that you think her precious adorable first baby actually stank – and something tells me that she’s not going to be all that thrilled about listening to anything else you have to say.   Harshness only alienates those whom we’re hoping to reach.

Of course, I’m guessing (and hoping) that most advocates of Wiessinger’s approach would have enough tact to temper their words in that kind of face-to-face situation.  But the words and actions of one part of a movement reflect on the whole, especially when the words come from those speaking on behalf of the breastfeeding movement.  If the voice of breastfeeding advocacy is telling women how awful formula-feeding is, a lot of women are going to expect – and fear – the same thing from individual breastfeeding counsellors.  And that’s going to put off that woman who’s formula-fed a previous child or children, or the woman who’s currently struggling to breastfeed but has found herself giving a few bottles of formula to get through the difficulties and is scared of what reaction she might get if she tries asking a breastfeeding counsellor for help (and, anecdotally, I’ve read stories from women who were put off asking for help with breastfeeding for precisely this reason), or even the woman with no previous experience who might have been willing to give breastfeeding a go but is too scared of how she might get harangued if it doesn’t work out.  Adopting Wiessinger’s attitude to formula will make us look horribly unapproachable to a large segment of the women we most want to have approach us.

It fails to connect with people.  When Wiessinger talks about breastfeeding being the biological norm, she ignores the fact that, for many women, it isn’t the social norm.  Talking to these women as if breastfeeding was the norm isn’t starting where they are.   When you start by ignoring someone’s own reality and life experiences in favour of focusing on where you want them to be, or think they really ought to be, you’re setting your advocacy attempt up for failure.  If you’re not starting where they are, you’re making it far harder to form the connection you need to form with them in order for advocacy to be effective.

The stress it causes may be counterproductive.  This is actually a point that hadn’t occurred to me, but that another blogger pointed out when we were discussing this online once.  She felt that Wiessinger’s approach would have been more stressful to her when trying to get lactation established, and that that stress itself might have done more harm than good by interfering with her milk production.  It’s a fair point – we do know that stress can affect milk production.  While there’s no way to eliminate all stress from breastfeeding initiation in all cases, we can at least do our best to avoid making matters worse by not making women who need to give some formula while getting breastfeeding going feel attacked for doing so.

It encourages an all-or-nothing attitude.  And this can also be counterproductive, by putting off women who might be willing to consider short-term feeding or mixed feeding or even breastfeeding with the occasional bottle given now and again, but who just can’t see themselves wanting to aim for the current gold standard of ‘breastfeed for at least a year with nothing but breastfeeding for at least six months’.  How often do you hear ‘Because I wanted someone else to be able to give a bottle sometimes when I went out’ given by a mother as a reason for her choice not to breastfeed?  How many more of these women might actually end up giving breastfeeding a try if they knew that it is perfectly possible to breastfeed and yet have somebody else give your baby a bottle when you go out?  Or that, if full breastfeeding is not an option, mixed feeding carries most of the same benefits as breastfeeding and is still worth considering?  It’s easy enough to introduce those ideas in a context of discussing the benefits of breastfeeding.  But how do we reconcile descriptions of formula as harmful and risky with the explanation that, in fact, it doesn’t appear to be a problem (despite some lactivist claims) to give a bottle of it to a fully breastfed baby now and again?  We probably don’t, is the answer – and that means yet another group of women we’ve barred ourselves from reaching.

So, with all these problems, why has Wiessinger’s approach been so popular?

When I told my husband about the article, he nodded gravely and commented ‘Some people just aren’t happy unless they’re being unkind to other people.’  Sadly, I think there’s some truth to that – there’s a nasty little satisfaction that comes from believing you’ve got a really good excuse to say unpleasant things to people, and I think that, on that subconscious level we don’t like to admit to, that may be part of the attraction for at least some of the people who espouse this philosophy.  However, I really don’t think that’s the whole story, and my guess would be that most of the people who believe this actually have much kinder motivations.

I think that a bigger reason is that, when you’re faced with a thorny and seemingly insoluble problem and someone who gives every indication of knowing what they’re talking about comes along and tells you, in authoritative tones, that XYZ is the answer, it’s pretty natural to believe them – especially when some of what they say is demonstrably true.  And, of course, Wiessinger makes a few good points in amongst the frighteningly bad ones.  Promoting breastfeeding by talking in the kind of fluffy superlatives better suited to cloud-cuckoo land isn’t that great a way of reaching women, either, and it’s easy for Wiessinger to convince people that the issue with that approach is the positive framing.  It’s true that making breastfeeding sound like something special makes it feel out of many women’s reach. (Although, oddly, by the end of the article Wiessinger seems to be taking the same approach herself.  Apparently, we should be advising women that they shouldn’t merely breastfeed, but ‘mother at the breast’ and form a ‘breastfeeding relationship’.  But, hey, no pressure to make it Really Special.)

