The MMR Decision, Part 2 – Singles Not Fabulous

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

I’m always pleased and flattered to stumble across links back to my own posts (assuming the context isn’t “For an example of an atrociously poor piece of writing, click…”).  This (the main part of the sentence, not the parenthetical bit) happened to me last night while blog browsing – I found my way to a post about the MMR which linked back (favourably) to the one I’d written on the subject.  This reminded me that I’d never written the follow-up posts I promised at the time, dealing with the ‘Yes, but…’s that I can see cropping up in some people’s minds in response.  Since this fitted in fairly neatly with my by now depressingly familiar need to find something quick and easy to blog about before the end of the month comes around and leaves me with the dreaded Permanent Gap In The Archives, I’m going to write the first of the promised posts – the explanation of why I didn’t opt for separate vaccines instead of the three-in-one.

For those who didn’t read or can’t remember the previous post and can’t be bothered to go read it now, it was about the reasons why I felt the MMR to be far safer than leaving my children at risk of catching the diseases against which it immunises.  The flaw that some people may have spotted in that logic is that those aren’t the only two options.  One alternative that many parents opt for is to give the three immunisations as separate jabs rather than as a three-in-one combination, seeing this as a compromise solution that protects their children while avoiding the scaaaaary MMR.

While I think singles jabs are far better than leaving children unimmunised, I have to say that I couldn’t see any point to them.  The reason usually given for choosing singles jabs (other than the fact that they haven’t hit the headlines in the same way as the MMR has, which does not actually strike me as the best basis on which to make decisions about safety) is that giving the vaccines one at a time avoids overloading the immune system.  This argument makes absolutely no sense whatsoever to me.  We are swimming in germs every second of every day.  The microbes we’re exposed to in nature don’t form an orderly queue and politely wait their turn to infect us.  If we didn’t have the capacity to fight off multiple germs in one go, we would have died out millions of years ago.  True, most of the millions of germs we have to deal with every day are stopped at a much earlier stage by the immune protection granted by our skin and by antibodies in the openings to our respiratory and gastro-intestinal tract – only a tiny proportion of them ever gain entry to the body, and injecting viruses directly into the body bypasses the first line of immune defence.  But the defences provided by the skin aren’t perfect, and it’s hardly uncommon for germs to get through.  I have a very hard time indeed believing that our bodies aren’t perfectly capable of fighting off a paltry three viruses (and bear in mind that we’re talking about severely weakened viruses, not the full-strength ones) without any undue difficulty.  I just don’t see any reason to assume that immunising against one virus at a time would be any less likely to cause complications than immunising against three in one go.

(I heard about some interesting calculations based, if I remember correctly – which I may not, but it was something like this – the amount of antibody needed to combat a microbe, the number of antibodies that each white cell can produce, and the number of white blood cells in the body, that culminated in working out that the human body can under normal circumstances protect against a staggering ten thousand germs in one go.  This is, of course, theoretical, and I suspect it’s probably a major overestimate – it seemed to be based solely on antibody production levels without taking into account that there may be other necessary parts of the immune response that may limit the rate of production of immunity.  However, even if that estimate’s out by a factor of a thousand, it would still leave us more than capable of simultaneously whipping up an appropriate level of antibodies to measles, mumps, rubella, and a few common colds and infected ingrowing nails into the bargain.)

Anyway, I could, on the other hand, see a number of reasons for preferring the MMR:

1. The extra research that had been done into the safety of MMR.  Ironically, as a result of the scares there’s actually been a lot more research done into MMR than into singles.

2. The extra four needles that my children wouldn’t need to have stuck into them if I went for the combined vaccine.

3. The occasional horror story that I’d heard about private clinics not operating according to correct procedure, and giving children vaccine that had been contaminated by bacteria.  (I know, I know… being scared away by occasional horror stories isn’t a great reason to make a decision, and is in fact a huge part of why we have an MMR crisis in the first place.  It just seemed to me at the time that going privately might mean I’d end up with who knew what quack clinic, whereas, if I went for the MMR, I’d know that the people giving the immunisation knew what they were doing and were working to standard procedures.  That belief may be unfair.)

4. The need for greater organisation on my part.  I’d need to remember to book all six of the appointments (an initial vaccine and a booster for each of the three) for both children, as opposed to simply turning up on a date sent to me.  Realistically, I knew there was a major risk I wouldn’t get it done.

5. Actually, there wasn’t a number 5 on my original mental list, because it was so obvious to me that I wasn’t going to go for singles that I didn’t even get as far as thinking about cost.  However, a quick bit of Googling just now clarified for me that going for the singles option would cost me the best part of £700.  Since I live in the UK, we could get the MMR done without paying a penny.

If someone said to parents “Here’s a treatment that we think should reduce the risk of your child ever becoming autistic.  It will cost you upwards of £600, it will involve sticking several needles into your child, and we have no evidence at all that it actually does anything to reduce the risk,” then I doubt they’d get very many people accepting.  That’s essentially what choosing singles instead of the MMR seems to me to be.  So, again, I found that one a no-brainer.

Advertisements

August 31, 2009 at 10:29 pm Leave a comment

The MMR decision and death rays from Mars

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

I wanted to write this post because I know that the alleged MMR link has worried many parents, and thought it might help at least some people to hear from a mother and a GP about how and why I reached the decision to give the MMR and why I’m happy with that decision in retrospect.  It’s not meant to be an exhaustive study of all the available evidence.  It’s the story of the way the evidence looked to me when I was making my own decision about the vaccine, and the factors I took into account. (Obviously, some new and relevant points have come to light since then, all of which have only strengthened my belief that I made the correct decision.  I’ve included those as footnotes.  The main body of the text is about how I made the decision at the time.)

It is fair to say, first off, that I was quite strongly influenced by what I’d seen of the anti-vaccination movement.  Their arguments seemed so loaded with the features I’d learned to associate with poor science (their trumpeting of poor-quality research while ignoring large-scale studies that contradicted their hypotheses, their hints of conspiracy theories, the general impression that they’d made up their minds and now were out to find the data that suited them rather than finding what the data showed and making their minds up based on that) that my automatic inclination was to assume they were wrong.  The more anti-MMR hype I saw, the more I found myself feeling that if people who argued that way were against the MMR then I should probably be all for it.

