Good Enough Mum

It's April, so...

...according to the somewhat optimistic promise on the button that you may have noticed on the left of my blog, I am now supposedly blogging for autism awareness. 

You may also have noticed that I don't, so far, appear to have been living up to this promise.  This is not for lack of trying, but, as usual, for lack of spare time - I have spent the month so far trying to work on this post while feeling that blogging for autism awareness is something I might be able to see my way clear to finding a few minutes to do some time around, oh, say, September.  Of 2009.  Possibly.  But there is currently at least some of April left, so here is my first stab at a Blogging For Autism Awareness post.

If someone with a handy crystal ball had told me, a few months back, that I would be Blogging For Autism Awareness This April, I would probably have been fairly surprised.  I do not mean that in the "I never expected to find myself dealing with the world of autism" sense (that, I'd completely expected) - I mean that I would have been surprised at the idea that I'd think blogging for awareness was something to which I could productively contribute.  People already are aware of autism - everybody's heard of it, haven't they?  I wouldn't have had any particular inspiration as to what I should say to increase this awareness.  "Hey, everyone!  Did you know that some people are autistic?" doesn't really seem like a promising beginning to pad out to blog-post length.

After all, everybody knows the important stuff about autism.  Right?  We've all read the newspaper articles and the magazine stories and the heart-wrenching True Life stuff about Our Autism Nightmare or My Child's Terrible Affliction.  So we all know about autism.  Don't we?  Helpless, hopeless, a life-destroying disaster that renders a child incapable of enjoying life or doing any of the things normal people do, unaware of what's going on around him, and, barring miracles, devoid of hope for any sort of future.

In other words, the general public thinks about autism in pretty much the same way as it used to think about physical disability.  A few decades ago, that last sentence would have exactly described the kinds of attitudes a child in a wheelchair would have to face.  People talked about them as though they weren't there, assumed they were incapable of learning, working, or contributing usefully to society, and wrung their hands over the tragedy of it all.  Disabled people tried to point out that they'd actually vastly prefer it if everybody else shut up with the pity and the stupid assumptions and got on with something useful, like building ramps, but unfortunately nobody really seemed to want to listen.  Which, of course, is still the case to a depressing degree.  But, in general, society's attitude towards the physically disabled has improved a hell of a lot over the last several decades.  There's still a long, long way to go.  But if you heard someone today describing children in wheelchairs by gushing about what a tragedy it was, how awful it must be for them to have such hopeless lives, and how awful it must be for their families to have to bear such a burden, then you'd probably recognise that they were being both ignorant and offensive.

When it comes to the autistic, however, we think absolutely nothing of talking that way about them.  It's standard phraseology for any story about autism.  How often does it ever occur to any of us that we might be just as wrong - and causing just as much offense - as we would be if we talked about other forms of disability in that way?

Over the past few months, I've been reading a lot about autism, browsing through weblinks.  At first I was just trying to brush up on my knowledge of diagnosis and current treatment approaches, and the stuff I found when I Googled was pretty standard stuff along those lines - DSM criteria, early signs to look for, applied behavioural analysis therapy, biomeds, yadda yadda yadda.  And then, gradually, I found more and more links to webpages and essays that challenged a lot of the traditional views about autism and its treatment.  Quite a bit of the stuff I was reading was from autistic people themselves - the very people that we've always thought to be incapable of communicating.  They're voicing their opinions, loud and clear, on just what they think of society's attitudes.  It makes fascinating, thought-provoking, challenging, uncomfortable reading.  Turns out we've assumed a whole lot of stuff about autistic people that's wrong.

We've assumed that, because autistic people have a hard time speaking and often can't learn to speak at all, that this must mean that they can't communicate.  In fact, lots of them can learn how to communicate fluently in other ways - just as a deaf or paralysed person might find it easier to use communication tools other than speech, so can autistic people.  Many can type far more articulately than they can talk.  Others might benefit from using picture card systems.

We've assumed that, because autistic people don't seem to react to their surroundings, this must mean that they're not aware of them.  In fact, it seems the lack of reaction is more likely to be due to lack of processing/reacting skills than to lack of awareness - just as a totally paralysed person can hear everything you say despite not being able to respond to it, so too can even a severely autistic person.  (And... you know all those times people talk about what an awful burden it is to have an autistic child or how autism is some kind of terrible living death?  Yup.  If you're talking that way in front of an autistic person, or writing that stuff in a newspaper that they can read, or putting it on a television programme where they can see it, then that person is probably listening and understanding.  And is probably just as hurt and offended by having their life described in such a way as a non-autistic person would be.)

We've assumed that, because a life looks different from ours, it must not be worth living.  We've assumed that autism is a terrible affliction and that the only hope for people thus afflicted is for us to come up with A Cure, something that will get rid of that awful autism and let the person be just like everybody else.  In fact, it seems that most autistic people don't want that at all.  What they want is to have practical help with dealing with the ways their disability impacts on their lives, help that starts from the point of what they actually need rather than from an assumption that the most important thing is for them to look as normal as possible.  To be allowed to be different, as long as those differences do not harm others.  To have their opinions listened to.

As I read more and more on those subjects, I was amazed and excited and saddened.  Amazed by how little I'd really known about autism, after a lifetime of interest in the subject.  Excited by all that I was learning.  And saddened that these issues aren't far more widely known about.  The growing popularity of computers and the Internet mean that autistic people have more chance than ever before to let people know how they really feel about the way that autism is portrayed in society and about the treatment (in both senses of the word) that autistic people get.  But very few people know that these things are even issues.  In fact, the impression I've been getting is that a lot of people aren't even interested in hearing more when autistic people try to tell them.  People don't want to listen.  But we need to.  Otherwise, autistics will continue to be short-changed.

So that's why I'm blogging for autism awareness this April.

Naturally, I dissent

I had both my babies by what you might call natural childbirth.  I don't in fact call it that, partly because the term makes it sound as though the naturalness was somehow the goal in and of itself in some sort of Luddite repudiation of technology, and partly because it's yet another example of how overused and meaningless the word 'natural' is.  After all, porcelain tubs filled with hot water are no more likely to grow in the natural setting than epidurals are, but I certainly found a soak in the bath of vital importance to handling the pain in my first labour.  However, I had unassisted low-tech vaginal deliveries for both, pretty much unmedicated (I had two Paracetamol when in labour with Jamie, and a very brief go on the gas and air with Katie, but no Pethidine or epidurals).

This is, apparently, highly objectionable to Dr Crippen.  Part of this, it appears, is because he has much the same semantic objections as I do to the term itself.  Much of it, however, seems to be because he thinks, incorrectly, that natural birth is another term for homebirth.  Dr Crippen is against homebirth, which he believes to be unacceptably dangerous.  The only evidence I've seen him offer to back up this viewpoint is of the Scary Isolated Anecdote variety so beloved by, say, anti-vaccine scaremongerers, but I only read a relatively small proportion of his posts and for all I know I may at some point have missed a more rational discussion of the relative risks of homebirth and hospital birth involving the citing of some actual evidence.  However, it's a moot point, since he's wrong in thinking that natural childbirth automatically means homebirth.  It's a term generally used to refer to birth without intervention or medication, which (theoretically at least) is perfectly possible to do even in the most high-tech of hospitals.

