Monthly Archives: April 2011

What Dreams May Come

"I keep waking up, don't I?!" Katie crowed in delight. 

I wasn't quite sure how to respond to this; as far as I could see, my daughter doesn't make any more of a habit of waking up than the average person who does it on a daily basis.  Rather less so, if anything, since she usually has to be woken up each morning (with some difficulty), due to our schedules being non-conducive to her getting enough sleep most nights. 

It seemed, however, that what she was referring to was the two occasions in recent weeks when she woke up in the middle of the night.  On the first occasion, Barry found the poor little mite sobbing in the hall, having apparently had a nightmare about cobwebs in her bed.  (Yes, I am aware of just how poorly this reflects on my housekeeping skills, thank you.) 

I made a big show of brushing away imaginary cobwebs, but this apparently only kept them at bay for a few seconds and I ended up having to lie down next to her until she fell asleep again, which apparently did the trick.  Or perhaps I don't get the credit; when I came to get her the next morning, she assured me that Froggyted (her current favourite stuffed toy) had got rid of the cobwebs.  She did have some concerns over the following days as to whether they would come back again, but decided that, if this were to happen, she would brush them into Jamie's bed.  "Jamie don't be bothered of cobwebs" she told me.  I felt this assessment was accurate enough, even if the grammar wasn't.  Fortunately it did not become an issue – Katie's dreams have, so far, remained unplagued by imaginary cobwebs.  I suppose at some point I really ought to go deal with the real ones.

The second time, when I woke half-way through the night to find her standing next to the bed, I vaguely assumed it was another bad dream, but being a bit too sleep-bleared to deal with anything requiring coherency I simply went for the time-honoured option of scooping her up into bed with us (and then returning her to her own bed some hours later when I was woken again to find that she had twisted into a perpendicular position and forced me over to the edge of the mattress).  After getting up the next morning, she explained that what she had actually wanted to do was to ask us what buttons to press on a computer.

"That depends on what you want it to do," I told her.

"It was a pretend computer," Katie explained.  "It tickles you and then puts you on the floor and then goes back to bed."

I processed this for a moment.

"So you mean," I replied in the solemn tones of one seeking clarification, "it tickles you…" I tickled her, " puts you on the floor…" I lowered her from my lap to the floor, "and then goes back to bed."  I fell sideways onto the nearby beanbag in artistic imitation of going to bed.  "I was pretending to be a pretend computer," I explained to her. 

Katie, of course, loved this so much I had to repeat the procedure a few times, although I don't know if we ever figured out the answer to the original questions of what buttons to press on the hypothetical computer.  (Although she did then tell me that one of the little boys from her nursery had pressed the wrong button, thereby leading the computer to skip the tickling stage and move on directly to putting him on the floor and going back to bed.  Such an easy mistake to make, I'm sure.)

"But today I woke up by myself!" Katie continued.  (This isn't the clearest of narratives, is it?  We've now finished the flashbacks and moved back to the point at which she made the statement that started this post.)  Indeed, she had – I'd been downstairs with Jamie, who usually wakes up before his younger sister, when I heard a noise on the stairs and found Katie, tousle-haired and beaming, making her way down them.  "Today, I didn't dream about a computer that tickles you and puts you on the floor and then goes back to bed!"

I felt quite sorry to hear it.  She seemed to be accepting this lack with equanimity, but I can't help feeling that surely anyone's day can only be the poorer for failing to dream about a computer that tickles you and puts you on the floor and then goes back to bed.

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Breastfeeding for longer than a year – myths, facts, and what the research really shows

Welcome to the April Carnival of Breastfeeding!  For this month, the organisers have picked a delightfully controversial topic – extended breastfeeding.  It's one on which I have plenty to say.

Extended breastfeeding is the term given, in our society, to breastfeeding a child beyond the first year.  An increasing number of women are choosing to do this, and, sadly, are more often than not incurring heated disapproval for doing so. Breastfeeding toddlers or older children is believed to make them overly dependent, mothers who do so are accused of thinking only of their own needs and not of their children (that ultimate indictment for mothers), and the practice is looked on as inappropriate and downright perverse.

