Tuesday, January 25, 2011

Prescriptive Parenting, Part 2: What's the Deal With Babywise?

A while back I noticed something puzzling a friend had posted on Facebook. It was a screenshot of an iPhone sleep-training app. The idea is that app helps the weary, stressed-out parent keep track of how many minutes have actually passed  (usually less than they think, I'd imagine) since the last time they were in the nursery attempting to lull a fussy child to sleep. The app itself wasn't puzzling, but the comments under the picture confused me. I don't remember them verbatim, but essentially people were scandalized that Apple would allow its users to purchase an app that facilitates child abuse.

Child abuse? Holy shit! I've never had to use sleep training myself, but I think it's a potentially useful tool for parents who are too overwhelmed by their children's crying to make sensible sleep decisions. Calling it child abuse seemed a little extreme. I commented: I don't get it. What's so bad about this? My friend commented back with links denouncing a series of parenting materials called Becoming Babywise. Apparently, a large part of this strict, Christian fundamentalist approach to parenting is devoted to structuring a child's sleep schedule, which is what got my friend so worked up. The man behind the Babywise series, an evangelical minister named Gary Ezzo, believes that babies should be sleeping through the night by eight weeks. This is among many unrealistic beliefs being promoted by a man whose only child-care expertise comes from raising his own children. But just how bad could Babywise be, and was it possible that my friend (who practices attachment parenting, breastfeeds exclusively, and considers circumcision to be genital mutilation) was just overreacting?

Trying to find unbiased sources of information on this topic was surprisingly difficult. AP advocates like Katie Allison Granju describe Babywise as a sinister right-wing Christian agenda with potentially serious consequences in terms of children's mental and physical health. But Babywise parents and members of Ezzo's GFI ministry emphasize just how normal and common-sense the approach is, especially when compared to those who take attachment parenting to extremes. Now, I admit I haven't read these books myself (nor have I read Dr.Sears's attachment parenting book), but I've tried to figure out his basic approach to parenting by finding the answers to the following qustions.

What is the Babywise stance on sleeping, and can it be considered abusive?

Like attachment parenting, Babywise is focused on the way things ought to be. In Gary Ezzo's view, children should be sleeping through the night from a very young age. Parents should expect this and plan the infant's schedule accordingly. If a child wakes up crying, the parent should let him go at it for a while before checking on him. Ideally, the baby falls back asleep on his own. This is where sleep-training apps can come in handy. Time becomes extremely relative in the wee hours of the morning, and to an exhausted, aggravated parent a minute of crying can seem like an hour.

What this method doesn't take into account are the variability of a baby's cries. Sometimes fussing and whimpering can smooth out on its own as the baby shifts position or drifts back into sleep. But if he is uncomfortable or has a wet diaper, ignoring the problem only lets him get even wider awake as he waits for help. This can be stressful for him as he wonders why you are not responding to his cries. Plus, newborns get hungry every few hours, regardless of the time of day. Trying to ignore his hunger cries can be agonizing for mom and dad (and I doubt there is a mom alive who could sleep through such a sound), but can also be distressing to the baby, who is completely overwhelmed by the intense biological need to nurse.

So, while sleep-training itself is not abusive, using it in lieu of common sense can be. If you and your baby are both utterly miserable, then what you're trying is not working. Some parents who have refused to back down from Ezzo's expectations have ended up with children that are malnourished, dehydrated, and failing to thrive. Some babies really do sleep through the night starting at eight weeks or even younger. But to expect that of all babies is wildly unrealistic and potentially harmful.

What advice does Babywise offer about feeding?

Babywise emphasizes Parent Directed Feeding (PDF), which is just what it sounds like. Unlike attachment parenting, in which the baby's hunger cues determine when he is fed, the Babywise parent decides when, how often, and how much a baby should eat. Even breastfeeding (which the program encourages mothers to do) is to be done on a strict, carefully timed schedule. The idea is that you can "train" your child to only eat at appropriate meal times, even if it means they get very hungry between meals.

As children get older, the meals get even more controlled, to the point where kids as young as eight months are expected to have impeccable high-chair manners. They are to be discouraged from playing with their food, making a mess, throwing food on the floor, or rubbing it in their hair. This discouragement is often physical, in the form of squeezing a child's hand or swatting him. Based on the way my own toddler eats, I'd imagine it is an uphill battle for parents to get their children to behave the way they "ought" to at meal times.

So, Babywise condones parents hitting their children as a form of discipline?

Yes, but only in "appropriate" ways. While information in the more secularly-oriented Babywise series doesn't go into much detail on how to spank, the more openly fundamentalist Growing Kids God's Way (which Ezzo also wrote and published, previously to Babywise) has more specific instructions. Starting when the child is 14 months old, the parent should use "a somewhat flexible instrument (that) stings without inflicting bone or muscle damage…if there is no pain, then the instrument is probably too light or too flexible." Pain is the natural outcome of bad behavior and the parent must induce pain to ensure that the child understands this life lesson.

This belief is contrary to virtually any advice given by experts in the field of child care or child psychology. Physical punishment like spanking more often than not leads to angry, troubled children. The short term, fear-based improvement in behavior can lead to more serious behavioral problems down the road.

Is everyone who follows Ezzo's advice abusing their children?

Not at all. As with attachment parenting, most people who read these books do not follow Ezzo's advice to the letter. Many people (myself included) feel that the parent should be in charge of the child's schedule concerning eating and sleeping, at least after the baby has grown out of the feeding-around-the-clock stage. And a lot of parents, especially when harried and worn-out, have let loose with the occasional swat or firm grab of a misbehaving child. This is by no means effective behavioral management, but it is a far cry from actual child abuse.

