Are Vaccines Safe?

The World Health Organization (WHO) has declared the week of April 21, 2012 to be World Immunization Week. The purpose of the initiative is to spread information about the importance and safety of vaccines.

The question are vaccines safe and effective? weighs heavily on many parents. I’ll admit that even I, as staunch an advocate of vaccines as you’ll find anywhere, pondered that question on my way to the pediatrician with W. Not that I didn’t ultimately trust — no, KNOW — that they are both. Rather that the doctor was going to Stick A Big Needle! In My Baby! Regardless of where a mother or father stands on the vaccine issue, we’ve all had to answer this central question in our own minds.

Edward Jenner, By Vigneron Pierre Roch (1789-1872)

As this is World Immunization Week, I want to take some time to acknowledge and thank the father of modern vaccination, Edward Jenner. Dr. Jenner was an English country doc, born in the mid-18th century. During his time, smallpox was still very much epidemic, and was deadly in up to 60% of infected adults and 80% of infected children. Jenner was intrigued by the fact that milkmaids didn’t generally contract smallpox. They did, however, contract an illness called cowpox early in their milking careers. Cowpox wasn’t particularly serious. The milkmaids recovered and went on to live full cow-milking, smallpox-free lives. On the basis of these observations, Jenner inoculated (this word means to introduce an infective organism) several individuals with pus from an infected sore on the hand of a milkmaid with cowpox; this was the first modern vaccination. The vaccinated individuals felt a little sore and feverish, but did not contract full- blown cowpox. Those that Jenner vaccinated — including his own 18-month-old son — though certainly exposed in the course of everyday life, did not contract smallpox. They proved immune to the disease.

A child with smallpox, 1973. Photo from the CDC.

As parents, we might recoil in horror at the thought of a mad scientist father “experimenting” on his baby boy. Let me make it clear, though, that all this took place well before the development of germ theory (the notion that bacteria and viruses cause disease). Jenner and his contemporaries didn’t know WHY people got sick, they simply knew that people DID get sick (this actually adds to Jenner’s brilliance). As such, there would have been no possible mechanism for testing the vaccine in a laboratory, on animals, or anything of that nature. Jenner’s only options for testing his theory would have included stabbing a random passerby with cowpox pus and then exposing the unwilling victim to smallpox (not ok!), collecting many willing volunteers from the general public (not likely, since most people were afraid that if they were injected with cowpox pus, they’d grow cow limbs*), or using a combination of his own family and a very few willing volunteers. The natural question, of course, is did he vaccinate himself? The answer is no, but only because he was already immune to smallpox, having been inoculated as a boy through the hideously dangerous practice of purposeful exposure to the scabs and pus of smallpox patients.

*This seems ludicrous, I know. Then again, we’re 200 years after the fact now, and we can look back and laugh. Similarly, I’m sure the notion that vaccines are linked to autism will amuse future generations, who will think us peasants for having entertained that fear.

Some people shake their heads and say Jenner may have been a good doctor, but what a horrible parent, to expose his son to such risk. I would counter and say Jenner WAS a good doctor. Such a good doctor that he was DARN sure his theory would hold water. Such a good doctor that he wanted his theory tested so that, if accurate, it would literally save millions of lives. And I suspect he agonized about it. We don’t know; that part isn’t on record. But I suspect Jenner asked himself, in his own way and as we all do, will this be safe and effective? Then, too, there’s the fact that Jenner wasn’t exposing those he vaccinated — including his son — to a deadly disease. Rather, he was exposing them to cowpox. He suspected (and was correct) that they wouldn’t get a full-blown case of cowpox, but even had they done so, that wouldn’t have been a serious consequence. He didn’t vaccinate his son just to test a theory. He vaccinated his son because he believed in his theory, and wanted the boy protected from the disease. He engaged in some scientific critical thinking — a risk-to-benefit analysis — and decided that the risk of contracting cowpox was nothing compared to the benefit of immunity from smallpox.