Would Dr Crippen object to a woman having natural childbirth in a hospital?  I doubt it, but it's hard to be sure - some of his criticisms don't seem to have anything to do with the place of birth:

"Right on, trendy “natural” child birth is about jumping into the birthing pool with husb... sorry, “life partner” [Goodness.  And here was me thinking that the days when doctors could make snide comments about pregnant women not being married went out circa 1960], the vicar and the independent madwife, singing ten green bottles whilst the baby struggles to get out and then eating the placenta with a rocket salad."

All of which, of course, a woman could do perfectly well in hospital.  So what's the problem?  Well, his objection to those various potential methods by which a woman might make herself feel comfortable during labour or circumvent the lack of decent hospital food after it's over (placenta-eating isn't an idea I fancy in the slightest, but, thinking back to the quality of the only available meal on the ward the evening I'd given birth to Katie and was starving for some protein after a day of eating nothing but easily-digestible carbohydrates, I can see how it might have its attractions) is apparently that the perinatal and maternal mortality rates are unacceptable.  He does not provide any statistics or details on the impact that any of the things he listed have on intrapartum mortality, but I await with interest his presentation of the randomised controlled trials studying the mortality rates of "Ten Green Bottles" renditions.

I did not, as it happens, have any of the above in either of my births, although the lack of the birthing pool in the second certainly wasn't by my choice.  (In my first labour I used the bath instead, which worked perfectly well; whether or not that would call forth similar levels of derision from Dr Crippen, I don't know.)  For me, natural childbirth - or whatever term you can come up with that describes the choices I made concerning my children's births - wasn't about what I wanted to do during the birth, but what I wanted to avoid. 

I did not want, for example, to have major abdominal surgery on the day when a new helpless person requiring a lot of care and a lot of heavy lifting joined my family.  I did not want cuts made in my genitals.  I did not want my children's first experience of life to be the application to their heads of a suction machine vigorous enough to cause major bruising. If, of course, I found myself in a situation where the consequences of not having one of those interventions were likely to be worse than the consequences of having them, then so be it.  However, I wanted to reduce the chances as much as I could.  From my reading, there seemed to be good reason to think that the stronger forms of analgesia might increase my risk of getting one or other of those interventions, as well as having various other potential and unpleasant side effects.  So I found out as much as I could about alternative ways of dealing with labour pains, and decided to see whether I could get by on those ways if possible.  Which, as it turned out, I could.

You can't get side-effects from a drug you haven't taken or complications from an operation you haven't had.  That's why I wanted to keep intervention to a minimum.  I'd have had any intervention for which there was a genuinely good reason; but I was also aware of how often "This is just the way we do things" is considered a good enough reason on hospital wards, and I didn't consider it a good reason.  So, call it natural childbirth if you like - it's what the term means, after all - or call it by a better name if you have one.  But those were the choices I made about my labours; and those are the reasons why I made them.

Puréed dogma

The latest absolute and utter no-no for parents (or maybe not the latest - I am, as usual, some weeks months late with getting round to commenting on this, and in the parenting world that's plenty of time for some totally new thou-shalt-not to have emerged) is, apparently, feeding babies puréed food.  I kid you not.

A post from Emily (whose blog has first been abandoned and then hacked, so I've had to take out the direct link) alerted me to this article by Gill Rapley and the BBC on the subject.  I phrase the latter part of that sentence in the way I do because I have learnt never to underestimate the ability of the media to mangle anything anybody has to say on any subject ever, and it is thus quite possible that whatever Rapley originally said was a lot more reasonable and the scary spin on it is courtesy of the BBC.  However, regardless of where, precisely, the blame lies, Rapley and the BBC between them seem to have come up with an article likely to strike fear into the hearts of any parents who've ever dared smush a fork into their babies' food.

Having kicked off with that meaningless old standby of a criticism, 'unnatural' (in what sense?  In the sense that spoons and forks don't grow on trees in the rainforests?), the article continues thusly:

'Spoon-feeding babies pureed food is unnatural and unnecessary, a childcare expert has warned.  Gill Rapley, deputy director of Unicef's UK Baby Friendly Initiative said feeding babies in this way could cause health problems later in life.  ...She said: "In 2002 the World Health Organisation backed research that found breast or formula milk provided all the nutrition a baby needs up to the age of six months.  That research said feeding a baby any other food during the first six months would dilute the nutritional value of the milk and might even be harmful to the baby's health." '

Since this lacks in specificity what it provides in alarmism, I'll now attempt a look at the actual facts behind all this gloom and doom.  What, exactly, has research shown about the effects of starting solids before six months?

The first question to clarify here is: How far before six months?  There are excellent reasons why we've moved away from the old practice of trying to get babies to eat solids in the first few weeks (very small babies lack either the co-ordination to chew and swallow anything that isn't liquid or the digestive enzymes to deal with it if it does make it down to their gut), but these have been well accepted for a long time, and, prior to all this new fanfare about waiting till six months, four months had been the advised age for as long as I can remember.  (And, thanks to my odd and eccentric childhood spent indulging my passion for reading childcare books, 'as long as I can remember' goes back a fair few decades.  I definitely remember reading the wait-until-four-months advice from Penelope Leach in the early 80s - granted, it was probably avant-garde then, but I think it's well established now.)  All the books that haven't caught up with the six month advice say to wait at least until four months.  The instructions on all the commercial baby food jars say from four months onwards.  I don't think the burning question here is whether we should be waiting till six months as opposed to giving babies solids in their first few weeks.  It's how waiting until six months to start solids compares to starting between four and six months.

This is not, by the way, to say that I believe all parents were faithfully following the wait-until-four-months advice; I have no doubt that there are going to be a few parents around ignoring everything any expert has to say and spooning purées into babies far younger than four months in accordance with that good ol' traditional parenting principle of "My Mother Did It This Way And We All Turned Out Just Fine".  However, I suspect that those are precisely the parents who aren't bothered by this sort of article because they really couldn't care less about anything Gill Rapley or the BBC have to say on the subject.  The parents who are affected by articles like these are the parents who are trying to follow the expert advice and do what they believe to be the right thing for their babies, and who are caught off-guard whenever the advice changes.  So, for any parents who followed the old advice about four months and are now left worrying about what dreadful unspecified harm they've done to their babies through not waiting those crucial extra two months, here's a discussion of the available research.

(This is where I start getting all technical and wordy and going on and on about studies and statistics and analyses.  Sorry.  I'll try to keep it as straightforward as possible - feel free to yell loudly at me if I don't.)

The available research consists of a number of studies which have compared breastfed babies who first received solids and/or formula supplements at four months with babies who were kept on breastmilk alone until six months.  The first thing to note here is an important difference between this focus and the thrust of the comments in the BBC article.  While Rapley's comments seem to imply that the problems are specifically with starting solids and that they apply to both breastfed and formula-fed babies, all the research so far is in babies who were previously fully breastfed.  There is no research that I've ever seen that compares the effects of starting solids at four months versus starting at six months in babies who are already getting formula as well as/instead of breastmilk.  And although the standard advice has worked on the assumption that the results from the studies of exclusively breastfed babies can be applied to formula-fed or mixed-fed babies, this simply isn't a valid assumption. 

