Tuesday, August 19, 2008

Feminist Parenting: Advice, Doctors, and Dr.'s Advice

(Note to readers: As sometimes happens after I've posted in a hurry, I've reread this piece and discovered that, although it seemed fine when I pressed publish, something about it now doesn't sit well with me. Regular readers will know that we're geeky sorts of feminists here, and usually pretty good skeptics to boot. So, I'd like to stress that the advice of your doctor is not to be ignored. When posting, my intent was not to cast aspersions on the ability of pediatricians to give good advice, but rather to prompt some discussion about how new parents cope with the bombardment of suggestions that often accompanies pregnancy and birth - and how doctors can best help them sort the good from the bad.)

Part of the stress of being a new parent comes from having to sort through often conflicting messages about what's best for you, your family, and your baby. Grandma, Dr. Spock, Elmo - everyone seems to have an opinion on what you should be doing, and what you're probably doing wrong. Worse, this is pared with the realization that - possibly for the first time in your life - your decisions don't just impact you, there is someone else entirely dependent on you, upping the ante of each choice. Still worse - companies know that expecting and new parents are stressed about making healthy living choices, and will try to take advantage of our fears and confusion in order to sell crap like Mummywraps, designed to protect against "electro-smog."

Between the advice from other parents, half-believed "old wives' tales," and books like What to Expect when You're Expecting, it can be difficult to know what - or who - to believe.

Of course, your doctor should be the expert who sorts through all the woo and superstitions, and provides solid facts. Yet, even in the pediatrician's office, new parents can feel insecure about any choice they make, as Elena of California NOW explains:
“Is she still breastfeeding?”

“Yes, we’re still breastfeeding,” I said proudly.

“You need to work on weaning.”

I sat there in shock. After a year of strong breastfeeding encouragement I was suddenly supposed to immediately wean her?

“Well, we were planning to let her self-wean when…” I started.

The doctor cut me off in mid-sentence. “Is she sleeping through the night yet?”

“No,” I said, guiltily wondering if that was somehow my fault.

“That’s because of the breastfeeding; it doesn’t fill their stomachs enough. You also need to move her into a crib,” she said, looking at us significantly, “You need to be able to get more time as a couple. Move her into her own room if you can.”

Jesus Christ, I thought, is she actively trying to destroy any chance of sleep for me?... And who was she to tell us with that knowing look that my husband and I needed “more time as a couple”? When did my baby’s pediatrician get a say in our sex life?

Elena's experience brings up multiple issues new parents often face when at the doctor's office. Parents worry that the decisions they thought were best might hurt their child anyway. There can also be confusion about what is solid medical advice backed up by research, and what is simply a doctor's personal opinion. Finally, there's the conundrum of what to do when your doctor's advice goes against your own ideas about what's best for your family and relationships.

Of course, our blog's contributors include a couple of doctors and medical professionals, so we have to look at these issues from both sides. So, I'm inviting some discussion:

Parents: How did you decide what was good advice and what was baloney? How did you set your boundaries with advice-givers? Did you have any problems with your doctors, and how were they resolved? Finally, what tips would you give young parents just beginning the challenge of deciphering what's good advice and what's complete bunk?

Doctors: How do you help patients make the best decisions for themselves and their families? How do you help them figure out what of the advice they've been given, sometimes from beloved grandmothers, is tripe? Is there such a thing as feminist doctoring, or is it rather a question of having a good 'bedside manner'?


maggie said...

I found that I finally just started ignoring everyone's advice and started trusting my own instincts about what to do. If I needed parenting advice I'd turn to sites such as Love and Logic, and pick and choose what felt right to me. I may not be the best mom in the world, but my kids love me and that's really all I care about. :)

Anonymous said...

Have you heard about SIDS? Sudden Infant Death Syndrome? putting a a baby to sleep on his/her back on a firm surface, without too many soft and fluffy things around (like mom, blankets and pillows) reduced the incidence of SIDS by tons (cant remember the exact number right now, but it is very well researched). That is typically why a pediatrician will recommend putting a baby in his own crib.

habladora said...

This is just a little note to say that the above Maggie is not our regular contributor, but a new commenter Maggie - welcome! And I'm going to have to go look for some data that deals with SIDS and co-sleeping. Unless, of course, there is a doctor in the house who just happens to be up on the lit...

daedalus2u said...

I am not a doctor, but have read a lot about SIDS and physiology. The "back to sleep" campaign did greatly reduce the incidence of SIDS. Why it did is not understood. Neither is the cause of SIDS. I suspect it has to do with nitric oxide physiology and how breathing is regulated and how that regulation changes over time.

There are 3 major signals that trigger breathing, low O2, too much CO2 and high levels of S-nitrosothiols. This last mechanism is the least well understood and is the most complicated. The relative sensitivity of these different mechanisms changes in infancy, and there is some thought that SIDS occurs during a vulnerable period during those changes.

Co-sleeping is controversial. It is not uncommon for infants to be smothered by being rolled on by a sleeping adult. Some infant deaths during co-sleeping that are termed SIDS probably are being smothered. Trying to differentiate between smothering and SIDS can be extremely difficult. Sleeping with mom can less stressful for an infant and for mom.