But the use of positive language isn’t the problem with the ‘best possible start in life, special bond of breastfeeding, blah blah’ approach.  The problem is partly that that way of describing is too overblown to be taken seriously (most people, quite rightly, are just not going to be convinced by the implication that the most important choice you can possibly make to get your children well launched into a fruitful life is that of how to feed them at the beginning of it), and partly that it doesn’t connect with people any more than Wiessinger does.  The hypothetical lactation consultant Wiessinger quotes isn’t finding out where each individual woman is and dealing with her particular concerns and beliefs.  She isn’t giving women information about the differences between breast and bottle in any sort of practical, easily comprehensible way that can be used as a foundation for sound decision-making.  She isn’t having a genuine discussion.  She isn’t starting from where women are.  She isn’t connecting.  And the answer to those flaws is not to adopt an approach that keeps those flaws and combines them with several more.  The answer is to put right those flaws.

I’ve already written about what I’d like to see in breastfeeding promotion.  Wiessinger’s article is a prime example of what I don’t want to see in breastfeeding promotion.  Let’s please, please, please, forever put to bed the attitude that unpleasantness and scare tactics are the most effective ways of persuading anybody to do anything.  Let’s go, instead, for an approach that’s actually likely to work.

August 12, 2011 at 9:48 pm 3 comments

Breastfeeding for longer than a year – myths, facts, and what the research really shows

(This post first appeared on the Good Enough Mum blog as a submission to the April 2011 Carnival of Breastfeeding.  You can read the original here.)

Extended breastfeeding is the term given, in our society, to breastfeeding a child beyond the first year.  An increasing number of women are choosing to do this, and, sadly, are more often than not incurring heated disapproval for doing so. Breastfeeding toddlers or older children is believed to make them overly dependent, mothers who do so are accused of thinking only of their own needs and not of their children (that ultimate indictment for mothers), and the practice is looked on as inappropriate and downright perverse.

Fortunately, it’s now being increasingly recognised that this position is not supported by either logic or evidence.  Not only is there not a shred of evidence that breastfeeding beyond a year is harmful, there is positive evidence to reassure us on this score – the world is full of societies in which it is considered normal and expected behaviour to continue breastfeeding for considerably longer than a year, and the children raised thusly seem to be doing perfectly well on the practice.  It is, of course, hugely beneficial for children in developing countries where food can be scarce and malnutrition rife, and it has some potential benefits even in our affluent society – it can be a valuable source of nutrition for otherwise faddy toddlers, and it slightly reduces a mother’s risk of breast cancer or rheumatoid arthritis.

I’m delighted to see it becoming more widely recognised that there is absolutely no reason why a mother should feel obliged to wean simply because an arbitrary date on the calendar is approaching.  However, there’s a twist to this; the pressure is starting to go the other way.  A small but vocal minority are pushing for breastfeeding past a year to be seen not merely as an option for women who want to do so, but as a goal for everyone to aim for.  Breastfeeding a toddler (or older child) is enthusiastically touted as having a host of physical and psychological benefits.  Lactivists are advising mothers that they should do their best to continue nursing until two years at the very least, and preferably longer (nursing until the child decides spontaneously to stop is held up as the ideal).  And the problem is that there really isn’t any decent evidence to support this attempted move towards yet another blanket parenting ‘should’.

I’m not objecting, here, to an individual woman deciding that there may be particular circumstances in her child’s case – deprived circumstances, an unusual health problem, or even just food faddiness – that might lead to her wanting to continue to breastfeed in hopes that it will be of some benefit.  Also, of course, I’m talking specifically about the situation in the developed world here, not about breastfeeding in developing countries where it is indeed likely to remain beneficial for long past infancy.  My objection is to the claims that extended breastfeeding has been shown to be of general benefit even in situations where other sources of nutrition are plentiful.  It hasn’t.  And while this kind of pro-extended-breastfeeding advocacy has been a huge comfort to plenty of women who, having struggled with the pressure from others to wean before they wish to, now feel vindicated, it’s also putting some women in the position of feeling obliged to nurse for longer than they really want to, in the belief that they’ll be somehow depriving or disadvantaging their children if they don’t.  That is not a trend I want to see.

That position, of course, is controversial enough in lactivist circles that it’ll need some defending; to break up what’s now set to be a very long post, I’m going to go for the ‘Debate With Imaginary Opponent’ format.

What do you mean, there’s no evidence that nursing past a year is beneficial?  Are you trying to claim that a fluid so packed with nutrition, antibodies, and general goodness somehow magically loses all its benefits just because a child has passed the age of one?

Of course not.  What happens is that the child gradually grows, develops and reaches the point where breast milk just doesn’t have anything much further to add.  (Just to clarify, in case anyone was forgetting how I began this post, I’m fine with children continuing to nurse after that point if they and their mothers so wish.   All I’m objecting to is the claim that they should continue to nurse, which I don’t agree with any more than the claim that they should stop.)

But there’s plenty of evidence that breasfeeding is beneficial to toddlers.  For starters, one study by Gulick (1) showed that breastfed toddlers between 16 and 30 months old get sick less often than non-breastfed toddlers and get better more quickly when they do…

No, it didn’t.

Huh?

It didn’t.  Although lactivist websites all over the Internet claim that that study shows a decreased rate of infections in breastfed toddlers between 16 and 30 months old, it actually shows nothing of the sort.  I know this because I’ve got hold of a copy of the study and read it for myself.  The toddlers being studied weren’t breastfed toddlers – they were toddlers who’d been breastfed in the past but had stopped breastfeeding before entering the study.  What the study was actually looking at was whether longer duration of breastfeeding during infancy had any benefit in terms of reducing infection rates in toddlerhood after breastfeeding cessation.  (It didn’t, in case you’re interested; at least, not in that study.)  Somehow, someone has managed to utterly and crashingly misreport what the study was into and what it showed, and lactivists across the Internet have simply repeated this misinformation without question.  It’s one of the biggest breastfeeding myths I’ve seen out there.

