Not So Smart Breastfeeding Studies

Two new breastfeeding studies landed in the news trying to remind us that breast is still best for baby and mom. The first study, a brain imaging study found breastfed kids have more white matter in their brains. Naturally the authors want us to conclude breastfeeding makes kids smarter. No, they didn't bother with assessing the actual intelligence (or obscure brain physiology) of any parent in the study. That would have been too difficult. But that didn't stop the authors from doing brain scans on their kids. Nor did it prevent them from getting the data published. Imagine if you were doing a study about breastfeeding and child height, let's say you suspect breast milk makes kids grow tall.  Can you imagine making conclusions without assessing parental height? It's not smart. Using SES or education level as a proxy for intelligence is like relying on weight or clothing size as a proxy for height. Why wouldn't you measure adult IQ? It's a paper and pencil test. Dry but pretty easy. Study participants might not enjoy it but it's less invasive than a brain scan and of course you don't have to tell them hey, come fill out this test, we wanna see how smart you are. I think someone's gotten lazy when it comes to measuring those confounded confounding factors.

Speaking of not so smart omission of confounding factors....the second study comes from our old friends Bartick et al., the anti-formula-activists-turned-biased-breastfeeding-researchers of Suboptimal Breastfeeding fame. They would like to remind us not lactating enough makes women ill and provide lots of scary numbers the Surgeon General likely will cite. Instead of adding up the health costs children incur from not drinking enough breast milk, this time the SubOp authors add up the maternal health costs of not enough boobie milk. So instead of dead babies we got dead or at least very sick women. No, the authors once again failed to tabulate any costs associated with breastfeeding (i.e., lost sleep, lost work, lost time with other children, anxiety, stress, etc) - pretending once again that using one's body to act as the sole provider of sustenance for a tiny human for 6 months has absolutely no obstacles or downsides. It goes without saying they believe breastfeeding prevents or cures like every major health ailment.

I was going to debunk these here but a friend forwarded me a post by Dr. Amy, the SkepticalOb who did a bang up job and included her own stick-figure graphics that I think should become de rigueur in the boob-is-best literature. 

A Box Reduces Infant Mortality?

Photo Credit: BBC News, Milla Kontkanen

Ladies and gentleman, the answer to all your early parenting fears and needs: a box. The media has been a buzz about boxes supplied to expectant mothers by the Finnish government and filled with such nursery necessities as baby clothing, nappies, nail clippers and a picture book. The boxes each include a small mattress and thus double as tiny beds too. It is claimed the boxes have reduced infant mortality since the late 1930s. Indeed Finland boasts one of the lowest infant mortality rates on the planet. The boxes are said to increase pre-natal care and more recently, breastfeeding rates. In other words, behold the miracle box!

 A simple cardboard box helped Finland reduce infant mortality UPI

How can a mere box keep infants from dying? Good question. Some suggest the very act of sleeping in the box prevents death:

Health officials have long warned parents not to place their infants in adult beds because it can put babies at risk of suffocation or falling in between the headboard and the mattress. UPI

The suffocation explanation is simply not reasonable given the rarity of suffocation and also the other well-known and documented factors surrounding infant mortality, namely pre-natal care and premature births.

No surprise, other experts point towards the fact mothers must visit a prenatal clinic or doctor early in pregnancy to get the box:

Mika Gissler, a professor at the National Institute for Health and Welfare in Helsinki, gives several reasons for this (reduced infant mortality) - the maternity box and pre-natal care for all women in the 1940s, followed in the 60s by a national health insurance system and the central hospital network. BBC News

It's reasonable to assume the boxes increased pre-natal care but what about breastfeeding rates? It won't surprise anyone familiar with the Baby Friendly Hospital shtick here in the US that baby bottles have been removed from boxes. Did the lack of free bottles discourage formula or was it the heavy pressure put on women to breastfeed? 

Huffington Post couldn't help mention the Finnish boxes but in true New Media fashion contained their comments (news article? teaser?) to a mere 47 words: For 75 years, Finland's expectant mothers have been given a box by the state. It's like a starter kit of clothes, sheets and toys that can even be used as a bed. And some say it helped Finland achieve one of the world's lowest infant mortality rates. HuffPo

So upon reading the illuminating 47 words we learn the free goodie boxes might help save infants but have no idea how. 