However, in all fairness, I knew that wasn’t really the best way to decide the issue.  Just because I didn’t like the way people sounded didn’t mean that I should be dismissing what they had to say out of hand, and the fact that they gave every appearance of jumping to conclusions certainly didn’t mean I was entitled to do the same thing.  So I tried to look at the available evidence as fairly as I could.  As far as I could see, the story went something like this:

Back in the 1990s, a number of parents had noted that their child seemed to have developed symptoms of autism around the time that said child got the MMR immunisation, and started wondering, worrying, and sometimes drawing conclusions about a possible connection.  In 1998, a paediatrician by the name of Andrew Wakefield wrote a paper for the Lancet in which he wrote about twelve children that he’d seen in his outpatients’ clinic with autism and bowel symptoms, eight of whom had allegedly developed symptoms shortly after having the MMR.  Wakefield theorised that there might be a link – according to his theory, the MMR might be causing bowel damage which then led on, secondarily, to autism.

So, the question had been raised.  However, so far all we had was a question, and it’s crucial to remember that that’s not the same as an answer.  Since autism primarily affects areas such as language and imaginative play which undergo noticeable spurts of development during the second year of life, that’s very often when parents first start to notice differences about their child, and since the MMR happens to be given around the beginning of the second year, purely by the law of averages there are going to be a certain number of occasions when parents notice autistic symptoms in their child around the time that the MMR was first given.  Not only that, but taking your child to a doctor’s office to have a needle stuck in him is an unusual and nerve-wracking event that tends to stick in people’s memories, so, if your child has autism and you’re desperately wondering what could have caused it and are looking back racking your brain to think what was happening at around the time you first noticed the symptoms of autism, the fact that your child happened to have a vaccine around then is going to be something you’ll remember.  It was entirely possible, therefore, that the associations that had been noticed in some children could be purely down to coincidence.1,2  The question had been raised, and it needed an answer.

So – and this was the bit that somehow seemed to get left out of much of the media hype around the topic at the time – researchers set out to find that answer.  They looked at large-scale groups of children, looking for any correlation between the age at which children got their MMR shots and the age at which they were first noted to have symptoms of autism that might be above and beyond coincidence, or any link between the sort of bowel symptoms Wakefield had described in the children he’d studied and either autism or the MMR, or – most importantly – any difference in autism rates between children who’d had the MMR and children who hadn’t.  Esther, over at Mainstream Parenting, has a good summary of the research in this area, but the important bottom line was that none of these studies showed any link.  Children were no more likely to show symptoms of autism just after their MMR than they were at any other time around that sort of age, there didn’t seem to be any sort of link between autism and inflammatory bowel disease, and – most importantly – children who’d never had the MMR were just as likely to be diagnosed with autism as children who’d had it.

The only other arguments in favour of the MMR-autism link seemed to be a claim that there were unexplained rises in the rates of autism in recent years (except that no-one could even say for certain that this was the case, given that this coincided with health professionals becoming a lot more on the ball about picking up subtle symptoms of ASD that might have gone unnoticed before – it looked more as though we were just getting better at diagnosing the cases of ASD that had always been around), and that Wakefield claimed to have found measles virus in the bowel wall of some children with autism (which was supposedly linked in with his whole theory about MMR triggering bowel disorders which then led on to autism, but frankly sounded like a pretty tenuous and inconclusive link to me.  Besides, if it turned out that Wakefield was right about that and that measles virus really did put children at risk for bowel disorders, why on earth should that be an argument in favour of me leaving my children unimmunised and thus at risk of contracting the full-strength unexpurgated version of the virus that the vaccine was meant to protect against?)3

And that, as far as I could see, seemed to be evidence in and case closed.  We’d questioned whether the MMR might increase autism risks, looked into the matter, found out that it didn’t, and that was that.  Since the result of the question being raised in the first place was that a lot of extra research had been done into the vaccine, I felt that – thanks, indirectly, to Wakefield and his cronies – I could feel particularly confident that it was safe to give to my children.

However.  I wanted to give the anti-vaccine arguments as open-minded a consideration as I could before rejecting them.  Besides, my experience with a health visitor who flat-out refused to accept that Jamie’s near-complete failure to gain any weight in his first two months could possibly have anything to do with his uncut tongue tie had left me with a lot of sympathy for any parent who felt convinced that X had caused Y in their child yet was getting short shrift from medical professionals.  So, I played Devil’s Advocate with my conclusion. This is the bit where I feel I’m skating on thin ice, because I know the risk that someone might be disingenuous enough to quote parts of what I’m going to say out of context to support an anti-vaccine argument.  I hope people will have the integrity not to do that, and to read the whole of my post and treat it as fairly as I’ve tried to look at the arguments with which I disagreed.

What if, I asked myself, what if there was a grain of truth in the midst of the hype, a flicker of flame in amidst all the smoke?  The thing is, no study can prove a negative – that’s just a simple fact of science.  No study can ever prove that there is absolutely zero chance of any risk associated with a particular thing or action.  So, what if just a few of the parents who believed the MMR had triggered autism actually were right?  What if the risk wasn’t actually non-existent, but just so small that all the studies to date had missed it?  It would, of course, have to be a pretty miniscule risk for that to be the case; but it remained a theoretical possibility.  I felt comfortable with the evidence for the MMR’s safety, but I did also recognise the fact that it was not possible to absolutely completely one hundred per cent exclude any chance of any risk of the MMR causing autism.