Well, come on – what about the other studies on the topic?  Look – Kellymom has a whole list of studies showing the immunological benefits to breastfed toddlers!

One of those is a study set in a developing country, showing benefit to children who are severely malnourished children.  As I said, breastfeeding can indeed be beneficial past infancy in such a setting, but it just isn’t valid to assume that those results will be applicable to children living in our relatively privileged Western settings.  One wasn’t even studying toddlers – it was a study of breastfeeding benefits in babies up to the age of 20 weeks, which is not toddlerhood by any remote stretch of the imagination.  The rest, as far as I can see, all just look at concentrations of antibodies in breastmilk of mothers of nursing toddlers, not at whether those antibodies are actually adding anything to the toddler’s own antibodies when it comes to fighting off infections.

Oh, come on.  Surely all those antibodies have to be doing something.

Not necessarily.  Bear in mind that a child’s own immune system also develops rapidly during the early years, and at some point it’s going to reach the stage where breast milk just doesn’t have a lot else to contribute.

That surely can’t be as early as a year, though.  I can’t believe that breastmilk doesn’t still have some benefit to children older than that.

You’re welcome to believe what you like.  It’s the claim that it’s been proved to be beneficial that I’m objecting to.

So have you any evidence that it isn’t?

In the one study I have been able to find on infection rates in breastfed vs. non-breastfed toddlers – a study in New Zealand that followed over a thousand children up to the age of two, looking at respiratory and gastrointestinal infections – breastfeeding didn’t show any benefit in toddlers, or for that matter, in older babies (2).  Of course, there are flaws in every study, and I can think of several possible reasons why this one might have underestimated results enough to miss a small but genuine benefit, but it does seem to me that, if that’s the case, we can’t be talking about that great a benefit.  And, frankly, when the one study we have on the subject shows a complete lack of any benefit, I don’t really think that the people claiming evidence of benefit are on solid ground.

But, what about the other benefits for breastfed toddlers?  Just look at the way that it helps an upset or tantrumming toddler to calm down.

I agree that that can be a wonderful convenience of breastfeeding.  However – and feel free to take this or leave it as you like, because we are temporarily stepping out of the realm of objective scientific evidence and into that of my own opinion – I do have my doubts as to whether it’s a good idea to do so.  After all, what message does it send children when we regularly and repeatedly teach them to turn to a sweet-tasting food source at times when they need comfort?  I wouldn’t use any other form of food or drink to distract my child from a tantrum, because that’s not the message I want to be giving to my children about how food should be used; it’s not encouraging healthy eating habits.  Why should I make an exception for breastfeeding?  I tried to avoid doing so, for both my children.  Just because something is the most convenient way to calm an upset child doesn’t mean it’s necessarily the best way in the long term.

But it has psychological benefits over and beyond just calming tantrums.  Breastfeeding for longer actually helps children become more independent!

No evidence for that claim.

Look, Jack Newman says so!  And Elizabeth Baldwin!

And they’re entitled to their opinion on the matter.  However, I don’t see any reason why I should automatically believe it, any more than I should automatically believe the equally unreferenced opinions of the doctors who claim that longer breastfeeding makes children more dependent.  Either way, they’re opinions, which are not the same thing as evidence.

But there is evidence!  Check out this quote on Kellymom’s site – ‘One study that dealt specifically with babies nursed longer than a year showed a significant link between the duration of nursing and mothers’ and teachers’ ratings of social adjustment in six- to eight-year-old children’ (3).  Or are you trying to claim that that study’s being misrepresented as well?

Oh, not with the kind of spectacular degree of inaccuracy as the study by Gulick we discussed above.  However, that quote makes the results sound far more impressive than they were.  We’re not told that the differences found were very small, that they showed up in only one of the several measures of psychosocial adjustment that were tested, that adjusting for other factors eliminated practically all the difference found in the teachers’ ratings, or that the researchers themselves were pretty unimpressed by their results.  To quote from their conclusion: ‘In general the evidence above gives only very weak support for the view that breastfeeding makes a significant contribution to later social adjustment.  The research findings tend to be both inconsistent over time and between measurement sources and at best suggest a very small association between breastfeeding and subsequent social adjustment.  Further it is more than likely that even the small and inconsistent associations that have been reported could have arisen from factors which have not been controlled in the analysis.’  As evidence goes, I have to say that that doesn’t really strike me as compelling enough to justify trying to persuade women to continue breastfeeding if they don’t want to.

So what about all the other studies listed on Kellymom?  Showing that breastfed toddlers suffer from fewer allergies and have higher IQs?

I’ve checked all five of the papers she lists as supposedly backing up her claim about reduced allergies in breastfed toddlers (full text of four of them, the abstract of the other), and none of them are about toddlers.  They’re all looking at breastfeeding in infancy.  In fact, one of them (a review rather than a study) actually mentions in passing that the existing research shows ‘some suggestions’ that longer breastfeeding may be related to an increase in allergy risk.