Ideally, of course, all babies would be exclusively breastfed for at least the first few months.  However, given that this is very far from the current situation and that most babies are already getting at least some formula regularly by the age of four months, how applicable is the available research to the majority of babies whose parents are going to be reading this article?  The answer is, of course, that we don't know.  We don't know whether the research can be applied to mixed-fed or formula-fed babies at all.  While the general comments I made above about not starting solids in the first few months will still apply, what we don't know is whether there are any added disadvantages for these babies in starting solids a bit earlier than that magic six-month mark.

But, with regard to babies who are exclusively breastfed, what does the evidence show? 

The studies to date have explored a variety of outcomes - various growth measures, likelihood of anaemia, and incidence of various symptoms of infection.  Most of them found no differences between the two ages in terms of effects on the babies.  This is actually an important and useful finding, since it means we can now dispense with the opposite problem - parents being told (as they were up until the updated advice came out) that they have to start solids at four months because babies need the extra food to grow.  We now know that that isn't true.  Babies will grow perfectly well on nothing but breastmilk for the first six months - or formula, if exclusive breastmilk isn't an option for whatever reason - and starting solids early gives babies no extra advantages in terms of growth.  Which is knowledge that can potentially save parents a large amount of trouble.  (One factor that tends to get overlooked in all the hoo-ha about unspecified but dire adverse effects on health from starting solids too early is that there are practical advantages in what is now known as baby-led weaning.  Trying to spoon purée into a propped-up four-month-old, and then clear up afterwards, is a pain, and those carrot stains are the very devil to get out of baby clothes.  Waiting until your baby is old enough to sit up, grab pieces of food, and stuff them into his own mouth, and then giving him a few pieces of stuff cut to an appropriate size that he can practice eating for himself, strikes me as likely to be a whole lot easier; and the reports I've heard from people who've tried this method seem to bear this out.)

However, although it's very nice to know that we can now wait until six months if we want to, that in itself doesn't add up to this message about how we must wait until six months or we'll be Harming Our Babies.  So, let's look further.  What studies have actually shown differences in outcomes for babies who wait until six months as opposed to babies who start something other than breastmilk at four months?  So far, there seem to be three. 

Two of these studies, carried out in the Honduras, found that babies kept exclusively on breastmilk for six months crawled a few weeks earlier than babies in whom purées were introduced at four months.  Whether this adds up to a blind bit of difference in terms of long-term development is unknown and debatable, but I suppose it might be nice for the sort of mother who likes boasting about her children's achievements.  For the most part, these studies didn't find any other differences between the two groups. 

I say 'for the most part' because one of those studies did find that the group who started solids at four months were found to have higher haemoglobin levels and iron stores, on average, than the group who were kept on exclusive breastmilk until six months.  However, although I mention this for the sake of completeness, it turns out that this doesn't detract from the wait-until-six-months advice - further research shows that iron supplements from four months are actually a better way of dealing with this problem than iron-fortified purées, probably because babies this young can digest supplements more easily than purées.  It's also worth noting that this study was done in the Honduras, in an area where nutrition was poor and the mothers were more likely to have iron deficiency before the birth of their babies, resulting in lower iron stores for the babies at the time they were born; this risk may not apply at all to babies born to well-nourished women in the First World.  In fact, there is some evidence that the reverse may be true.  Plus, the actual differences found were not great enough to result in a greater proportion of babies actually becoming anaemic, and didn't seem to be a particular problem for babies who were normal weight at birth.  All things considered, this research probably isn't even an issue for First World babies except in fairly rare cases; if you have a four-month-old baby who has been exclusively breastfed so far, for heaven's sake don't start assuming you need to rush for the iron supplements, let alone the purées.  Once again, most babies seem to be fine on breastmilk until six months, iron levels and all.

Of course, this also means that four months and six months are still coming out neck and neck as far as age of starting solids goes.  What else does the research show?

The tie-breaker (ding ding ding! We have a winner!) is a study published in early 2006, which compared rates of pneumonia and ear infections in babies who were fully breastfed until six months and babies who were fully breastfed until four months and then started some formula, solids, or both on a regular basis.  (Babies who got nothing but breastmilk on a daily basis were counted as fully breastfed even if they'd had occasional formula supplements in the past - a sensible point that probably makes the study more widely applicable.)

The study found a difference in reported rates of pneumonia between the two groups of babies.  (That may need a mite of clarification.  Data on feeding methods and disease rates were obtained from the results of a national survey, the NHANES questionnaire - I haven't been able to find a copy of the questions asked, so I don't know how strictly 'pneumonia' was defined, and thus can't rule out the possibility that it may cover a lot of what, strictly speaking, would have been better described as nasty chesty colds.)  Also, although there was no difference between overall rates of ear infections, the babies who started formula or solids at four months were more likely to suffer from frequent ear infections (more than three).

What were the actual numbers involved, in terms of increased chance of getting pneumonia for a baby who'd started something other than breastmilk at four months rather than waiting till six months?  According to the numbers in the abstract the extra risk was around 1 in 20, but this is actually a bit misleading since these were the unadjusted figures.  (Results from a study like this can be affected by what are called confounding factors - for example, it may be that smokers are more likely to use formula rather than breastfeed and that their babies are more likely to develop chest problems because of the smoking, or that women with babies in day care are less able to keep breastfeeding and that their babies are more likely to catch infections due to being in day care.  Factors like these can obviously affect the results by showing an association between earlier weaning and adverse outcomes that's actually due to reasons other than the earlier weaning.  However, where these confounding factors are known there are ways of adjusting for their effect in the study results; and, therefore, the most accurate figures in this sort of study are the ones that have been adjusted for all the confounding factors known.)

(Sorry.  To avoid confusion for any US readers, I should clarify that in the above paragraph, and anywhere else where the word happens to come up in this post, I'm using 'weaning' in the British sense of meaning 'initial introduction of solids in a baby still getting baby milk', rather than in the American sense of stopping breastfeeding.  I was trying to avoid the word for fear of causing confusion, but typing out 'starting something other than breastmilk', or phrases to that effect, just became too much of a hassle.)

The study did give the adjusted figures, but, unfortunately, gave them in a different format that isn't as easy to interpret - the odds ratio.  This is a measure of how much more likely a baby from one group was to develop pneumonia compared to a baby from the other group.  In this case, it tells us that the babies weaned before four months were more likely to get pneumonia than the babies fully breastfed until six months.  However, it is not possible to tell from an odds ratio what the actual risk is.  I tried working it out for myself from the raw data given in the article, and, by my calculations, the risk is 1 in 40 - in other words, of the babies fully breastfed until four months and then started on solids, you would expect approximately an extra 1 in every 40 to catch pneumonia compared to babies who are fully breastfed until six months.  Between my appallingly poor arithmetical skills and my calculator's failing battery I'm not sure I'd recommend depending too much on the precision of that figure, but I figure it's probably at least ballpark.  So, although the chances of benefit aren't that great, it certainly seems that some babies benefit from the extra delay in weaning.