This is what I call the ‘Death Rays From Mars’ argument.  The name comes from a scene I once saw on a television drama.  I have no idea what the drama was or even what most of the plot was, since I wasn’t actually watching it – someone else had the TV on and I happened to be in the room.  From what I remember of it, it was a courtroom drama in which a doctor was accused of having caused the death of one of his patients through being unfit to practice.  In the scene I remember, the defence lawyer was questioning one of the witnesses, also a doctor, and asked the witness about the possibility that the patient might in fact have died from such-and-such an alternative (and highly unlikely) cause.  Was it possible, the lawyer asked the witness, that this whatever-it-was other cause might in fact have been what killed her?  The witness fixed him with a weary stare and replied “It’s possible that death rays from Mars killed her.”

The moral being, of course, that just because something’s possible in the can’t-one-hundred-per-cent-disprove-it sense doesn’t mean that it’s a possibility we actually have to take seriously for practical purposes.  But also that the whole ‘but it’s possible that…’ argument can get very silly.  If we’re going to worry about the possibility that something might happen even in the absence of any evidence that it will and/or the presence of positive evidence that it won’t, then where do we stop?

So, my answer to the idea that, theoretically, there might still be an infinitesmal risk of the MMR causing autism was “Compared to what?”  If you’re going to start worrying about hypothetical undetectably small risks of the MMR causing autism, why stop there?  The whole point about vaccines, after all, is that they’re given in order to stop a child contracting the actual diseases.  It’s every bit as logical to hypothesise that infection with measles or mumps or rubella themselves might carry that risk.  It seems to me to be rather more illogical to claim that the weakened viruses in the injection are too risky to give to a child but that it’s quite all right to leave that same child unprotected against the full-strength viruses that they might then catch.  At least the possibility has been thoroughly studied in the case of the MMR vaccine – I don’t know of any study reassuring me that children aren’t at any increased risk of developing autism as a result of catching rubella.

But I did, on the other hand, know of incontrovertible evidence of problems and risks that are associated with catching measles or mumps or rubella.  Fatalities and serious complications from measles or mumps may be rare in healthy children, but they do happen.  Rubella wasn’t something that would cause Jamie himself any problems, but what if he caught the disease and passed it on to a pregnant woman?  A decision on my part not to immunise my own healthy child could indirectly have devastating lifelong consequences for another child. And, of course, if Katie wasn’t immunised against rubella she ran the risk of having a severely damaged child herself – an actual, known, proved risk, unlike the theoretical in-the-face-of-all-the-evidence risk that the MMR supposedly carried.

Even an uncomplicated case of these diseases can be pretty darned unpleasant experience for the child.  My sister had measles as a child – no complications, no problems, just a straightforward case with a straightforward recovery.  Over twenty years later, I can still remember how miserable she was with that particular ‘simple childhood illness’.  I didn’t find it at all difficult to decide that I’d like my children to be spared that experience.

So, there you have it.  My decision wasn’t based on a belief that there’s absolutely no chance that the MMR could possibly have caused autism in any child ever ever ever.  It was based on a belief that, between a theoretical possibility of an MMR risk too small to show up on any studies and a theoretical possibility of a completely unstudied and unquantified autism risk with measles or mumps or rubella, on top of the actual known side-effects of those diseases, I found it a no-brainer to go for the option that had been most extensively studied and had repeatedly come up in the studies as showing no problems.  In other words, the MMR.

……………………………………………………………………………………………………………………………………………….

Footnotes:

1. One other factor here is the possibility that, once a few people have voiced their concerns about the MMR and thus started other people wondering, this in itself can make people more likely to conclude that their child’s disorder may have been caused by the MMR, and that can affect the way in which people remember and interpret events.  There is now evidence that at least some of the children who are believed by their parents to have developed autism only after the MMR actually had documented evidence of autistic features and/or of concerns about their development before having the MMR, Michelle Cedillo being the most famous such case.

2. With regard to Wakefield’s paper, it has now turned out that it was indeed not a coincidence that several of the parents whose children came to see him reported their child showing symptoms of autism after the MMR.  However, the link wasn’t due to the MMR having caused autism.  It was due to the fact that Wakefield had previously expressed sympathy with the belief in an MMR-autism link, and thus lawyers representing families with this belief in planned court cases against the vaccine manufacturers were deliberately advising them to go to Wakefield to get their children seen by him.  Wakefield knew this perfectly well but didn’t report it in the paper he wrote, despite the fact that it would have put an important new slant on others’ interpretation of the results to know that all these children hadn’t shown up in one hospital’s outpatient clinic through sheer random chance.  He also didn’t report the payments he was receiving from the lawyers for this work, even though it’s considered ethically correct for the author of a medical paper to report all conflicts of interest at the end of the paper.

3. Wakefield’s laboratory experiments in this area have since been completely discredited, as it has been shown that his work was riddled with errors in technique that could have caused false positive results.  The same studies have been attempted by other researchers using correct techniques, and no-one else has found any sign of measles virus in the guts of autistic children.

February 21, 2009 at 10:20 pm Leave a comment

CIO, sleep training, and evidence or the lack thereof

(This post initially appeared on the Good Enough Mum site in 2006 – I’m reposting it here some years later, under the original date.  Comments on the original can be seen over there.)

The sleep training debate has, to no-one’s great surprise, popped up again in Parentland.  In the red corner, Rosa Brooks: hell, yeah, stick in those earplugs, sling ’em in the cot and let ’em howl!  What harm could it possibly do?  In the green corner, Hathor, the Cow Goddess Of Attachment Parenting: heresy!  Don’t you realise this will traumatise your child and damage his or her trust?  What caring mother could ever do such a thing?

I’ve commented previously on my opinions on both sleep training in particular and OneTrueWayism in parenting in general, but, as it happens, what drew me into the debate this time was another favourite bugbear of mine – the spot-the-difference game between what the evidence on a contentious topic says and what people with strong opinions on the topic claim it says.  What Hathor claimed, you see, is that her anti-CIO stance had been proved right by scientific research.  Years of study and reams of inquiry, she assured us, all consistently maintain that it is harmful to force your child to cry it out.  Indeed, Ferber himself had been proved wrong on the subject and had recanted his claims as a result.

