Will cry-it-out hurt your baby?

The Pediatric Insider

© 2013 Roy Benaroch, MD

Jess, like many parents, has been hearing conflicting information about what crying can do to your baby. She wrote: “So, my husband and I accidentally let our kiddo (5.5 months) cry it out. So of course, I’m spending all sorts of time on Google finding out that I’ve caused long-term damage to my son and he’ll be more likely to get ADHD and be dumber now that I’ve let him cry. I know the studies on cortisol show that some longer-term stress may be evident (at least for a few days), but are there any other real, scientific studies that show long-term damage due to cry it out? I’m pretty sure the other studies cited in the article above are irrelevant to this–am I right? I know you’ve written about cry it out before, but with all the hype, can you clarify?”

A friend of mine is working on a project called “Guilt Free Childbirth”, meant to dispel the guilt and hand-wringing that so many families seem to experience during and after childbirth. What if I need a c-section? What if I can’t do it “naturally”? What if I can’t “bond” instantly with my baby?

This cry-it-out worry—I think I could make an entirely new blog, “Guilt Free Parenting,” just to try to dispel this nonsense. Parents are so saturated with messages telling you that everything—I mean everything—we do is wrong, it’s a wonder we don’t all just curl up in a ball in the closet sucking our thumbs.

Wait, thumbsucking. That’s bad, too.

Anyway: the sky isn’t falling. We are not raising warped, worthless, sick, incompetent kids. There are always things parents could do better (including me!), but that doesn’t mean that if we don’t do everything “right”, our kids will suffer.

Back to cry-it-out: babies don’t always learn to sleep straight through the night on their own, and there are several competing “methods” to help nudge them towards independence. Some parents are very eager to help train, others take a more “easy-going” approach. How you tackle this depends on how parents feel about the importance of a good night’s sleep, and also on the temperament of the baby. I am not going to declare that any one method is perfect for everyone.

But if sleeping through the night is a priority, I have offered up one simple solution that works well for many families. Yes, there is crying. No, I don’t think there is any good evidence that shows any lasting ill effects from letting your baby cry some. There are certainly lots of web sites, pro and con, and lots of people with strong opinions—sometimes they’ll even comment in ALL CAPS for emphasis. But you are not damaging your child by letting tears fall without instant intervention.

Babies have been crying for many, many years. It is how they get our attention. If crying were so damaging, well, I don’t think any of us would have survived.

Jess included an example of reporting that stressed the damage done by cry-it-out sleep training, a list of 10 reasons it’s bad for babies. Most of the reasons were undocumented opinions from the author, who has clearly made up her mind on this issue. The references that were included are rife with methodologic issues—especially retrospective bias (of course parents with children who are thought of as problematic are going to report more sleep issues, in retrospect, when asked), or skim though the complex issue of cause-and-effect. That is, did the excessive crying cause the later problems, or are children who are temperamentally difficult more likely to resist sleep and more likely to later experience emotional problems? One thing may not cause the other, even if they are correlated.

Studies of levels of the cortisol rely on that hormone as a biomarker of stress, and cortisol does indeed increase with stress in humans and other animals. But is that bad? Didn’t human babies always have stress in their lives? Some studies point out that cortisol can change the way brains develop, or can perhaps contribute to the pruning of interconnections between neurons- but that is a normal process that occurs in the development of the human brain. Interfering with this process by avoiding undue “stress” may actually be harmful in the long run.

Or maybe not. I am not saying that babies need to cry to be healthy. Certainly I spent a lot of time holding and reassuring my babies (and even babies in my practice!) But these studies that some claim show cry-it-out = bad for babies, it’s a stretch. And it is not something that parents ought to be worrying about.

Though there aren’t a lot of great, long-term, clinical studies of the consequences of these different sleep approaches, one published last year was reassuring—a method that allowed more crying didn’t lead to scary consequences later.

Also: there are consequences to poor sleep, both for babies and for parents. Underslept babies are fussy and unhappy. Underslept parents are irritable and miserable, and may be more likely to get in car accidents, get divorced, or smack their child. It’s not unreasonable for parents to want to take an active role in pushing towards a good night’s sleep.

A great website with far more detail and insight into baby sleep issues is at www.troublesometots.com—including a detailed guide to one common-sense way to help babies learn to sleep better. Yes, there may be some crying. It’s OK.