Jenner has been strongly criticized in modern anti-vax circles for his “questionable experiments.” For instance, the website Vaccine Side Effects states:

Convinced of the virtue of vaccination Edward Jenner inoculated his 18-month-old son with swinepox, on November 1791 and again in April 1798 with cowpox, he died of tuberculosis at the age of 21 [sic]. James Phipps was declared immune to smallpox but he also died of tuberculosis at the age of 20.

That is to say, inoculating the children caused them to contract tuberculosis and die. This is out-and-out ludicrous. First of all, tuberculosis was rampant at that time, and was responsible for the death of about 25% of the population. Not 25% of the infected population, 25% of the ENTIRE population. Let’s put that another way; any one otherwise healthy person had a one-in-four chance of dying from tuberculosis. This makes it entirely unremarkable that both the boys referred to above died of the disease. Note that Jenner vaccinated many, many children, and the overall rate of death from tuberculosis among the vaccinated was no different than that in the general population. Oh and also? Tuberculosis is completely unrelated to pox, be it cow, small, or otherwise. The quote above is tantamount to saying The flu shot causes death! Every single person who gets the flu shot dies! Some of them die of heart attacks! Some die of strokes! Some die by overdosing on meth! The flu shot causes heart attacks, strokes, and meth use!!!

Those among us who are uncomfortable with Jenner’s experiments can rest assured that things are different now. Armed with germ theory and mechanisms for testing medical hypotheses in the lab long before they’re ever tested on people, no one needs to expose their toddler son to a microorganism in order to advance the science of medicine, or to a vaccine that hasn’t been tested in hundreds of different ways for safety and efficacy.

These days, smallpox exists only in biological laboratories. Photo from the CDC.

In any case, modern vaccines (named for the cows that carried the cowpox Jenner used to inoculate those early patients — vacca is Latin for cow) have indeed saved millions of lives. The CDC has a page that’s well worth a read on what would happen if we stopped vaccinating today. So Edward Jenner, during this World Immunization Week 2012, let me just say thank you. Thank you for being an excellent scientist, a true naturalist, an observer of the world and generator of ideas. Thank you for following through in testing your hypotheses, despite public fear and negativity. Thank you for being willing to put your own family on the line to save so many lives. Thank you for advancing the field of immunology. Thank you for the modern vaccine. Thank you.

On May 8, 1980, the World Health Organization officially endorsed a resolution declaring the global eradication of smallpox. Modern vaccinations are based upon the theories developed by Edward Jenner during his work with cowpox and smallpox.

 

What do you think about Jenner and his work?

 

 

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Pain Relief Techniques For Immunization Shots

The World Health Organization (WHO) has declared the week of April 21, 2012 to be World Immunization Week. The purpose of the initiative is to spread information about the importance and safety of vaccines.

Immunizations protect children and save lives. However, the idea of a shot (or two, or three) can be intimidating to young people, and the shots themselves are generally uncomfortable. In a recent blog post, I discussed the analgesic properties of sugar and — to a certain extent — of breast milk. For young infants, sugar water before or nursing during immunizations can provide significant analgesia. For older babies, toddlers, and young children, however, sugar water loses its analgesic properties. A study published in Pediatrics (Schechter et al) reviews some of the pain relief options that parents and doctors can use to help reduce the discomfort of vaccinations. These techniques not only reduce the perception of pain during the procedure, they also lessen the extent to which children associate the doctor’s office with discomfort, which reduces the likelihood of battles on the way to the pediatrician’s office.

The authors found that the effective techniques for reducing pain during immunizations included better preparation for both parent and child. Nervous parents make for a nervous child, so the authors recommend that health care providers review with parents the facts about vaccinations, including the reason for each shot, the benefits conferred by the shot, and a realistic discussion of side effects and discomfort associated with the injection. The parents can then use this information to educate their children in an age-appropriate way. For the youngest patients (those younger than two years of age), there’s not much in the way of pre-shot coaching that is helpful or relevant. Nevertheless, an informed, relaxed parent provides a reassuring presence. Older toddlers and preschoolers tend to anticipate upcoming events (which increases anxiety), so the authors suggest waiting until as close to the shot as possible to talk to them about what’s coming. In talking to a child about vaccinations, parents should address what will happen (in specific terms, including how many shots and where they’ll be given), what it will feel like (during and afterward), and various coping strategies (deep breathing, thinking about something pleasant, etc).

