Tag Archives: early intervention

How to engage a baby

When you share a laugh with your baby, it can be one the warmest feelings as a parent. But is this a genuine mutual exchange, and how does it come about?

This is a video of what is now a classic experiment in developmental psychology. It shows a mother happily engaging face-to-face with an equally happy baby. The mother then ceases all facial engagement – the “still face” – to which the baby reacts by trying, with all its might, to reestablish the happy interactions. It’s quite a marked and powerful effect:

A historical review of the experiment quotes the researchers who first documented the effect:

“the infant first “orients toward the mother” and “greets her expectantly.” But then, when the mother “fails to respond appropriately,” the infant …

… rapidly sobers and grows wary. He makes repeated attempts to get the interaction into its usual reciprocal pattern. When these attempts fail, the infant withdraws [and] orients his face and body away from his mother with a withdrawn, hopeless facial expression.”

The experiment, in this form, was first presented at a scientific conference in 1975, but it wasn’t the first to document what happened when infants are exposed to varying social interactions. It was, however, the first to use “then-novel videotape technology” on the conference hall’s big screen. Adamson and Frick, in their historical review, suggest that the  immediate and dramatic illustration of the phenomenon contributed to the broad interest this experiment gained. An early lesson in the power of ‘modern’ technology for effective science communication and to maximise research impact.

This may all seem a little obvious to some parents. You may feel that you don’t need a psychologist with a video camera to tell you that a baby is happiest when you are engaging them face-to-face. But there are a number of reasons why the methodical description of this effect has had profound and lasting influence.  

What this experiment first showed, by deliberately manipulating the parent’s engagement, was that the baby is an active player in this exchange. The infant’s social behaviours can influence the parent’s level of engagement, just as the parent can influence the baby, and it can subtly alter these depending on the context. It’s not simply the parent reacting to the baby’s randomly generated cues. It has even been detected in babies as young as a few weeks old.

As Jason Goldman at The Thoughtful Animal says:

“The still face experiment demonstrated that very young infants already have several basic building blocks of social cognition in place. It suggested that they have some sense of the relationship between facial expression and emotion, that they have some primitive social understanding, and that they are able to regulate their own affect and attention to some extent. The infants’ attempts to re-engage with their caregivers also suggest that they are able to plan and execute simple goal-directed behaviors.”

But one reason why this experiment has been so important and enduring is that it provided a standard and reproducible way of measuring children’s social emotional development.

By using the same set-up time-and-time again, it has shown how a child’s social and emotional development becomes richer as they grow older. The response becomes increasingly complex with age, and can include deftly timed facial cues, dampened smiles, sideways glances at their parent and yawns. Adamson and Frick cite a lovely example for the original set of experiments in which a five-month old boy, upon encountering a still face, stopped being wary and…

“…looked at the mother and laughed briefly. After this brief tense laugh, he paused, looked at her soberly, and then laughed again, loud and long, throwing his head back as he did so. At this point, the mother became unable to maintain an unresponsive still face.”

An experience I’m sure many a parent can relate to when – armed with a stern face – they try earnestly to tell off their child, only to be met with a cheeky grin or giggle!

The experiment has also allowed researchers to deconstruct these parent-baby social interactions into visual, auditory and tactile components. Vision and hearing, it seems, is especially important as children get older, but touch can be enough to, at least partially, lessen an infant’s anxiety when confronted with a still face.

Nevertheless, a still face is usually enough to produce the basic negative reaction in a child, even if it’s in response to their mother, father, a stranger or someone on television. Children make a distinction, however, for inanimate objects, even if they appear quite human-like, demonstrating their ability to form genuine social relationships.

This experimental set-up has also revealed possible negative consequences of a parent’s still face. According to Adamson and Frick, children actually show a more dramatic reaction to a still face than to a brief period of separation or to situations in which the parent interrupts interactions to talk to a researcher. Babies assimilate and react to a negative social cue, rather than simply becoming distressed at the lack of stimulation.

The “still face” experiment has shown its use in further understanding various developmental disorders, such as Down’s syndrome, deafness and autism, as well the effects of environmental conditions like infants exposed to cocaine prenatally or to depressed mothers.

The still face experiment has been used to ask questions about how early social and emotional engagement may affect later behaviour. The strength of an infant’s still face effect has been linked to their mother’s normal sensitivity and interactive style, and it may predict the degree of later infant attachment, depression or anxiety, and even behavioural problems.

Clearly, parents who may have a lower level of engagement, such as those experiencing postpartum depression, should not be guilt-tripped, especially as this could have an exacerbating effect. But the still face experiment has shown that simple procedures can help in these situations – depressed mothers who are encouraged to provide more touch stimulation are often able to offset the lack of visual or auditory engagement to bring about more positive social interations.

As Ed Tronick – one of the original researchers of the “still face” experiment – says on his website:

“An infant’s exposure to “good, bad, and ugly” interactions with the mother, as repeatedly communicated by her facial expressions or lack of expression (i.e., a still-face) has long-term consequences for the infant’s confidence and curiosity, or social emotional development, with which to experience and engage the world.

Though let’s not forget the role of fathers, or other partners, either.