There's also the question of whether there might be benefits that are as yet unproven simply because we haven't done the studies (which, of course, does work both ways - theoretically, there could also be disadvantages that we have yet to discover).  One question that has been asked is whether the extra time on nothing but breastmilk might also decrease the chances of getting tummy bugs.  There have not yet been any studies specifically comparing the risks of weaning at four months and the risks of weaning at six months with regard to this issue, but one good-quality study that compared weaning at three months to weaning at six months found an increased rate of episodes of diarrhoea in the three-month group.  The chances of getting diarrhoea as a result of weaning that bit earlier was around 1 in 40.  This doesn't prove that weaning at four months would increase the risk of tummy bugs compared to weaning at six months (and, if there is any increased risk, presumably it would be correspondingly less than the risk of weaning at three months), but it's quite possible.

So, to sum up the story so far - if you have a fully breastfed baby and hold off on giving him anything other than breastmilk until he's six months then he will have a slightly smaller risk of pneumonia, of being plagued with frequent ear infections, and possibly of tummy bugs, than he will if you start solids at four months.  He will also, as Rapley points out, be at less risk of bouts of constipation, which is one of life's nuisances that it's nice to be spared if possible.  You'll be spared either the trouble of making tiny quantities of purée or the cost of buying jars of the stuff.  You'll also be spared all the hassle of trying to spoon semi-solid gunk into a baby too young to sit up properly, and of cleaning up afterwards.  And your child's clothes will be spared a lot of ugly stains.  All in all, I'd say it sounds like a pretty compelling case - all other things being equal, I'd say that there are indeed good reasons to wait until six months before starting solids.

I would not, however, say that there are good reasons to scare parents silly with alarmist articles suggesting that parents who've started solids earlier have in some way damaged their babies.

The advice about waiting until six months before starting solids is at least based on some evidence.  (Which, I might add, is more than was the case when that advice was first given out.  The WHO report Rapley mentioned came out, as she says, in 2002 - the research about increased rates of diarrhoea where solids were started at three months was available then, and they extrapolated from that, but at the time there was no research available showing any benefit for six months over four months.  Which did not stop the government and health visitors from collectively presenting six months as The New Parenting Gospel.) 

However, I'm not too impressed by a vague phrase like 'might be harmful to the baby's health' to refer to earlier weaning - too scary, too open to being embroidered by parental imagination into worst-case scenarios.  I'd far sooner see parents given a brief summary of the facts so that we can weigh matters up for ourselves.  What the organisations who give out this sort of health message regularly fail to take into account is that people don't make health-related decisions in a vacuum.  There are all sorts of other factors that may influence our decisions; and there are a myriad of reasons why a decision that may not,strictly speaking, be the best one purely from the health perspective may still be the best one for that person in that situation.  Instead of simply telling us that we 'should' do things one way or another, why not trust parents enough to tell us about the evidence so that we can take it into account when making our own decisions?

But the biggest problem is that the article doesn't stop there.  It also leaves us with the message that purées are somehow inherently harmful - that there's something wrong with feeding babies puréed food even once they've reached the grand old age of six months.

"After six months, Mrs Rapley said babies were capable of taking food into their mouths and chewing it.  Therefore, feeding them pureed food at this time could delay the development of chewing skills."

I suppose it could - after all, the more we practice a skill the better we get at it, and so it sounds plausible that a baby who mostly gets puréed food could be slower to grasp the essentials of chewing than a baby who spends that time working on masticatory skills.  So.... freakin'... what?  Exactly why should the precise age at which a child masters chewing skills matter?  Is this a race?  Are these babies under a deadline for sitting their Chewing Exams?  Is this some vital new part of the National Curriculum of which I was hitherto unaware?

Baby-led weaning is a new enough concept in this country that almost every person you know will have been weaned onto puréed foods back in their own weaning days.  How many people do you encounter who are having difficulty with chewing solids because of having missed out on the practice in their first year of life?  I'd say we have compelling evidence that, purées or no purées, kids do eventually pick up the general idea of what's involved in chewing.

However, parents who've realised this for themselves, or who just don't care all that much about whether their baby's chewing skills are keeping up with those of the Jones's baby, don't get off scot-free - the article then falls back on taking the tried-and-trusted allusions-to-unspecified-future-risks line.

"Mrs Rapley argued that babies fed pureed food had little control over how much food they ate, thus rendering them vulnerable to constipation, and running a risk that they would react by becoming fussy eaters later in life" the article tells us.  And in case that didn't make it sound quite scary enough, the opening paragraphs get even vaguer on the subject: "Gill Rapley, deputy director of Unicef's UK Baby Friendly Initiative said feeding babies in this way could cause health problems later in life."

"There's an article on the BBC website," I told my husband, "saying that feeding babies puréed foods might cause them to have health problems later in life."

"Well," Barry replied "it might cause Satan to rise up out of the bowels of the earth and take over the world.  But unless you've any evidence for that..."

Rapley, as far as I know, doesn't.  (For the health problems, I mean.  Well, I think it's probably a reasonable assumption that she doesn't have any evidence for Satan-invoking potential either, but that wasn't what I wanted to comment on.)  At any rate, I have heard no mention of actual research on the long-term effects of baby-led weaning vs. other methods, and the only research that I can find mention of Rapley having done is her Masters' degree, necessarily a short-term project.  And, since the whole idea of Baby-Led Weaning as a specific concept only developed in recent years, I really doubt that there have been any follow-up studies on the correlation between quantity of purée consumption in babyhood and degree of food fussiness later in life.  Rapley and the BBC are welcome to theorise about this all they want, but it would be appropriate to be clear about the fact that we don't, currently, have a shred of evidence for or indeed against this theory.

All this, of course, goes back to the general OneTrueWay attitude to parenting.  There is, it seems, no middle ground between mandatory and forbidden when it comes to advising parents.  After years of experts telling parents that they had to start solids at four months, someone discovers that actually they don't.  So does the advice to parents change to "It's fine to wait until six months if you want to.  Feel free to decide for yourself."?  No.  It changes into another 'must'.  Another Commandment From On High that we are all supposed to follow blindly until the advice changes again.

What effect does it have on parents when theories get handed out as if they were proven fact?  It promotes worry and guilt, and it damages trust.  When parents are continually told that innumerable minor things that they've done or are thinking of doing are harmful to their babies, that damages the trust that they have in their own abilities to parent.  And, for those parents who are strong-willed enough to resist this erosion of their confidence, the inevitable result is that it instead damages the trust they are willing to place in experts.  Which means that when genuinely evidence-based advice comes out, it's more likely to be widely ignored because parents are so disillusioned by the times they've been told they absolutely must/must not do something only to have the advice switch 180 degrees on them.

To summarise the actual evidence on feeding babies solids and what my husband once referred to as 'smusheds'; Most parents will find that there are good practical reasons for leaving the introduction of solids until such time as their baby is sitting up and grabbing them for himself.  A few babies will also avoid chest infections or ear infections as a result of waiting the extra time.  If you've got a four-month-old baby and are wondering when to start them on solids, those are the benefits of waiting.  But if you're a parent who did start solids earlier than six months and/or (gasp) fed your baby purées and, following that article, have been anxiously wondering what terrifying consequences you may have stored up for your apparently healthy happy baby, then worry no more.  You may well have done irreparable harm to your baby's clothes with all those orange mushes, but there's not a shred of evidence that you've done any harm to your baby.

Gina Ford: Who Are You To Tell Us?