When it came to the studies on breastfeeding and intelligence, after a while I simply gave up.  The only study I did manage to find that looked at breastfeeding over a year didn’t find any substantial difference in intelligence or school performance between children breastfed for that length of time and children who stopped shortly before that – longer duration of breastfeeding was initially associated with a slight increase in intelligence level, but then the effect leveled out.  (That one’s not available on line, but you might be interested in checking out this one by Mortensen et al that Kellymom also links to, which also studied the association between intelligence and breastfeeding duration and reached a similar conclusion – initially the increased duration of breastfeeding was associated with slight improvement on the intelligence scales, but the effect then levelled off, with children breastfed for longer than nine months having scores no better than those breastfed for 7 – 9 months.)

I checked several other studies on her list which, again, all turned out to be follow-ups on breastfed babies, not children breastfed past a year.  So, as I say, I gave up.  Checking all the studies she lists would have taken forever and I’m afraid there are limits to the amount of time and effort even I can put in to checking references from someone who’s clearly such an unreliable source of information.  (And, before anyone gets offended at me dissing Kellymom, I do actually think she’s a great source of information when it comes to dealing with breastfeeding problems; I’ve just found her to be appallingly bad at giving accurate information on any research dealing with any question in the general category of ‘Is it possible that breastfeeding in circumstance X is anything less than incredibly beneficial?’)

So, for all you know, there might be studies on her list that do show benefits of toddler breastfeeding and you just haven’t seen them?

Well, if you find any, by all means let me know.  I mean that – I’d be interested to read them and happy to spread the word about them.  But, until I actually see a decent-quality study providing good evidence that breastfeeding past a year is actively beneficial for children, I’m not going to tell women it is.  And, given how many studies are being erroneously cited as showing benefits of toddler breastfeeding when they show nothing of the sort – frankly, I think my scepticism about the existence of any studies that do show benefits is completely excusable.

Well, I don’t care!  I love breastfeeding my older child and I want to carry on whether or not you’ve found any studies proving that it’s beneficial!  We’re both enjoying it, and that’s benefit enough!

EXACTLY!  And that’s the ONLY reason you need.  You don’t need to prove that it’s in some way superior to what all the other mothers are doing.  You don’t need to score Good Motherhood points on some imaginary scale to justify your choice to others.  You just need the confidence to believe that it’s OK and that it’s what works for you.  Enjoy nursing your toddler or older child, accept that mothers who have made a different choice from you are doing just as well by their child and shouldn’t be conned into nursing for longer than they want to, and support every mother in the choice she makes on the matter, in the knowledge that, as far as we can see from the available evidence, nursing or not nursing a child of that age are equally good options to go for and thus we can happily leave this one in the realm of personal preference where it belongs.

 

References

1. Gulick E. The Effects of Breastfeeding on Toddler Health.  Pediatric Nursing 1986; 12(1): 51 – 4. 

2. Fergusson D.M., Horwood L.J., Shannon F.T., and Taylor B.  Breast-feeding, gastrointestinal and lower respiratory illness in the first two years.  Australian Paediatric Journal 1981; 17: 191 – 5.

3. Fergusson D.M., Horwood L.J., and Shannon F.T.  Breastfeeding and subsequent social adjustment in six- to eight-year-old children.  Journal of Child Psychology and Psychiatry 1987; 28(3): 378 – 86.

April 18, 2011 at 9:40 pm 11 comments

The Case Of The Lactivist Propaganda – A Reply To Ann Calandro

(This post was originally published on the Good Enough Mum blog, in response to a link to Calandro’s essay in a comment on someone else’s blog.  Since the particular comment seems fairly irrelevant now, I haven’t bothered with the references back to it, and have thus edited the beginning and end of it slightly – the substance of the post is unchanged.  You can read the original here.)

It is generally accepted as gospel within the lactivist world that mothers should not only breastfeed, but should, for at the very least the first six months, avoid any exposure at all of their precious babies to that scary horrible formula.  A well-known and particularly lurid example of this is  ‘The Case of the Virgin Gut‘, by Ann Calandro, which I have also seen posted under hammer-the-point-home titles such as ‘Even The Occasional Bottle Of Formula Has Its Risks’ or, from someone who doesn’t appear to have quite grasped the use of the subjunctive,  ‘Yes! Just ‘One’ Bottle Of Formula Will Hurt’.  The content of the article is even more unnerving:

Since my baby had received lots in her stomach besides breast milk, her little gut was not virginal. What did this mean? Had the hospital nurses inadvertently done some kind of damage to her? Had I? What was going on inside my little girl?

But what happens when breast milk is not the only food in that little gut? The truth is very interesting and also very scary.

…destroying the characteristic intestinal flora of the breast-fed baby. [This one was a quote from a breastfeeding book.]

…there is very little that can be done to remedy the situation and save the virginal gut.

A huge increase in diarrheal diseases occurs in babies who do not have optimal “intestinal fortitude,” which is only possible with guts that have never been exposed to infant formula.