[Thanks to mum-in-law Jenny (once again) for the video and @matthewcobb for the Adamson and Frick article]

Should babies watch TV?

This question seems to trouble many parents, and can cause a lot of guilt too.

“Will the TV numb my baby’s brain?”

“Are they destined for a sedentary life?”

“AM I CONDEMNING THEM TO LIFE AS A MINDLESS AUTOMATON?!”

This is why an interview last week with psychologist Annette Karmiloff-Smith on the BBC’s The Life Scientific caught my ear (thanks to a pointer from mum-in-law, Jenny). It’s a fascinating insight into how babies learn to learn, and how their brains develop to understand the world around them. You can listen here: The Life Scientific.

But on TV watching, Prof Karmiloff-Smith, an expert in developmental disorders, argues that if the subject matter of the programme is carefully chosen and scientifically based, then the TV can be better for a child’s learning than even a book.

This was largely in response to advice reissued by the American Academy of Pediatrics (AAP) that babies under two shouldn’t watch any TV or DVDs. There are three main concerns: poorer language skills, a negative effect on sleep, and less time spent taking part in other types of unstructured play that are critical for the proper development of mental capabilities.

This is based on a growing body of scientific research. TV/DVD watching is common: in the US at least, by two years old over 90% of children regularly watch TV, spending an average of 1-1.5 hrs a day in front of the box. Very young babies (under 1.5 years old) cannot, however, really understand TV programmes, and are instead mainly attracted by obvious changes like applause or visual surprises.

Children learn new words or actions better when an adult is teaching it to them live, rather than via a television screen, and the worry is that parents talk to their kids less when the TV is on. And a growing number of studies suggest that children who spend longer watching TV/DVDs have delayed language development, at least in the short-term, and may also develop a worse attention span.

A child’s play may also be hindered by the distraction of a TV that’s on in the background, so the AAP advise to turn it off altogether. Many parents also use TV/DVDs as a sleep aid, but there is evidence that bedtime viewing may lead to more disturbed and shorter sleep.

Karmiloff-Smith, on the other hand, argues that we live in a media saturated world and it’s unrealistic to expect parents to shut down all media use. This view has support from some of the evidence cited in AAP report itself. Despite the original recommendation in 1999 that parents should be discouraged from letting their babies watch TV/DVDs, over 90% of them in the US currently do so by the time their child is two years old. What’s more, the average age that TV is introduced is 9 months, so the advice is clearly not striking a loud enough chord.

From my experience, I can certainly appreciate this. The AAP report says that many parents use the TV so that they can have a shower or cook dinner. Absolutely! Even these seemingly mundane activities can feel like an exercise in military-like efficiency when you’re looking after a child. A 10-minute respite when they’re quiet and content gazing at a TV or prodding an iPad can be just too tempting.

It’s also interesting to consider that throughout history many new technologies have been treated with caution. Dr Vaughan Bell, a psychologist based at King’s College London, has highlighted how the printing press, popularisation of the radio, and now the Internet have been damned for ruining kids’ brains.

Karmiloff-Smith goes on to say that, rather than banning TV for babies, TV programmes just need to be made better and based on science developments. For instance, the visual system is attracted by movement, but most kids’ TV programmes have their focus on the centre of screen. Instead, objects and features that come in from the sides, move across screen and encourage the child to interact promotes the active participation that’s good for mental development. For very young babies, moving image media may even have advantages over books, which are static and whose main attraction is the rustling of the pages.

The caveat in this is that Karmiloff-Smith reveals herself to be a scientific consultant to a DVD company that is designing such programmes. This could cause suspicion of a financial conflict of interest. But her honesty and gusto make me suspect that she became a consultant so that she could promote these ideas, rather than the other way around.

She finished the interview by emphasising that parents still need to interact with their children and the TV shouldn’t be used as a babysitter. But we should think more carefully about which types of media can stimulate the visual and auditory systems, so as to help train the attention and memory systems early.

I’ve written before about the various kinds of programmes and the various contexts in which kids can watch TV, which may have different effects on child development. And some of the evidence cited in the AAP report highlights these complexities. The effects on children’s attention, for instance, seem to depend on the programme content and style, with problems seen not when the content is deemed educational but only when it’s geared towards entertainment. And when a parent watches a programme with an infant and talks them through it, the child tends to become more attentive and responsive. The AAP report also points to evidence that watching Sesame Street can have a negative effect on expressive language in children under two. But the same study showed that watching other programmes, such as the North American-based shows Dora the Explorer, Blue’s Clues, Arthur, Clifford, or Dragon Tales, was associated with greater vocabularies and higher expressive language scores. So it appears that not all ‘screen time’ is equal.

The AAP report seems to fall into the trap of treating all TV and DVD viewing as the same:

For the purposes of this policy statement, the term “media” refers to television programs, prerecorded videos, Web-based programming, and DVDs viewed on either traditional or new screen technologies.

Another major limitation of the AAP report is that all of the cited studies are, by necessity, observational. These investigations are good at highlighting whether two factors are associated with each other, but they cannot tell you whether one causes the other. As the report itself asks, are children with poor language skills simply placed in front of the TV more? Are children with shorter attention spans more attracted to screens? Are parents who are less attentive on the whole, more prone to resort to screen time? If so, then turning the TV off would not necessarily lead to more parent-child interactions.