On Monday 5th March, Five Live screened a programme of the above title about the one and only Gina Ford, author of the infamous Contented Little Baby Books.  The moderator of one of my mailing lists asked for our comments on it.  Never one to turn down a chance to ramble on at great length blogging opportunity, I figured I'd post mine here.

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"So," my husband asked me, as he set up the video to record the programme as I'd requested, "do you think Gina Ford's right or wrong, then?"  I told him that I thought this was the biggest problem with the whole debate - everyone frames the question in those terms. 

It's a meaningless question.  Right or wrong for whom?  Babies are as individual as people of any other age group.  Anecdotally, many babies seem to get positive benefits from her routine.  Others would probably benefit more from having things done a different way.  And, of course, most babies are adaptable creatures who are going to do perfectly well on any method that includes love, affection, and basic care, Gina's included.  But, unfortunately, most of the people in the perennial Gina debate either seem to tout her method as The Solution To Every Parenting Problem, or to vilify it as eeeeevil.  And people will argue back and forth over whether her methods are 'right' or 'wrong' without ever stopping to ask whether they might, in fact, simply be one among many possible and valid ways of parenting.

To my lack of surprise, the programme pretty much took this approach as well.  "I would say there's no way someone could follow that routine and it not work, honestly," Michelle Gayle enthused.  "The people who say 'We did it and it didn't work'... then they didn't do it properly," stated Ruth Holmes, GMTV presenter and a Gina follower so passionate that she refers to her, only partly jestingly, as 'Saint Gina'.  (Why, yes - it's so much easier to blame the parents than to admit that your heroine might not have a perfect one-size-fits-all solution that's right for every baby out there.)  Similarly, the anti-Gina brigade gave no hint that they thought the method might be right for anyone. None of this was any less than I'd expected - but, oh, how I'd have loved to see one of the many interviewees pointing out that the real question is why we're so determined to frame childcare debates in terms of 'right' and 'wrong' instead of being willing to see children as individuals and look at what might work best for each child, as part of each family.

There was a certain grim justice in this, given that Gina herself is such a classic proponent of the one-method-fits-all idea.  I was fascinated to hear that Clare Byam-Cook, one of Gina's advisors, advised her to state in the foreword to one of her books that these were guidelines, not rules, and that Gina declined; according to Byam-Cook, Gina feels that you can vary the rules as you would a recipe, but that her way is the 'perfect' way of doing things.  It may, of course, be unfair to be too nit-picky about the choice of words there, given that it was someone else's opinion of something Gina thought and thereby liable to the usual Chinese Whispers phenomenon; but the idea of parenting as a recipe or as something that can be done in one perfect way does certainly fit with the aura of OneTrueWayism that her books exude.

As usual in such debates, unsupported statements abounded.  We had Sheila Kitzinger darkly telling us that the methods were "dangerous" for reasons left unexplored; somebody else's (Margot Sunderland's?) claim that Gina's methods taught children to ignore their own feelings; and, capping them all, Oliver James's claim that Gina Ford's methods protect the parents' mental health "at the cost of the baby's mental health."  "If you're going to claim something like that," my husband howled at the screen "you'd better have the evidence to prove it."  Quite. 

Of course, we don't know what was left on the cutting-room floor, and it is a reasonable bet that all of these people did, in fact, come out with what they thought of as evidence against her methods.  (One of the other participants certainly did, incidentally - she's a member of the aforementioned mailing list, and told us that her own lengthy comments on the topic weren't included.)  Whether it actually was valid evidence is another matter entirely.

After some years of following the whole Gina Ford debate and similar parenting debates in which people regularly claim to have 'proof' that these or associated methods are psychologically harmful, I have yet to see any study findings that haven't been wrenched so far out of context as to be inapplicable.  In fact, another psychologist actually pointed out at the end of the programme that Gina's methods have never been formally studied.  He claimed that this was a reason why they shouldn't be used (exactly what parents are supposed to do if they can't ever try anything with their children which hasn't been formally studied, given the number of tricks of the parenting trade that have never been subject to any assessment more formal than "Well, it worked for Cousin Elsie", is a question that was left unanswered); but nobody pointed out that the obvious corollary of this was that the dark and unspecified allusions to the hideous dangers of her methods to the psychological health of infants were unproved speculation, no matter how much the interviewees tried to present them as fact.

(Incidentally, no-one pointed out a flaw in Gina's methods which I would have thought actually was supported by evidence - her insistence on putting babies to sleep in their own rooms from an early stage.  Given that several large studies have found an association between this practice and an increased cot death risk, I'm surprised that we hear so little discussion of this point in Gina debates.)

It would have been interesting to hear the opinions of the Gina followers on the programme about what they felt the effect had been on their children's psyche and general happiness, but this was an issue that the programme rather seemed to skirt.  One Gina mum did describe her children as "just dead 'appy", but there was little other discussion of the subject, the parents' comments seeming to focus largely on their children's sleeping habits to an extent that left me with images of a cult of Contented Stepford Babies.  At the time, this annoyed me; looking back on the programme as a whole, I do have to wonder how much of it was due to careful editing.  I have learned never to underestimate the ability of the media to present things out of context when it suits them. 

When I've browsed the 'Net for mentions of Gina Ford, I've come across not only numerous parents raving about how happy their babies are on the method but several who actually feel, having tried non-Gina approaches as well as Gina's method, that their babies actually improved markedly on Gina's method.  (In fact, I've found it a good deal easier to find such accounts than to find accounts from anyone who tried the method and didn't like it.)  It makes sense - after all, adults get cranky and upset when overtired or stressed out, and some adults can't get to sleep unless they have darkness and quiet and no stimulation to keep them awake, so it seems reasonable that the same would be the case for babies and that there would be some babies who thrive best on a regime where they get quiet, peaceful naptime scheduled into the day at regular intervals to let them sleep well.  I would have enjoyed hearing from a mother who felt this had been the case with her child, as a counterpoint to all the doom and gloom claims and the general refusal of anyone in the anti-Gina camp to accept that her method might have any advantages beyond convenience for those nasty selfish parents.  Would it really have been so difficult to find one?

The programme did make some good points, chief of which was Michelle Gayle's delightful debunking of the persistent myth that Gina's methods and loving affection are somehow mutually exclusive.  "Because her book doesn't say 'Now hug the child... now kiss the child...'," Gayle told us, "I think they assume that she's making a routine with no love allowance.  But the 'love allowance' is for you to apply, not for her to apply.  All she's doing is giving you a routine.  It's like when you take the timetable of a train - you know what time the train's coming, it's up to you whether you bring your i-pod or your newspaper."

Another mother brought up an issue that is, to me, far more of a problem than anything Gina says - the way she says it.  The whole tone, this mother pointed out, is off-putting with its talk of how you 'must' do this or that.  Even Clare Byam-Cook, Gina's advisor, seemed to agree that the tone could be more flexible. Ruth Holmes dismissed this as an unnecessary attempt to make it into 'a book of jokes', but I don't think that's the issue at all.  As a new mother, I didn't need a book of jokes either - what I needed was some reassurance that there are no 'musts' in childcare.  I found Gina's book downright scary while finding my feet as a mother, because she really does make it sound as though parents who don't follow her method are doomed to weeks of misery. 