Warning: The medication may cause… anything

The Pediatric Insider

© 2013 Roy Benaroch, MD

Have you listened to the ending of a TV or radio ad for a new medication? “Side effects may include palpitations, chest pain, stoppage of the heart, sneezing, itchy scalp, limping, emotional upset, tiredness, wakefulness, getting an 80s song stuck in your head ….. do these lists ever end?

Regulations require that pharmaceutical ads and promotional materials include the information in the approved “Product Insert”, or “PI.” That’s the big sheet of tiny type, folded up into a little wad, that you’ll find in a new box of medicine from the pharmacy. It traditionally starts with a chemical description of the medication (just to be sure that no one reads any further), followed by a summary of research studies, and ending with dosing guidelines. In there somewhere will be paragraphs of information about any potential side effects—lists of any symptoms that occurred more often with the new drug than with placebo.

These lists end up so long that they’re almost useless. One study showed that new drug labels, on average, include 70 listed side effects—and some drugs included over 500. How could anyone, patient or doctor, slog through a list of 500 “potential” side effects to determine if any of them are relevant or worth worrying about?

The PI, like many other warning labels, seems to be more a tool to protect against lawsuits than a way to convey useful information. It’s like those food labels—“Made in a facility that also processes peanuts and shellfish and eggs.” What does that mean? People don’t get allergic reactions from eating food that was near something they’re allergic to. Just tell me what’s in the product, not what was in the building.

We need clear information about common, significant side effects and any early warning signs of rare but serious side effects that mean the drug should be stopped immediately. For almost any medicine I can think of, this list ought to be one short paragraph. A list of 500 side effects isn’t anything anyone will ever be able to use. Information overload is de rigueur, but it doesn’t help anyone avoid real risks.

Adapted from a WebMD post I wrote in 2011

More reassurance for parents on vaccines and autism

The Pediatric Insider

© 2013 Roy Benaroch, MD

First, it was the MMR-autism link—that turned out to be a complete fabrication, a fraud invented by a single “researcher” who made up his data. He was taking money from plaintiff’s lawyers, and he was trying to patent his own, competing vaccine. Too bad for the scare and the resulting surge in measles.

Then, the mercury connection. A mercury-containing preservative, thimerosal, came under scrutiny. To be safe, it was removed from almost all vaccines in 1999—and rates of autism didn’t fall one bit.

The most recent vaccine-autism link can be abbreviated as the “too many too soon” hypothesis, that somehow the antigens in vaccines “overwhelm” the immune system, leading to mischief. It doesn’t matter that the quantity of antigens from the current generation of vaccines is far fewer than what was used in the past. Those needles have got to be doing some harm, right?

The “too many too soon” idea never made any sense, from a logical or scientific standpoint—it’s well deconstructed here. The “load” on the immune system from ordinary life, from the exposures we all have from living in a world full of bacteria and germs, is hugely greater than the comparatively tiny exposures from vaccines. But the true, hardcore anti-vaccine propagandists have found their latest idea, and as usual they don’t need no stinkin’ evidence.

Still, there is evidence. For the many families who have sincere questions about vaccine safety, it’s good to have yet another study to add the mountain of evidence that vaccines are safe, and that vaccines do not cause autism.

Published in The Journal of Pediatrics this month, this study compared children with autism (including several subtypes) to typically developing children. They combed records to determine just how many vaccines and how many vaccine components were given, to see if they could find a link. Could increasing vaccine exposures increase children’s risk of autism?

No. Increasing exposures to the antibody-stimulating products in vaccines during the first two years of life did not increase the risk of developing any autism spectrum disorder.

At this point, the evidence for the lack of any vaccine-autism link is overwhelming. Continued vaccine study for any sorts of side effects needs to continue, but the singular focus on vaccines as the cause of autism as voiced by some in the autism community has become a hindrance to genuine progress and a public health nightmare. Let’s keep our kids healthy. Make sure your kids are fully vaccinated, on time and by the established schedule. It’s time to put this vaccine-autism thing behind us, so we can speed up the progress towards better understanding, prevention, and treatment. I’d hope that’s something we could all agree on.

Introducing solids to baby: Which ones, and when?