And some results are just contradictory. One study in the US showed that when the mother’s educational status and household income were taken out of the equation, the association between TV viewing and poor language development disappeared. This appears to have been glossed over by the AAP.

So how do I answer my original question?

The AAP are right to caution against a lot of TV for under twos (over four hours a day, say), as this is when the damaging effects are really apparent. But Karmiloff-Smith is also right to say it’s unrealistic to expect no TV at all, and that the right programme in the right environment is fine and potentially beneficial.

And I’ll leave you with this quote in Time from Dr Dimitri Christakis, a paediatrician at Seattle Children’s Hospital:

Ask yourself why you’re having your baby watch TV. If you absolutely need a break to take a shower or make dinner, then the risks are quite low. But if you are doing it because you think it’s actually good for your child’s brain, then you need to rethink that, because there is no evidence of benefit and certainly a risk of harm at high viewing levels.

Parenting science: 12 top stories of 2012

It’s that time of year when we’re flooded with ‘best of’ lists, so allow me to jump on the bandwagon. 2012 has been a great year for science – the discovery of the Higgs Boson, the landing of Curiosity rover on Mars, and the ‘encyclopaedia of DNA’ that has given us the deepest insights into the human genome.

Here, I’ve picked out some of the stories that might interest parents, covering areas such as child learning and development, reproductive technologies, embryology, genetics, and even a bit of public policy thrown in. I’m sure I’ve missed some interesting ones too, so please add yours in the comments!

Mouse eggs created from stem cells for the first time (New Scientist)

Once a fully functional body cell develops from a ‘parent’ stem cell, it’s thought there is no going back to the previous state. A team of scientists in Japan, however, used a cocktail of signalling molecules to reprogram skin cells to become immature egg cells in mice (they had already done this to create sperm cells). What’s more, these cells could be fertilised and, in some cases, led to healthy mouse pups. This was a stunning feat of biological engineering that will help in the study of mammalian development and also hold promise in treatment of infertility. In a related story, controversy over whether biology textbooks need to be re-written took a turn when more convincing evidence was published that the number of eggs in a female isn’t fixed for her lifetime but can instead by replenished from a stem cell stock.

‘Chimera’ monkeys created in lab by combining several embryos into one (The Guardian)

The headline is pretty self-explanatory and the article itself is a fascinating read, so I won’t re-invent Ian Sample’s superbly crafted wheel. So if you want to know more about the controversial technique of creating normal, healthy monkeys with cells from more than one embryo and why it might benefit stem cell therapies, go read it! This may not be as bizarre and ‘unnatural’ as it first sounds, though, as we may all be walking chimeras and carry cells from siblings, aunts and uncles.

Genome Sequencing for Foetuses (Wired Science)

Being able to test foetuses for genetic faults that increase the risk of a serious disease, such as Down’s syndrome and blood or nervous system disorders, is hugely important. This is currently done mostly by invasive techniques such as taking samples of the placental tissue or amniotic fluid. This study, however, showed that it’s possible to work out the foetus’ genetic make-up by piecing together tiny fragments of DNA floating around in the mother’s blood. The ease of such a test would, of course, raise ethical issues about what is appropriate to screen for and what counselling parents would need, as well as requiring a firm and clear communication of risk.

DNA-swap technology almost ready for fertility clinic (Nature News)

Mitochondria are little energy powerhouses within most of our cells and they contain a small amount of their own DNA that is inherited wholly from the mother. A range of devastating diseases, that can affect the brain, liver, muscle and many other organs, are caused by defects in this mitochondrial DNA. A group of US researchers showed it was able to swap the mitochondria in a mother’s egg with one from a healthy donor to produce a normal looking embryo free from the mitochondrial genetic faults (restrictions on this technology would not allow a live birth). You can read about how the scientists actually did this in David Cyranoski’s article. And I would add that, contrary to some scare stories, these would not be ‘3 parent babies’ – mitochondrial DNA contains only 37 genes (involved in protein synthesis and biochemical reactions that make up respiration) compared with the many thousands of genes coded for by the DNA in the nuclei of our cells.

Babies are born dirty, with a gutful of bacteria (New Scientist)

Earlier this year I blogged about the “The microworld that lives inside you” and how the microorganisms that outnumber our own cells 10:1 are first transmitted from mum as a baby is born. A study by Spanish scientists, suggested that this isn’t the whole story. By studying the “meconium” – the baby’s first poo that is made up of materials ingested during the time in the womb – they detected two types of well developed bacteria. We don’t know for sure, but these were probably passed from the mother through the placenta. Our so-called “microbiome” is really important, because it influences our digestion, immune system, risk of disease, and maybe even our personalities.

Childhood stimulation key to brain development, study finds (The Guardian)

A US study provided more evidence that a sensitive period of learning and development exists early in childhood. They surveyed children from when they were four years old, recording details such as the number of books and the types of toys they had, to measure the amount of mental stimulation to which they were exposed. They also scanned the brains of the same children when they were between 17 and 19. As Alok Jha explains: “…the more mental stimulation a child gets around the age of four, the more developed the parts of their brains dedicated to language and cognition will be in the decades ahead.” Of course, this was an observational study and so limits the strength of the conclusions about whether the types of toys really caused brain developments, but the way the researchers tracked the same children over many years and the factors they took into account (parental nurturance had little effect, for example), was particularly impressive. Another cautionary note: the results were presented at a scientific conference and, as far as I know, have not appeared in a scientific journal, which means it won’t have yet been properly quality assessed by experts.