Not to mention, of course, the story of the baby who had a few innocent-seeming bottles of formula and then developed a severe allergic reaction to cow’s milk and was rushed into hospital and had stacks of medical tests and nearly DIIIIIIIEEEEED, all because of that scary formula.  If you can make it through that lot without being reduced to a quivering wreck at the prospect of your baby possibly ending up consuming some formula and being irrevocably damaged, you’re a much more confident mother than I was in those scary first-time-around days.  It’s thanks to that article, and others like it, that breastfeeding my first baby was turned from the pleasant and relaxing experience it should have been to a miserable, anxiety-ridden chore haunted by the fear of dire consequences if I fell down on the job the least little bit.

Which is terribly sad.  Because – surprise, surprise – despite Calandro’s claim that there is ‘much research to support avoiding supplementation if at all possible’, the available evidence doesn’t really seem to support her alarmist tone.

There’s not much back-up, for example, for the claim that risks of diarrhoea are hugely increased.  A study in New Zealand in the late ’70s comparing babies receieving various amounts of formula in their diet with exclusively breastfed babies (Fergusson et al, the Australian Paediatric Journal, 1978, vol 14(4), pages 254 – 8) found that giving some formula supplements to breastfed babies on an irregular basis carried slightly greater than a one in twenty chance of causing diarrhoea. Now, those were the figures unadjusted for possible confounders, so that will in fact be an overestimate – and it’s still hardly the ‘huge risk’ claimed by Calandro. And that, of course, is more than thirty years ago, when sterilisation techniques were poorer than today. What do more recent figures look like? Well, a 1997 study available in Pediatrics looked at the infection rates in babies receieving different proportions of formula in their diets. Babies getting formula supplements up to around 10% of their total diet showed *no* increase in rates of diarrhoea over babies who were exclusively breastfed. Seems like all those babies were somehow managing to do just fine despite the defloration of their precious virgin guts. Maybe getting a bottle of formula now and again, despite what it might do to bacterial counts, is actually not such a big deal in terms of outcomes that actually matter?

As far as the risk of cow’s milk allergy goes, a couple of studies have indeed shown a small risk of cow’s milk allergy associated with early formula top-ups (in the one for which I have figures, the risk of developing some sort of later reaction to cow’s milk as a result of having had some in the hospital was around one in forty), but the research is actually quite conflicting – another study showed negligible effect, and a randomised controlled trial actually showed a marked decrease in risks of milk allergy in babies with a strong family history of allergy who received formula before having any breast milk. So that one is a possible risk, but far from conclusive.  As for other forms of allergic disease, again, two studies into the effects of early cow’s milk exposure haven’t shown any increase in later risk of allergies.

The increase in risk of developing Type 1 (insulin-dependent) diabetes does seem to be backed up by better evidence, but needs to be kept in perspective – this is effectively only going to be an issue for children who are genetically predisposed to develop Type 1 diabetes in the first place. In other words, only a tiny minority. If your baby has a close family relative with Type 1 diabetes, it’s probably worth trying to avoid any formula in the early months. If not, then this one is likely to be a negligible enough risk not to be worth bothering about.

It’s fair to say that the available evidence, despite what Calandro and her ilk claim, is in fact fairly limited, and can’t currently exclude a small chance that there might be risks associated with even the occasional bottle.  If so, they certainly don’t appear to be wildly significant in practical terms, and neither the evidence for them nor the likely magnitude of them justify the kind of scaremongering Calandro is indulging in. If the only reason you’re giving a bottle is to get your baby used to one, then I think it’s probably worth trying to pump a couple of ounces of milk for that, if possible, rather than giving formula. But, for those parents who’ve already given or need to give their breastfed babies some formula now and again, do I think that these uncertain and largely theoretical risks are worth getting worried about? Hell, no.

July 25, 2010 at 9:49 pm Leave a comment

Why I don’t believe that sleep training is incompatible with children’s rights

(This post originally appeared on the Good Enough Mum blog here.)

Mothers for Women’s Lib regularly host a Carnival of Feminist Parenting.  Every month (recently reduced to every two months) they post links to a selection of posts about various diverse topics on the general themes of feminism, sexism, and other forms of discrimination, and about how parenting is affected by these issues (both by discrimination and by the need to fight against it).

A few months ago, one of the featured posts was an anti-sleep training polemic.  Just Let Her Cry started out with a fictional first-person tale of an ill and depressed woman shut in her room by her husband every evening when it suited him regardless of whether she was hungry, in pain, or just not tired.  The author then drew her analogy between this and controlled crying or other forms of cry-it-out (CIO) sleep training, which she referred to as ‘neglect with a different name’.  She claimed, inaccurately but ominously, that scientists everywhere knew the short and long-term consequences of CIO to be ‘vast’, and was scathing in her condemnation of parents who’ve tried sleep training: ‘They aren’t setting out to harm a child, but that doesn’t change the fact that they are.  Argue with me all you want.  Say “I let my baby cry it out, and he/she is fine”.  I don’t believe you.  I believe you broke your child like an animal.  I believe they gave up.  They didn’t magically learn to “self-soothe”, they just figured out that you suck at being a parent at night time.’  This wasn’t a discussion of feminist parenting; this was a no-holds-barred shot in the Mommy Wars.