Fortunately, it's now being increasingly recognised that this position is not supported by either logic or evidence.  Not only is there not a shred of evidence that breastfeeding beyond a year is harmful, there is positive evidence to reassure us on this score – the world is full of societies in which it is considered normal and expected behaviour to continue breastfeeding for considerably longer than a year, and the children raised thusly seem to be doing perfectly well on the practice.  It is, of course, hugely beneficial for children in developing countries where food can be scarce and malnutrition rife, and it has some potential benefits even in our affluent society – it can be a valuable source of nutrition for otherwise faddy toddlers, and it slightly reduces a mother's risk of breast cancer or rheumatoid arthritis.

I'm delighted to see it becoming more widely recognised that there is absolutely no reason why a mother should feel obliged to wean simply because an arbitrary date on the calendar is approaching.  However, there's a twist to this; the pressure is starting to go the other way.  A small but vocal minority are pushing for breastfeeding past a year to be seen not merely as an option for women who want to do so, but as a goal for everyone to aim for.  Breastfeeding a toddler (or older child) is enthusiastically touted as having a host of physical and psychological benefits.  Lactivists are advising mothers that they should do their best to continue nursing until two years at the very least, and preferably longer (nursing until the child decides spontaneously to stop is held up as the ideal).  And the problem is that there really isn't any decent evidence to support this attempted move towards yet another blanket parenting 'should'. 

I'm not objecting, here, to an individual woman deciding that there may be particular circumstances in her child's case – deprived circumstances, an unusual health problem, or even just food faddiness – that might lead to her wanting to continue to breastfeed in hopes that it will be of some benefit.  Also, of course, I'm talking specifically about the situation in the developed world here, not about breastfeeding in developing countries where it is indeed likely to remain beneficial for long past infancy.  My objection is to the claims that extended breastfeeding has been shown to be of general benefit even in situations where other sources of nutrition are plentiful.  It hasn't.  And while this kind of pro-extended-breastfeeding advocacy has been a huge comfort to plenty of women who, having struggled with the pressure from others to wean before they wish to, now feel vindicated, it's also putting some women in the position of feeling obliged to nurse for longer than they really want to, in the belief that they'll be somehow depriving or disadvantaging their children if they don't.  That is not a trend I want to see.

That position, of course, is controversial enough in lactivist circles that it'll need some defending; to break up what's now set to be a very long post, I'm going to go for the 'Debate With Imaginary Opponent' format.

What do you mean, there's no evidence that nursing past a year is beneficial?  Are you trying to claim that a fluid so packed with nutrition, antibodies, and general goodness somehow magically loses all its benefits just because a child has passed the age of one?

Of course not.  What happens is that the child gradually grows, develops and reaches the point where breast milk just doesn't have anything much further to add.  (Just to clarify, in case anyone was forgetting how I began this post, I'm fine with children continuing to nurse after that point if they and their mothers so wish.   All I'm objecting to is the claim that they should continue to nurse, which I don't agree with any more than the claim that they should stop.)

But there's plenty of evidence that breasfeeding is beneficial to toddlers.  For starters, one study by Gulick (1) showed that breastfed toddlers between 16 and 30 months old get sick less often than non-breastfed toddlers and get better more quickly when they do…

No, it didn't.

Huh?

It didn't.  Although lactivist websites all over the Internet claim that that study shows a decreased rate of infections in breastfed toddlers between 16 and 30 months old, it actually shows nothing of the sort.  I know this because I've got hold of a copy of the study and read it for myself.  The toddlers being studied weren't breastfed toddlers – they were toddlers who'd been breastfed in the past but had stopped breastfeeding before entering the study.  What the study was actually looking at was whether longer duration of breastfeeding during infancy had any benefit in terms of reducing infection rates in toddlerhood after breastfeeding cessation.  (It didn't, in case you're interested; at least, not in that study.)  Somehow, someone has managed to utterly and crashingly misreport what the study was into and what it showed, and lactivists across the Internet have simply repeated this misinformation without question.  It's one of the biggest breastfeeding myths I've seen out there.

Well, come on – what about the other studies on the topic?  Look – Kellymom has a whole list of studies showing the immunological benefits to breastfed toddlers!

One of those is a study set in a developing country, showing benefit to children who are severely malnourished children.  As I said, breastfeeding can indeed be beneficial past infancy in such a setting, but it just isn't valid to assume that those results will be applicable to children living in our relatively privileged Western settings.  One wasn't even studying toddlers – it was a study of breastfeeding benefits in babies up to the age of 20 weeks, which is not toddlerhood by any remote stretch of the imagination.  The rest, as far as I can see, all just look at concentrations of antibodies in breastmilk of mothers of nursing toddlers, not at whether those antibodies are actually adding anything to the toddler's own antibodies when it comes to fighting off infections. 