Now, I can totally understand being anti-CIO – even its strongest proponents admit that it can be a pretty unpleasant experience for everyone concerned.  I’m a lot more sceptical about the belief that it’s likely to cause long-term emotional damage – personally, I think babies are a lot more resilient than some of us give them credit for, and I don’t think a child who’s getting plenty of affection in his life overall is going to suffer permanent trauma as a result of a few bedtimes and naptimes crying alone – but it’s a big old world and there’s room for a lot of different opinions out there.  But claiming that there’s scientific evidence for the supposed harmfulness of CIO – well, that’s where things leave the realm of opinion and get into the realm of ascertainable fact.  Or, as it may be, fiction.

I’ve spent a lot of time looking at what different parenting forums and websites have to say about CIO, including a lot of the CIO-is-the-work-of-the-devil sites, and I’ve often come across this claim before.  Invariably, the ‘evidence’ presented (when the person making the claim actually does present any evidence instead of just assuming that the existence of evidence is so obvious as to need no further comment) falls into one or more of three categories:

1. Opinion.

2. Anecdote (often of cases where a number of other things were changed in a child’s life at the same time.  “This two-month-old baby was left to cry herself to sleep and her parents stopped spending as much time with her during the day and she was fed less often and, guess what, she didn’t thrive.  Obviously the sleep training!”)

3. Actual research that isn’t actually into CIO. There is a huge amount of research out there to show that regular positive attention and affection is crucially important for children’s emotional development, and one of the few issues in parenting that just about anyone with any glimmer of a clue can actually agree on is that prolonged, regular neglect during childhood is liable to cause children problems; sometimes huge problems.  However, sleep training isn’t prolonged, regular neglect.  It involves leaving children for short periods at specific times, while giving them just as much loving care as normal at other times (possibly more, since responding lovingly and affectionately to another person tends to be rather easier if you’re not going insane with sleep deprivation).  Pointing to studies on the desperate harm suffered by Romanian orphans left abandoned in their cribs all day and every day as evidence of what a Bad Thing sleep training is is about as valid as pointing to studies on starving, malnourished children in the Third World and using them as support for a claim that you’re doing your child terrible damage by expecting her to wait an extra twenty minutes for her dinner now and again.

Since no-one from the anti-CIO-for-sleep-training brigade ever seemed to cite any actual studies on the use of CIO for sleep training, I searched Medline to whether any such studies had ever actually been done.  (The technical term is “extinction”, if you want to do the same thing.)  There are no long-term studies that I could find, but I did find two studies that looked at the psychological status of children shortly after sleep training.  Both of these seem to have passed unnoticed by the very people who are supposedly most fascinated by the psychological status of children following sleep training.  Call me cynical, but am I wrong in thinking that this might possibly have something to do with the fact that both studies actually showed children to be, if anything, somewhat more secure following CIO?

So, I replied to Hathor’s claim with a quick summary of the above.  Since the list of references she gave in reply was fairly typical of the kind of stuff that gets presented as evidence in these debates, I’ll go through them.

One reference to a speech by James McKenna in which he cited primate studies into short-term mother-infant separation.  Now, I can’t comment directly on how these studies might or might not relate to CIO, because direct references weren’t given in Hathor’s quote or anywhere else on the ‘Net that I could find.  However, a Medline search on “mother-infant separation” shows that, while lengthy separations do indeed appear to be harmful to infants, infants separated from their mothers for brief periods of time only were actually less fazed by separation when older than primates who hadn’t undergone such separations.

One newspaper article about Margot Sunderland’s new book, The Science Of Parenting.  I haven’t read the whole book, as yet, but I’ve read the section on sleep training.  No references to studies on CIO.

Two articles about the infamous Commons and Miller paper.  I call it infamous because it gets mentioned in tones of reverence all the time in CIO debates.  It is, according to popular legend about it, a study by two Harvard psychiatrists that showed CIO to be harmful.  The only part of that that’s correct is that the authors do indeed work at Harvard.

The Commons and Miller paper wasn’t a study and wasn’t about CIO.  (And the authors are psychologists, not psychiatrists.)  It was a discussion of the many ways in which child-rearing practices differ in two different societies (the USA and the Gusii tribe of Kenya) and what kind of long-term effects this might have on children reared in the two societies.  It’s a fascinating paper, but it isn’t a study.

One reference to a study stating that all of 186 hunter-gatherer societies looked at in one study practiced co-sleeping.  Which tells us, um, precisely zero about the effects of CIO.

One webpage on the general evils of leaving babies to cry, devoid of any actual references.

And one article about a study showing that infant rats who received plenty of affection from their mothers were more secure than infant rats who received little maternal attention.  Which, as I discussed above, adds to the already sizeable body of evidence that giving your child little attention overall is A Bad Thing, but tells us nothing about the effects of a specific short-term intervention such as CIO.

My dissent on the issue of whether this constituted adequate evidence of the evils of CIO caused, as you can imagine, some debate.  Since there are now quite a number of questions for me in the second comment thread still awaiting a reply, I decided to move the discussion over here and answer them in this post.

What exactly are you looking for for something to be a study?

Well, not wanting to sound tautologous or anything, but a study involves studying something.  When someone says that CIO is harmful but doesn‘t actually provide any evidence to back this up, that’s an opinion.  When someone speculates on whether CIO may be harmful, that’s a theory.  When someone makes an attempt to assess the state of children following CIO, that’s a study.  (Whether or not it’s a good study is, of course, a whole separate and important question.)

Or to have compelling information for you to see that CIO is not a good thing for babies?

I’m not trying to claim it’s a “good thing” (although I believe that, for some babies, it’s a better thing than the alternative).  I’m objecting to the claim that research has proved it to be a harmful thing.  But, to answer your question: if well-conducted studies into the psychological state of children following sleep training showed them to be psychologically worse off after CIO, then that would be compelling evidence.

If I may be so bold as to ask, what exactly are you doing on a site that is pro co-sleeping trying to defend CIO?

Objecting to misinformation.  I don’t object to people being anti-CIO; I do object to people claiming the evidence states something that it doesn’t.

Or at least trying to say that there needs to be studies to prove that co-sleeping is benificial (sic)?

I haven’t said that.