The Pediatric Insider

© 2013 Roy Benaroch, MD

Anna posted: “I have a question about starting solids and grains. I am starting my 6 month old on solids. A friend recently told me that babies younger than 1 year cannot digest grains as they don’t have the necessary enzymes. Is there any truth to this? Also, one of the pediatricians in our practice told me we can start eating red meat- isn’t it too early?”

There’s been a big change in the thinking about solids over the last ten years or so. In the past, it had been recommended to delay certain foods—the ones thought to be the most likely allergens—until certain ages. The thinking was that this would somehow prevent allergies. You can still find these elaborate schedules on the internet: avocado at 33 weeks, egg whites at 34 ½ weeks, chopped venison au poivre at 36 weeks, all very specific, and all very strict. It turns out that was all nonsense, too.

A 2008 AAP statement threw all of those recommendations out of the window, pointing out that there was never any evidence that delayed introduction of any foods decreased allergy risk. In fact, evidence was accumulating from here and abroad that foods started earlier were LESS likely to become foods that children would become allergic to. Cultures with earlier consumption of peanut, for instance, had far less peanut allergies than places where peanuts were not part of an infant diet.

Now, the allergists have formally agreed, with their own recommendations from the American Academy of Allergy Asthma and Immunology (the AAAAI—how do they pronounce that?) Start complementary foods, any ones you’d like, at 4-6 months. That could include egg, peanut butter, fish, berries, you name it. There is no reason to delay certain foods—that’s quite unlikely to prevent allergy, and might well make allergy more likely.

Some further evidence-based guidelines about food allergies from the AAP and AAAAI: there is no reason for pregnant women to avoid any foods, unless they themselves are actually allergic. (There are foods to avoid for infection reasons, I’m only talking about allergy issues here). And breastfeeding prevents allergy, too.

Anna, whatever you’ve heard about babies lacking enzymes to digest grains, that’s just weird internet rumor. Babies do fine with ordinary grains like rice, oats, barley, and wheat (though they don’t need anything but breast or formula for the first 4-6 months of life.) And meat is fine to introduce at 4-6 months—in fact, in many countries, meat is a first weaning food, before cereal. It’s easy to digest and a good source of protein and iron.

So: these firm rules about exactly what and when to feed babies can be ignored. You do need to avoid choking hazards (no peanuts, no hot dogs for infants!), and you need to avoid raw unprocessed honey until 12 months to prevent botulism. Other than that, starting at 4-6 months, your baby can taste what you’d like her to taste. Yummy!

The perils of banning plastic grocery bags

The Pediatric Insider

© 2013 Roy Benaroch, MD

I’m one of us who tries to remember to use those cloth, reusable bags at the grocery. Really. There’s a bunch of them, sitting in the trunk of my car, just ready to be filled and re-filled with groceries. They usually just sit there, forgotten.

Apparently, they’re more active than I realized. They’re busy growing a whole host of nasty germs.

As reported in detail by Ramesh Ponnuru at Bloomberg.com, there may be an unexpected downside to using those cloth bags. Researchers have found that they’re often filled with bacteria from human and animal stool that can make you sick. Apparently, these sorts of bacteria can be transferred from fresh veggies and other food onto the bags, and they multiply like crazy in your warm trunk.

Mmmm. Colon bacteria.

It’s not just theoretical, either—some evidence has shown that those bags really could make you sick. Local ER visits for E coli infections, caused by one of those tasty stool bacteria, increased immediately after San Francisco’s plastic bag ban, as did salmonella-related illnesses.

There is some good news: the same researchers who documented that these bacteria were  common also found that ordinary washing could dramatically decrease bacterial colonization. Too bad only 3% of the families surveyed bothered to ever wash their bags. I know I don’t.

So: could the net effect of the discouragement or banning of plastic grocery bags be detrimental to our health? I would say the jury’s out. Too many variables to be sure. But clearly, as usual, there may be unintended consequences of legislation to ban these bags. We may end up sicker. Or, we might have to wash our cloth bags—which uses more water and electricity, offsetting the environmental advantage of reusable bags. This whole situation might encourage the use of more paper, recyclable bags, but they have their own, different environmental impact on trees and water and energy use.

I don’t think there’s a simple, best answer here. It makes sense to reduce the use of resources, to re-use plastic or paper or cloth bags when practical, and to recycle things that can be recycled. Beyond that, are cloth bags definitely, always better than plastic? Maybe not.

Cervical Cancer Awareness Month: Are you protecting your kids?

