We got the latest World Magazine today and I was reading it in the car on our way to midweek communion service and something just really grated my nerves.
From “The Buzz” — MEDICINE Parents will further reduce the risk of sudden infant death syndrome (SIDS) if they will offer pacifiers at bedtime and let infants sleep in the parents’ room—but not in their beds. The new recommendations are part of a long-running effort by the American Academy of Pediatrics to lessen SIDS, which remains the leading cause of death in U.S. infants between ages 1 month and 1 year. More than 2,000 U.S. babies die of it each year, but the rate has fallen dramatically since AAP recommended that infants sleep on their backs rather than their stomachs.
I saw the new guidelines a week or two ago when they were released and I wasn’t thrilled. First of all, the meta analysis study about pacifer use and decreased risk of SIDS seems so strange to me. The premise is that babies who use pacifiers to sleep don’t fall into as deep of sleep. Except, I don’t know many babies who keep the pacifier in their mouths while they sleep. So how does pacifier use –> less deep sleep? It just seems like there has to be some other factors they aren’t considering.
I’ll let Dr. Sears handle the co-sleeping thing. The AAP is really ridiculous about this. SIDS is virtually non-existent amongst co-sleeping babies and the 65 deaths a year from accidental roll-overs, etc. most often have extenuating factors (drugs, alcohol, etc.). And 65/year is a lot less than the 2500 SIDS deaths every year of babies in cribs.
But, all the info aside, I was annoyed at the way World presented it, as if the AAP guidelines were concrete truth and not the best guesses doctors have right now (which are subject to change at any moment.)
I don’t know what the big deal is. Recommendations are made for a reason, and it’s not like it’s some conspiracy with the pacifier makers to sell more pacifiers. I scanned the article, and it looks legit, as much as a meta-analysis can be, in that any of the flaws of the original studies will just be passed on. I can’t comment on the statstical stuff, but I imagine it wasn’t published without a statistician looking over it.
They only recommend the pacifiers after breastfeeding has been well-established, and their guesses as to the biological mechanisms are just that. They admit there are several plausible explanations, and that they don’t know which is the right answer.
They also say:
“The pacifier should not be used as a substitute
for nursing or feeding, nor should it be coated
with sugar, honey, or other sweet substances. Once
the infant falls asleep, the pacifier should not be
reintroduced if it falls out of the mouth, nor should
infants who refuse a pacifier be forced to take one.”
and
“Although the mechanism for its beneficial action
is still not known, few would argue against this
intervention now that we have experienced its dramatic beneficial results. Implementing this new intervention may help us come closer to reaching our
goal of eliminating these tragic deaths.”
It all sounds quite reasonable to me. They also make it a point to say that it’s a level B recommendation, meaning it’s not the strogest level.
I won’t comment on the co-sleeping thing as I have not read enough.
I don’t think pacifiers are evil. Kate used one. I just don’t get the logic behind it at all. It makes no sense to me. How does sucking on a pacifier for 2 minutes before sleeping reduce the risk of SIDS? They haven’t the foggiest. Co-sleeping DOES reduce the risk of SIDS because moms and babies sleep cycles align. Yes, this does happen to some extent with sharing a room, but even more so in sharing a bed. We understand the mechanics behind that. What I don’t get is why the AAP is pushing things they don’t have a clue about and continuing to make people feel guilty about cosleeping when studies have shown that up to 50% of AMERICAN parents do it anyway (and everyone else in the world does it.) The AAP needs to educate people about safe cosleeping. That would certainly reduce SIDS rates. We know that. SIDS is non-existent in co-sleeping cultures. When SIDS first emerged they called it “crib death.”
Our son would ONLY sleep face down. I remember worrying about that as a risk factor, but when it comes down to it, you generally want to see your kid sleep at some point in the first few months.
You don’t get that?
I don’t understand what SIDS is. Sudden Infant Death Syndrome. The word makes it sound like a mysterious syndrome that causes babies to die. So I don’t understand how over-sleeping while co-sleeping qualifies. If a baby dies is it automatically SIDS or something?
Evelyn partakes of Eucharist every Sunday on her pacifier. I’d hate the AAP to get after us for that. And MAD, too. And whoever else.
Right, rolling over your baby while cosleeping is considered “accidental death” not SIDS. And, truly, most of those cases are in dangerous places (on couches, baby gets stuck in the crack) or have other dangerous factors (alcohol, prescription or illegal drugs, etc.).
I am not saying all parents should co-sleep. It’s a personal choice issue. I am just tired of it getting such a bad rap in the US medical community and media.
Co-sleeping wasn’t mentioned in anything that I read about the new recommendations. I don’t remember anything in particular about co-sleeping preventing or causing SIDS in our education (granted, Kathleen is the one to ask, not me).
All I’ve got is the AAP policy statement, and it seems pretty qualified, so I’m not sure what your exact beef is. Lots of citations to do more background research if that so interests anyone.