I guess it all comes down to doing what works best for your family, taking into consideration that babies/children are people too, and that they have needs that they can not meet themselves do to their age.

Doing what works best for your family is exactly my philosophy, as well.  However, my experience is that when that statement is followed by that sort of qualifier in this sort of debate, what it actually means is that you don’t believe CIO is ever going to be what works best for anyone’s family.  And, having read a lot of different stories from different people with different experiences, I can’t agree with that.

There are may ways to help a child learn to sleep that do not involve them having to cry for extended periods of time.

And I’d like to see them much more widely known (by which I do not just mean the blanket “Co-sleeping will solve all your problems!  What more could you possibly need to know?” recommendation that seems to be all that some attachment parenting advocates have to offer).  I’d also, however, like to see it more widely recognised that – like everything else in parenting – they aren’t universal solutions that work for all children and all families.

But I think we need to remember that there are a lot of parents out there who might well have tried alternative solutions to sleep problems with their children if they’d known about them, but who didn’t know about them and thus tried some form of CIO.  Now, leaving these families thinking “Damn, if only I’d known about that at the time!  Could have saved us an unpleasant few evenings” is one thing; leaving them thinking “Oh, no!  There’s scientific evidence that the way I handled things was actually damaging for my child!“ is another.  If we’re going to do that to parents, we ought to be damn sure we have our facts straight first.  If there isn’t any actual evidence that CIO is harmful then we shouldn‘t be claiming that there is, no matter how vehement our personal opinions on the subject.

Touche on the Harvard study, I haven’t seen the actual paper the article was based on.

Well, if you want to, you can read it here.  Right where I said it would be, in fact.

But a comparative multi-disciplinary investigation of different societies is not necessarily less valid than lab-controlled experiments. It’s what anthropologists do.

It’s a valid research method for some things, although I don’t think it would be a good way of studying CIO – there are so many differences between different societies that it wouldn’t be possible to single out one specific brief episode during childhood and pinpoint the effects of that.  However, the objection I was making is not that their paper is an anthropological study, but that it isn’t a study at all.  It’s a discussion of previous research into the topic, and it doesn’t contain any actual information on how the different methods of child-rearing affect children.  It simply theorises on how the differences might affect children, and suggests this as a topic for further research.

These [the children in the first CIO study] are 6-24 month old children they studied. How would you guess they rated the security and anxiety of these children?

They used a modified version of a scale called the Flint Infant Security Scale, filled in by the parents.  The second study I cited used the same scale, and also visual analogue scales to measure the parents’ impressions of how depressed and how anxious/insecure their children seemed.

I personally can’t see how being left alone to sleep can make anyone more secure.

I’ve found that dealing successfully with a situation I originally thought to be beyond me usually leaves me feeling more secure.  Knowing that I can deal with it leaves me with more confidence in my own abilities.

It’s also worth remembering that children who have difficulty getting to sleep and wake frequently in the night are often sleep-deprived themselves.  If adults find it easier to cope with life’s stresses when well-rested, why shouldn’t the same be true of children?

To me this abstract is pretty unconvincing.

That’s fine.  I’m not out to bang a CIO-is-wonderful drum here – that isn’t the way I feel at all.  What I’m trying to point out is that the existing evidence doesn’t show it to be harmful.

I don’t believe in CIO.  Sarah, you obviously do to some extent

What I believe in is finding solutions that work for individual families, individual children.  I believe that sometimes, that solution is going to be CIO.  And I believe that though another method could potentially have worked just as well or better in most (not all) cases where CIO is used, that doesn’t mean that using CIO in those cases was actually harmful.

Anyway, people also used to widely believe in ’spare the rod spoil the child’ and were full of evidence of how spanking led to better children.

And stories like that don’t tell you that we should be extremely careful about not claiming that the evidence supports a particular way of doing things purely because that’s what it suits us to believe?

I just don’t see how a three or six month old baby for example can know the difference between just having been left in his safe nursery and having been abandoned completely.

Well, when his mother turns up again, I think he’s going to figure out that it was the former.

And how do you really know that a three month old really isn’t hungry, or that something isn’t really bothering him?

In fact, I don’t know any experts who advocate using sleep training for a baby as young as three months.  But, assuming that you didn’t feel that to be the crucial point of your question: By knowing your child and by using common sense.  For example, if you’ve just nursed your child and he isn’t taking any more milk then it’s a fair bet that hunger isn’t the problem.

And besides that, why are only physical needs valid when speaking about babies? Certainly judging by the numbers of relationship gurus out there, all the books, all the Dr. Phils and beyond, we in North America believe that we have emotional needs that deserve to be met.

Certainly.  But that doesn’t mean that someone has to be available to meet them every minute throughout the day and night.  I don’t expect my partner to drop absolutely everything he’s doing to talk to me whenever the fancy takes me, even if it’s 4 a.m. and he’s in a sound sleep.  I know that he has other things to do that are important; and I know that that doesn’t detract from his love for me or his ability to be supportive and available to me overall.

Why is it less valid for a baby to be lonely than it is for an adult to be lonely?

It isn’t.  But, similarly, why should it be so much more valid?  If a friend staying with you was regularly expecting you to come and keep her company regardless of what hour of the day and night it was or what else you might need to do, how long would it be before you started saying no some of the time?

I mean no offense by this, but I don’t really need you to answer these questions. I know what the answers are for me.

Which is good.  The point at which I start having a problem with these sorts of discussions is when people start deciding that they know what the answers are for everybody else.

I think ultimately all there is to this topic is to follow your heart, as Julinda and Serendipity said above.

And if your heart leads you to the conclusion that CIO is the right answer for your baby?

I hope these articles make people think about this issue a little bit more, to reconsider, to tune into their heart and see what is right for *them*.

I’d love it if there were more articles that did that, but I don’t think either Rosa Brooks’ or Hathor’s had that aim.  What Hathor, like Brooks, really wants other people to do is to tune into her heart and do things the way she thinks is right.  That’s the problem I have with this issue, as with so much else in parenting; so many people think they’ve got the one right way that’s going to work for all children, just as though children weren’t individuals as much as the rest of us.