As Byam-Cook seemed to be saying, the book would probably have been a lot more successful had she presented her methods as useful options for parents to try and see whether they worked.  (She is, of course, hardly unique among babycare authors in not doing so.)  As it is, the struggle to try to figure out what you 'should' be doing at each stage of the day according to Gina and make that happen can potentially get in the way of simply relaxing, figuring out how you want to be doing things, working towards that, and getting to know and enjoy your baby.  Just as I'd have liked to hear more from mums whose children had positively benefited from the method, I'd have liked to hear something from mothers who'd been happy doing things a different way.  It would have been a nice counterpart.

Gina's method was demonstrated in action by the struggles of Millie Gregory, a new mother clearly so unhappy with the method from the start that it seems a fair assumption that she only tried it in the first place in response to recruitment by the production company.  Gina complained about this section of the programme not only on the (fairly reasonable) grounds that having a camera crew crowding out your home isn't really the best start either to new life or to new parenthood, but also on the grounds that it did not fairly represent her methods.  The Contented Little Baby Book, Gina claimed, makes it clear that a baby should always be fed if it's hungry regardless of whether or not it's the recommended time.  (The programme did in fact point this little-recognised fact out, I was pleased to see.)  But, while it's certainly true that her book says this, I would not agree that it makes it clear.  It mentions it in passing.  When I looked for the statement in question in hopes of clarifying precisely what she said for this post, I couldn't even find it again.  I suspect that the chances of an exhausted shell-shocked new mother stumbling on that statement while flicking through the book trying to figure out what the hell to do next about her screaming baby would not be that great.

Which, of course, illustrates another big problem with the CLBB: it is so darned complicated in places that it's easy to be left completely befuddled as to what you're meant to be doing if things ever fail to go exactly according to plan.  Millie bewailed the lack of a Plan B when the baby doesn't sleep or feed at just the recommended times, but, in fact, the book has several Plan Bs to deal with various contingencies.  It's just that it's pretty darned difficult to find the one you want at the time you want it, because it might be in any of several sections of the book, probably buried in the midst of a densely complicated case history entangled in a thicket of eye-glazing detail about the precise number of ounces of formula and minutes for which Baby Johnny cried at each nap before Gina's magic solutions sorted everything out.  A method is only as good as the way it's followed, and a method that's horribly complicated to follow is going to go wrong a fair bit of the time regardless of how well it might work if followed perfectly.

The use of the Hippo Waddle as background to a rather unflattering cartoon of Gina was, as my husband pointed out, a cheap shot.  He isn't keen on what little he knows of Gina and her methods, but, by the end of the programme, I think he was starting to feel a certain amount of sympathy for her.  "Look, I don't agree with routines for small babies - but if you don't like Gina, why not just not read her books?" he demanded indignantly of the television.  "Why be so horrible to her?" 

He also picked up something that I wouldn't have pieced together in a million years.  At one point, as the parents left the baby in his room for his scheduled Gina nap, the father looked back into the room to tell the baby "We'll be back to get you if you start crying" despite the fact that the crying was in fact ringing out loud and clear already.  It seemed odd, but I put it down to new parent befuddlement - which, of course, may for all I know have been the case.  But Barry, a man whose perceptiveness and smarts never cease to amaze me, picked up on the significance.  The scene, he pointed out, had cut from a shot of the baby crying in his basket to a shot of the parents leaving the room - but the background crying hadn't had the momentary discontinuity that it should have had if it actually had been in both scenes.  My husband's conclusion?  The baby hadn't in fact been crying at all when he was left, but the scene had been edited to make it look as though he had. 

According to Barry's interpretation, the editor had taken a shot of the baby from another occasion to paste into the scene of him being left for his nap - in itself, a normal and accepted practice for a documentary, where it just isn't always practical to film every shot you need during the scene where it happened.  (To get a picture of the baby during that scene, a cameraman would have had to be left behind in the dark bedroom as the door closed for the baby's nap!)  But instead of taking a scene that represented what had actually been happening, the editor had, whether deliberately or through sloppy editing (Barry's vote was for the former), picked a shot of a crying baby rather than a settled baby and portrayed the scene as one of parents leaving a three-day-old baby crying in the name of Gina's methods.

While disagreeing as vehemently as he does with the principle of this sort of deceptive filming, I found it hard to get too worked up about the specifics of this example; after all, Gina does say that once a baby has been fed and burped and settled and it's naptime, she does leave them for a certain amount of time to 'fuss and yell' until they get to sleep.  (10 - 20 minutes is the timespan given in the CLBB, though she modifies this to 5 - 10 minutes on her website.)  This may well have been a misrepresentation of what happened on this occasion, but, as out of line as that is, I would not say that it's a misrepresentation of what her book actually advises.  On this point I feel more sorry for the parents - if they really were aiming not to leave a crying baby alone, then they shouldn't have been shown as doing so.  But this edit does seem to be in line with a subtle, pervasive anti-Gina theme underlying this superficially balanced programme.

And a more worrying example of this theme was in something I found on her website while writing this post - the reason for her odd and unexplained absence from the programme.  According to this, the director had contacted Gina for interview only in the final stages of making the programme, giving her less than a week to arrange an interview if she wanted to make her views known personally.  Gina, who has a heavily booked schedule, couldn't manage it at such short notice.  It does look as though the makers of 'Gina Ford: Who Are You To Tell Us?' didn't have much intention of making it easy for Gina to tell us anything in her own defence.

She did send a written statement giving her views, of which only a couple of lines were used on the programme.  "The aim of The Contented Baby philosophy," Gina wrote to the production team, "is to ensure that from the very beginning the baby’s needs are being met so completely that crying for whatever reason is minimal... I receive a huge feedback from the parents who buy my books and the response is the same: following the Contented Baby Philosophy results in a happy contented baby, who rarely cries."  These comments were not repeated in the show.

Singly Asked Questions

I haven't got as far as an FAQ list yet, but a couple of my commentators have now provided me with SAQs.

Firstly, from my sister, a salient point:

I'm all for it (your blogging more, and less perfectly if that's what it takes) but baffled by the idea that you should have more of an imperative to be perfect in blogging than in motherhood. A blog on that please?

Well, one has to have ones priorities right...

Seriously, I suppose it's because of the difference between a blog and a child.  A blog is an object.  Well, a virtual sort of object, but still an object.  It consists entirely of my own thoughts as transmitted to the world through my own articulacy skills.  (Well, all right, I suppose the software from those nice people over at Typepad plays a role, but you know what I mean.)  Any imperfections in that are entirely mine - an imperfection in my inner core, laid out for the world to see.

Which isn't the way I feel about Jamie.  Like all children, he's his own little person, a separate individual.  On top of that, he's influenced by all sorts of people and things in his life besides me.  While I hopefully have quite a lot of input into him, he's a lot more complex than just a product of me.  As such, there are limits to the extent to which what he does is a reflection of what I've done.

Nor is there ever a point at which I hit the 'Publish Now' key on Jamie and he becomes an Official Finished Product, as happens with blog posts.  (Well, actually, it's perfectly possible to edit blog posts at any time, whether they're published or not.  But somehow it just feels like cheating to edit them once I've posted them.)

And one other factor is a protective instinct (protective of Jamie) at work. There's such a thing as over-mothering.  My blog isn't going to feel smothered if I put too much time and effort into trying to get every detail of it Just Right.  Jamie might.