“Bed sharing between an infant and adult(s) is a highly controversial topic. Although electrophysiologic and behavioral studies offer a strong case for its effect in facilitating breastfeeding and the enhancement of maternal-infant bonding,35,36 epidemiologic studies of bed sharing have shown that it can be hazardous under certain conditions. Several case series of accidental suffocation or death from undetermined cause suggest that bed sharing is hazardous.34,37–39 A number of case-control studies of SIDS deaths have investigated the relationship of SIDS with parent(s) and/or other adults or children sleeping with an infant.16,31,40–48 Some of these studies have found the correlation between death and bed sharing to reach statistical significance only among mothers who smoked.41,47 However, the European Concerted Action on SIDS study,42 which was a large multisite study, found that bed sharing with mothers who did not smoke was a significant risk factor among infants up to 8 weeks of age. Similarly, a more recent study conducted in Scotland48 found that the risk of bed sharing was greatest for infants younger than 11 weeks, and this association remained among infants with nonsmoking mothers. The risk of SIDS seems to be particularly high when there are multiple bed sharers31 and also may be increased when the bed sharer has consumed alcohol or is overtired.42,47 Also, the risk of SIDS is higher when bed sharing occurs with young infants.40–42 It is extremely hazardous when adults sleep with an infant on a couch.31,40,41,48 Finally, the risk of bed sharing is higher the longer the duration of bed sharing during the night.41,47 Returning the infant to his or her crib was not associated with an increased risk in 2 studies,40,41 and in another, the risk was significant only when the bed sharing occurred for more than 1 hour or for the whole night.16 There is growing evidence that room sharing (infant sleeping in the parent’s room) without bed sharing is associated with a reduced risk of SIDS.41,42,43,48 Data from the European Concerted Action on SIDS42 study led to the recommendation by its authors that the most protective sleep setting for an infant is in a crib in the parents’ room. On the basis of their study results, investigators in Scotland48 endorsed the United Kingdom Department of Health’s advice that the safest place for an infant to sleep is in a crib in the parents’ room for the first 6 months of life.”
As for SIDS, there are specific criteria for an infant death to be classified as such:
“the sudden death of an infant under one year of age which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history”
There is some evidence to suggest rare metabolic conditions not usually tested in the post-mortem investigation (fatty acid oxidation defects), because they are so rare and the tests aren’t very sensitive, are contributory factors.
THE AAP guideline does say “A separate but proximate sleeping environment is recommended such as a separate crib in the parent’s bedroom. Bed sharing during sleep is not recommended.”
Anthropologist James McKenna has done a great deal of research on co-sleeping and SIDS, some of which is available on the web — http://www.nd.edu/~jmckenn1/lab/
Looking at the Blair study in BMJ (sometime in 1999) a while back, it noted that if you adjusted for alcohol consumption, smoking, etc. etc. there was no increased SIDS risk for co-sleeping. I also recall seeing a study at some point about mischaracterized SIDS deaths among co-sleeping infants but I can’t remember WHERE.
As the end of Phil’s comments suggest, I’ve understood that researchers understand little about the causes of SIDS. In a NPR interview with this study’s researchers, they admitted that they don’t in fact understand the why of both suggestions. They simply see that doing both helps reduce the likelihood of SIDS. (This is similar to the suggestion of placing babies on their backs to sleep. I think that the same interview said that researchers still don’t know why this causes a reduction, but the drop in SID deaths since the recommendation have been significant.)
Rebekah
Well, sleeping in the same room makes sense. McKenna’s research (see above link) shows how the closer in proximity mothers and babies sleep, the more “in-sync” they are biologically. We might not be able to explain *that* but we can say that we understand that sleeping closer helps naturally regulate infant breathing.
The pacifier thing just baffles me. And the association is pretty small (unlike back-sleeping, which has a strong correlation.) Pacifiers do cause a host of other problems later (weaning from the Paci, orthodontics, breastfeeding problems, etc.) and I do realize that the AAP qualified the pacifier thing pretty well, but World and other media didn’t, and I’d hate for people to try to introduce a pacifier simply to reduce SIDS risk without considering all the other factors.
I looked around there and elsewhere, and didn’t see much that went one way or the other on co-sleeping, at least in any definitive sense, by the AAP or other “establishment” sources.
So far as I can tell, it looks like the jury is still out on whether there is a true statistical correlation between co-sleeping and SIDS, and given the absolute #s, I’m a lot less worried about co-sleeping and then strangulation/suffocation, than I am true SIDS.
I did run into a La Leche League response to the pacifier rec. I think they didn’t read the recommendation by the AAP before the wrote the press release.
Besides, relatively speaking, lots more kids die from accidents and the like than SIDS, still, so there are lots of other things to worry about long before trying to decrease a relatively small risk of SIDS to begin with.
I just think its interesting how much cultural bias is brought to medicine and research. *shrug*
I am annoyed at the continued refusal to support co-sleeping even a little in the AAP. I wish they would get some guidelines together to help people sleep safely with their children, because they sleep with them regardless of what the AAP and their in-laws say. (*wink* my in-laws were big co-sleepers, actually! Much moreso than Mike and I.)
And really, the paci thing is more scientific skepticism than anything else. And annoyance at the media for clipping everything to the degree that they remove essential content and make what is a weak recommendation a much stronger one.
We can talk about cultural bias in any sort of research for days. I’m no deconstructionist, but I think we do overlook (in all fields) our biases all too often. Or at least don’t deal with them seriously if we admit they exist. So we really do need to deconstruct things sometimes. That’s one of the reasons I’m not doing “regular” medicine, but want to do this philosophy stuff.
As an interesting side note, the hospital in India where we were at for 4 weeks doesn’t even have a single bottle in the entire place, or at least that’s what Kathleen said. It was breast feeding all the way, with the exception of the NICU kiddos. I think they were fed through an OG/NG tube.