The authors also found that the injection site can make a difference. While the thigh is the vaccination site of choice for children younger than 18 months, and the deltoid is common in children older than three, there’s ambiguity regarding the best site for children between 18 months and three years. Generally, however, injection in the thigh is considered more painful, so the authors recommend making the switch to the upper arm as soon as the arm has adequate musculature. Further, they note, there is some compelling research to suggest that the “hip site,” which sits on the lateral buttock, is much less painful than many other injection sites. There isn’t currently enough research on the delivery of vaccinations in this location to recommend its routine use, but hopefully research will support the use of the hip site in coming years.

During the injection, parental behavior appears to significantly impact a child’s ability to cope. Children respond best to parents who interact in a calm, distracting way with the child (telling an interesting story, for instance, or using humor), or who help the child remember coping skills. Parents who are overly critical, apologetic, or — strangely — overly empathetic tend to increase their child’s distress. The best thing a parent can do during a child’s shot(s) is to stay calm and relaxed, help the child use pre-determined coping skills, or talk about something totally unrelated to the shot.

Another simple technique that can reduce pain is applying pressure to the injection site after a shot. There is not a significant body of controlled scientific research on the effectiveness of this technique, but anecdotal evidence suggests it’s effective, and there appear to be no risks, so it’s worth trying. Parents can ask the health care provider to put pressure (with a finger) on the shot site after withdrawing the needle. The idea here is that the brain can’t process multiple types of stimulation at once, so the sharp pain of the injection is “lost” beneath the more powerful stimulus of pressure. This is the same reason that people instinctively rub a bumped shin or funny bone.

 

Science Bottom Line:* Being informed, informing your child (in an age-appropriate way), encouraging coping skills, and helping to provide distraction can all reduce immunization-associated pain. Pressure on the site afterward also helps. Remember, vaccinations save lives; the discomfort associated with the shot is not a reason to skip or delay vaccinations!

 

How do you help your kids cope with shots?

 

Reference:

Schechter et al. Pain reduction during pediatric immunizations: evidence-based review and recommendations. Pediatrics. 2007 May;119(5):e1184-98.

2011 U.S. Measles Rates Highest In 15 Years

I’m willing to bet he would have been happier with the shot.

Misconceptions and fear have been fueling the anti-vaccination movement in recent years, particularly with regard to the measles, mumps, and rubella (MMR) vaccine. This is in part because a study published in The Lancet that linked the MMR vaccine to autism (Wakefield et al). In addition to rampant misinformation spread via the Internet, the Wakefield study continues to fuel public concern, despite thorough and unanimous scientific debunking by more than 20 studies (Poland), retraction by all but one of the authors – Wakefield himself — and retraction by The Lancet.

Unfortunately, despite overwhelming scientific evidence that the risks associated with the MMR vaccine are small and uncommon, particularly relative to the serious and more common risks associated with contracting the measles, some parents continue to refuse to immunize their children.

A report by the U.S. Centers for Disease Control and Prevention (CDC) not only underscores the significant risks associated with being unvaccinated for the measles, it also helps demonstrate the fallacious nature of many of the arguments against vaccination and highlights the importance of vaccination in protecting the community.

According to the CDC report, there were more measles cases reported in the U.S. in 2011 than in any of the prior 15 years. A total of 222 cases were reported, the majority of them in people less than 20 years of age. 65% of cases were in unvaccinated individuals, and another 21% of cases were in individuals whose vaccination status was unknown or not on record. Of those who were unvaccinated, a fraction (27 total cases) were under 12 months of age, and were therefore too young for the vaccine.