I enquired as to the appropriateness of this post as a carnival submission.  One of the site’s authors replied ‘We are advocates of children’s rights as well as women’s rights and believe the two are very much intertwined.’  So be it; their Carnival, their choice as to what they consider appropriate, and I wouldn’t even want to go down the road of telling people what views they can or can’t express.  But I disagree with the implication that a belief in children’s rights automatically means a belief that controlled crying is always wrong, and I think it would be a shame if that particular post was the only view a site supposedly for anyone interested in feminism and parenting had on the matter.  So this is my explanation of why I do not agree with that poster’s analogy, and why I do not agree that a belief in children’s rights is incompatible with a belief that sleep training may be a perfectly reasonable option for a parent to consider.

First off, some background explanation of what sleep training actually is, what it’s not, and what purpose it serves:

A little-known fact that’s important for understanding sleep training is that all babies wake up multiple times each night.  I’m not talking just about the sleep pattern of very young babies or about occasional bad nights in older babies (although it’s important to recognise those as facts of parenting life as well); I’m talking about what happens in every baby, every night, including all the ones whose parents think of them as sleeping through the night.  The parents of those babies aren’t lying; the key is not that those babies don’t wake up, but that they get back to sleep again right away when they do wake up.  If, on the other hand, the only way a baby can get to sleep is by being rocked or nursed or what-have-you by someone else, then the someone else is going to have to wake up several times every night to do this; and that’s where it becomes a problem.

One way of dealing with this is simply to have the baby in bed with you, thereby meaning that you can cuddle or nurse them or whatever without waking up.  As long as the parents are also happy with this and have taken proper safety precautions, this can be a perfectly good solution.  However, there are various reasons why this is not a universal solution for every situation, and so the other option is to teach the baby to go back to sleep alone.  (Older babies, that is; babies in their early months still need to feed every few hours and so trying to get them to sleep through an entire night can actually put them at dangerous risk of dehydration.  For this, among other reasons, sleep training methods are not recommended for babies in the early months.)  Sleep training is the term used for the various methods used to do this.

Sleep training is not meant for use in situations where the problem is actually that the baby still needs night feedings, or isn’t well, or has had a nightmare, or some other need for help or comfort.  (I’m not trying to claim, here, that nobody has ever ignored a baby in such situations and mistakenly referred to that as sleep training; I’m pointing out that this is not why sleep training methods were designed or how they are appropriately used.  From what the author said in this post and others on her blog, it is absolutely clear that she was not merely warning against misuse of sleep training – in which case I’d have agreed with her – but was lumping all sleep training in under that description and condemning it wholesale.)  Sleep training is for teaching the baby to be able to get back to sleep in situations where nothing’s actually wrong.

The method usually recommended a few decades back was simply to leave the baby crying for however long it took to fall asleep alone, cold turkey style, but this method was pretty distressing for everyone (including the neighbours), and hence a variety of modifications were introduced.  The first of these was the advice to come in at regular intervals to comfort the baby briefly before going out again, extending the length of the intervals as time went on; this is the infamous controlled crying method, also referred to as Ferberisation after its inventor, Richard Ferber.  He advocated a fairly rigid schedule for going back in and very limited time in the room/interaction with the baby.  Most of the other suggested methods are just variations on this initial method with different advice about intervals for which the baby is left and/or the amount of time spent comforting the baby.  There are a couple of others which don’t involve leaving the baby alone at all; Ferber had an alternative which I think of as Ferber-lite, in which the parent stays in the same room but moves further and further away from the baby’s cot, and Tracy Hogg of Baby Whisperer fame had a version to which I personally am very partial called PU/PD, standing for Pick Up/Put Down and referring to doing precisely that with the crying baby until it gives up and falls asleep.  (By the way, if you go looking for that last then a) the full description is in this book, not this one which is a near-complete waste of time, and b) be prepared to grit your teeth, because she was one of the most annoyingly patronising baby experts on the market.  But I still think the method’s a good one.)

The plethora of methods can seem fairly bewildering, but makes a lot more sense when you think of them all as just being different ways of getting from point A (baby needs cuddling or rocking or whatever to get back to sleep) to point B (baby gets back to sleep without any sort of requirement for parental help).  The trick, as with an awful lot else in parenthood, is in finding a method that’s not unduly harsh yet is firm enough to get the message across.  I don’t think there’s any such thing as a ‘best’ method because it will depend on the baby and the situation and what-all else; in any case, most methods will work perfectly well for most babies at the end of the day.  But the point of all of them is not to neglect babies who are hungry or wet or frightened, but to teach babies how to get themselves back to sleep after normal night wakings where there aren’t any other problems.  Penelope Leach nicely summed up the principle behind sleep training when she said that the idea was to show the baby that you were always available but after bedtime you were very boring.  As the delightful Libby Purves comments, it is possible to get very boring indeed by three in the morning.

So, if the neglected-wife analogy in this post was rewritten to reflect the way in which sleep training is actually supposed to be used, how would it look?  Something like this:

There was a time, not so long ago in my life, when I had some major problems with getting to sleep.  The only way I could get to sleep was to have somebody hug me and rock my body back and forth in their arms, which would relax me enough to drop off.  As well as needing this at bedtime, I was waking up several times a night and needing the same thing each time.  Everything else in my life was going fine – I was happy, healthy, and had no other problems.  I just couldn’t get to sleep by myself, that was all.