Oh, come on.  Surely all those antibodies have to be doing something.

Not necessarily.  Bear in mind that a child's own immune system also develops rapidly during the early years, and at some point it's going to reach the stage where breast milk just doesn't have a lot else to contribute.

That surely can't be as early as a year, though.  I can't believe that breastmilk doesn't still have some benefit to children older than that.

You're welcome to believe what you like.  It's the claim that it's been proved to be beneficial that I'm objecting to.

So have you any evidence that it isn't?

In the one study I have been able to find on infection rates in breastfed vs. non-breastfed toddlers – a study in New Zealand that followed over a thousand children up to the age of two, looking at respiratory and gastrointestinal infections – breastfeeding didn't show any benefit in toddlers, or for that matter, in older babies (2).  Of course, there are flaws in every study, and I can think of several possible reasons why this one might have underestimated results enough to miss a small but genuine benefit, but it does seem to me that, if that's the case, we can't be talking about that great a benefit.  And, frankly, when the one study we have on the subject shows a complete lack of any benefit, I don't really think that the people claiming evidence of benefit are on solid ground.

But, what about the other benefits for breastfed toddlers?  Just look at the way that it helps an upset or tantrumming toddler to calm down.

I agree that that can be a wonderful convenience of breastfeeding.  However – and feel free to take this or leave it as you like, because we are temporarily stepping out of the realm of objective scientific evidence and into that of my own opinion – I do have my doubts as to whether it's a good idea to do so.  After all, what message does it send children when we regularly and repeatedly teach them to turn to a sweet-tasting food source at times when they need comfort?  I wouldn't use any other form of food or drink to distract my child from a tantrum, because that's not the message I want to be giving to my children about how food should be used; it's not encouraging healthy eating habits.  Why should I make an exception for breastfeeding?  I tried to avoid doing so, for both my children.  Just because something is the most convenient way to calm an upset child doesn't mean it's necessarily the best way in the long term.

But it has psychological benefits over and beyond just calming tantrums.  Breastfeeding for longer actually helps children become more independent!

No evidence for that claim.

Look, Jack Newman says so!  And Elizabeth Baldwin!

And they're entitled to their opinion on the matter.  However, I don't see any reason why I should automatically believe it, any more than I should automatically believe the equally unreferenced opinions of the doctors who claim that longer breastfeeding makes children more dependent.  Either way, they're opinions, which are not the same thing as evidence.

 But there is evidence!  Check out this quote on Kellymom's site – 'One study that dealt specifically with babies nursed longer than a year showed a significant link between the duration of nursing and mothers' and teachers' ratings of social adjustment in six- to eight-year-old children' (3).  Or are you trying to claim that that study's being misrepresented as well?

Oh, not with the kind of spectacular degree of inaccuracy as the study by Gulick we discussed above.  However, that quote makes the results sound far more impressive than they were.  We're not told that the differences found were very small, that they showed up in only one of the several measures of psychosocial adjustment that were tested, that adjusting for other factors eliminated practically all the difference found in the teachers' ratings, or that the researchers themselves were pretty unimpressed by their results.  To quote from their conclusion: 'In general the evidence above gives only very weak support for the view that breastfeeding makes a significant contribution to later social adjustment.  The research findings tend to be both inconsistent over time and between measurement sources and at best suggest a very small association between breastfeeding and subsequent social adjustment.  Further it is more than likely that even the small and inconsistent associations that have been reported could have arisen from factors which have not been controlled in the analysis.'  As evidence goes, I have to say that that doesn't really strike me as compelling enough to justify trying to persuade women to continue breastfeeding if they don't want to.

So what about all the other studies listed on Kellymom?  Showing that breastfed toddlers suffer from fewer allergies and have higher IQs?

I've checked all five of the papers she lists as supposedly backing up her claim about reduced allergies in breastfed toddlers (full text of four of them, the abstract of the other), and none of them are about toddlers.  They're all looking at breastfeeding in infancy.  In fact, one of them (a review rather than a study) actually mentions in passing that the existing research shows 'some suggestions' that longer breastfeeding may be related to an increase in allergy risk.