But that’s not why I wrote the reply I did to Hathor’s post.  I replied to it because I believe that she was not correct in claiming that the existing scientific evidence proves CIO to be harmful.  And I hope I’d have had the guts to say so even if I was passionately anti-CIO on a personal level.  Judging the evidence on the basis of what we want it to show is a temptation that’s impossible to avoid altogether – but we should be willing to be as honest as we can be about what it actually shows.

July 7, 2006 at 10:20 pm Leave a comment

Stats.org breastfeeding article, Part 2 – In which we get bogged down in the murky details of statistics

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

The story so far: Goldin, Smyth, and Foulkes, of STATS.org, claim to have the truth about What Science Really Says About Breastfeeding – unlike the AAP and the NYT, who are, allegedly, using sloppy science and misleading us all on the issue.  They start out their article by listing what would appear to be every possible or potential breastfeeding-related problem they could manage to come up with.  Having thus set the scene for their impartial and unbiased approach to the subject, they proceed to discuss the statistical evidence.

Hang onto your hats – we may have to start getting technical at this point.  If I’m going too fast, just wave your arms at me and yell loudly, or something.

The article does raise some crucial points about the difficulties with research into breastfeeding.  As they point out, it is not possible (for obvious ethical reasons) to conduct the gold standard of research – a trial in which mothers are assigned by the toss of a coin or equivalent procedure into breastfeeding or non-breastfeeding groups.  (One point that I must make here, to soothe my pedantic little soul – this type of trial would be a randomised controlled trial, not, as they called it, a ‘case-controlled study’.  A case-control study is something completely different.  While it doesn’t ultimately make a difference to the point they were making, I did find it bizarre that two statistics professors could make such an elementary mistake.)

Non-randomised studies have a flaw in them from the start – they’re subject to what we call  confounding factors.  Mothers and babies who breastfed are likely to differ in other crucial ways from mothers and babies who didn’t.  Women who choose to breastfeed may well be making other choices about their parenting that differ from those of women who choose to formula-feed; women who are unable to breastfeed or to continue breastfeeding may have been rendered unable by some factor that, in itself, is relevant to the baby’s health.  This makes it difficult to know to what extent the differences found between breastfed and non-breastfed babies are due to the breastfeeding itself, and to what extent they’re due to factors that tend, in practice, to be associated more with breastfeeding than with formula feeding or vice versa.

There are statistical ways to take confounding factors into account in a study analysis and hence cancel out their effect on the end results, and any good-quality research will do this as far as possible.  The problem, however, is that we can only do that for confounders that we know of and can collect data on.  This is a potential source of bias in any non-randomised study.  It’s an inevitable flaw in breastfeeding research, and STATS.org are quite right to point it out.

However, using this problem as a reason to be appropriately cautious about interpretation of results is one thing; using it selectively as an excuse to reject only the research whose results you don’t like is another.  I’ve previously mentioned one of our most deep-rooted sources of bias; our tendency to reserve our criticisms of study design only for studies whose conclusions we don’t like.  This article was, as it happened, the perfect example.  Smoking can no more be randomised than breastfeeding can, and hence all our existing research into the harms of smoking in humans is based on non-randomised studies. But STATS.org’s criticism of the research into breastfeeding (which they ultimately dismiss as “voodoo science”) stands in stark contrast to their unquestioning acceptance of the research showing that smoking during pregnancy is harmful.

Please don’t misunderstand this: I am not saying that smoking during pregnancy is harmless.  Quite the reverse.  I am saying that in spite of the flaws inherent in non-randomised studies, we have no problem saying that the research on smoking and pregnancy is sufficient for us to accept a harmful effect.  We don’t dismiss that evidence out of hand simply because the studies aren’t perfect; and, similarly, we are not justified in simply dismissing the huge number of studies that show beneficial effects from breastfeeding.

A far more realistic and constructive approach would be to consider what criteria a good-quality study should fit, pick out the studies that met those criteria, and consider the strengths and weaknesses of the evidence overall.  An article aimed at doing that could have been both useful and fascinating.  (Writing it is on my list of things to do in that mysterious alternative universe I keep hoping to stumble into where I actually get large amounts of spare time.)  Goldin, Smyth and Foulkes, however, simply seem to have picked out a few studies they could pick at and acted as though these were representative of the body of research generally.

For example, the article’s conclusion that the benefits of breastfeeding are limited to ‘certain kinds of low-risk infections’ seem to be based largely on analysis of a single study. Not only was the study in question fairly small, but, from the STATS.org description of it, it seems the two groups being compared could be roughly described, not as “ever breastfed” and “never breastfed”, but as “sometimes breastfed, quite a lot of formula” and “sometimes formula-fed, quite a lot of breastfeeding”.  This is a design flaw that is automatically going to cause the study to underestimate any breastfeeding benefits, because the effect is going to be so diluted by the overlap between the groups.  In view of these problems, it’s telling that this study came up with any benefits for breastfeeding – we really can’t deduce much from the fact that the benefits it found were limited.  STATS.org, however, seem to be taking it as the final word on the matter.

Now, the AAP position paper on breastfeeding from which STATS.org takes this reference cites – by my count – sixty-eight references for studies showing possible short-term or long-term benefits for breastfed babies (plus fourteen references to potential benefts for the mother).  STATS.org single out a grand total of five of these for specific discussion (if we count the passing mention of the studies on breastfeeding and diabetes as ‘discussion’).  So, out of all those dozens of studies, why did STATS.org place so much weight on one that seems so likely to underestimate benefits of breastfeeding?

The only reason we’re given why this particular study is singled out for mention is that it is, supposedly, an example of one of many studies that, according to STATS.org, “simply didn’t find what AAP claimed they did”.  In other words, STATS.org claim that AAP are making incorrect claims about study findings.  A serious accusation indeed.