Golden ratio discovered in uterus (The Guardian)

At the risk of straying into mysticism, this was a nevertheless alluring report of a Belgian gynaecologist’s claim that the uterus represents an aesthetically pleasing “golden ratio”. This ratio is derived from something called the “Fibonacci sequence”, which is a sequence of numbers starting 0,1,… where every subsequent number is the sum of the previous two (so: 0, 1, 1, 2 , 3, 5, 8, 13, 21,…). The ratio between pairs of number in the sequence (divide one by the other) ends up being 1.618, which is the “golden ratio”. As Alex Bellos explains, its devotees believe it expresses aesthetic perfection and is found wherever there is beauty. According to Dr Verguts, when women are between the ages of 16 and 20 and at their most fertile, the ratio of uterine length to width is 1.6, spookily close to the “golden ratio”.

What happens to women denied abortions? This is the first scientific study to find out (io9)

Another set of results presented at a scientific conference, rather than in a scientific journal, but that is worth noting nonetheless. Annalee Newitz cites a Facebook post written by the lead researchers of a study that followed up women who had sought abortions at different abortion clinics in the US: “We have found that there are no mental health consequences of abortion compared to carrying an unwanted pregnancy to term. There are other interesting findings: even later abortion is safer than childbirth and women who carried an unwanted pregnancy to term are three times more likely than women who receive an abortion to be below the poverty level two years later.” Newitz further emphasises the preliminary results: “When a woman is denied the abortion she wants, she is statistically more likely to wind up unemployed, on public assistance, and below the poverty line.” If these findings turn out to be valid when further quality checks are carried out, they could help shape the debate on abortion policies and the state support a women seeking an abortion receives.

Boys and girls may be entering puberty younger (New York Times and The Guardian)

A study on the timing of puberty in boys by the American Academy of Pediatrics complements an earlier study on girls, which both hinted that puberty is, on average, starting gradually earlier in both sexes. Current estimates, at least for US children, are that the average age of puberty onset is around 9 years in black boys and girls and around 10 years in white boys and girls (although full sexual maturity may happen later than this). No one, as yet, knows why, but speculations include diet, changes in physical activity, improvements in healthcare, and chemicals present in the environment that affect our hormones.

Fathers bequeath more mutations as they age (Nature News)

A Swedish study concluded that a father passes on more genetic mistakes to their children than do mothers, and the older the man, the more mutations he is likely to pass on. This is most probably explained by the fact that sperm are generated from dividing ‘precursor’ cells throughout a man’s life and this cell division becomes less precise with age. Most inherited mutations won’t lead to any problems for the child, but the occasional one may increase the risk of a genetic disease like autism or schizophrenia. Taken together with rising average age of fatherhood, does this help explain, at least in some part, why autism rates are rising? (It could, but awareness and diagnostic changes are also likely to be at play). It’s not definitive and it shouldn’t scare older would-be fathers, but it may help in better informed decision-making.

An HPV Vaccine Myth Debunked (New York Times)

One of the arguments opposing vaccinating children against the Human Papilloma Virus (HPV), which can cause warts and cancer, is that in the minds of the young girls it frees them up to be sexually more promiscuous. Studying long-term medical data from girls in Atlanta, USA, however, showed no difference between vaccinated and non-vaccinated girls in pregnancies, sexually transmitted diseases, testing for sexually transmitted diseases, or contraceptive counselling. The article finishes by saying: “As one expert said, parents should think of the vaccine as they would a bicycle helmet; it is protection, not an invitation to risky behavior.”

Hungry mothers give birth to more daughters (Nature News)

Another eye-catching story was the report that during the Chinese Great Leap Forward famine, the proportion of boys being born dropped (from 109 boys for every 100 girls to 104 boys for every 100 girls). This sets up the tantalising possibility that sex ratios are adjusted in response to environmental conditions such as nourishment, a situation already known in deer where undernourished males tend to have fewer offspring than undernourished females (although in humans other factors like psychological and physical stress could be at play).

A final story that caught my eye was the latest results from the Avon Longitudinal Study of Parents and Children (ALSPAC), also known as the Children of the 90s, which probably warrants a blog post in itself. Nature News covered it and The Guardian’s sublime Science Weekly podcast featured it too (after 26:10). My favourite bit was how they collected the children’s milk teeth: “We had to negotiate for those. They are worth money to children, after all. In the end, we only got the milk teeth when we presented each boy and girl with an official Alspac form, signed by the tooth fairy.”

How sweet!

Telly addicts: alarm over kids’ TV viewing habits

There was a flutter of activity across Twitter and blogs the other day, in response to some reports that suggested kids’ increasing TV viewing was having a detrimental effect on mental health. According to the reports, TV viewing should be limited for children even into their teens and banned altogether for under-threes. The issues highlighted here will be familiar to detractors of Bad Science and Bad Reporting, but I wanted to record some thoughts for posterity.