The most entertaining reader comment on HuffPo: 

We would have to create a department of cardboard boxes. They would hire 10,000 employees to write 20,000 regulations pertaining to the boxes. The boxes would require years of testing and clinical trails. By the time a box is approved it would be valued at about 200,000 per box because of all the government expense required to bring us the official approved box. If a box failed, we would spend months in congressional hearings and new box legislation would be introduced and we would start over again with another box. Some people would choose not to use the box and we would have to find a way to enforce box use. Parenting box use training would have to be required to ensure proper box usage. Eventually the Chinese would make the box and we would have toxic chemicals in the cardboard. Start the hearings and legislation again. Look at how our government works now and you know my sarcasm is actually not far from the truth. Most stores will give you a box if you ask. Why get government involved.

This anonymous libertarian missed a few things like how the media and health officials would report the boxes prevent childhood obesity, SIDS, ADHD, diabetes, learning disabilities and gaps in educational readiness skills. Then some mompreneur would offer customized, eco-friendly boxes with baby's name, organic cotton mattresses (up to California code) and chemical-free lavendar-infused baby body butter, etc. She'd name it something cloying like Baby Booty and end up at Mom 2.0, Evo, TED and land a book deal as the latest parenting expert.

As for the libertine commenter, he or she also missed the pre-natal care part. The local supermarket can supply a cardboard box but as of yet not a pre-natal exam. Manicure, vision test, flu shot, yes but no stirrups or ultra-sounds.

Does anyone else find this statement particularly chilling given the anti-formula climate right now?

Some people would choose not to use the box and we would have to find a way to enforce box use.

Are we enforcing breastfeeding? No but locking up formula along the narcotics in hospitals is not exactly encouraging to mothers. It's certainly not any way to treat a woman who due to any number of valid real-life reasons does not attach a baby to her nipples up to several hours a day for a year during which she remains the sole provider of nourishment for said child for the first six months. It might not be the best way to treat a new mom.

Yet it's just so convenient to pretend breast milk or  a bunch of cardboard and a few onesies keep babies alive and healthy. If you live in an impoverished region of the world then sure, a few devices and techniques, some inexpensive medicines could have a huge impact. Each year almost two million babies die on the day they are born, almost 99% of those babies are born in the developing world. Many die simply because they can't start breathing on their own although a simple inexpensive hand pump could save them. So when we talk about a powerful maternal gift bag, yes such a wonder exists and could save lives but it doesn't look like something your thoughtful auntie would wrap up for a baby shower.

Working Mothers are Healthier?

A recent Pew Research survey showing 40% of households rely on the woman as the primary or sole breadwinner.  Been talking about it then saw it cited in Stephanie Coontz's op-ed in the New York Times this weekend, The Triumph of the Working Mother. Coontz argues among other points that working provides moms health benefits. She cites a recent study showing women who work full-time after the birth of their first child report better physical and mental health at age 40, than their stay-at-home peers. These benefits didn't apply to women who worked in low-paying positions with inflexible schedules and demands (i.e. ones where they couldn't pump in the privacy of a lactation lounge). So it appears working provides health benefits for most women. Right? Not so fast. It's complicated.

The Pew study found working doesn't stave off depression or make women any happier. According to their survey anything other than full-time employment (staying at home, doing irregular or part-time jobs) doesn't make women more miserable: 

There is also a significant gap in happiness between working and non-working mothers: 45% of non-working mothers say they are very happy, compared with 31% of mothers who work either full or part time. When other factors (race, ethnicity, income and education) are taken into account, marriage is a significant predictor of a mother’s happiness while employment status is not. Modern Parenthood, Pew 2013

Did you get that last part? Employment not a significant predictor of happiness when other factors considered. So how to explain this seeming discrepancy in the literature? That's when I started to get suspicious about the working-makes-women-healthier claim. Is it just a difference between asking people about depression versus happiness? Just a wording issue? Not working makes women depressed? Or a lousy marriage makes them depressed but not their work status?  Which is it? 

Take a closer look at the data in the study Coontz cited by sociologists Adrianne Frech and Sarah Damaske.  They divided moms into 4 groups - full-time/part-time/interrupted, irregular/stay-at-home (no work). Their analyses included a host of variables and  not surprising, the link between work and health got messy in their statistical models: 

Mothers who “pull back” from full-time employment by cutting hours or delaying entry into the full-time workforce report worse physical health (but not mental health) at age 40 relative to steadily working mothers after adjusting for prepregnancy and at-birth characteristics and accounting for selection, but better physical health than their interrupted and stay-at-home peers. This suggests that part-time work may provide important benefits to women.