When it came to the studies on breastfeeding and intelligence, after a while I simply gave up.  The only study I did manage to find that looked at breastfeeding over a year didn't find any substantial difference in intelligence or school performance between children breastfed for that length of time and children who stopped shortly before that – longer duration of breastfeeding was initially associated with a slight increase in intelligence level, but then the effect leveled out.  (That one's not available on line, but you might be interested in checking out this one by Mortensen et al that Kellymom also links to, which also studied the association between intelligence and breastfeeding duration and reached a similar conclusion – initially the increased duration of breastfeeding was associated with slight improvement on the intelligence scales, but the effect then levelled off, with children breastfed for longer than nine months having scores no better than those breastfed for 7 – 9 months.) 

I checked several other studies on her list which, again, all turned out to be follow-ups on breastfed babies, not children breastfed past a year.  So, as I say, I gave up.  Checking all the studies she lists would have taken forever and I'm afraid there are limits to the amount of time and effort even I can put in to checking references from someone who's clearly such an unreliable source of information.  (And, before anyone gets offended at me dissing Kellymom, I do actually think she's a great source of information when it comes to dealing with breastfeeding problems; I've just found her to be appallingly bad at giving accurate information on any research dealing with any question in the general category of 'Is it possible that breastfeeding in circumstance X is anything less than incredibly beneficial?')

So, for all you know, there might be studies on her list that do show benefits of toddler breastfeeding and you just haven't seen them?

Well, if you find any, by all means let me know.  I mean that – I'd be interested to read them and happy to spread the word about them.  But, until I actually see a decent-quality study providing good evidence that breastfeeding past a year is actively beneficial for children, I'm not going to tell women it is.  And, given how many studies are being erroneously cited as showing benefits of toddler breastfeeding when they show nothing of the sort – frankly, I think my scepticism about the existence of any studies that do show benefits is completely excusable.

Well, I don't care!  I love breastfeeding my older child and I want to carry on whether or not you've found any studies proving that it's beneficial!  We're both enjoying it, and that's benefit enough!

EXACTLY!  And that's the ONLY reason you need.  You don't need to prove that it's in some way superior to what all the other mothers are doing.  You don't need to score Good Motherhood points on some imaginary scale to justify your choice to others.  You just need the confidence to believe that it's OK and that it's what works for you.  Enjoy nursing your toddler or older child, accept that mothers who have made a different choice from you are doing just as well by their child and shouldn't be conned into nursing for longer than they want to, and support every mother in the choice she makes on the matter, in the knowledge that, as far as we can see from the available evidence, nursing or not nursing a child of that age are equally good options to go for and thus we can happily leave this one in the realm of personal preference where it belongs.

 

References

1. Gulick E. The Effects of Breastfeeding on Toddler Health.  Pediatric Nursing 1986; 12(1): 51 – 4. 

2. Fergusson D.M., Horwood L.J., Shannon F.T., and Taylor B.  Breast-feeding, gastrointestinal and lower respiratory illness in the first two years.  Australian Paediatric Journal 1981; 17: 191 – 5.

3. Fergusson D.M., Horwood L.J., and Shannon F.T.  Breastfeeding and subsequent social adjustment in six- to eight-year-old children.  Journal of Child Psychology and Psychiatry 1987; 28(3): 378 – 86.

 

Do come and check out the other links in the Carnival!

Mamapoeki from Authentic Parenting: Extended Breastfeeding?

Mama Alvina of Ahava & Amara Life Foundation: Breastfeeding Journey Continues

Elita @ Blacktating: The Last Time That Never Was

Diana Cassar-Uhl, IBCLC: Old enough to ask for it

Karianna @ Caffeinated Catholic Mama: A Song for Mama’s Milk

Judy @ Mommy News Blog: My Favorite Moments

Tamara Reese @ Kveller: Extended Breastfeeding

Jenny @ Chronicles of a Nursing Mom: The Highs and Lows of Nursing a Toddler

Christina @ MFOM: Natural-Term Breastfeeding

Rebekah @ Momma’s Angel: My Sleep Breakthrough

Suzi @ Attachedattheboob: Why I love nursing a toddler

Claire @ The Adventures of Lactating Girl: My Hopes for Tandem Nursing

Elisa @ blissfulE: counter cultural: extended breastfeeding

Momma Jorje: Extended Breastfeeding, So Far!