Yeah, there is some strong research showing the benefits of co-sleeping to breastfeeding, which is the single biggest reason I think that it should be less poo-poo-ed in the medical establishment. *shrug*
But I saw the new AAP recommendations the day they came out and didn’t feel the need to comment on them. I still disagreed with the co-sleeping thing and thought the pacifier thing was bizarre. It was only when I saw them snipped in World to that degree did it really, really annoy me.
I did maybe see one or two bottles, but they were few and far between in India. Breastfeeding there is really emphasized (rightly so considering the access to clean bottles and formula). However, I saw one really sad case of a baby born to an HIV infected mother who, thankfully, was not breastfeeding the child (there are some parts of the world where HIV infected women breastfeed b/c of lack of access to formula). The family couldn’t afford formula and had been feeding the baby watered-down cow’s milk. That baby was so sick, malnourished, and anemic! It was horrible. Thankfully, the family was connected with some AIDS organization that provided formula for the baby. I really think feeding a baby completely via spoon would be very difficult – I have to wonder if that baby would have done better to have a bottle.
Well, as LLL says… “Pacifiers, which are recommended in this policy statement, are artificial substitutes for what the breast does naturally.” (from their press release in response to AAPS statement.)
I believe it is God’s design that young babies sleep lightly and sleep close to or with their parents. A responsive breastfeeding relationship naturally encourages these things. I do not think it is God’s design for young babies to be encouraged to sleep alone and for long stretches at young ages, and believe that this is supported by mainstream research and the very tragic reality of SIDS in our culture. :(
While I do believe that there are certain aspects of life that are better left without external intervention when possible, merely because something is natural does not necessarily make it better or more “holy.” There was also a time when the infant mortality and maternal mortality rates from pregnancy and childbirth was extraordinarily high. All because people refused to believe that hand-washing was able to decrease the spread of infections.
I’m not saying co-sleeping and SIDS is on that level, but I don’t think the LLLI read the AAP recommendation. Very simply, the AAP recommendation said various studies seem to have shown that merely placing a pacifier in the child’s mouth as the child is falling asleep. They also say it does not replace good breastfeeding technique. They also explicitly say that you don’t put the pacifier back in if it falls out, or that you have to make sure it stays in, or force it on the child if it’s not wanted. It just says if you give it to the child, and the child sucks, the statistics seem to show the child is less likely to die from SIDS. They specifically state that the rec is to start after 1 mo of age, and stopped at the latest at 12 mo. I don’t see the problem, even from the LLL’s standpoint. I usually like them.
I don’t think SIDS is caused by babies not sleeping with parents. I also don’t think all things natural must necessarily be better by virtue of being a part of “God’s design,” just like not all things new are necessarily better by virtue of “progress.”
I don’t really know you at all, Phil, so I’m not really sure where you’re coming from… but I guess I am saying “if it ain’t broke, why fix it?” I believe that the AAPs recommendations are basically a response to try to “fix” the damage that some parents have done (encouraged by our culture today) to choose to formula feed instead of breastfeed, to put their babies in a crib in another room, to use CIO techniques. I think that, yes, probably, for a formula-fed baby who will not wake up as often for a feeding as a bf baby, then there may be some benefit to pacifier use… however, I see NO evidence whatever that a pacifier does anything for a bf baby. My bf baby (23 months) still nurses before sleep, and at the age when SIDS was a risk it would have been absolutely ridiculous to stick a paci in her mouth after she had nursed to sleep.
I think their guidelines *may* reduce risk for a select population, but are really not useful for bf babies, and the benefits of bf and co-sleeping were virtually ignored.
And yes, I think that the natural approach, as God intended it, is optimal for the development of babies. I don’t think you can improve upon God’s design, it doesn’t make sense.
My point is similar to Kristen’s response to the World Magazine article, except directed at LLLI. I feel like their press release was not dealing with the AAP recs at all.
I can’t quote all of the article, but it makes it quite clear that the recommendation is NOT to force a paci on a child. It is very clear that you can try to give it once, if the kid takes it, leave it. if not, don’t force it. if it falls out, don’t put it back in. It’s a one-time thing. It specifically said that breastfeeding is still the way to go, and that this should not be started until after breastfeeding is properly established, and that this should not be continued. It says nothing about co-sleeping, it says nothing about using the paci for some other reason, it says nothing about formula feeding.
I don’t see how the new policy is a response to those things. It’s about trying to decrease the #1 cause of mortality among infants 1 mo to 1 year. The study just looked at various uses of pacifiers in kids and the effect it had on the rate of SIDS. That’s it. Nothing else.
SIDS can affect any child, breastfed, bottlefed, etc. Even if the kid sleeps on his/her back, they can still die from SIDS because we don’t know what causes it, and we don’t know how the protective effects of various things work, so we don’t know how to truly prevent it. I don’t think SIDS is a “result” of some of these other things (non-co-sleeping, bottle feeding, etc.). Recent research, as I mentioned before, postulates possible underlying neurological defects, possible metabolic defects, and sometimes, just unknown stuff.
As for the “ain’t broke, don’t fix it,” I agree. However, as SIDS is still the #1 cause of death in that age range, I think something is broke, and things that can be used to lessen the risk are welcome, especially when it’s as benign as sticking a pacifier in to see if the kid will take it.