Fortunately, this wasn’t a problem for me, as my husband was there to help.  Whenever I woke up during the night, I just woke him as well to rock me back to sleep (or, if he hadn’t gone to bed yet and was trying to do something else, I’d just interrupt whatever he was doing and call him up to the bedroom to rock me).  That, as far as I was concerned, was the problem sorted out.  Oh, sometimes the disturbed sleep made me grumpy and grouchy during the daytime, but my husband could handle that.  And I didn’t see a problem with calling on him at any hour of the night that I wanted to, every night.  After all, he loved me and was very attentive to my needs by daytime; I didn’t see any problem with expecting the same intensity of service during the night-time hours.

It seemed not everyone saw it the same way.  At one point I heard my mother-in-law talking to my husband about the situation.  “You have to put your foot down.  You can’t go on like this.  You haven’t had a decent night’s sleep for months!  You’re going to make yourself ill with exhaustion – and for what?  She doesn’t really need anything.  She should learn to get back to sleep by herself.”  I didn’t understand what she was talking about, and, even though my husband was looking haggard and was also becoming a lot more snappy during the daytime, I didn’t see what that had to do with anything I was doing.  Even though I love my husband more than anything in the world, I didn’t really see him as a person with his own needs.  I’d never seen any reason why I shouldn’t expect him just to give me everything I want when I want it, or how this could have any sort of impact on him.  This wasn’t my fault – I certainly wasn’t intentionally being selfish.  It’s just that, at that stage of my life, I wasn’t yet mature enough to be able to think that way.  I wanted my husband’s help to get back to sleep every time I woke up, so I called out expecting to get it.

But things changed.  My husband told me it was time for me to learn how to get back to sleep on my own.  I wasn’t happy about this in the slightest, and burst into tears when he walked out leaving me alone to get back to sleep, but he stood firm.  He didn’t leave me alone for long at a time – every so often he would come back to comfort me, check I was all right, and speak reassuringly to me – but he absolutely refused to stay in the room for long enough to help me to get back to sleep in the way I was now used to.  I was bewildered, upset, and furious at being left awake and alone, and at first I would lie awake for long periods of time, crying with frustration and upset that my husband had stopped doing things the way I wanted.

Fortunately, it didn’t last long – I found that, eventually, sheer tiredness was enough to overcome my difficulty in falling asleep, and, the more often I fell asleep without my husband there, the easier it got.  Within less than a week of this starting, I found I had reached the stage of being able to get back to sleep easily when I woke up without needing to call out for help.  If ever anything was genuinely wrong, my husband was quick to help out; but on most nights I could now get by without him.  He was as attentive as ever during the day – in fact, if anything, he seemed more attentive and less snappy than when I was waking him up multiple times at night – and it wasn’t long before the new night-time pattern had taken over as the norm in our house. 

Does that still sound like an appalling story of a cruelly neglectful husband?

Also, do bear in mind that a baby may cry at bedtime simply out of annoyance that it is bedtime.  Babies are as capable of adults of wanting to stay up and have fun rather than putting everything on hold for the night to get some sleep, and rather less capable than adults of recognising the possible ramifications of this.  Have you ever had a friend wanting you to stay up and boogie the night away with her when you had to work the next day and knew that you – and, for that matter, she – would end up regretting it if you did?  If you said no, was that a shockingly neglectful act on your part that was likely to traumatise your friend so deeply that she would never be able to trust you as a friend again and would possibly suffer lifelong psychological damage into the bargain?

Babies cry when they need something.  But they also cry when they want something, and it is a really big mistake to assume that if a baby is crying for something this must mean that they need it to the point of risking psychological damage if denied it.  (One obvious reason why this is a really big mistake is because it would rapidly lead to you giving your baby sharp knives and live electrical circuits to play with.  Babies are totally capable of crying for things that they very much need not to be allowed to have, thankyouverymuch.)  I don’t believe that setting limits on the extent to which you can meet a person’s wants violates that person’s rights in any way, regardless of their age.

One other point worthy of mention here, which is technically not sleep training but is very frequently mistaken for it, is that some babies actually need to cry for a few uninterrupted minutes as part of their wind-down into sleep, and attempts to soothe and settle them can backfire and keep them awake.  My daughter was like this; I’ve heard of other babies who are.  If your baby is one of these and you’re locked into a rigid dogma of never leaving a crying baby alone, you’re in for some problems, because all your efforts are actually going to be keeping your baby awake rather than settling them and what they really need is for you to back off and leave them alone while they go through the wind-down process.  In which situation, leaving your baby alone to cry is meeting his or her needs.

I wish I didn’t even have to make the next point, because it seems so obvious to me, but… absolutely none of this is meant to try to persuade any parent that they should use CIO.  Believe it or not, I’m all in favour of avoiding CIO methods wherever feasible; not because I think CIO violates children’s rights or damages their psyches, but because it’s simple common sense that if you have a choice between equally effective ways of solving a problem it’s good to go for the one that doesn’t cause upset to anyone.  And I’m all in favour of minimising the amount of crying involved where crying does have to be involved, for the same reason.  I believe that parents should set limits gently, sympathetically, with full regard for age-appropriate behaviour, and with careful consideration of what limits really need to be set in that particular household and what limits don’t actually matter.  I don’t, however, think it a good idea to confuse any of that with the notion that we can get by without ever setting limits or ever causing at least some upset to others by doing so.