Stephanie Precourt from Adventures in Babywearing: “Continued Breastfeeding”: straight from the mouths of babes

The Accidental Natural Mama: Nurse on, Mama

Sarah @ Reproductive Rites: Gratitude for extended breastfeeding

Nikki @ On Becoming Mommy: The Little Things

Dr. Sarah @ Good Enough Mum: Breastfeeding for longer than a year: myths, facts and what the research really shows

Amy @ WIC City: (Extended) Breastfeeding as Mothering

The Artsy Mama: Why Nurse a Toddler?

Christina @ The Milk Mama: The best thing about breastfeeding

TopHot @ the bee in your bonnet: From the Mouths of Babes

Beth @ Bethstedman.com: Extended Breastfeeding: To Wean Or Not To Wean

Callista @ Callista’s Ramblings:  Pressure To Stop Breastfeeding

Amanda @ Postilius: Nursing My Toddler Keeps My Baby Close

Sheryl @ Little Snowflakes: Tandem Nursing- The Good, The Bad and The Ugly

Zoie @ Touchstone Z: Breastfeeding Flavors

Lauren @ Hobo Mama: Same old, same old: Extended breastfeeding

Tanya @ Motherwear Breastfeeding Blog: Six misconceptions about extended breastfeeding

Jona (Breastfeedingtwins.org): Breastfeeding older twins

Motherlove Herbal Company: Five reasons to love nursing a toddler

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May Contain Traces Of Nuts

"What jobs are there in the universe?" my son enquired from the bathtub.

"The universe?  Oh, do you mean the university?"  Jamie's explanation to my visiting mother-in-law over dinner of the different years of his primary school ("…and then there's Year 3 and then Year 4 and Year 5 and Year 6.  So you're at [schoolname] for a long time") had led on to my mention that secondary school happened after that, and thence to Jamie asking, once we were upstairs for bathtime, about whether there was any more school after that and my explanation of the various options available post-school.  "University isn't a job – you do jobs after you finish.  Or you can do jobs instead of going to university."

"No, but what jobs are there in the university?" Jamie struggled to get his point across.

"Do you mean, what jobs do you need university to do?"  Interpreting a Jamie conversation can require a certain degree of lateral thinking.  "Well, lots of different ones.  For example, I learnt about how to be a doctor.  That's called medical school"

"What did you recognise at medical school?"

"Do you mean, what did I learn?" This translation appeared to be correct.  "Lots of things.  I had to learn about all the different parts of the human body – do you remember that anatomy book I showed you this morning?" (I do not, I should probably point out, make a habit of showing my son anatomy books.  This had been in response to last night's bathtime query, which was about what the thing on his back was.  Since it was in fact a prominent shoulder blade, I thought he might be interested in looking at some pictures, and had hauled my good old Grant's Anatomy out to look up pictures of scapulae to show him.)  "I had to learn about all the bits in that.  All the bones in the body, all the muscles, all the…" (I realised he wouldn't know the word 'organs') "…all the different bits.  And…"

"Did you learn about these bits?" Jamie indicated the bits in question.

"Testicles?  Yes, I had to learn about those as well."

"What colour are they?"

"Um, pink, I think."  Testicular colour had not, in fact, been on the curriculum at medical school, as far as I could recall.  I wished he'd asked me about possible causes of testicular pain or swelling, which I'd have felt much better equipped to answer.

"I want to know," Jamie explained, "so that if anyone asks me what colour my, um, tentacles are, I can tell them."

I am all in favour of being prepared for all possible conversational as well as other eventualities, but did feel able to reassure him that I was 99.999999% sure that nobody was ever going to ask him what colour his testicles were.  However, out of interest, I did ask about it on the urology forum of the medical website where I ask all my medical questions and in reply got three rather good jokes, one related Amusing Child Anecdote, one photo, one groan from a doctor who'd been looking at the photo when his daughter came in and demanded to know what those were, some interesting information on the different colours they turn in pathological situations, and the actual answer.  Which is, just in case anyone ever asks you what colour your testicles are, grey and white with a white membrane round the outside.  So glad to have been able to help; I always wanted to contribute to increasing the world's store of general knowledge, although it is fair to say that this is not quite what I had in mind.

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Filed under Here Be Offspring, The doctor is OUT. To lunch.