Monday, September 26, 2011

What's on Tap, Mom?

The day J.J. was born, my loving husband prepared cosmopolitans to celebrate the birth of our first child as well as the fact that I wouldn't have to abstain from alcohol anymore.  (This was back when Sex and the City was big).  Having endured a 36-hour labor, followed by a C-section, I was in no shape to partake, but we still got dirty looks from our nurse as she eyed our vodka.  Honey, couldn't you have gone with the socially acceptable champagne bottle?

I knew from brief Internet searches that while there is "no safe amount" of alcohol to drink during pregnancy, the expert advice on drinking during breastfeeding ran the gamut.  Some lactation specialists actually recommend alcohol to relax the mother and infant, while others think even one drop is too much.  I'm no longer nursing, but let's see if I can find evidence to support my habits retroactively.

Let's put to rest one old wives' tale, that alcohol facilitates nursing.  Multiple studies have found that alcohol actually reduces milk production. In one trial, women who drank a screwdriver produced on average one less fluid ounce compared to when they drank OJ alone. ("The transfer of alcohol to human milk.") So why do some women think alcohol improves breastfeeding?  Well, when milk production goes down, infants suck for longer, creating the impression that they're eating more.  Another, similar study done by the same authors found that 78% of women who consumed alcoholic beer noticed fullness in their breasts after nursing, making them think that they were producing a lot of milk, and lending empirical evidence to the existence of beer goggles.  ("Beer, breastfeeding and folklore.") Finally, infants just like the taste of alcohol-flavored milk.  They will suck down bottles of it, compared to virgin milk. ("Infants suckling responses to the flavor of alcohol in mothers' milk.") So in effect, a nursing mom who drinks is producing Milker Lite -- tastes great, less filling!

Alcohol does enter breastmilk, at the same or higher concentration than in the mother's blood.  One study recruited nursing mothers to "drink as much alcohol as they could manage in the form they preferred in as short a time as possible."  ("Alcohol in breast milk.")  Let's hope their babies had a designated parent.  One enthusiastic mom enrolled in the study twice, getting legally drunk both times.  Based on the alcohol content in her milk, the investigator then estimated that her infant's blood alcohol level would be 0.006% -- meaning Baby could drive Mama home. 

What most moms want to know is whether this miniscule exposure will affect development.  And here the research is as muddled as a mint julep.  One observational study of 400 nursing women found that mothers who drank an average of one drink a day had children who scored slightly lower on a motor development scale at 12 months of age.  There were no differences in mental development.  ("Maternal alcohol use during breast-feeding....") A follow-up study of 915 women found that the more mothers drank, the higher their children scored in general intelligence, motor development and personal-social development at a year and a half.  ("Alcohol, breastfeeding, and development at 18 months.") It's pretty unlikely that alcohol is good for babies, so there are probably unmeasured factors that influenced the results of both studies.  The other flaw in these studies was that few women drank more than 2 drinks a day, so the effects of truly excessive drinking are unknown -- and would be hard to sort out from generally bad parenting.

Based on these iffy studies, the American Academy of Pediatrics, ever the party-poopers, state in their guidelines, "An occasional, celebratory (what, postpartum women can't wallow?), single, small alcoholic drink is acceptable (if you must), but breastfeeding should be avoided for 2 hours after the drink."  For the anally compulsive, a nomogram is available to tell you when it is safe to nurse after a night of carousing.*  ("Alcohol and breastfeeding: calculation of time to zero level in milk.") I have very helpfully reproduced it here, so you can tuck it into your little black bag before hitting the clubs:
According to this chart, any alcohol would have disappeared from my milk 2.36 hours after one drink.  Dang it, I could have downed 6 shots a day on my every 4 hour nursing schedule!

But I didn't.  So, please, those dirty looks are completely uncalled for.

*By the way, girls, no need to pump and dump.  Alcohol will diffuse out of your milk at the same rate as it does out of your blood.

Tuesday, September 20, 2011

Can the Idiot Box Make Your Baby Smarter?

Last week I wrote about a small study that looked at the effects of Spongebob on "executive function" in 4-year-olds.  While that was my most popular post to date -- apparently quite a few of you are fans of the phylum Porifera -- it barely tapped into the mountain of research on T.V. and kids. Today let's talk about whether Baby Einstein will, indeed, make your baby an Einstein.

The American Academy of Pediatrics recommends that children under the age of 2 not be exposed to any electronic screens, including T.V., computers and smartphones.  (As one reader asked, "Does that include Skype time with Grandma?"  There are probably no studies, but let's just stipulate that the AAP would allow that loophole.)  Practically speaking, there aren't too many 1-year-olds with the manual dexterity to play Angry Birds, so we'll stick to the studies on T.V. in the under-2 set.