I agree that if things go well with a natural approach, that’s wonderful. I am merely saying that there are also many other “natural” things that are not good, not nice, and not as God intended. Babies who aspirate meconium are in for a world of hurt if left to “natural” processes. But if we use “unnatural” suction and get that kid under close watch, and maybe additional suction, the kid’s risk of lung problems is dramatically decreased. The point is just that not all things natural are good, and I think anyone would be hard pressed to say we shouldn’t use some “unnatural” tools to decrease the risk of some horrific thing happening to a child. I don’t see how these pacifiers aren’t a place to start.
I think it is doing a disservice to parents to make the paci recommendation when they do not even specify the mechanism by which it reduces risk… *my* point (and LLL’s too, I believe) is that using a pacifier mimics what nursing to sleep does naturally… I think this point was ignored by the AAP, and would be useful info for many parents.
I think it’s rather insulting to say that the LLL didn’t read the recs… they obviously did but are working from a different perspective than the AAP is.
Well, I heared about it on the news and my immediate thought was “Why don’t they metion a co-sleeper”? I mean, they immediately say the baby should not sleep with you, he/she should sleep in a crib. But, there are other alternatives. We used a co-sleeper that attached to our bed. So, the baby was close but, not so much that we could have harmed her while sleeping. It bothered me too because anytime they talk about it on the TV they automatically say that babies should sleep in their own crib. But, there are other options than the crib!
Re: making recs w/o knowing the mechanism. There are many many many things in medicine in every field that is done/recommended because there is good statistical evidence showing a certain intervention prevents disease/bad outcomes. For example, laying a child supine to lower risk of SIDS, or using steroids in any number of diseases to lower morbidity and mortality. And just this week, the NEJM published another article on our further understanding of how steroids work. There are also many drugs there the mechanism is not fully understood, but we know without a doubt that it drastically reduces morbidity and mortality for millions of people. Medicine can’t wait to recommend stuff until it totally understands the mechanism or else there wouldn’t have anything. If the statistical evidence is there, medicine must make a choice about whether the benefit outweighs the burden, even if we don’t have the mechanism fully understood.
In this case, I think that statistical evidence is there. That’s not to say that pediatricians aren’t going to continue to study this and improve on what we know, and maybe find out the opposite (which is entirely possible as more evidence is collected). There is nothing in the article about NOT nursing to sleep. If anything, it just says if you’re going to put the child down to sleep, try sticking a pacifier in the kid’s mouth. If the kid takes it, GREAT, leave it. If not, don’t. If it comes out, don’t stick it back in.
You don’t have to wake the kid, you don’t have to change anything else that you’re doing. If you’re breast feeding, continue! that’s wonderful and right and ideal. If you’re co-sleeping, great! Keep doing that. I applaud those efforts, and think it’s wonderful. But that’s NOT what this AAP rec is about.
I have read both the LLLI press release and a good 80% of the AAP article. I am quite familiar with the LLLI and I actually believe in a lot of what they do. However, I don’t think the LLLI’s response deals at with the article. Perhaps we just have to agree to disagree on this point, but that’s my opinion.
“Therefore, we recommend that pacifiers be offered to infants as a potential method to reduce the risk of SIDS. The pacifier should be offered to the infant when being placed for all sleep episodes including daytime naps and nighttime sleeps. This is a USPSTF level B strength of recommendation based on the consistency of findings among the available studies (which are of weaker design [ie, case-control studies rather than controlled trials or cohort studies]) and the likelihood that the beneficial effects will outweigh any potential negative effects.”
“As for the criticism that we should not implement an intervention without understanding the mechanism of its action, the same could be said for implementing the supine sleeping recommendation for SIDS prevention. Although the mechanism for its beneficial action is still not known, few would argue against this intervention now that we have experienced its dramatic beneficial results. Implementing this new intervention may help us come closer to reaching our goal of eliminating these tragic deaths. Ongoing monitoring of rates of SIDS and other sudden unexpected deaths using population-based infant mortality statistics, as well as pacifier usage in these infants and in the general population, will be needed to help evaluate the impact of this recommendation.”
I’m not trying to pick a fight about co-sleeping vs not, or breast-feeding or not (in fact, I’m all for breast feeding). It’s about doing what we can to save the lives of children.
Kristen,
I linked two articles on my website that are pretty interesting responses to the AAP–one is from the Academy of Breastfeeding Medicine and the other is from the Massachusetts Breastfeeding Coalition, which is actually the fuller article, examining the gap between the recommendations and what the research actually says.
I broke off too soon. According to the analysis offered by the Mass Breastfedding Coalition, the pacifier studies showed only that parents of SIDS babies reported that on the night in question, the baby went to sleep WITHOUT a pacifier, but NORMALLY WOULD HAVE HAD ONE, and they reported this at greater rates than parents of babies who had their pacifiers on a given night. And also at greater rates than babies who didn’t ever take pacifiers. They also pointed out that parents of babies who died of SIDS might remember and report details differently than parents of babies who didn’t die of SIDS on a given night.
At any rate, it’s just as likely to be something about making that change….
This quote from the second article captures my personal concerns…
“One problem with this approach is that the association with SIDS was not found in babies who did not usually use pacifiers. We do not know if pacifiers themselves decrease the risk. We also do not know why these babies were using pacifiers to begin with – did they already have breathing problems and thus needed pacifiers or did the pacifiers create a dependency on them for breathing and arousal regulation? Were they breastfed or not? Breastfed babies may be less likely to use pacifiers and some data link breastfeeding, itself, to a lower risk of SIDS. The articles from the meta-analysis do not distinguish whether it is the absence of a pacifier (eg, babies who never use them) or whether it is being accustomed to or dependent on a pacifier but then being denied it that puts the baby at risk. ”
Also, I have a background in research methodolgy and developmental pyschology… I am wary of conclusions drawn from meta-analyses personally… but then in dev pysch we weren’t making “life-saving” suggestions.