Okay so part-time provides mental health benefits to the same degree as full-time work but also potentially worsens physical health but as the authors point out part-time employees often get a raw deal in terms of low-paying wages, insurance, hours, status, etc.  To some degree they control for previous conditions influencing whether women work but it's far from definitive here. They also found women who were married in relatively affluent households were also more likely to stick it out in the workplace full-time after birthing out a baby.  Is that a surprise? They had the better jobs in the first-place.  And might I add, probably better childcare or at least more choices with more income.  

This sounds empowering for many women who go off to work every day. I was ready to go find an office outside the house quick. But then I realized I don't really fit into the 4 categories above and couldn't say for sure where I would have been stuck at the time my first child was born. For those of us who work at home, it gets a bit trickier. I'm not sure the above research really addresses a segment of parents working from home. 

So what about those of us who work from home? How do we fit into this equation? It's unclear. I'm trying to find that research and am emailing a few researchers to ask. 

As for those stay-at-home, largely non-paid parents, I'm thinking there are many different types of staying at home just as Frech and Damaske specified 3 types of working parents, I bet there are at least 3 distinct and possibly relevant groups of parents that stick it out close to home.  Jumbling them all together is like mixing apples and oranges.  

Speaking of staying at home, I stumbled around this Huffington Post article, Success for the Stay At Home Parent, a thoughful though very brief discussion of a huge topic, how to define success without an office, a large salary or other markers of status and success often unavailable to parents who don't work outside the home.  Hhhmmm.  Speaking of pay and status, I cannot help but notice this (unpaid?) post appears thanks to Arianna Huffington who despite gathering a whole lot of content and advertising moola pays relatively few people.  As it turns out the (unpaid?) post is part of a series attempting to redefine success: 

This post is part of a series produced by The Huffington Post in conjunction with our women's conference, "The Third Metric: Redefining Success Beyond Money and Power" which will take place in New York on June 6, 2013. To read all of the posts in the series and learn more about the conference, click here.

I bet Huffington Post would like to redefine success. A truly American-made entrepreneur, Arianna Huffington. Give us your tired, your poor, your huddled, unpaid masses.... 

Yes, please let's redefine success. Money, health insurance, status, they're so over-rated especially when it comes to the joys of parenthood.  Kids are small, how much food and clothing could they need anyhow?

*Check out how much Stephanie Coontz, Champion of the Working Woman, resembles Mary Tyler Moore. Coincidence? My imagination gone amok amidst the end of school-year mayhem?

Proving the Benefits of Breastfeeding

Breastfeeding might help lower a women's blood pressure for decades. Researchers at the University of Western Sydney School of Medicine couldn't help but notice (in their pile of data) that women who reported breastfeeding also had lower blood pressure. Then they set about to get proof breastfeeding actually lowers blood pressure according to Science News Report:

To prove their hypothesis, researchers examined the relationship between breastfeeding history and the occurrence of high blood pressure in 74,785 Australian women. These participants belonged to the age group 45 years and older. Researchers worked on data taken from the 45 and Up Study. This is a large scale study of healthy aging involving over 260,000 men and women in NSW. Breastfeeding Lowers Risk of Mothers Developing High Blood Pressure via Babble

Oh my. Science at its best...cough cough? Or science writing at its best? Let's hope the researchers set out to test rather than to prove their hypothesis. But from what I've learned thus far, it's a little bit of both.

In any event, let's think about the women here aged 45 and "up" - some several decades older than 45.  How rare do you think it was for those older women to breastfeed back 30, 40, 50 years ago? Do you think they might have been more health-minded than their peers? Me thinks these are not your average semi-sedentary coffee and donut seniors.

Thank you Babble for keeping us informed about the benefits of breastfeeding. In next week's news... how breastfeeding can make you live 10 years longer, have better sex and earn more money.

The Gift of Siblings: When Everyone's an Expert

Brothers and sisters likely influence our lives in many ways but are they more important than parents? Do more siblings mean a tighter family bond and hence an even more potent effect over a lifetime? Who knows.  These are interesting questions raised by Frank Bruni in his column at the New York Times this weekend. He does, by the way, seem to think siblings pack a powerful punch, especially his brothers and sister. He doesn't bother citing any empirical evidence but does throw in  quotes by his friend Campbell along with sibling experts or at least people who wrote books about siblings, the first, Jeffrey Kluger, the author of The Sibling Effect and the other, George Howe Colt, the author of "Brothers."