So, if you’ve found an alternative method of dealing with the sleep situation in your household that seems to be working out all round, more power to you and go for it.  If you’ve found that that doesn’t work and that, for whatever reason, your baby does have to be left alone for a bit as part of the process of getting them to sleep, then do that.  Either way, don’t assume that whatever it is you’re doing would work for every other family as well, and don’t resort to scaremongering, guilt-tripping, or poorly-informed parent bashing to try to get others to fall into line.  I’m not trying to replace the anti-CIO polemic with a pro-CIO polemic; I’m trying to replace it with an anti-Mommy Wars polemic.

Instead of the Mommy Wars, I’d like to see a widespread willingness to trust parents.  To trust that parents, if given information about different options (which is not code for ‘scare stories about the options we don’t like), are actually pretty good at making decent choices for their children.  To trust that even if a parenting choice isn’t what you would choose/what would work for your child, it doesn’t automatically follow that that parent did something terribly wrong and harmful to their child.  To trust that parents know their own children and that if a parent has done something that happens to go against your particular dogma but they genuinely believe their child is doing fine then it might just be that it’s your dogma and not the parent’s knowledge of their child that’s wrong.  A feminist parenting site strikes me as a very good place to eschew the Mommy Wars and promote that kind of trust.

May 9, 2010 at 10:35 pm 3 comments

Do multiple vaccines overload the immune system? Apparently not.

(This post was originally posted on the Good Enough Mum blog, here.)

One common claim of the anti-vaccine movement is that there are just too many vaccines these days, and that the sheer number given is overwhelming the immune systems of many children and leading to all sorts of potential ills specified or unspecified (autism is a biggie here, but there are others attributed as well).  Hence, the whole theory of ‘selective vaccination’, where you pick particular ones to give your children and leave the rest.

I never found this theory terribly convincing.  After all, we’re swimming in germs all the time – the vaccines we get are a tiny fraction of the bacteria and viruses that our immune systems have to deal with on a day-to-day basis, even before you take into account the fact that the germs in vaccines have been deliberately weakened or even killed off before being administered to people.  It always seemed to me like plain common sense that our immune systems wouldn’t find it that much of a big deal to handle several vaccines at a time.  However, I never had anything more concrete than that to counter the claims about overloading of the immune system.

Then, I read Paul Offit’s “Autism’s False Prophets“.  This is the book I have been hoping for years that somebody would write; a clear and simple account by a paediatric microbiologist of the whole story of the vaccine/autism controversy, giving the true stories behind the many frightening and plausible-sounding claims made by the anti-vaccine campaigners and explaining why the evidence does not support them.  The debunking of conspiracy claims was marvellously welcome; the scientific parts of it, of course, I already knew quite a bit about because of having access to medical journals. But I learned one particular piece of information that I actually hadn’t known and that sounded so simple and obvious once it was explained that I still can’t believe it isn’t publicised far more by the pro-vaccine side of the argument; the scientific reason why the ‘overloading the immune system’ theory doesn’t stand up.  I share it with you here in honour of National Vaccines Week.

You see, although we think of vaccines in terms of how many germs are vaccinated against (and thus it looks to us as though the list is getting longer and longer; and, while I don’t see that as a problem for the reason given above, I can appreciate that to a lot of parents it does look daunting), that isn’t how it works on the level of the immune system.  The immune system ‘sees’ things in terms of how many proteins it has to mount an antibody response to.  And this is not a simple one-to-one relationship; in fact, every germ that the immune system mounts defences against has multiple surface proteins against which antibodies need to be made.  The number of proteins involved (they’re called antigens, by the way, if you want the technical term) depends partly on the size of the virus or bacterium being fought against; in the case of vaccines, I believe it also depends partly on the technique used to render the germ in question unable to cause full-blown infection so that it can be safely injected into the human body.  (When Offit made this point, I did in fact remember something I’d seen mentioned in passing during the huge controversy over the five-in-one vaccine that was brought in a few years ago; that it actually contained fewer of these proteins than the separate vaccines had, and was thus, if anything, going to present less of a challenge to the immune system than the vaccines given prior to that.)

Anyway, about a hundred years ago or thereabouts, the only vaccine children received was the smallpox vaccine; now, of course, they receive far more than that.  But, according to Offit, the number of foreign proteins presented to a child’s immune system by the total vaccination schedule currently recommended for children in the United States today is actually substantially less than the number of foreign proteins that were contained in the smallpox vaccine alone.  (Here in the UK, of course, it will presumably be even fewer, as there are a couple of vaccines on the US schedule that we don’t have on ours.)  The smallpox vaccine (which is no longer given) contained a grand total of 200 foreign proteins for the immune system to deal with in one go; the vaccines advised for a child in the US today contain a somewhat more petite total of 153 foreign proteins.  So, if overloading of children’s immune systems from vaccines actually was the cause of autism or of whatever disease the anti-vaccine lobby happen to be currently claiming, we’d expect to see the rate of the disease in question dropping rather than rising.

The logical conclusion?  No, the current vaccine schedule is not causing any sort of overload of children’s immune systems.  Children’s immune systems, in fact, have noticeably less to deal with than they did a hundred years ago.  153 proteins?  Luxury.

April 27, 2010 at 10:33 pm 2 comments

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