Oh! Another great quote…
“Using a pacifier increases arousability, something which is already present in a breastfed infant. Arousal thresholds from sleep are different between breastfed and bottle-fed babies. Breastfed babies are more easily aroused from active sleep at 2-3 months of age than formula fed babies. This age coincides with the peak incidence of SIDS. Breastfeeding a baby during the critical risk period for SIDS (2-4 months) “covers” the period of time when reduced arousal capability impairs the infant’s ability to respond to life threatening situations.”
This is what I mean by “ignoring the mechanism by which paci’s work.” We are NOT totally ignorant of what is going on… No mention of arousability was made in the AAP recs, right? Here’s my conpiracy theory. ;) I think they think the average parent just won’t “get” it, and they assume that the average parent won’t make the commitment to bf the first 6 months of life… so they decided, “well, we can at least encourage parents to use pacis, even if it’s just a substitute, it appears to do some good.” This is my personal impression as an informed parent, and I find it quite insulting and disappointing.
Sigh. This is it. I’m done with this conversation. I’m sorry if I’m coming off a little curt now, but I think this is ridiculous. Yes, the AAP paper talks about possible mechanisms. Yes, arousability is mentioned in it. I have not read the specific shorter recommendation/position paper, but the big paper talks about it. It also talks about other things. It also admits its weaknesses as a meta-analysis based on case-control studies. It also recommends further study.
You don’t know how many things in medicine have been initially implemented based on “weaker” meta-analyses, just because double-blinded, randomized control trials are HARD and expensive to do. Lots of things have been discovered that way, to the benefit of LOTS and LOTS of people, and not just in pediatrics.
If you think that the AAP is in a racket to prevent BF, there’s nothing anyone can do or say to prove otherwise. I’m sorry you think that way.
I know that people don’t read. I know that people don’t take it on themselves to be informed and responsible parents like you do. However, the problem is not the AAP then, because they’ve been quite thorough in admitting strengths, weaknesses, and calling for more research. If you really want to get pissed, get pissed at the media which oversimplifies things, and the parents who are too lazy to listen to their pediatricians completely. BF has been STRONGLY recommended out the wazoo for decades by pediatricians, and even more so now that we have a deeper understanding of all the good stuff it does/provides (macrophages, antibodies, etc.).
And you know what? your impression may very well be true, because of those stubborn, less-educated, less well-intentioned parents than you. That’s part of the population that pediatricians have to deal with – people who DON’T care as much as you do. In that case, in trying to look out for the best interest of the child, they have to recommend things to the parents that will decrease the risk of that kid dying from SIDS. Those sorts of parents already aren’t doing the things that you would hope, like breastfeeding, and so on. If they’re not going to do that, we can still decrease the risk of SIDS through other interventions, and we’d like to encourage people to do that.
So I ask, what do you want the AAP to do? Just ignore a life-saving intervention, and let 1 in 2733 (the approx. number needed to treat to prevent a single SIDS death) kids die because they were afraid of recommending something that might be misinterpreted?
For the record, the medical field has been trying for decades to persuade people that antibiotics are not for every runny nose and cough. People, including well-meaning parents, don’t listen, all over the world, for many different reasons. That is the environment in which medicine must work, with all sorts of people, educated and not, rich and not, with all sorts of cultural and superstitious baggage, in its efforts to prevent and decrease morbidity and mortality.
Phil, from what I can discern, we are just coming from very, very different places. I respect the medical community, I have a long history of doctors in my family, my uncle is a doctor, and I am close friends with a couple of doctors now. I do believe that generally the “medical community” tries to do their best and do save lives everyday. I have friends who work in Public Health who share those goals as well. I am sorry this conversation has been frustrating to you. But I’m coming from this as a parent with high expectations for myself AND the medical professionals I deal with. I have been very dissapointed at times, and very blessed and thankful to have worked with great medical professionals at other times. However, I’m sorry, but I do think there are major short-comings in the AAPs’ statement AS IT WAS PRESENTED TO THE PUBLIC AT LARGE… and yes, that is troubling. And I have also encountered Doctors and Nurse Practioners who were SADLY misinformed about breastfeeding practices, and I am not the only one with this experience.
So, I guess my challenge to you is to be one of those doctors who *does* get it, and I’m am sure you are on your way there. But please do not be too quick to dismiss the concerns of well-informed parents like myself, and immediately jump on the side of whatever “recommendation” has been made… though I don’t get the sense that that is the case, you have obviously taken the time to continue with this conversation. :) But I do hope that you wouldn’t recommend a pacifer to a nursing mother, honestly. Let that be her choice but DON’T put the “it will reduce the risk of SIDS” guilt trip on her, b/c I don’t think the evidence supports that for nursing moms.
Also, I’m convinced on the antibiotic issue… I don’t know ANYONE IRL who isn’t, it frequently comes up as we talk about how to keep our kids healthy. So I hope that is encouraging to you. :)
In terms of what I would want the AAP to do… make the statement to the general public, the one that people read as they glance over the newspaper, more nuanced… don’t always assume people can’t understand. People NEED to hear about the importance of breastfeeding, and the AAP is a powerful voice, and I think they could do more to support breastfeeding.