I first saw the story in The Guardian and it was also picked up by BBC News, The Independent, The Telegraph, Daily Mail, Metro and many other outlets. Whilst it’s an interesting and worthwhile area of study, the paper published in the journal Archives Of Disease In Childhood and the subsequent press statements, had a few problems that undermine the stark headlines.

The paper was not an original research paper, but an opinion piece that looked back at some previous research. The chief agitator in this is Aric Sigman, a psychologist whose method of ‘cherry-picking’ evidence Ben Goldacre has had much to say about in the past. ‘Cherry-picking’ is essentially picking the bits of evidence that support a particular claim, whilst ignoring other evidence that doesn’t. As Goldacre points out, a better way to analyse previous research is to perform a ‘systematic review‘. These reviews say exactly how the literature was searched and compiled, which means it is more free from bias and allows others to reproduce it.

As for this specific case, Pete Etchells at SciLogs does a good job at highlighting the problems with the selective nature of the analysis and why it’s important to understand the cause of something before issuing guidance on fixes. I worry that many developmental outcomes – such as empathy, attention, educational performance – are lumped in under the banner of ‘mental health’, but that is probably for someone more qualified to comment on. Professor Dorothy Bishop‘s remarks in the Guardian article are salient too – if Sigman’s concerns are to do with kids just sitting for long periods, you shouldn’t advocate reading books for too long.

My first thought on reading the reports was that the conclusions seem to be based entirely on correlative studies, so it’s hard to determine cause-and-effect. What if children who watch more TV are also more likely to have inattentive parents? You may still see an association between more TV watching and developmental problems if these are both caused in some way by inattentive parenting, but enforcing a reduction in TV time wouldn’t do anything – getting parents to interact more at other times would have the most effect. (For the record, this is just an example of ‘correlation does not imply causation’ and I’m not suggesting this is supported by the evidence!)

On a more general but related point, there is a real problem with defining ‘screen time’, because you’re essentially describing a medium and not an activity. The Mind Hacks blog (written by KCL psychologist Vaughan Bell and Sheffield University psychology lecturer Tom Stafford) has written about this in relation to internet use. Bell has also written about how there have been worries throughout modern history over new technology. Even ‘education’ was once considered a risk to mental health.

As for TV, there are clearly different types of programmes kids can watch – some are aimed at learning and education, some are musical and participatory, some are interactive, and so on. And there are also different contexts in which to watch TV – alone, with parents talking things through, in the background whilst doing other things, etc. Understanding whether different types of TV interaction have different effects or whether other factors in the child’s environment tend to lead to a particular sort of behaviour, are critical in getting to the root of the issue.

The evidence just isn’t strong or reliable enough to make the sort of alarmist claims Sigman has made. And this is why it is again so disappointing to see the same blanket coverage across much of the press, with little in the way of a proper critique (Prof Bishop’s comments aside). It was once again left to bloggers and commentators on social media to provide a more discerning look at the issues.

I want to emphasise that I’m not dismissing these issues, and there may well be problems caused by excessive use – however that’s defined – of certain types of ‘screen time’ (as Etchells notes too). But it’s important to know what you’re measuring and understand the nuances. It is also crucial to have proper evidence before issuing supposed evidence-based guidance.

Is breastfeeding all it’s cracked up to be?

Zoe Williams wrote an intriguing article in The Guardian that challenged some widely held assumptions and beliefs about the benefits of breastfeeding (‘The backlash against breastfeeding’). It did, as you might imagine, generate strong reactions from those who vehemently espouse that “breast is best”. It was written on the back of a recent front cover of Time magazine that caused an even greater furore (‘Are you mom enough’), which championed a form of ‘attachment parenting’ that encouraged breastfeeding until the child is well over one year old.

I did feel that Zoe Williams’ article raised some interesting points, some of which I wanted to address here.

But I also had the strong suspicion that the claims made for [breastfeeding’s] benefits – the higher IQ, the protection against obesity, the superior bonding, the warding off of disease both now and for ever, both for baby and for mother – were mostly bogus. A lot of the reasoning seemed syllogistic (babies born into low-income families end up fatter; low-income mothers breastfeed less than high-income mothers; therefore breastfeeding prevents obesity) or frankly lame.

This relates to the concept I’ve written about before, that correlation does not imply causation. As she quotes Joan B Wolf later in the article: “Breastfeeding cannot be distinguished from the decision to breastfeed, which could represent a more comprehensive commitment to healthy living.”  

While this is true, that is not to say that the researchers who conduct these types of observational studies are not aware of this limitation. It is hard to do interventionist, controlled studies, as you would do in a lab or in randomised controlled trials to test a new medicine. Imagine randomly assigning new mothers to one of two groups – breastfeeding or formula-feeding – and getting them to stick to this regimen so that you can measure the outcomes of the children. Not likely, which is why such interventionist studies have been limited (1 & 2).

So researchers work with the tools available to them. They try to include appropriate comparator groups and make statistical adjustments to account for potential confounding variables. Not perfect by any stretch, but the best available methods.

I knew a lot of mothers who formula fed; they didn’t seem to love their babies less.