However, those who are already inclined to hurt children may see Ezzo's books as justification for their violent tendencies. Instead of feeling guilty for losing their tempers, they feel vindicated and, in some cases, holy. There is also the problem of the insecure parent who trusts Ezzo's advice over their own experiences. I imagine a young Christian first-time mother trying to ignore a wailing child, crying because she believes something must be wrong with either her child or her. This is a tragic yet plausible outcome of committing fully to Babywise.

I realize this isn't the most topical post--after all, Babywise was denounced in 1997 in a "letter of concern" to the AAP signed by approximately 100 health-care providers. Since then, it has fallen out of mainstream popularity. But I think the damage from Babywise is still being felt by parents who attempt to structure their child's eating or sleeping habits, especially when other parents are so quick to label something as abusive.

Monday, January 3, 2011

Safe and Effective Cough and Cold Treatment for Children Under Four

Watching your young child suffer through a cold or flu virus is a particularly insidious form of torture. The snot, the ragged breathing, the pervasive crankiness. To add to the misery, the primary caregiver and snot wiper (in our family's case, me) often catches the same bug. The caregiver, however, has the option of taking drugs to alleviate the symptoms. A couple teaspoons of Tussin and I'm good to go, or at least able to breathe again. Not so for my little guy. The warning labels on children's cough and cold medicine have changed since my days in child care, strongly advising us not to administer doses to kids under four.

If you're anything like me, you wonder why. What happened in the past few years to change these products from helpful symptom relief to little-kid poison? Don't these things help children to sleep, breathe, and just plain feel better? What prompted the American Association of Pediatrics to change their guidelines  and what can we do to help our little sickie-poos feel better?

Which cough and cold medicines are affected by the new guidelines?

Antihistamines, decongestants, antitussives (cough suppressants), and expectorants. These active ingredients are found in a wide variety of products marketed for relief of cough and cold.

Pain relievers/fever reducers such as acetaminophen (Tylenol) and ibuprofen (Advil) are still okay for use in infants and small children, provided doses are measured properly.

Why did the AAP make these changes?

According to an FDA advisory panel, these products are ineffective and potentially hazardous when given to small children. There is not enough evidence of efficacy to justify the risk of adverse reaction or overdose.

Ineffective? But doesn't it make kids feel better, or at least help them sleep?

Intuitively, this seems to make sense. The caregiver doses the miserable, crying, phlegmy child with medicine and, usually within the hour, the child becomes drowsy and seems to breathe more easily. The medicine must have worked, right?

Not necessarily. The caregiver has fallen prey to the post hoc ergo propter hoc fallacy--in other words, he or she has confused correlation with causation. I admit I've fallen for this one myself; it's easy to attribute the seeming regression of symptoms to the administration of a drug. However, viral illness is not a fixed, static state. Symptoms fluctuate, with peaks of misery followed by valleys of relative improvement. Chances are, the kid would have calmed down and fallen asleep regardless, with or without the medicine.

In fact, one study comparing dipenhydramine (Benadryl) and dextromethorphan (cough suppressant) to a placebo found that cough and cold medicines are not effective in providing nocturnal symptom relief for children, nor do they improve quality of sleep for their parents. In other words, the family of a sick kid will be awake and miserable whether the kid is medicated or not. But there is a silver lining to this bummer of a study--all families in the study reported significant improvement on the second night, regardless of whether the children were given placebos or drugs.

Are cough and cold medicines really dangerous? 

Not if administered properly; most adverse reactions are due to dosing errors and accidental ingestion. If parents are diligent about measuring doses (and can tell a mL from a tsp), and always keep medicines out of reach, that shouldn't be a problem. Unfortunately, a recent study shows that parents are quite likely to incorrectly measure a dose (especially with the little plastic measuring cups--oral syringes are far more accurate), usually giving more than the recommended amount. In fact, emergency rooms visits for "adverse events" (i.e. overdoses) decreased substantially after the withdrawal of infants' cough and cold formulas from the market.

What about alternative remedies? Are they safe and effective?

While many people swear by Airborne, Oscillococcinum, and Zicam, there is no credible evidence that these products work as advertised.  Not only are they ineffective for symptom relief beyond the placebo effect, but they can also have serious side effects. Airborne containsVitamin A, which is toxic in high amounts. The makers of Zicam were sued and settled out of court after their product caused more than 130 people to lose their sense of smell. And a homeopathic remedy like Ocsillococcinum poisoned children after manufacturing errors led to an excess of an active ingredient (usually active ingredients are diluted until not a trace molecule remains, as in all "true" homeopathic remedies). Considering the typically high price of these products, there seems to be very little benefit to justify the risks.

What can I do to help my poor baby feel better? 

Medically speaking, not much. Cool-mist humidifiers can help ease congestion. If you're brave (and your child will let you), you can use a bulb aspirator to suck snot from the nostrils (be sure you're using it correctly so you don't puff air up there). You can also use saline drops to soothe and loosen the sinuses, and children's Vapo-Rub to help the child breathe (though this is not recommended for children under 2 because of the toxicity of camphor if ingested and the possibility of skin irritation).

Mostly, you just need to be patient. Kids get 6-10 colds a year on average, which tend to last up to two weeks at a time. That's a lot of snotty nights and grouchy days. But if you keep your child hydrated, well-fed, and comfortable, he or she will get better in a reasonable amount of time. Short of keeping children in a plastic bubble, there is no reliable way to prevent or cure occasional viral outbreaks. We just have to get through them the best we can. Children under four should be doing that without the aid of medication.

It's tempting to head to the drug store to buy something, anything, that will help our sick kids. It makes us feel in control, like we're being proactive and doing something to make what's wrong right again. But beyond that fleeting feeling of being a "good" parent, very little is gained from the purchase and administration of over the counter cough and cold remedies.