Not trying to claim any of this is particularly logical, by the way.  Just the way I feel.

Secondly, Clare Wilson appeared on the blog and, quite unintentionally, stumbled across one of my pet bugbears:

Ooooh, getting into bed with them in the morning...setting yourself up for disaster - or so the books say anyway. Sure it was nice and cuddly this morning, but are you happy to do it every morning? At earlier and earlier times?

(Which was, incidentally, not aimed as a criticism - she did make it clear that she did the same thing with her child.)

Well, that depends on what it's an alternative to.  While I probably wouldn't be as happy to do that as I would be to enjoy uninterrupted cosy sleep in my own bed on a regular basis, I'd be considerably happier to do that than I would be to spend ages putting him back to bed/making him stay in his room without being able to get back to sleep at all myself.  So, if that happened, I'd have to decide at what point my desire for the former outcome was great enough that it meant spending some days on the latter.  Believe me, one morning isn't even close.

But I think what's worth questioning here is the Myth Of The Bad Habit.  As you say, parenting books often give the message that you should never be willing to deviate from the Standard Plan in things like sleeping arrangements because it will inevitably be the thin end of the wedge, the opening of the floodgates, the other-metaphors-which-escape me that lead on to More And More Of The Same Only Worse.  As with many parenting myths, the myth probably isn't so much over the fact that it happens, but over the degree to which we actually need to be worried about it.

Bear in mind that parenting book authors have a somewhat biased view of the situation here.  As a rule, we only tend to go to experts when we have a problem.  You are probably not going to go to all the trouble of seeing an expert just because your child, say, woke up once in the early hours of the morning and, having been settled to sleep by you curling up with them, slept to a comfortable hour on subsequent mornings.  So, the children that parenting experts see aren't a random sample of children - they're a sample that are skewed heavily towards children in whom the initial problem did develop into an ongoing problem.  Which, of course, tends to give the people who go on to write the books a less-than-accurate view of just what proportion of all children this applies to.

So... on Friday, I cuddled up with Jamie because I think it's perfectly reasonable to want a cuddle once in a while if you've woken up in the middle of the night and maybe you've had a bad dream or you're just a bit upset or confused at waking up all alone in the dark.  What would have happened if I'd decided instead that I couldn't possibly do this Even Once for fear of heading down Bad Habit Highway?  Well, instead of having a lovely cosy cuddle with my son and a bit more sleep, I'd have been sitting outside his room, shivering and sleepy and wishing I could get back to bed, but stuck there to make sure he didn't get up.  That's the best-case scenario.  Worst-case - if he'd been upset about it, it's possible he might have worked himself up enough that he'd have woken himself up thoroughly and not gone back to sleep at all.  Which would have meant my husband hardly getting any sleep either because he'd have had to get up to take care of him, and having to spend all morning dealing with a very overtired child when he was horribly tired himself, which he would have been most unhappy about.

(Admittedly, this happened anyway - after I'd settled him again, he then had a dirty nappy and woke himself up earlier than he should.  But at least it was better than it could have been.)

And the point is, it would have all been a complete and total waste.  Know what actually happened the following morning?  He did wake up again at about 5 a.m. and cry, but he was only half awake and when I went in and popped his dummy back in, he settled immediately.  Then he slept through until twenty to nine in the morning.  (Bliss.  I got a nice lie-in myself, had time to put a load of laundry in the washing machine and unload the dishwasher without interruption, and even got a few sentences worth of blogging done.)  The next morning, he slept straight through, no waking, again until around twenty to nine.  Monday morning I don't know about as I was at work and it was Barry's day to take care of him, but Tuesday morning, same thing.  I can't remember when I've had such a good run of him sleeping late in the mornings.

So, no, I don't set a huge amount of store by those "Do this once and you will create a monster" warnings.  When Jamie was a baby, my mother told me that one of the most important pieces of parenting advice ever was "Don't solve the problem until it happens".  I've long since learned to appreciate the wisdom of this.

Uh, yes, I did know that. But thanks anyway.

The gorgeous-and-divine Tertia has written a post entitled Do they owe the sisterhood anything? - the 'they' in question being celebrity mothers who conceive in their forties.  I am shamelessly hijacking this in order to give me a jumping-off point to rant about a perennial irritation of mine - in view of this, I should probably specify from the start that my irritation here isn't primarily with Tertia, but with the way this subject gets treated generally.  Besides, Tertia's too gorgeous and divine to get all that irritated with.

From Tertia's post:

Let me share with you a fact that you might not be aware of. Your fertility declines, fairly rapidly, after the age of 37... So many women don’t seem to realize that age has an enormous affect on your fertility... Women see other older women having babies – high profile celebs seem to pop out babies left right and centre. Look how easy it is for them, surely we can wait too...

 What the poor woman in the street doesn’t realize is that many of these older women who are having babies after the age of 40 have done so with assistance (fertility treatment) and often with the use of donor eggs... I know that, many don’t. And that makes me a little cross.

 I think it creates a false sense of security, a false sense of how much time an older woman has left over in which to start trying for a family. It makes me want these older celeb moms to come out and be honest about the fact that they needed help to conceive, that it isn’t easy to get pregnant on your own after 40...

 And yet, do they owe us anything? They have the right, just as we do, to be private about who and where and when they conceived...

 What do you think? Do you think these older celeb moms owe us any form of honesty about how difficult it is to conceive later on in life, or don’t they owe us anything?

Well, my answer to that question would be "Hell, no."  The mere fact that you are a famous singer/actress/whatever does not mean that it somehow becomes your job to educate the public on fertility issues, and the mere fact that the poor sods never actually get any privacy does not mean that they are not technically as entitled to it as anyone else.  The details of how they build their families are their business, and whether they choose to share that information or not is up to them.  (Oh, and the answer to Tertia's other question - the one I didn't quote - is that, no, I'm not infertile.  Or at least I wasn't when I last tried to get pregnant, although I should point out that since then I've passed that magic age of 35 at which a woman's eggs all start to implode and so this may, for all I know, no longer be true.)

But I've got a question of my own here.  Is what Tertia says really true?  I don't mean about the decline of fertility in later life: I know that's true.  I mean, is it really true that substantial numbers of women are unaware of this fact?

I know it's widely believed that this is the case.  Ever since I can remember, I've been reading articles in popular women's magazines at regular intervals on the general theme of how women are foolishly leaving childbearing until their biological clocks have run down, all because they're blithely ignorant of the risks.  I've yet to see anyone present any evidence that this is the widespread problem they claim it is - after all, when you can dig up one or two examples of women who made this mistake and are willing to tell their stories, why bother with any actual figures?  But I've seen the claim itself made more times than I could count. 

Which means, presumably, that millions of other women have also read those articles.  With the number of people telling us what a major problem it is that women don't know that there's a time limit on our fertility, I wouldn't have thought there could be that many women left who are oblivious to the fact that there is a time limit on our fertility.  The term 'biological clock' has become a cliché, for goodness' sake.  Oh, I have no doubt at all that there are some women out there who really don't have a clue that getting pregnant at 40 is likely to be far more difficult than it would have been at 20.  But does anyone actually have any hard data on the proportion of women in, say, the mid-twenties to mid-thirties age range who are postponing childbearing based purely on the belief that, la-la-la-la-la, they have all the time in the world?  I certainly haven't seen any figures.  And, in the absence of figures, perhaps journalists could stop assuming that this supposed ignorance is the huge problem they keep saying it is.