The Pediatric Insider

© 2013 Roy Benaroch, MD

January is cervical cancer awareness month—a time to remind people about this terrible disease, but also to highlight some huge advances in cervical cancer prevention, early detection, and treatment. And it is preventable. Almost all cases of cervical cancer are caused by a handful of types of HPV infection, most of which could be prevented by a combination of education about safe sex, and the use of a safe and effective vaccine.

HPV is by far the most common sexually transmitted infection in the world, affecting about 40% of young adults. Most people who’ve picked up HPV don’t know they have it, but they continue to spread it to other people. Sometimes, HPV infection can cause genital warts or cancer, including cervical cancer and other cancers that affect men and women both.

Please protect your kids by talking about sex, setting appropriate expectations, and making sure they get this vaccine.

More info:

Media Scaremongering

HPV vaccines for men

An HPV vaccine win!

CDC’s comprehensive HPV info page—here are answers to just about any question you can think of about HPV diseases, screening, prevention, detection, and treatment.

A simple, cheap way to promote child development in the developing world

The Pediatric Insider

© 2013 Roy Benaroch, MD

This was a simple study from November 2012, but it has a striking conclusion. Small, inexpensive steps can go a long way towards improving child development in the most impoverished nations.

Researchers in Pakistan in 2003 enrolled about 461 children in a study to determine the effects of hand washing and improved water hygiene, confirming then that giving families soap and promoting hand washing greatly reduced diarrheal illnesses in children. In this more-recent study, the same researchers looked at those same kids in 2009, and were able to show that the net effect of the hand washing intervention, several years later, was a strong and measurable improvement in the developmental skills of the children in the hand washing group. These children, compared to peers who were not offered free soap and hand washing instructions, had improved motor, cognitive, and social skills. The magnitude of the improvement was about the same as is seen in the USA when underprivileged children are enrolled in Head Start preschool programs.

Head Start is very expensive, though it’s still a good deal for children from at-risk situations. That third world countries might be able to get a similar magnitude of improvement with something as inexpensive and easy to distribute as soap is truly impressive. These kids could do very well—at a very low price, common sense interventions could dramatically improve their development, potentially leading to more productive and enjoyable adult lives. All it takes is a few good ideas, a few dollars, and the political and social will to help people improve their lives. That’s a bargain at any cost.

The AAP weighs in: Kilograms required

The Pediatric Insider

© 2013 Roy Benaroch, MD

Last week*, I wrote about a small study from Pakistan where researchers showed that a very cheap, easy intervention—handwashing—led to sustained, measurable, and significant improvements in the intellectual and motor abilities of third world children. Really, quite impressive. These scientists showed that it doesn’t take a huge wad of cash to make a big difference. Hopefully governments and NGOs will pay attention, to fund these kids of efforts that can make the most impact on the most vulnerable children.

It’s a funny contrast, haha, with today’s tidbit from the American Academy of Pediatrics (AAP): they’ve now endorsed an official statement, making it the declared policy of the AAP, that scales should only be programmed in kilograms, and weights should only be measured in kilograms, and electronic health records should only allow weights to be recorded in kilograms.

I’ll admit, my office still uses pounds and ounces. I know, metric measurements are internationally recognized and more sciency, but I’m more used to pounds, and my parents are more used to pounds, and my patients are used to pounds. If I’m talking about healthy weight with a patient, I don’t want to be fooling around translating what I say into numbers that make sense. Healthy weights are important. The units in which they’re measured? Not so much. We need to make sense to each other, and we ought to use whatever unit of weight communicates most clearly with our patients.

There’s got to be something more important for the AAP to be doing than hectoring pediatricians into buying scales that can’t measure pounds. Honestly, the cost of a new equipment could probably buy enough soap to improve the developmental outcomes of entire neighborhoods of children. AAP: let’s keep our eyes on children’s health instead of the type of scales we’re using, ‘k?

*EDIT: OK,  sorry about that. The post was that was going to run last week didn’t run… so this first paragraph really doesn’t make any sense.  I’ll post about the handwashing study tomorrow, so then this link will work. I know, I need an editor.

Dr Bob’s Alternative Vaccine Schedule? He made it up

The Pediatric Insider

© 2013 Roy Benaroch, MD

Thinking of buying a car? Talk to the people who know about cars. Look in those magazines that rate cars. Try, maybe, driving some different cars around for a while. Or asking people who’ve already purchased one: do you like it? Would you buy it again?