Ignoring the submission to anecdote, which is a mortal sin to evidence-based thinkers, a more worthwhile point to address is an argument I’ve often heard that goes approximately: “Well, they say breastfeeding is best, but I formula-fed and my child turned out alright”.

There are two key flaws in this reasoning. One is that by advocating breastfeeding, it is implying that formula-feeding is bad. No. It’s just there’s less chance that any outcomes associated with breastfeeding will also be seen with formula-feeding. The second misconception is that there’s a complete separation, or dichotomy, between the two groups. But here we’re comparing averages of large study groups – there will be huge amounts of variability around the averages and a lot of overlap, and only the right statistical analyses can reveal any true differences.

Put simply, there will be mothers of formula-fed babies who form strong attachments (to carry on the example in the article) and mothers of breastfed babies who do not.

By analogy, there will be some people that do all the ‘right’ things – not smoke, eat healthily, exercise, apply sun cream – who will get cancer and there will those who smoke 40-a-day and drink to excess who do not. It doesn’t disprove the link, it’s all about stacking the odds in your favour.

(I should clarify that the evidence I’ve seen for superior bonding associated with breastfeeding is somewhat weak, but I referred to it here to address a more general point about the common use anecdotal evidence).

This struck me as a bizarre place to have arrived at; where even to talk about the evidence behind the benefits of one type of infant feeding over another is heretical.

Absolutely correct. We should constantly gather and scrutinise data, and if strong enough evidence emerges that contradicts our prior assertions, then we should be prepared to change our minds. I applaud the fact that this article was written, even if there are bits I wouldn’t necessarily or wholeheartedly go along with, as we should always be ‘talking about the evidence’.

The questioning of the orthodoxy is taken as a direct attack on babies.

[Charlotte Faircloth, sociologist]: “… Everything has got very heated, and very moralised. How you feed your kids is no longer a personal decision. There’s this idea that you can breastfeed your way out of poverty, or if you don’t breastfeed your kid’s going to be fat or have a low IQ…” She pauses. “It’s all got a bit out of hand.”

Williams is right that some breastfeeding advocates are evangelical and overly ideological about breast milk, to the point that some mothers feel over-bearing pressure to breastfeed. As Charlotte Fairclough is quoted, it’s a personal decision. Fairclough also touches on my earlier point that there’s no binary distinction in the outcomes of children who are breastfed and those who are not – breastfeeding doesn’t determine the outcome but may make it more probable (and, if it does, it will certainly still only be one factor amongst many).

Williams then quotes French feminist Elisabeth Badinter:

“when it’s recommended that you breastfeed your child for one year – six months exclusively, with nothing else, day and night, on demand – there are obviously consequences for a couple.”

“There are women for whom breastfeeding is a true pleasure. It’s very good for them and it’s very good for the baby. But to breastfeed a baby if the mother herself doesn’t like it? It’s a catastrophe. The decision to breastfeed is an intimate and private decision. No one should be able to interfere.”

In my mind, this touches on something I have written about before – that to lay down a hard-and-fast prescription for parents to follow is not always straightforward or productive. A more nuanced approach is often required that takes into account the familial circumstances and considers the parents’ well-being as well. It would be no good hectoring parents to follow a particular path, if it leads to a significant worsening of their own physical or mental health, especially if the knock-on effect is a deterioration in family relationships.

It seems highly unlikely that this would allow people to be good parents nor provide a decent environment for the child (a brief look at the scientific literature suggests this assumption isn’t entirely unreasonable, e.g. thisthis and this). It also risks attaching blame to a parent for any perceived character flaw in their child, and guilt-tripping parents in this way seems a counter-productive approach.

The research about ear infections, respiratory disease and diabetes is very mixed. Neither fussiness around new foods nor constipation are classic or very salient markers of good health. The obesity studies are debatable. The weight loss of breastfeeding mothers is taken from a WHO report, based on two interventionist studies in Honduras. It’s nothing like that straightforward: it does use 500 calories a day, but if your appetite increases at the same time, it is amazing how quickly and easily you can pop 500 calories into your mouth. Meanwhile, Wolf points out, no study on maternal cancer has “distinguished the effects of breastfeeding from the behaviour of women who breastfeed”

Again, I agree, it’s not straightforward! But I would, perhaps, strike a more positive tone.

The studies aren’t perfect (Williams also quotes the American Academy of Paediatrics: ‘There are a lot of methodological problems’), but that’s no reason to just give up on evidence altogether. The best available evidence, as far as I can see, is saying that breastfeeding is likely to bring a range of benefits to the child, and possibly some to the mother. A Cochrane Review from 2009 includes many citations that support various benefits of breastfeeding, as well as a discussion of some of the uncertainties.

I also agree that the weight loss data must be taken in context, such as whether you are dealing with developed or developing countries, and some effects, such as iron status, can be achieved through supplementation. So, in some instances, there’s no need to be over-zealous about breastfeeding, as long as adequate healthcare advice is in place.

“The notion of risk [has been] transformed from a dichotomy to a continuum.” It’s no longer a case of “safe” versus “dangerous”; rather, everything carries some risk and you announce your fitness as a parent to the world by interpreting hazards in the most credulous, fervent way. The onus isn’t on the researcher to prove the point any more – the onus is on the parent, or parent-to-be, to prove that they’ll believe the researcher.