Despite the paucity of empirical evidence from Bruni, there is a large body of research on siblings. Having a sister makes boys kinder.  Having a brother makes girls better at figuring out spatial problems. Having an older brother raises the odds of a man being gay. Siblings duke it out more over toys and possessions than anything else (big suprise). And then there's the occasional nugget like this:

A new study of Bolivian villagers shows a link between having a younger brother and slightly increased blood pressure levels later on in adulthood, though Brandeis University researchers did note the effect seemed to diminish with age. Huffington Post

Phew, have always wondered about blood pressure in Bolivian villagers. I would have brought you more curious sibling studies but every single article started with the author's attention-hogging little brother or freakishly talented older sister, daughter, son or other personal details that kept me from the data.  

Anywhoooo, there is no talking siblings without an appearance by that darling of the media and the public imagination - birth order. I can't possibly get into that labyrinth of mythical and valid results.  But just as first-born/last-born gets a nod the discussion then must turn to the only child...optimal number of children....parental happiness...adopted parents....step parents...co-habitating unmarried parents.....co-habitating unmarried step-parents.....gay parents.....blah blah blah.

Are sibling the most critical predictor of success, happiness and future mental health? That question is beyond the scope of this post but I can tell you one thing for sure. Everybody has an opinion and they're likely to give it in the opening paragraphs of their news story or blog post along with a personal anecdote about their own brother, sister, daughter, son, great aunt or neighbor. Everyone's an expert. Everyone's got a story. Why call on science when we have our stories.

ADHD makes people fat? ADHD's Cameo in the Obesity Epidemic

Adult males diagnosed with attention-deficit/hyperactivity disorder (ADHD) in childhood face nearly twice the odds of becoming obese according to a new study published online at Pediatrics.  Witness the latest chapter of ADHD, the Diagnosis Eating Away at America:

The prospective study included 207 white men diagnosed with ADHD at an average age of 8 and a comparison group of 178 men not diagnosed with childhood ADHD, who were matched for race, age, residence and social class. The average age at follow up was 41 years old. The study was designed to compare Body Mass Index (BMI) and obesity rates in grown men with and without childhood ADHD...Results showed that, on average, men with childhood ADHD had significantly higher BMI (30.1 vs. 27.6) and obesity rates (41.1 percent vs. 21.6 percent) than men without childhood ADHD. via Science Daily

Now this isn't the first study to link ADHD to obesity and it certainly won't be the last but it's an improvement as my friend Tara Haelle over at Scientific American almost single-handedly pointed out much to the delight of those of us who like our news sprinkled with context and nuance:

The previous studies, however, were retrospective (relying on participants’ recall), did not focus exclusively on ADHD (included other conduct disorders) or compared only men suffering from adult ADHD with those having remitted childhood ADHD, rather than to controls without ADHD. This prospective study is the most long-term and the first to focus exclusively on adult obesity rates in men with childhood ADHD compared with those who did not have the condition as children. Its findings therefore contribute to the growing evidence base for an association between obesity and childhood ADHD. Childhood ADHD Linked to Adult Obesity, Scientific American 

Why might men with childhood ADHD be prone to obesity?

One theory favors ADHD culprits like poor impulse control and decision-making that have continued to dog these men into adulthood. Others speculate about a more physiological mechanism, maybe one related to, cue the anti-pharma camp, the use of ADHD meds in childhood that ironically are known to suppress appetite and might somehow mess up appetite control or satiety.

In any event, obesity should savor its fifteen minutes this week but it better be prepared to share the spotlight with the other ne'er do wells hanging with ADHD.  Drug and alcohol use, depression, anxiety, low career aspirations, lower income, criminal arrests, bad grades, bad marriages...It's only a matter of time before the increasingly popular disorder gets a larger role in the obesity literature earning mentions in the same breath as diabetes and heart disease. Oh my.

Thank goodness the researchers cared enough about the perilous health implications of childhood ADHD that they set out to uncover its vicious life-long carnage on America's waistlines. Not quite. Initially they weren't worried at all about expanding girths but potential brain anomalies associated with ADHD.  It was only after several study participants couldn't squeeze into the brain scanner that the obesity hypothesis popped to mind. Thanks to Time Healthland's Bonnie Rochman for breaking this curious detail.

All this talk of eating and squeezing not to mention MRIs calls to mind the decided lack of behavior in this study about a disorder involving a multitude of behavioral symptoms. Although the participants reported their own height and weight it's anyone's guess if or how men with childhood ADHD behaved in real life, that is, when they weren't being asked personal questions and subjected to claustrophobia-inducing spaces. Did they eat more? Eat more trans fats and high-fructose? Exercise less? And if they did, why? Who knows. It's ever so much fun and impressive to labor over high tech brain contraptions even if some underpaid research assistant has to rearrange a few pounds of flesh from time to time.