Of course, there are plenty of women who postpone childbearing for other reasons.  What I'm doubting here is whether there are really that many women for whom "Well, it's not as though I'm going to have any major problem getting pregnant no matter how late I leave it" is a major factor influencing their reproductive decisions.  I suspect it's much more common for people to postpone childbearing for the same reason I did - because they felt that their lives were not currently at a stage where having children would be a responsible and appropriate decision for them.

Personally, I made the decision that I shouldn't have children until I had the emotional maturity and financial stability to take on responsibility for a dependent life, plus a prospective father with whom I could see myself being happy to share the job, and my life, on the sort of long-term basis that would be necessary.  It's a choice that was spoken of disapprovingly in a BMJ editorial almost a year ago: "[T]he availability of in vitro fertilisation (IVF) may lull women into infertility while they wait for a suitable partner", wrote Bewley, Davies, and Braude.  (By the way, if you're having trouble with that link, try it again after September 17th - on-line BMJs are only available to members until a year after publication, but should be available to the general public after that.)  What they're silent about is what, precisely, they're suggesting should be the appropriate alternative to waiting for a suitable partner.  Unsuitable partner?  Sperm bank and single parenthood?  Both of those have quite enough potential disadvantages that I preferred to take my chances on waiting for Mr Right.

I wasn't 'lulled into' postponing childbearing by the belief that IVF was a fine-and-dandy backup plan (in fact, I was fairly sure that if it turned out I couldn't get pregnant then I'd want to adopt rather than go down the road of fertility treatment) or that my ovaries were going to stay young forever.  I postponed childbearing, despite feeling desperately impatient for a baby and anything but 'lulled', because I didn't feel that the mere fact that I wanted a baby gave me some sort of automatic right to have one without considering the consequences for the baby.  (And, for that matter, the other person involved in conceiving it.)  I believed (and still believe) that my parental responsibilities began before conception and included considering not just whether I wanted a baby, but whether I was in a situation to give it the good start in life that I wanted to give it.  I knew I was risking heartbreak by doing things this way; and I also knew that that really wasn't the most important issue, because it wasn't all about me.

All of which is why I find the 'Postponing pregnancy?  Why, they clearly don't have a clue about basic biology.  What fools these women be!' articles intensely irritating.  When you are trying to stick to life choices you believe to be responsible and ethical despite knowing that there's a very real chance they might ultimately result in an unhappy ending for you, it is somewhat galling to see yourself portrayed in media stereotypes as making those choices out of ignorance.   I do realise that 'Postponing pregnancy?  Why, they're clearly making sensible and well-thought-out decisions after careful weighing of the pros and cons of different alternatives.  How responsible these women be!' doesn't have quite the same immediately apparent potential for attention-grabbing headlines, but it's an image I'd like to see journalists portraying more often.

CIO and sleep training - the debate continues

When I brought the CIO debate over here from Hathor's site, I hoped other people would also be willing to come over and continue, but resigned myself to the fact that everyone else would probably have got bored and moved on to the next thing - after all, I'd taken my usual sweet time about actually getting my post up.  However, fortunately, Heather from Tucson has been patient enough to keep checking, and she's now responded.  Thank you.

I do, as a matter of fact, believe if I have a problem in the middle of the night that my dear husband should get up and help me deal with it, just as I do for him. Whether it be a nightmare, cramp, or what not. I believe that that is what it mean to be married to someone.

I believe that being married to someone means that you take their needs, and their wishes, into account as well as your own; and you find a balance as best as you can.  My husband has a need to sleep, as well as some other things he needs to do during the day (most of which are actually for the ultimate benefit of me and Jamie as well as himself).  Sometimes my needs will take precedence over that and I'll have to interrupt what he's doing.  But that doesn't mean that everything I want, no matter how large or small it is, should take precedence over his needs.

I believe that the same sort of balancing act goes on between parents and children.  I believe that if children need something in the middle of the night - a drink of water, a clean nappy, comfort - they ought to get it.  If it's just that they want company or want playtime or want someone to rock them because they find it easier to go back to sleep that way, then sometimes Mummy's and Daddy's needs are going to be more important than Baby's wants.

Plus why is it that two adults can sleep together all night long, but a baby gets the boot?

Different families are going to have different answers to that question (for example, if you asked Beanie Baby, presumably she'd answer that this turned out to be the only way that her baby could sleep herself, as well as being the only way that she could get enough sleep to be functional enough during the day to be the responsive, caring mother that her daughter needed).  But it's actually not a question that relates to CIO, as such.  It's a question that relates to co-sleeping.

Some people seem to see this as all one debate - CIO vs. co-sleeping, as though those were the only two ways that a parent would ever be dealing with a child's sleep issues and the question is about which you should choose.  It's typical of the way that mummy debates get polarised into The Right Way and The Wrong Way.  In actual fact, of course, it's nothing like that simple - some families do neither CIO nor co-sleeping, some do both at different times or at different stages.  The question of whether or not to co-sleep obviously has some overlap with the question of whether or not to do CIO, but it certainly isn't just the same question phrased in a different form.

In our case, for example, 'all night long' was never the issue.  Whenever Jamie woke up during the night, I took him into bed with us and we both went back to sleep - simple and straightforward.  What this totally failed to solve was the problem of how to manage the evenings before we went to bed.  This was the time of day when Jamie needed to sleep, even though he still wanted to play; when I needed dinner; and when Barry needed some adult company and conversation after a day looking after a toddler.  Eventually, after trying various other ways of dealing with the situation with various degrees of success, we used a version of CIO, and that was what worked beautifully for all of us.  And we went on co-sleeping during the night until Jamie started sleeping through the night several months later.  In fact, since his cot is still in our room a few feet away from our bed, I believe we're still co-sleeping, if I'm remembering the Official Attachment Parenting Definition correctly.

And you never answered my question reguarding what would you like to be done to you if you were a helpless adult.

I did, in fact - you just didn't want to accept my answer.  If somebody had to look after me 24/7, I'd want them to get whatever breaks they needed to recharge and be physically and emotionally able to keep going.  Even if that meant I didn't always get company when I wanted it, that would still be better, long-term, then being looked after by a carer who was so exhausted and burnt out that he or she had become resentful and just couldn't be that caring any more. 

The difference, of course, is that I'd be able to recognise how important this was and a baby can't.  But that doesn't mean it's any less important to the baby, as well as the mother.

Would you really want to be left alone, all night??

I doubt if I'd notice - after all, I'm usually asleep.  I suppose it's possible that I might have insomnia one night and want company, but I wouldn't expect someone to wake up purely for that reason.  But as for going to sleep at the beginning of the night, I usually do prefer being alone for that.  It's a time when I like to get a bit of space and think my own thoughts.  Having someone else there trying to put me to sleep would probably just keep me awake.  I can understand why the same seems to be true for at least some babies, and why, for those babies (not for all babies), sleep training actually seems to work better than the 'gentle' methods.

CIO, sleep training, and evidence or the lack thereof

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

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

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

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

1. Opinion.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I haven’t said that.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

To me this abstract is pretty unconvincing.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Now, this study is c