First of all, do parents even follow the AAP guidelines?  One study, conducted five years after the recommendations were published, found that 18-month-olds watch an average of 2.2 hours of T.V. a day -- which means, of course that some really lazy parents let their toddlers watch 4 hours a day, to average out the TeleNazi parents who ban the boob tube altogether.  Of course, I'm not one to talk: my 18-month-old watches about an hour a day, more on weekends.

The amount of time babies watch T.V. has risen over the years, largely because there are now many programs developed specifically for the very young.  The blurb on my old copy of the immensely popular Baby Mozart DVD promises "countless hours of viewing and listening delight, coupled with meaningful learning....You can choose to expose your child to eight languages through the use of pictures, text and pronunciations by native tracks are designed to develop vocabulary and reading skills."  The suggested viewing age?  1 to 36 months.

Then a 2007 study blew the creators' claims out of the water.  ("Associations between media viewing and language development in children under age 2 years.") It was a telephone survey of over a thousand parents of children ages 2 to 24 months, exploring possible associations between parental interaction, the type and amount of television exposure, and language development.  First, the good news:  daily reading resulted in a 3- to 4-word increase in vocabulary in 8- to 16-month-olds.  But if your baby watched either Baby Einstein or its chief competitor, Brainy Baby, he or she suffered an average 7- to 8-word decrease in vocabulary for every hour of video watched.  The study drew first blood, the lawyers started circling, and Disney offered a full refund to Baby Einstein customers.

So how might T.V. retard language acquisition in babies?  One theory is that babies simply don't learn concepts as well from video as they can from an equivalent live experience.  This "video deficit" has been verified in several laboratory studies.  Though this might explain why a video might not be educational, it doesn't explain the "dumbing down" effect.  Another possibility is that exposure to T.V. reduces parental interaction, which is highly correlated with language acquisition, as well as playing with toys, which also promotes learning.  And finally, remember that association doesn't prove causation.  Parents who spend less time with their babies, for whatever reason, may simply have the T.V. on all the time.

Of course, that one study didn't prove that all T.V. is bad for babies.  One better designed, prospective study had 51 families keep a log of what their 6- to 30-month-old children were watching.  ("Infants' and toddlers' television viewing and language outcomes.")  The investigators then tested the children's language skills every 3 to 6 months.  It turns out that what the toddlers watched was every bit as important as how much they watched.  Babies who watched Blue's Clues and Dora the Explorer had a significant increase of 13 words above the average at 30 months, followed closely by those who watched Arthur and Clifford.  On the other hand, Barney and Teletubbies were negative influences, with about 10 fewer words.  Confirming what most parents have suspected all along: that being forced to listen to the cultish refrains of "I love you, you love me" destroys brain cells.  Intriguingly, Sesame Street did not seem affect vocabulary acquisition in toddlers, despite its well-documented benefits in older kids.
So the AAP's recommendation of absolutely no screen time for those under 2 is probably overreaching.  Even in the case of Baby Einstein, the saga isn't over.  The creators of the videos just won a settlement against the University of Washington, when they discovered that their 2007 study debunking their videos had a number of flaws.  For one thing, the investigators changed their outcomes midway through their study, a practice known as data dredging (essentially they were casting a wide net and seeing what turned up "statistically significant").  For another, by the time the children were 17- to 24-months, all the vocabulary deficits had disappeared.

Even though the jury is still out, it is pretty unlikely that these baby DVDs will turn my JoJo a genius.  So do I plan on getting a refund from Disney?  Not on your life.  Just because something isn't evidence-based doesn't mean I won't use it.  As un-educational as they may be, these DVDs sure are good babysitters, and let's face it, sometimes Mommy just needs a break.

Monday, September 12, 2011

Who Lives in a Pineapple Under the Sea?

If you know the answer to that question, welcome to my world.  I was planning to blog about something "serious" today, but an article in my morning paper caught my eye: "SpongeBob in hot water from study of 4-year-olds."  A randomized, controlled trial on SpongeBob SquarePants?  How could I resist?  I found the study easily.  It was a free "early online release" from the venerable Pediatrics journal.  ("The immediate impact of different types of television on young children's executive function.")  Early release articles are typically trials that post such impressive results that they have to be published online immediately, to save as many lives as possible.  I guess the editors of Pediatrics felt that they had to put a grinding halt to the zombification of American 4-year-olds.

The researchers randomized sixty 4-year-olds to 9 minutes of SpongeBob, Caillou (the most boring educational cartoon ever produced; the only reason to watch is to learn how to pronounce "Caillou") or drawing.  They then had them take four different tests of "executive function," a fancy term for "more complicated decision-making."  One of these tests, for example, was the classic delay-of-gratification task, in which the child is told he could either have 2 marshmallows immediately, or 10 marshmallows in about 5 minutes.  The child is timed, and the longer he can hold off, the better he is at delaying gratification.  