In light of this disturbing report, some common myths about measles…and the facts:

Myth: Measles is exceedingly rare in the U.S., as vaccination rates are generally high. Unless my children will be traveling to Europe or other parts of the world with higher measles rates, they don’t require measles protection.

Fact: While measles isn’t as common in the U.S. as it is elsewhere in the world (there were no U.S. cases in 2000, for instance), it’s imported from other countries (either by foreign travelers or by U.S. travelers returning from a measles-prone area) and can spread in the U.S., mainly due to unvaccinated individuals. Measles is contagious for about four days before any rash appears, meaning that travelers from foreign countries can bring the disease to the U.S. without being aware that they are doing so. The CDC notes that most cases of measles in the U.S. were brought in from Europe. Further, measles is so contagious that casual exposure to an infected individual (even one who doesn’t yet show signs of the disease) is very nearly 100% effective in transmitting the infection. Measles is spread through the air, meaning that it’s possible to get the disease without any physical contact with an infected individual.

Myth: Measles is a common, routine childhood illness, and there’s no reason to vaccinate for it.

Fact: Measles was common in the U.S. before the introduction of the vaccine in 1963. The disease is so contagious that essentially 100% of the population contracted it prior to the development of the vaccine. Simply because a disease was once common, however, does not mean it is “routine” or harmless. Measles complications are relatively common, and include severe dehydration and pneumonia. 32% of individuals who contracted measles in the U.S. in 2011 had to be hospitalized for complications. Thankfully, there were no deaths among these individuals. However, swelling of the brain and death are possible complications of the disease, occurring in about 3/1000 cases. Even among the individuals who do not require hospitalization, measles is a truly miserable experience. It comes with a high fever, which is accompanied by muscle aches, headache, and sensitivity to light. Unlike chicken pox, to which measles is sometimes erroneously compared because they both cause skin rashes, measles is respiratory and causes a dry cough and extremely sore throat, which contributes to dehydration. The rash can be very extensive (in many cases, it enters the mouth), and itches.

Myth: The MMR vaccine is more dangerous than the measles.

Fact: The MMR vaccine is associated with some mild side effects, including an innocuous and temporary rash in about 5% of vaccinated individuals. Moderate side effects, such as seizure, are very rare, occurring in about 1/3000 doses. Note that the moderate side effects (which are not life-threatening) are three times rarer than the risk of death from the measles. Serious side effects of the MMR vaccine, including death, are so rare that they can’t be statistically quantified. In other words, people die so rarely after getting an MMR that no one can be sure the death was due to the shot.

Myth: Since almost everyone in the U.S. is vaccinated against measles, my child will be protected.

Fact: The vast majority of U.S. citizens are vaccinated against measles. This means that measles won’t be able to take hold and spread across the country in the form of an epidemic, as it could have done before 1963. However, the disease can still spread from one individual to the next, particularly in areas of lower MMR compliance. The 222 cases of measles in the U.S. were primarily due to small outbreaks (there were 17 such outbreaks), where the average outbreak size was 6 individuals. Put another way, for every one case of measles brought into the country by a foreign traveler or returning U.S. citizen, five people who had never left the country got sick.

Myth: If I choose not to vaccinate my children, I’m not hurting anyone but my own family.

Fact: This is not so. To protect a group of people from a disease as effectively as possible, it’s important to keep the vaccination rate as high as possible. The fewer unvaccinated individuals in a population, the less likely that someone with measles will come into contact with an unvaccinated individual, which reduces the likelihood of an outbreak. Vaccines are highly effective — vastly more so than most other medical treatments — but they’re not 100%. This is especially true in children who have had only one of their MMR shots (the CDC recommends a booster at age 4-6). Maximizing the number of immunized individuals helps to protect those for whom vaccination may not be effective. There are also those, including babies under one year of age, who are not eligible for vaccination. Maximizing the vaccination rate among the eligible minimizes the risk to vulnerable members of the population.