Also, I just wanted to say that the “average parents'” impression of whether pediatricians “strongly” recommend bf is probably different than yours… when forumula is sent home from the hospital, when formula samples are in the office, etc., when advice is given that undermines establing a good supply, nursing is not encouraged. I know that there are exceptions, and I think things *are* getting better, but it seems a BIG stretch to me to say “BF has been STRONGLY recommended out the wazoo for decades by pediatricians.” :(
Again, I think you assume way too much about the patient populations doctors deal with. I’m in an office right now where I would guess (quite accurately, I think) that the average education level of the patients/patients’ parents is less than a high school diploma. They don’t get most of what we’re talking about.
Again, if you don’t like the AAP recs, don’t blame the AAP. Their recs are very nuanced. The quoted the paper. If that’s not nuanced enough for you, I don’t know how else you want it to be said. If you don’t like what was said on the news, don’t blame the AAP for how the media chopped out the parts where they said do it after breastfeeding has been started, or whatever else.
I still don’t get where you’re getting the “Let that be her choice but DON’T put the “it will reduce the risk of SIDS†guilt trip on her, b/c I don’t think the evidence supports that for nursing moms.” The paper is there for you to read. If you can show me where that is stated or implied in the paper Kristen linked above, I’d be happy to see it.
Everything is “her choice,” including the breastfeeding, or placing the baby to sleep supine, unfortunately, as much as we try to persuade people to do things a certain way. You can’t have it both ways if you want everything to just be “mom’s choice.” Either you take the recs with the relative strengths of the recs based on the relative strengths of the studies, or don’t. You can’t just ask medicine to only give the recs you like.
As for the formula in hospitals/offices, take it up with them. Just because the AAP recommends something does not bind any practitioner anywhere to do anything. Take it up with the individual docs. Again, all this is “their choice.” If you ask any academic physician, they will tell you that breasfeeding is the way to go. If you ask any medical student, they will tell you that we are taught that breastfeeding is the way to go from the beginning. When/how people decide to change their mind is a totally separate issue from what is the current standard of care, and whether patients actually listen to what providers say.
We don’t have the luxury of educating some of these people. We try. Lord knows we try. But it just doesn’t happen. There are a million factors why that is, including many non-medical, social, and emotional factors. So assuming that we can’t get through to them about breastfeeding, which we often can’t, if they use a pacifier, great, it will most likely reduce the risk of SIDS. If you don’t believe that, there’s nothing I can do.
By the way, if you don’t trust case-control studies using regression analysis, I hope you don’t give your kid aspirin the next time he has a viral illness. Because that’s all the “proof” we have of such a thing as Reye’s syndrome. Never mind that kids died from it before we told people to stop using aspirin and viral illnesses (which they still do, and where kids still develop Reye’s syndrome, but not in the same #s as before).
For the record, I have already told, and will continue to tell people that the most recent research is that pacifiers used appropriately will most likely reduce the risk of SIDS in their kids, breastfed or not. For the record again, I told this to a breastfeeding mom. For the record, she also knows that breastfeeding is the way to go.
Phil,
I have to agree with Elizabeth in saying that I don’t think the establishment (doctors, hospitals, etc.) in the US is nearly as supportive of breastfeeding as you think. It’s not just the hospitals, almost every new mom gets formula samples sent to her door. Where do they get that info from? From ob-gyns. Pediatricians are VERY quick to suggest supplementation to new breastfeeding moms who are concerned about supply issues, when every stitch of research shows that supplementation is about the worst thing you can do if you want to successfully breastfeed. (I do know there are some women who can’t breastfeed. I am not speaking about those cases.)
Anecdotally, I have seen 5 pediatricians (in three practices in two states) with Kate. All of them highly recommended in the evangelical (very pro-bf) or AP/LLL communities. I would consider 2 of the 5 supportive of breastfeeding. One asked me at her six month well baby visit, “Is she on formula yet?” That sets formula up as milestone that should be reached. A much better question would have been, “how is breastfeeding going?” When I got pregnant, another pediatrician told me “She’s 9 months old, so you can switch to whole milk.” She could have said, “As long as your ob/gyn or midwife isn’t concerned, you can continue to breastfeed, though starting whole milk isn’t out of the question at this point.” The first time I called the nurses line at the practice of the first midwife I saw, the nurse berated me for breastfeeding and being pregnant and told me that the ob/gyn would tell me NOT to do that and she had no idea what to tell me because people just don’t do that.
Pacifiers do come with a price. They are not medically neutral. They shorten the time of infertility between children, cause dental and orthodontic problems, can contribute to supply issues for breastfeeding women, etc. I would recommend any breastfeeding woman to research carefully before offering a pacifier to their child, meta-study or no. Kate sucked on our fingers for hours a day for her first six weeks of life, so we ended up giving her a pacifier, but I knew the risks and benefits of that decision. Most people don’t know there’s a downside to them. As others have pointed out, the studies seem to indicate if the child typically slept with a pacifier and then didn’t, that contributes to SIDS. That’s not quite the same as saying pacifiers reduce the risk. Consistency reduces the risk, perhaps. *Shrug*
I give up.