What you probably wouldn’t do is take advice from someone who readily admits that he made it up.

Today, Reddit did one of their “IamA” features, starring Dr. Bob Sears, author of “The Vaccine Book.” This is the guy who created his own “Alternative Vaccine Schedule”, different from the one supported by every genuine health authority in the world. He suggests that parents delay some vaccines, space them out differently, or skip some altogether. One might assume it’s because he has some kind of special insight, or tremendous knowledge, or maybe is just more clever than the rest of us.

Nah. In his own words, when asked about the evidence he relies on to support his alternative schedule, he says:

“There is very little to no evidence.”

This is the entire exchange from Reddit, starting with the question posed by “itsajelly”:

[–]itsajelly 6 points 1 hour ago*

Dr. Sears, what evidence do you have to support your alternative vaccine schedule? Do you think it’s possible it validates parents’ fears about vaccines rather than alleviates them?

[–]DrBobSears[S] 8 points 1 hour ago

There is very little to no evidence. I agree that it’s possible it can validate some parents’ fears, but those parents have probably already chosen to not vaccinate anyway. What I think it achieves MORE often is that it allows parents to go ahead and vaccinate, when they wouldn’t otherwise have done so because they won’t follow the AAP schedule. I think it increases vaccination rates. Anyone who is already naturally opposed to or in favor of vaccination probably is unaffected by my schedule.

[–]itsajelly 2 points 1 hour ago

Thank you for your candid response.

Dr. Sears readily admits he made it up. He goes on to explain that his odd delusions actually increase vaccination rates—as if fear-mongering and pandering actually helps. He could have written a book that rationally explains the evidence, and draws a logical conclusion. Instead, he chose to ignore science to sell more books.

Dr. Bob also claims that “Anyone who is already naturally opposed to or in favor of vaccination probably is unaffected by my schedule.” Tell that to the people catching preventable diseases from unvaccinated children.

The “Alternative Vaccine Schedule” is a sham. It’s been thoroughly deconstructed elsewhere—please see here or here if you really want to get into the nauseating details of how Dr. Bob twisted information, ignored science, and created a pagan idol for unnecessary worry. The man was candid, and I’ll give him props for that. Thanks for the honesty, Bob. In his own words, there is “very little to no” evidence that his schedule is safe or effective. It is, in fact, demonstrably less safe because it exposes children to an increased risk of disease. At the same time, there is no evidence (nor any reason to even speculate) that it is in any way safer than following the established schedule.

Be safe. Rely on science and the people who know what they’re talking about. Vaccinate your child, on schedule, on time.

Can a face mask prevent flu?

The Pediatric Insider

© 2013 Roy Benaroch, MD

We’re still swamped with flu at the office—this year is bad, bad, bad. I’ve recently written about preventing and treating influenza, and another detailed piece about exactly how flu is transmitted and how to protect yourself.

What about face masks? You see them on TV this time of year, and maybe you’ve seen them at your doctor’s office. Should flu patients wear masks? Should all of us?

There’s some evidence supporting the use of masks to prevent transmission of flu to healthy people. Studies have looked at both household and dormitory transmission of flu, and healthy people who routinely wear masks are less likely to contract flu, even when people sharing living quarters have influenza. The effect is largest when mask-wearing is combined with hand washing, vaccinations, and other steps to limit contagion.

As far as putting a mask on people who themselves have the flu: I could find no studies showing that this actually works. It does make sense to keep flu victims out of the workplace and away from other people, and perhaps putting a mask on them will also help. But it’s not clear that this will really make a difference.

Why would wearing a mask help prevent a healthy person from catching flu? A cough from a flu patient within three feet of your nose or eyes can transmit flu, so perhaps a mask could block that (there is no evidence that this is actually true.) More importantly, wearing a mask will remind you NOT to touch your nose or mouth. So even if you do get contaminated, infectious mucus on your hands, it won’t get you sick.

I’ve covered the best ways to prevent flu before: avoid sick people, wash your hands, don’t touch your face, and get immunized. Perhaps wearing a face mask can also help (I don’t recall these guys getting the flu!) Hopefully, this year’s flu season will burn out soon, and most of us will make it through OK. Next year, be sure to get that vaccine, OK?