 

If you vaccinate, do you worry about those who don’t? If you don’t vaccinate, what about it makes you uncomfortable?

 

References:

Poland. MMR Vaccine and Autism: Vaccine Nihilism and Postmodern Science. Mayo Clin Proc. 2011 Sep;86(9):869-71.

Wakefield et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children [retracted in: Lancet. 2010;375(9713):445]. Lancet. 1998;351(1903):637-641.

Lessons In Chemistry and Physics From A Toddler

1) 1st Law of Thermodynamics — the energy of the universe is constant. That is to say, if one system or object gains energy, another system or object must have lost energy. As the day progresses, I steadily lose energy, and W steadily becomes more and more energetic.

2) 2nd Law of Thermodynamics — entropy is always increasing. “Entropy” is a fancy chemical word for disorder. ‘Nuff said.

3) Processes are reversible. However, a process that occurs spontaneously in one direction requires an input of energy in the reverse direction, and vice versa. It takes me significant effort to clean up the house. W can take it apart again with no apparent expenditure of energy.

4) Macromolecules bind to one another via an “induced fit” rather than a “lock and key” mechanism. If you pound hard enough, you can get the square peg into the round hole.

5) The laws of the macroscopic universe are constant, and effects are predictable and reproducible. When W squeezes the fruit smoothie pouch, fruit smoothie comes boiling out all over the floor. Every. Single. Time.

6) The most damaging types of radiation are undetectable by humans. Beware the silent toddler.

7) The true nature of a particle is a mathematic combination of all possible states of that particle. Like Schrodinger’s cat, a toddler can exist in multiple (and completely oppositional) states at once. Like ecstatic and enraged. Or exhausted and wired.

8 ) The Heisenberg Uncertainty Principle states that it’s impossible to know both the position and momentum of a particle at the same time. This is because the act of measuring the position affects the momentum, and vice versa. Similarly, the very act of checking up on a toddler’s current activity affects the toddler’s next action, making it impossible to predict with any certainty what said toddler might do next.

9) Newton’s 3rd Law of Motion — every action has an equal and opposite reaction. When W throws herself on the floor of the grocery store and starts screaming and ripping all her clothes off in an attempt to get me to pick her up, all I want to do is run. Far. Away.

10) Gravity. It works.

 

What lessons in the physical sciences has your child taught you?

 

 

Sleep Training and Night Weaning a Breastfed, Co-Sleeping Toddler — Part 2

If it's called "co-sleeping," why isn't there room for anyone else in this bed?

Recently, I’ve blogged about my experience beginning sleep training with W. It’s been a week, and we’ve had both ups and downs, so I thought I’d post on our progress thus far.

After the totally failed attempt to get W to sleep in her crib (in honesty, it’s a pack ‘n’ play) last Thursday afternoon, I didn’t even try on Thursday night. Instead, I cuddled her in bed, and then lay her down next to me. She couldn’t seem to settle, though, so eventually I got up and put her in her crib and rubbed her back. Very few tears, very little fuss. She went to sleep and stayed that way until about 2 am, at which point she woke and I brought her into bed with me, where she slept until 5 and asked to nurse…but I made her wait until 6.

We were visiting relatives over the weekend, and she categorically refused to sleep in the pack ‘n’ play that I brought from home, so we took a giant step backward.

Consequently, Monday nap was really rough; lots of crying and carrying on. I took her out of the crib and tried to get her to nap in bed, but she just crawled around all over the place and wouldn’t settle. The fact that naps (or at least, getting naps started) can drag out into an hours-long process that is emotionally exhausting (for both of us) and that I don’t have time for is one of the reasons I’ve been wanting to get her moved into a crib for nap. I don’t care whether she sleeps in a crib at night or not — I am happy to have her in bed with me — I just need naps to be enforceable. Anyway, after totally failing to get her to sleep in our bed for Monday’s nap, I put her back in the crib and left the room for five minutes. She cried, of course. When I came back, I helped her lie down and rubbed her back, and she went right to sleep.