My guess would be that co-sleeping reduces SIDS a little (provided the infant is on his/her back), but the risk of SIDS during back sleeping alone is quite small. Co-sleeping greatly increases the risks of smothering. I think that increase in smothering is much larger than the decrease in SIDS. I think the change in risk due to back/tummy sleeping is larger than the difference between co-sleeping and alone sleeping (but there isn't really data to support quantifying those differences).

I think the compulsion that mothers and infants have to want to be together during sleep is a hold over from when our ancestors were living in "the wild", and there weren't safe cribs, warm clothing, and secure houses and the only thing that kept an infant safe was being with mom. Infant mortality was extremely high then, on average each woman only had 2 children survive and reproduce over her reproductive lifetime. The risks of SIDS and smothering were tiny compared to being carried off by a predator. Those millions of years of evolution have configured our instincts to protect against what were the most important risks then, not what are the most important risks now.

To put those risks in perspective, in the absence of birth control, a woman would get pregnant many times. If we assume on average 10 pregnancies but only 2 survive that is a mortality rate of 80%. Now the total infant death rate (under 1 year old) is 0.687%, for SIDS it is 0.054% and for accidents is 0.026. Most infant deaths are due to congenital deformities, short gestation, low birth weight other complications of pregnancy/birth 0.334% and other 0.219.

habladora said...

More (here) on Parenting, Experts, and Advice from Petpluto.

Anonymous said...

SIDS deaths in the U.S. decreased from 4,895 in 1992 to 2,247 in 2004. But, during a similar time period, 1989 to 2004, SIDS being listed as the cause of death for sudden infant death (SID) decreased from 80% to 55%. According to Dr. John Kattwinkel, chairman of the Center for Disease Control (CDC) Special Task Force on SIDS "A lot of us are concerned that the rate (of SIDS) isn't decreasing significantly, but that a lot of it is just code shifting”.

In a 2006 letter to the editor in the Journal of Pediatrics Dr. Rafael Pelayo, Dr. Judith Owens, Dr. Jodi Mindell, and Dr. Stephen Sheldon asked the following question of the American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome after their Pacifier and Co-sleeping report was published:
"...from the perspective of the field of pediatric sleep medicine, the policy statement's laudable but narrow focus on SIDS prevention raises a number of important issues that need to be addressed. In particular, the revised recommendations regarding cosleeping and pacifier use have the potential to lead to unintended consequences on both the sleep and the health of the infant. The potential implications of a SIDS risk-reduction strategy that is based on a combination of maintaining a low arousal threshold and reducing quiet (equivalent to Delta or slow-wave sleep) in infants must be considered. Because slow-wave sleep is considered the most restorative form of sleep and is believed to have a significant role in neurocognitive processes and learning, as well as in growth, what might be the neurodevelopmental consequences of chronically reducing deep sleep in the first critical 12 months of life?"

In a currently utilized model that explains the process in which slow wave sleep is involved in memory consolidation the hippocampus acts as a temporary storage facility for new memories which are then transferred to the neocortex during slow wave sleep (SWS) [8]. In this model, acetylcholine acts a feedback loop inhibitor inside the hippocampus during REM sleep and wakefulness. The activity during the high cholinergic wakefulness period is believed to provide an environment which allows for the encoding within the hippocampus of new declarative memories. The low cholinergic environment during SWS is thought to then allow these memories to be transferred from the temporary storage of the hippocampus to their permanent storage environment in the neocortex and for memory consolidation [9, 10].
A significant way of decreasing slow wave sleep in infants is by changing their sleeping position from prone to supine. It has been shown in studies of preterm infants [11, 12], full-term infants [13, 14], and older infants [15], that they have greater time periods of quiet sleep and also decreased time awake when they are positioned to sleep in the prone position.

8. Hasselmo, M.E. 1999. Neuromodulation: Acetylcholine and memory consolidation. Trends Cogn. Sci. 3: 351–359.
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10. Hasselmo, M.E. 1999. Neuromodulation: Acetylcholine and memory consolidation. Trends Cogn. Sci. 3: 351–359.
11. Myers MM, Fifer WP, Schaeffer L, et al. Effects of sleeping position and time after feeding on the organization of sleep/wake states in prematurely born infants. Sleep 1998;21:343–9.
12. Sahni R, Saluja D, Schulze KF, et al. Quality of diet, body position, and time after feeding influence behavioral states in low birth weight infants. Pediatr Res 2002;52:399–404.
13. Brackbill Y, Douthitt TC, West H. Psychophysiologic effects in the neonate of prone versus supine placement. J Pediatr 1973;82:82–4.
14. Amemiya F, Vos JE, Prechtl HF. Effects of prone and supine position on heart rate, respiratory rate and motor activity in full term infants. Brain Dev 1991;3:148–54.
15. Kahn A, Rebuffat E, Sottiaux M, et al. Arousal induced by proximal esophageal reflux in infants. Sleep 1991;14:39–42.