No one claimed there are no risks to pacifiers, just like no one claimed there are no risks to co-sleeping, or antibiotics, or any other intervention. Everything we do anytime has risks. It’s whether the benefits outweigh the risks or not. If you’re not convinced of the relative risk/benefit of the pacifiers based on the paper, then I got nothing. I reread the article, and it talks VERY little about whether or not breastfeeding has to do with it. In fact, it even takes into accounts studies that tried to control for breastfeeding.
As for the practitioners, I can’t make up excuses/reasons for them except to say that lots of people don’t practice to the standard of care recommended by their respect professional organizations, mostly because many people either 1) don’t belong and don’t know/aren’t up to date or 2) choose not to for any number of reasons. Again, that doesn’t change the official AAP recs.
To quote from the AAP policy statement on breastfeeding:
“the AAP firmly adheres to the position that breastfeeding ensures the best possible health as well as the best developmental and psychosocial outcomes for the infant. Enthusiastic support and involvement of pediatricians in the promotion and practice of breastfeeding is essential to the achievement of optimal infant and child health, growth, and development.”
http://www.aap.org/advocacy/bf/brpromo.htm
Perhaps it’s not worded strong enough for your tastes, but IMHO, that boils down to preference. In terms of the actual information, it’s accurate, and does everything right.
As a side note regarding pacifier use, repeated studies have shown that pacifier use doesn’t necessarily cause weaning in randomized control studies, but is more strongly suggestive that “pacifier use is a marker of breastfeeding difficulties or reduced motivation to breastfeed, rather than a true cause of early weaning.”
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11466098&query_hl=4
Various studies have shown all sorts of psychosocial factors affecting early breastfeeding cessation, such as “Mother’s schooling, her intention, self-efficacy and earlier breastfeeding experience can be used as early predictors.”
I’m sure part of the pressures on practitioners is what patients want. If mothers no longer want to breastfeed, and if you don’t help them, they leave, and find another doctor. That’s the same thing with the antibiotics. It’s freaking incredible (as in unbelievable) how often that happens. I’m discovering now how many doctors “cave” to the patient’s demands in order to keep the patient in their practice.
I don’t know what to say anymore, except what I know. Breastfeeding has been strongly recommended everywhere I have been. Granted, it’s basically been only at academic medical centers, but there has always been a disparity between the academic centers and what is done “in the real world.”
*sigh* Phil, I find your attitude defensive and antagonistic at the same time. I applaud the AAP for some of their statements (official policy on BF) but, the AAP is not “divine” and it is my right to disagree with them (and you) on this issue. ;) I do not dismiss the medical community as a whole. I like drs, and do trust most of them on medical issues. I’m sure I’d like you personally if we met (Kristen says you & your wife are very nice people who really do support BF.) However, I do think you are wrong to advise a breastfeeding mother to use a pacifier to reduce SIDS risk. But then I don’t turn to my dr for BF or parenting advice either, so if you were my doc, it probably wouldn’t come up. ;)
Also, I don’t think doctors are required to “fix” all of their patient’s poor parenting choices. I have a background in developmental pyschology, so I am WELL aware of the complex factors associated with parenting decisions. I share your frustration that some parents continue to make poor choices. But I think people need SUPPORT to make better choices, and to persevere in them. A dr telling them what do to will only go so far. My area of research expertise is actually social support… that is one reason I currently devote a significant amount of my time to a parenting support board, and hope to eventually work in the community supporting breastfeeding moms and offering support to parents… in low income communities specifically. :)
Also, it’s not a matter of wanting recs I like- I think the recs need to be appropriate to the population they are intended for and well-supported. You think they are based on the populations YOU work with, I think they aren’t based on the moms I KNOW, obviously a different population. Apparently they can’t be tailored for nursing versus non-nursing moms, a “one-size fits all” statement must be made. (This is my MAIN issue… if they reduce the risk for FF babies, that’s great, stick ’em in there, and tell moms to do so, but as Kristen says, they are NOT neutral for bf babies, and I firmly believe unneccesary to reduce SIDS risk.) We disagree on this issue, so we’ll have to let it be. :)
I apologize for coming off defensive and antagonistic. It is merely that I feel like you are making assertions, but haven’t given me anything to interact with except for your opinion. I’d love to see numbers that show that compares how much BF alone reduces SIDS risk compared to BF + pacifiers to see whether or not your statement “I do think you are wrong to advise a breastfeeding mother to use a pacifier to reduce SIDS risk” is accurate or not. I have not seen anything personally, but I haven’t looked very hard. I’m more than open to the possibility, but thus far, I haven’t seen the studies. I scanned some of the various websites that have been noted in this conversation, but have found little that specifically deals with the assertion that we’re haggling over.
As such, given the lack of such evidence, I don’t see how one can rag on the AAP for doing what they did with their most recent pacifier recs. They DID try to analyze the existing evidence, and noticed a trend.
I doubt that many will try to conduct prospective randomized control studies in many of these situations, so we’ll have to be satisfied with retrospective case-control studies for a while.
Additionally, there are a few studies out there that do not that both BF and pacifier reduce SIDS risk, with very similar odds ratios, but they don’t compare BF alone to BF and paci to paci alone.
I am curious – what sort of/how many studies would you consider to be reliable?