Breast Still Best (Unless It's Not)

A little infant formula might help women breastfeed longer. A new study in Pediatrics showed newborns given small amounts of supplemental formula in the first days of life breastfed exclusively for longer than those given just breastmilk.

Whaaatttt?

Formula helped breastfeeding?

No it's not a typo. Just a bit of nuance in the breastfeeding literature thanks to one ballsy researcher, Valerie "Formula" Flaherman, an assistant professor of pediatrics, epidemiology and biostatistics at UCSF who ventured into unchartered and hostile territory by trying to actually test whether a few ounces of formula in conjunction with breastfeeding would promote or sabotage exclusive breastfeeding in newborn babies who'd already lost at least 5% of their birthweight.

The small study in Pediatrics found when babies were 1 week old, 10% of moms assigned to the formula group (babies got formula and breast milk) still used formula in some amount and sit down, 47% of those in the breastfeeding group started using formula. When the babies were 3 months old, 79% of the original formula moms were still exclusively breast-feeding compared to 42% of moms in the breast-feeding group. 

In other words, supplementing with some formula appeared to help mothers breastfeed exclusively.

Now before all hell breaks loose, some important details. The study included a mere 40 babies.  It's really a pilot study.  The dose of formula ended after a few days. Nor did it involve any bottles:

For the trial, Flaherman and her colleagues assigned half the babies a couple days of birth to receive two teaspoons of formula after each breast-feeding, via a syringe so as not to encourage “nipple confusion,” a condition in which a baby has trouble transitioning between breast and bottle. Mothers were instructed to discontinue the formula supplementation once their milk supply appeared, which generally takes two to five days. The other half were exclusively breast-fed unless the doctor ordered formula.  How Formula Could Increase Breast-Feeding Rates, Time Healthland

So feel free to shoot up your newborns with some formula, orally or otherwise. 

Now let's listen in to our fearless maternal and child health advocates...

Cue the cries of disbelief (from professionals who never challenge studies finding benefits of breastfeeding):

Tanya Lieberman, a lactation consultant who writes about scientific research for breast-feeding advocacy organization Best for Babes, says she’s “a little confused” by the results. “We know what works to increase breast-feeding exclusivity and duration and we’ve known it for 20 years. That includes no supplementation unless medically necessary.” How Formula Could Increase Breast-Feeding Rates, Time Healthland

Priceless. 

We know it. I know it. In my gut. 

Cue the outrage:

“This study goes against everything that’s been published for several years now from very reliable clinicians and researchers about the potential hazards of supplementing exclusively breast-feeding babies with formula,” says Dr. Kathleen Marinelli, an associate professor of pediatrics at the University of Connecticut School of Medicine and the chair-elect of the U.S. Breastfeeding Committee. “They’re flying in the face of years of research here and doing so rather glibly, stating that this is the new way to look at things.” How Formula Could Increase Breast-Feeding Rates, Time Healthland 

Reliable clinicians? Like her RN friend? The pediatrician down the street? The lactation support group? Goes against everything published!  Hhhmm, except the one randomized controlled study to directly test breastfeeding and small bits of formula. A researcher glibly glossing over empirical evidence (e.g., its limitations) to promote his or her own agenda. Now why does that sound so familiar? 

Cue the visions of nightmarish formula consumption by incompetent confused moms:

I worry that the headlines from this study will translate into 'A Six Pack of Formula Back In Every Bassinet!'" said Dr. Alison Stuebe*, an assistant professor in maternal fetal medicine at the University of North Carolina School of Medicine, who did not work on the research. Stuebe said the next step would be to replicate the findings, ideally using donor human milk, to see if they hold up. Could Formula Help Breastfeeding Moms? Huffington Post

Because donor human milk is so easy for most mothers to pick up at the CVS late night.

The study I'd like to see...whether supplemental formula beyond the first days of life helps women breastfeed for longer (not exclusively).  A bottle of formula a day helped me breastfeed longer. And did wonders for my mental health, you know, that little factor that eludes breastfeeding researchers except when they want to show lactating reduces the risk of postpartum depression.

*Breastfeeding researcher who routinely uncovers evidence of its health benefits (e.g., reduced risk of maternal diabetes) and who clearly states her mission to promote breastfeeding.