I’m not sure this is true and seems an over-generalisation. There’s a huge variety in parental attitudes and some are incredibly questioning, and whether and how this has changed in recent years is uncertain without any data. I think it misrepresents the role of a researcher, too – that the onus is on them to ‘prove a point’. Scientists don’t (or shouldn’t) undertake work to prove already held beliefs, rather they formulate hypotheses and design experiments to support or reject those theories.

There are lots of other points in and around the ones I’ve highlighted, a lot of which veer from my intention to address evidence-based decisions, but I do encourage you to read the whole article for some interesting discussion of feminism and social policy.

I’ll summarise by saying that I would still state that breastfeeding can potentially bring a range of benefits over formula-feeding, because that is where the balance of scientific evidence is, with little or no contrary evidence to dissuade me yet. And this should be reflected in the healthcare advice that is provided. I absolutely agree, though, that foisting this decision on mothers is, at best, unnecessary and, at worst, damaging. Healthcare advice must take context into account.

On a more general point, I welcome any sensible, critical look at the evidence behind claims, as Zoe Williams has done. It’s certainly made me re-evaluate – and in some instances, such as in the link to lowered risk of maternal breast cancer, made me temper – my own standpoint on the benefits of breastfeeding.

A final point, though. It was disappointing that an article that relied so heavily on rejecting or challenging some of the evidence that is used to promote the “breast is best” standpoint, did not once link to any primary research. A few quotes here and there from, no doubt, serious academics, and a link to a book, but nothing that could point the reader to the original research studies.

It is perennial complaint that evidence-based advocates level at popular journalists, so I don’t want to single out this author for special criticism. But it is something that could do with a cultural shift and, perhaps, mainstream commentators will start to follow the examples of their science colleagues.

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Hat-tip to Mum-in-law, Jenny, for The Guardian article.

The influence of early eating habits in children

Our little one, who is now 10 months old, seems to have got his eating sorted after a stubborn start. We started weaning around the World Health Organization’s recommended 6-month mark, using a mix of spoon feeding and baby-led weaning (more on that in later post). Since then, it has seemed apparent that some things have gone down better than others: scrambled eggs, yoghurt, cheese, toast, chicken, bananas and strawberries were all early hits, while broccoli, tomatoes and beef were swiftly rejected.

He seems to have developed an appetite for some foods after a unsure start, such as cucumber, carrot and apple. And this brought to mind a Naked Scientists podcast from a few months ago, which featured an interview with Marion Hetherington, Professor of Biopsychology at the University of Leeds, on children’s appetite and eating behaviour.

The full transcript is available here and the audio is available here. I’ve made a few summary points below, but do check out the full interview.

  • A developing foetus can encounter tastes and odours derived from the mother’s diet and toxins from the environment, and this may affect later food preference.
  • Babies fed with breast milk are exposed to a greater variety of flavours than are formula-fed babies, and this can mean they are more willing to try new tastes.
  • Babies are primed to accept sweet tastes from birth, whereas bitter tastes are rejected. This means that we have to learn to like bitter foods but not sugary foods.
  • Parents may need to try their baby 8-10 times with a new flavour before the child will accept it, so parents shouldn’t give up after the usual 2-3 times. Also, there may be a sensitive period between 6-9 months in which to introduce new flavours and textures, after which it becomes harder for the child to accept a new food.
  • If a child of school age is fussy about trying new foods, then using rewards and social praise is an effective way of persuading them to test new tastes.
  • Setting healthy eating preferences early on is best to keep healthy eating going into childhood. Even if eating habits go awry in teenage years, many return to their early healthy eating habits as adults.

I thought this raised some interesting points, such as the persistance needed to introduce new tastes during a sensitive time window, and was worth highlighting.

It’d be interesting to know how these environmental factors interact with genetically influenced preferences, such as whether early exposure to broccoli, sprouts or cabbage can moderate the repulsion certain people have towards a compound in those foods. It has been suggested that ageing, smoking or illness may modify this genetically based food preference, and so it would be intriguing to know whether child eating behaviour did so too.

On the benefits of breastfeeding (and getting the policy right)

Certain benefits of feeding children with breast milk over modified cow’s milk (‘infant formula’) have been well established, such as bolstered immunity, reduced risk of diabetes, and a lower risk to the mother of developing breast cancer. A recent article in the Observer introduces the possibility of an extra benefit of breast feeding, in that it could boost a child’s later cognition (as measured by IQ score). This is likely to be of interest to any parent wanting to help their child acquire the proper mental faculties to lead a fulfilling life.

by Flickr user: muskva*

This newspaper story, however, brings to bear some important cautionary tales. First of all, the types of studies the researchers have assessed mean results should be treated with a note of vigilence. It is unclear from the article whether the conclusions are based largely on the quoted researcher’s own research or a synthesis of past, published work conducted by others (more on that later), but the Institute for Social & Economic Research’s own website suggests that this is based on primary research. The Observer article does, however, indicate that the researchers analysed “studies in the fields of epidemiology and public health”. It is likely that these would have been observational studies, where the cognitive abilities of children from groups of women who had chosen to breastfeed their babies are compared with the IQ scores of children from other groups who had chosen to use infant formula. The Essex and Oxford researchers in the article appear to claim that those children who were fed breast milk, on the whole, outperformed those children who were fed formula milk. On the face of it, a neat result.