Except that it doesn’t seem to be true.  Or, at any rate, the authors totally fail to produce any evidence to support it.  They claim that the lack of difference of rates of respiratory infection in the study “contradicts the AAP’s claim that there were decreased upper and lower-respiratory illnesses for nursed babies”.  But the AAP didn’t claim that this particular study showed a difference in rates of respiratory infection.  They say that it showed a difference in rates of diarrhoea – which it does indeed.  (They cited nine studies as reference for their claim that rates of respiratory tract infection are decreased.  Goldin, Smyth and Foulkes discuss none of these.)

Are the authors deliberately lying, or are they just very sloppy about checking details?  Either way, it doesn’t say much for their reliability.  We are given no details on the other supposed studies that “simply didn’t say what the AAP claimed they did”, so I couldn’t assess whether there was any truth to this claim at all. However, this mistake on the part of STATS.org doesn’t bode well.

What did STATS.org tell us about the other studies it discussed?  The most important was the Chen and Rogan study on which the AAP base their claim of reduced mortality in breastfed babies.  STATS.org dismiss this on the grounds that the study showed that breastfed infants were less likely to die of injuries.  True, but certainly not the whole truth.

There’s another statistical concept that needs explaining briefly here – the idea of statistical significance.  Simply put, statistical significance is the likelihood that any findings in a study are down to something more than just coincidence.  It’s normal to get small differences between the outcomes in two groups purely by chance, just as it’s normal to get 501 heads rather than 500 if you flip a coin a thousand times.  But if a thousand coin flips come up with 600 heads, there’s probably something about the coin that’s giving you that result; and, similarly, the larger the differences in outcomes between two groups that differ only in the factor you’re studying, the larger the likelihood that the differences in outcomes are genuinely due to differences in that factor rather than to sheer coincidence.  By convention, once the chances of getting a particular result by sheer chance are less than one in twenty then that result is held to be ‘statistically significant’.

The difference in size between two outcomes necessary for the result to be statistically significant depends, among other things, on the frequency of the outcomes.  With small groups, a tiny difference between the numbers is less statistically significant than it would be with big groups.  (If you flip a coin 1000 times and get 600 heads, there’s probably something odd about the coin – if you flip a coin 10 times and get 6 heads, there’s nothing particularly significant about that, even though the proportion of heads is the same in each case.)  Hence, when you’re studying an outcome that’s as rare as infant death in the USA fortunately is, a difference between the figures in two groups has to be quite a sizeable percentage of the overall numbers in order to show up as statistically significant.  The more you split the groups down into sub-groups, the less likely it is that even a genuine difference will achieve statistical significance, because there just won’t be the numbers for it to do so.

This, as far as I can tell, is what seems to have happened in the Chen and Rogan study.  The author looked at death rates across the board (the only causes excluded from their analysis were cancers and congenital birth defects).  Death rates were down overall and in each subgroup studied.  However, when the deaths were divided into separate groups, although each group showed a reduction in death rates, the groups of babies dying from infections, SIDS, or other causes were too small for a small difference to show up as statistically significant.  It’s only when you combine all the deaths from all causes that you get a group large enough for the statistical significance to show up.

Now, this study is certainly not without flaw (something the authors themselves freely acknowledge).  And it’s also worth noticing that even if the 21% reduction in death rates is the true figure and not due to some confounding factor for which the authors couldn’t adjust, that equates to an extremely small risk for any individual formula-fed infant – that level of risk would mean that for every fifty thousand children not breastfed, nine would die as a result.  But looking at the results realistically is one thing; dismissing them on spurious grounds because they don’t happen to suit you is another thing entirely, especially when other studies have come up with similar evidence.  (STATS.org tell us that the reduced rates of SIDS in this study weren’t statistically significant; what they don’t mention are the other studies cited by the AAP that show a possible link.)

The only other three studies about which STATS.org had anything to say were the three pointing towards a possible association between breastfeeding and decreased risk of diabetes.  Two of these were apparently dismissed on the grounds of being based on Chilean and Pima Indian children respectively (why this should be grounds for ignoring them was not explained).  The third study, the authors claim, “only found results for children exposed to food. Infant formula wasn’t even considered!”  Which is most peculiar, because when I checked out the abstract it certainly mentioned finding an association between diabetes and early cow’s milk exposure (in babies who were already at high risk of diabetes), and cow’s milk was a major ingredient of formula last time I checked.

Of course, although STATS.org are incorrect in saying that no benefit has hitherto been shown of breastfeeding as far as diabetes prevention goes, it’s true that the evidence so far is still in the early and tentative stages.  But the AAP’s paper doesn’t try to claim otherwise – diabetes was one of the conditions listed in the section that specified “Some studies suggest decreased rates… Additional research in this area is warranted.”  So, again – why did the authors single out this particular topic for further discussion, when several important risks for which the AAP do claim strong evidence of benefit from breastfeeding (meningitis, sepsis, necrotising enterocolitis) were ignored?

Because, it seems, this was their chance to get in a swipe at the NYT.  “The Times takes the concept that an indictment is as good as a conviction to new heights” trumpet the authors, under the subheading “Baseless reporting”.  What they conveniently omitted to mention was that the Times did actually specify that there wasn’t enough evidence to prove a link.  I don’t know whether STATS.org are bashing the NYT solely in order to discredit what they have to say about breastfeeding, or whether it’s actually the other way round and they have some grudge against the NYT which is colouring their interpretation of subjects on which the NYT report.  What I do know is that by this stage it was clear that, whatever the authors pretended, they weren’t even attempting to look at the NYT article impartially.

They use the same technique of telling only part of the truth in order to pooh-pooh the AAP’s conclusions about the economic benefits of breastfeeding.  The AAP, they say, “is not officially in the business of making economic calculations” (side note: is that true?  As an employee of the National Health Service, I’m intrigued by the idea of a country in which a major medical body can get away without being in the business of making economic calculations), and their arguments about the economic benefits “are simply bad (social) science, and are fed by conviction or opportunism rather than hard evidence”.  But what they fail to mention is that the AAP aren’t simply making it up as they go along; they cite four studies and two economic analyses (which appear, from the government think-tanks mentioned in the article, to have been done by people who are officially in the business of making economic calculations) as evidence for their claims.  (One of the studies was a comparison of breastfeeding and formula-feeding among employed mothers, making a nonsense of STATS.org’s claim that economic benefits would be cancelled out by the incompatibility of breastfeeding and full-time employment.)