Phil, I don’t have numbers for you. I’m sorry. I think that the reason that we are frustrating each other is that we are drawing on different types of “knowledge”. You are a science guy, you want the studies, the numbers. I *used* to be like that. ;) Now I’m a mother. I’m drawing from a knowledge base of personal experience and hundreds of hours of reading, discussing and thinking about breastfeeding and related issues. More of an anthropological approach. :) And cross-cultural evidence supports my views, I believe- SIDS is NOT an international phenomena, it is an problem in Western culture.
I don’t think you will find “studies” to support the claim I am making… none that I’m aware of and honestly I don’t have access to the search tools I used to in order to search myself. My claim is based on knowledge and experience in terms of what cue-fed breast-fed babies *do*. It would be very unwise to discount this knowledge, it is a valid form of knowing and understanding, though it doesn’t always fit neatly into the medical perspective (unless written up as a case study ;))… though all the doctors *I know* love to draw on this type of knowledge, whether they are aware of it or not! Anyway, I digress. My baby nursed to sleep (and still does often at age 2). Using a pacifier before sleep is a substitute/alternative for this IMO. I would lay her down, and she would continue to “suck” while unlatched as she drifted into a more sound sleep, no paci necessary. At frequent intervals, especially during the “high risk” time for SIDS, she would stir and root instinctively, and I would nurse her. She had a very high arousability, and did not fall into extended patterns of deep sleep. (Annoying but perfectly normal and healthy!) I *think* this may be the key to the consistency thing as well… babies who are accustomed to begining their sleep period sucking a paci may be more likely to rouse themselves expecting their suck need to be met again. (I know some parents leave pacis around in the crib so the older baby can hunt for them, for example.) I’m just speculating here, though. ;) If they are not given the paci, perhaps that allows them to fall into a deeper sleep, or maybe it disorganizes their sleep patterns.
I really don’t think we’re going to agree about the appropriateness of the AAP recs, OK? You are satisfied with them across the board, I am not. Don’t take it personally! I *do* support pacifier use for crib-sleeping, formula fed babies though- this AAP rec has helped me realize that pacis are probably very important for babies who do not or cannot get their sucking needs fully met by mom. However, I know MANY moms like myself who have never used pacis, and I know some like Kristen who felt it was right for their family. :) But I would actually advise someone like my SIL, who FF from early on and had crib-sleepers to use a paci… which she did instinctively (stuck it in within an hour of birth with my nephew, knowing she planned to BF less than a month and did not like to allow her babies to nurse extensively.) So for that population, yes, absolutely use a paci, you’ve got me convinced. ;) Though I think ideally those moms would bf on cue, but as you point out, this doesn’t always happen when they *know* better. :( But it is just not logical for moms such as myself, I just do not see how it would change anything since it mimics what BF does naturally, as I describe above.
I agree that the kind of “ideal” prospective randomized control studies are not gonna happen, for very good reason. I’m ok with that though! :) I would like to see more studies along the lines of the last studies you cited, and more sleep studies similar to McKenna’s work. In an ideal world, I’d like to see a great deal of research in this area, a dozen or more studies in different populations. I am most familiar with large-scale survey research, and I think it would be awesome to have a comprehensive study large-scale representative survey, with a descriptive component and sleep observations in a sub-sample of families. (I left grad school ABD, but that would have been my DREAM to have access to such research, but with a focus on attachment issues!) Throw in some smaller high-quality studies in various populations, and I think that would be a start. :) Not to provide further support for the AAP recs, but to further understand what is happening, and how best to address the needs of all populations.
No recs are going to be appropriate for all populations. Even BF is not appropriate for all populations. So given the existing population, I think it’s very naive to ask the AAP to not say what it said. I fully applaud your efforts to educate, and don’t discount your experiential “evidence” and knowledge. However, other information clearly shows that you are the minority in the US. As such, recs must be given to deal with existing populations, while still making efforts to change mindsets and attitudes.
And something came up today while working with my doc – breast-feeding is less a pediatrician thing as it is an ob thing, since you have to start talking to moms and teaching them long before the pediatrician comes into the picture.
I am also fully aware of cross-cultural issues in regards to BF/SIDS, and I don’t think things are quite as nice overseas as we would hope. Most kids in India, a mostly rural country still (75% is rural), don’t breast feed past 3 months, IIRC. That’s straight from the mouths of Indian pediatricians and ob/gyns. I don’t have #s from other places, but I’m thoroughly convinced that BF is also losing ground in other places for various reasons (many people in many countries think that bottles and formula are more sophisticated and “cool”).
Besides in some of these other countries, the problem isn’t death from SIDS in kids less than a year old. It’s often other, much more preventable things.
Why do you say BF is not appropriate for all populations??? That makes no sense. What did moms do before formula? It *is* totally appropriate for all populations. That is the lack of support I’m talking about. *sigh*
Yes, I totally understand there are falling rates of BF around the world… ever heard of the Nestle boycott? There is a *great* deal of activism in this area.
You know, I’m really done with this conversation. Thanks for going back and forth with me though. :) Best wishes in your future medical career.
There are several medical contraindications to BF. For example, HIV positive moms. The risk is too high to the relative benefit. There are a handful of others, usually revolving around medications that are also secreted in breast milk that would have significant adverse effects on the child. That’s what I mean by it not being appropriate for all populations. That’s all.
Thanks for clarifying that, Phil. :)
No hard feelings, OK? ;)
Definitely no hard feelings. I have learned a lot through this discussion. I hope that this has also challenged you as well.
Awwww… on that note, I am going to close comments on this thread. It’s long enough as it is!