SpongeBob was classified as being fast-paced, compared to the pokey pace of Caillou:  the scenes in SpongeBob shift every 11 seconds, compared to every 34 seconds in Caillou. The investigators hypothesized that watching a fast-paced cartoon would negatively affect the subjects' attention spans, and thus their executive functions, and they were right.  Here are how the three groups performed on their tests:*
Predictably, a spokesman from Nickolodeon skewered the study, saying "Having 60 non-diverse 9 minutes of programming is questionable methodology and could not possibly provide the basis for any valid findings that parents could trust."  Hey, Nickolodeon, I'm sure you can always find some helpful legal advice from the folks at Phillip Morris!  Actually, I do think he has a point.  The study was small and only partially blinded, and the results may not pertain to older kids.  None of the subjects were tested before the videos to see what their baseline attention spans were.  Finally, the tests were performed immediately after the videos were shown, so even if the results are true, who knows if the negative effects are long-lasting?

The lead author did make a point which gave me pause: "I wouldn't advise watching such shows on the way to school or any time they're expected to pay attention or learn."  My kids watch not 9, but 30 minutes of SpongeBob every weekday -- before they leave for school.  Maybe I'll do their teachers a favor and detox them on Caillou

*HTKS, by the way, refers to "Head Toes Knees Shoulders."  I thought at first that they were making the kids run through the popular "Head, Shoulder, Knees and Toes" song, but no.  Instead, kids were asked to touch their head when the instructor told them to touch their toes, and vice-versa, with increasingly confusing variations.  I'm pretty sure my scores would have been unplottably low, SpongeBob exposure or not.

Thursday, September 8, 2011

Doctor My Eyes

 Patient Zero

I meant to post an entry earlier this week but was waylaid by a nasty viral infection.  Though infection is an occupational hazard of working in the hospital, I'm much more likely to pick up something from my 1-year-old, who in turn picks it up from his daycare, Little Lovin' Petri Dish.

JoJo started coughing and running a fever several days ago, followed by copious oozing from his eyes and nose, finishing up with the dreaded pink eye.  Unlike fever, which you can mask for 6-8 hours with Tylenol and ibuprofen, there is no easy way to hide a pink eye from your daycare provider. (For those of you who question my morals and judgment, I admit that the blog name "Bad Mommy" was already taken.)  So Joseph was banished to his home, where he ended up infecting three other members of his family instead of the tykes at LLPD, who probably gave it to him in the first place.

By day five, he was already starting to improve, but my husband brought him to the doctor just to get a note okaying his return to daycare.  He returned with a note, as well as some antibiotic eye drops.  I took the note and tossed the bottle.  DO NOT DO AS I DID. ALWAYS TELL YOUR DOCTOR WHEN YOU ARE PLANNING TO DISOBEY HIS OR HER  ORDERS.*  But I have my evidence-based reasons, and here they are.

Pink eye, or infective conjunctivitis, is caused by viruses about half the time, and bacteria the other half.  So automatically you know that antibiotic drops are not going to work in half of patients with conjunctivitis.  Unfortunately, it's often hard to distinguish between bacterial or viral causes.  There are some clues in the history and exam, but they're not that reliable.  You could also swab the eyeball, which is as fun as it sounds, but those results can take days to come back.  So most pediatricians just end up prescribing the drops to anxious parents.  (You read that right; none of the kids are asking for drops.)

There have been five good randomized, placebo-controlled trials of antibiotics drops for pink eye.  In the largest one ("Chloramphenicol treatment for acute infective conjunctivitis in children in primary care: a randomised** double-blind placebo-controlled trial."), 326 children in the UK underwent eyeball swabs, and then were randomized to antibiotic drops or borax water.  That's right -- half the kids had to endure an eye poke with a Q-tip, followed by dishwashing detergent.  (The harmless, low- concentration borax was added to make the water resemble the active drug.)  At the end of a week, there was no difference in the cure rates between the two groups.  Even in the subset of patients with confirmed bacterial conjunctivitis, 85% of those on antibiotics were symptom-free at 1 week, compared to 80% on placebo -- a nonsignificant difference.  The researchers did, however, find a difference in the duration of illness.  Those on antibiotic drops cut short their illness by half a day.  Other studies on bacterial conjunctivitis have shown similar results, with antibiotics shortening the duration of illness, with minimal effects on actual cure.

So is a 12-hour reduction in symptoms worth it?  Topical antibiotics aren't particularly toxic or expensive.  An additional benefit is that antibiotics do clear bacteria faster (as proven by repeated eyeball swabs -- these kids have done their duty for science), theoretically reducing infectivity and getting them back to school or daycare faster.  But of course, there are still the downsides of increasing antibiotic resistance and uncommon but potentially serious drug reactions.