So, the authors conclude, what should we take away from this?  Their “inescapable conclusion” is, apparently, that it is “nothing short of irresponsible” for a public health campaign to have compared not breastfeeding to smoking during pregnancy.  (This was, apparently, their biggest concern with the whole NYT article; I was somewhat amused that it was that, rather than the comparison with riding a mechanical bull during pregnancy, that apparently struck them as shockingly inappropriate.)

They also make one rather good point in their conclusion; namely, that we take risks every day, with our children as well as ourselves (crossed a road with your child recently?), and that it’s quite normal to accept a certain amount of risk if you feel the benefits are worthwhile.  But to make these sorts of choices, we need accurate information about what the risks and benefits actually are.  On the subject of choosing not to breastfeed, STATS.org mislead us sadly, and to an extent that can only be deliberate, about both.

July 1, 2006 at 10:12 pm Leave a comment

Stats.org breastfeeding article, Part 1 – Spin The Breast

(This article first appeared on the Good Enough Mum blog, here.)

The post I’m writing about the STATS.org breastfeeding article is getting so long that I’m splitting it into two parts.  I’ll look at their use of data and statistical analysis in the second part, but first I wanted to discuss the view of breastfeeding Goldin, Smyth and Foulkes present at the beginning of their article.

They start out by stating that “the costs of nursing are substantial”.  If they had genuinely been out to present a fair and balanced viewpoint, a statement that the costs of nursing can be substantial for some women would have served that purpose much better.  I struggled to nurse a baby with a tongue tie despite a sad lack of local facilities for the simple procedure that would have put things right, and then pumped regularly for eight months after my return to work; I know damn well that breastfeeding can sometimes be difficult.  And my experience was a bed of roses compared to that of some women I know.  But we’re the exception rather than the rule.  For the majority of women, breastfeeding is actually a lot easier overall than formula feeding.

I say “overall” because the first few weeks can be difficult, and breastfeeding at this stage often is more difficult than formula feeding.  However, by far the most common experience of women who can hang in there for long enough to get through the initial difficulties is that a few weeks down the line, breastfeeding becomes much easier than formula feeding, to the point where it’s well worth the initial investment of time and energy even from a purely practical point of view.  The problems settle down, and you can enjoy not having to spend your time over the rest of the first year mixing formula or sterilising bottles.  Of course it doesn’t always happen this way – sometimes the problems don’t settle, and sometimes they’re so severe in the first few weeks that a woman just can’t get past them (although these situations would happen far less frequently if all women had proper advice and support).  But a sweeping statement that the costs of nursing are substantial is unwarranted scaremongering.

The article continues: “[T]he reduced time for work due to the need to pump, nurse, eat and sleep has a huge economic and social impact on women and their families.”  Pumping can certainly be a hassle, though it’s not necessarily as negative as they make out – as I said, I pumped at work for eight months, and neither my employers, my family nor my salary suffered as a result.  I just rearranged my schedule to spend the pumping sessions on the paperwork and phone calls that would have had to be done in any case.  It was boring and a nuisance, but it was doable.  I know that this depends on the job and there are a lot of women for whom pumping at work just isn’t an option – but for a lot of others it’s perfectly feasible, and it’s a possibility of which I’d like to see more women aware.  (Mixed feeding is also an option that should be mentioned much more frequently than it is – women who want to breastfeed but can’t/don’t want to pump at work can nearly always still nurse during the times they’re at home.)

But I’m a little confused as to how eating and sleeping ended up on a list of supposed disadvantages of nursing; if I hadn’t breastfed, would I somehow have been magically transformed into a superhuman who could eschew such frailties and work 24/7?  I’m also not quite sure why nursing is supposed to take more of women’s time than formula feeding would (surely the reverse is more likely to be true?), unless the authors are trying to suggest that women shouldn’t feed their babies at all but should palm this task off entirely on others while they go and dedicate their time to earning money.

The article continues with a discussion of possible disadvantages of nursing which appears to owe more to a weakness for popular myth than to an attempt to present the facts in a reasonably balanced way.  It is indeed possible that an unsuccessful attempt at nursing could worsen depression, but it’s also possible, given the anecdotal evidence of nursing triggering hormonal reactions that lead to relaxed euphoric feelings, that nursing could actually offer some protection against post-partum depression.  (In the absence of prospective studies, we can only guess.  That applies to STATS.org too.)  Nursing can sometimes be painful, but something that is not nearly as widely known as it should be is that pain, far from being an inevitable part of nursing, is nearly always an indicator of a problem that can be straightforwardly solved. There are indeed sometimes medical reasons not to breastfeed, but there are also sometimes medical reasons not to exercise, and for some reason we don’t tend to see that disclaimer showing up in discussions of the overall health benefits of exercise.

CMV infection via breastmilk can affect premature babies, but a quick search through Medline shows that the currently available evidence doesn’t support this being a major problem, and STATS.org somehow failed to mention that the risk doesn’t seem to affect full-term babies.  Drug addicts may well, depending on the drug, be better off not nursing, but I wouldn’t go so far as to call this conclusion obvious – I was told by one of the paediatric consultants I worked for that, apart from cocaine, no drugs are absolute contraindications to breastfeeding, and I know there’s a theory that it may actually help ease withdrawal symptoms in a neonate.  Maternal smoking or drinking may affect breastfed babies, but don’t seem to do so at low levels.  And while some mothers genuinely don’t have enough milk, it’s worth knowing that most of the mothers who think or have been told they don’t have enough actually could have with the proper advice.

Most of what the authors say is not, technically speaking, actually inaccurate.  The problem is with the spin they put on it.  They seem to be setting out to present breastfeeding in as unmitigatedly negative a way as they can.

June 28, 2006 at 10:03 pm Leave a comment

Newer Posts


Categories