But that brings us back to familiar adage that correlation does not mean causation. It doesn’t take much scrutiny to realise that if children from more affluent families are more likely to breastfeed, then simply growing up in more comfortable, less stressful and education-rich environment could easily account for the improvement in cognitive abilities. The team that carried out the work are clearly aware of this, and claim to have corrected the data to eliminate the effects of other factors such as the family wealth, but this always introduces additional sources of potential error. This doesn’t make the research any less worthwhile, only limits the conclusions that can be drawn from it.

These types of study are often one of the first type to be done on human populations and it emphasises the experimental boundaries. If this sort of question were to be asked for, say, a rodent, the researchers could take a group of animals from the same population and split them equally into two groups. Each group could be raised in controlled environments that are identical to each other (temperature, access to food/water, number of companions, etc.). The only variable would be that one group would be suckled with mammary milk and the other fed with milk from another source. Any difference in the performance of the offspring in subsequent behavioural tests could suggest that it was down to the mammary milk. It wouldn’t prove it, though, as it could be more subtly due to increased mother-baby contact or an unknown variable, but it would be an interesting result that would warrant further investigation.

It is, understandably, improbable that this kind of experiment would be done in a human population – who could convince a mother to agree to be randomly assigned to one of two groups, breastfeeding or non-breastfeeding? – and so investigators have to use the next best thing. This could lead to targeting interventions or different levels of support at two or more groups from the same socioeconomic background and seeing whether that affects children’s IQ scores, which would allow comparison of women from the same group but receiving different treatment. But, again care needs to be taken to eradicate or account for potential confounding factors.** These limitations bedevil many researchers trying to find out more about factors affecting child development and is part of the reason why much of the guidance about parenting is not evidence-based or is, at best, based on suggestive findings.

Anyway, the second cautionary tale comes from the way the evidence is presented. The newspaper article states that the scientists are to present their findings at a policy conference. Conferences are the vital arenas at which researchers’ current theories are presented to and subsequently challenged (robustly!) by their colleagues. Many a hypothesis has been revised, re-interpreted or rubbished at a conference. Many pieces of work, such as that in the Observer article, will not have even been published in a peer reviewed journal. This means that it has not been formally reviewed and accepted as scientifically valid by other experts in the research field.

Even after this assessment and publication by a scientific journal, it is still only one piece of evidence in a vast sea of scientific work. It often takes a review of several scientific studies tackling the same research question before any firm conclusions can be made. So with this appreciation of the scientific process, the claims in the Observer article start to look less conclusive as the headline would suggest. As I mentioned earlier, the researchers are well aware of the caveats, but a casual reader may not be. It took digging beyond the article, to the ISER’s website, before I could determine the nature of the research, as the article didn’t link to anything other than more guardian.co.uk articles.

This is a problem that is widespread in science reporting – bold claims in newspapers are often based on tentative evidence, unpublished findings or misleading press releases (see ‘churnalism’) – and is a particular problem when it comes to parenting, as it can instantly affect the decisions parents make. One only has to look at scare stories about pregnant women’s sleeping position and the risk of miscarriage, vaccine safety, mobile phone use, plus countless other examples, to see the difficulties people face in picking out the sound evidence.

It is also problematic because evidence presented in the media can influence public opinion and the policies introduced by governments. Looking back to the breastfeeding story, if it is genuinely that the act of breastfeeding or a component of breast milk that boosts the chances of a child having improved cognitive scores, then the government may wish to look at improving breastfeeding support programmes. If, on the other hand, the major influence turns out to be the societal factors, then this would require a broader set of interventions that tackle social deprivation.

A further issue with policy documents, such as the one mentioned in the Observer, is that they circumvent the usual quality control for scientific research. They are often not published in peer reviewed journals and, as such, not subjected to the same rigour or openness as work that has been critiqued by other experts in the field. This opens up the possibility of a greater degree of bias and subjectivity. In this case as well, the report is not yet available (only a working paper) so the general public has to largely rely on the media’s reporting of researchers’ interpretations, something that is riddled with potential problems.

For the record, the Observer article seems fairly non-sensational – the headline is probably overly-conclusive, there’s a lack of linking to information about the conference and research, and the caveats could be included.

The causes and consequences of speculative science reporting have been dissected brilliantly elsewhere (see Martin Robbins of The Guardian on the subject and Brian Switek at wired.com for a recent example), so I will summarise by saying that it is incumbent on scientists to not inflate the nature of their findings for the sake of publicity, the universities or research institutions to issue balanced press releases, and for science journalists not to over-spin the story.

Not that I’m asking too much.

*(under Creative Commons licence, some rights reserved: http://creativecommons.org/licenses/by-nc-sa/2.0/deed.en)

**Interestingly, another recent research article does point towards a causal link of breastfeeding with infant IQ, by seeing whether the same trends are apparent in both high-income and middle-income populations