In my case, I opted not to treat JoJo because I was convinced he had a virus (you don't typically get fever, cough or runny nose with a bacterial conjunctivitis), and he was already improving.  If your kid comes down with pink eye, though, you really should consult with your pediatrician.***  In some severe cases, or in newborns, treatment is mandatory to preserve vision.  But if your doctor hands you a prescription for antibiotic drops, make sure to ask him or her, "Do we really need to use this?"

*My lawyer friends made me write this.  Also, it's not nice to lie to your doctor.
**I did not misspell 'randomised.' The entire country of England does.
***See above.* 

Thursday, September 1, 2011

Protect the Girls -- Vaccinate the Boys!

 Mommy, why are we looking at hats for Siamese twins?

That's a photo of my then-5-year-old son J.J., shrinking in terror when I dragged him into Victoria's Secret.  Poor guy -- there's surely nothing more mortifying than bra shopping with your mom (unless it's bra shopping with your grandma). I do realize that one day, hopefully far in the future, my innocent little boy will have a very different reaction to all those scantily clad plastic torsos.  And when he reaches that age, it will be my husband's and my solemn responsibility to guide and protect him against STDs.  So naturally we'll be enrolling him in an abstinence-only sex ed program.*

Kidding, folks!  Remember, I'm Evidence-Based Mommy, not Delusional Mommy.

Last week, I reviewed the data on the HPV vaccine for girls.  In addition to cervical cancer and genital warts, HPV causes the vast majority of penile and anal cancers, although these are much rarer.  Gardasil has been FDA-approved for use in males ages 9 through 26.  So what is the evidence that it works in this population?  And now that J.J. is on the cusp of turning 9, should I be asking his pediatrician for this series of expensive shots?

As with the HPV vaccine trials in women, there are no large studies in preteens, but again, the idea behind immunizing children is to protect them before they are potentially exposed to the virus in their teens or young adulthood.  The largest trial randomized over 4000 males ages 16 to 26 to the 4-strain HPV vaccine vs. placebo.  ("Efficacy of quadrivalent HPV vaccine against HPV infection and disease in males.")  The marketing geniuses at Merck couldn't come up with a snappy acronym this time, but I liked my Scrabble-savvy friend's suggestion of SPAWN, for Stop Penectomies** and Anal Warts Now.  Six hundred of the participants reported having sex with men, a major risk factor for HPV infection.

As in the female trials, the vaccine was quite effective in patients who were uninfected at baseline, with an 84% reduction in genital lesions (mostly warts) in those who received all three shots.  The benefit in the population as a whole was significantly less, but still a decent 60% reduction.  Three precancerous penile lesions occurred in the placebo group and none in the vaccine group, but SPAWN wasn't large enough, or of sufficient duration, to detect a difference in these rare neoplasms.

Despite the clear benefit in reducing genital warts, the most frequent and more politically palatable argument for immunizing boys is to protect girls against cervical cancer.***  So should the HPV vaccine be mandatory in boys?  As much as I feel that males should shoulder some of the moral responsibility for their partners' health, in this case, I have to say no.  One of the reasons I've come to this conclusion is that cost-effectiveness analyses have shown that immunizing boys in addition to girls is extremely expensive, compared to immunizing only girls.  The excess cost ranges between $100,000 to a million dollars per year of life gained.****

Having said that, I do plan to sacrifice my eldest son on the altar of public health when his time comes.  Unfortunately for my human pincushion kids, I'm an allopathic doctor who is unabashedly pro-immunization.  Some day they'll thank me for it.

*Evidence has shown that abstinence-only programs are useless in delaying sex.  This is not to be confused with the seemingly oxymoronic abstinence-only parenting.  Telling your child, "Like hell you'll be crashing at your boyfriend's tonight!" has been shown to delay sex.
**A penectomy is an amputation of the penis, standard treatment for penile cancer.  If men were made aware of this, we would have no problem achieving 100% vaccination rates.
***For my gay readers, I apologize for this obviously hetero viewpoint.  There is a much more compelling argument to vaccinate gay males, as the incidence of anal cancer is similar to that of cervical cancer before the era of Pap smears.  The problem with vaccinating only gay males is that by the time a teenager or young adult is comfortable enough to come out of the closet, he may already be infected with HPV.
****Technically speaking, "quality-adjusted life-years" gained.  Since the most frequent manifestation of HPV infection are genital warts, and since warts don't kill you, researchers ask participants to estimate how many years of life they would be willing to give up not to have warts. One study found that having warts was as bad as losing anywhere from 1.6 to 8.3 days of life. ("Cost of treatment and QALYs lost due to genital warts.")  Hard to believe, but I guess I could see how it could get to be over a week if the warts made their cameo on, say, prom night.