While she was sleeping, I did a little thinking about my goals with sleep training and how to achieve them. I decided my major goals are:

  • To get her to go down for a nap — or at least quiet time — by herself (that is to say, without me having to hold her the entire time) and in a relatively timely fashion each day
  • To night wean her (no nursing from the time she goes to bed until 6 am)
  • To make sure that none of this ever seems punitive to her

With that in mind, I realized that the business (as on Monday) of taking her out of the crib, bringing her into bed, and then putting her back in the crib would have to stop. No matter how I try to hide it, I suspect she can feel my frustration in this situation, and I don’t want her to think she’s being put in the crib as a punishment. Therefore, I decided that New Rule #1 is that she goes down for a nap in her crib every day. If she wakes up partway through her nap and it doesn’t look like I’ll be able to get her back down, I will go ahead and lay down with her in our bed, but she starts the nap — that is to say, falls asleep — in her crib.

To help reinforce the idea that the crib is her personal sleep area, I decided that New Rule #2 is that she starts each night in the crib. If (when) she wakes partway through the night, I will bring her into bed with me, but she starts the night on her own.

I want to make things as easy as possible on her (and me) emotionally, so New Rule #3 is that after we do our pre-nap or pre-bed routine (nurse, cuddle, and so forth), I lay her down in the crib and sit in a chair next to it, rubbing her back. The last few days, this has been sufficient to get her to sleep about 50% of the time for nap, and 100% of the time for bed.

On the days that rubbing her back for 10-15 minutes doesn’t work to get her down for nap (she’s too wound up, despite being tired, or she keeps standing up), I have been leaving the room for five minutes. This is not done in a punitive way; I basically say something like Sweetie, it seems like you’re having a hard time relaxing. I’m going to leave for a while and let you get settled. I’ll be back in five minutes. Leaving BEFORE I get frustrated keeps the frustration out of my voice. She cries when I leave, but with only one exception, as soon as I’ve come back in the room, she’s let me help her lay down and she’s gone right to sleep. It makes me wonder if some days, she just needs the emotional release of crying.*

*I know there will be those of you who wonder whether she couldn’t just cry with me in the room if she does, in fact, need the release of crying, so as to avoid the “trauma” of me leaving. First off, I’m simply not convinced that walking out of the room for five minutes is traumatic to a 14-month-old. Second, though, I’ve tried that. When I’m in the room, she’ll sob for an hour or more on the days she’s having trouble sleeping. If I leave for five minutes, she cries for five minutes, but then settles AS SOON as I come back in. I’m sorry, but I just can’t be made to believe that an hour of sobbing with me present (and comforting her with words and back rubbing, but refusing to pick her up despite her pleas) is superior to five minutes of her crying with me out of the room, followed by complete relaxation and SLEEP.

The one time leaving the room for five minutes didn’t work and she still couldn’t settle, I picked her up and rocked her for a while, then lay her back down…and she was fine. So New Rule #4 is that there are no hard and fast rules about HOW she goes to sleep, only about WHERE she goes to sleep. If she needs to get out of the crib and cuddle more, that’s ok. If she needs more back rubbing one day, and none the next, that’s ok. This rule has been the most important one so far, because it makes sure I’m consistent about getting her to sleep in her crib, but allows me to use different techniques to help ease her into sleep, so it’s reduced emotional trauma (for both of us) while encouraging continued progression with our sleep training.

For the last few days, this has been going pretty well. It seems like the night weaning is almost taking care of itself; she’s been sleeping until about 2 am in her crib, which has completely eliminated the requests to nurse between bedtime and 2. When she wakes at 2, she finds it so relaxing to snuggle next to me in bed that even though she’ll ask to nurse, she falls asleep easily without actually nursing. She’s been waking at around 5 asking to nurse, but I’ve been making her wait until 6, and I’m hoping that she’ll get that figured out eventually.

 

Any comments, questions, or suggestions?

 

 

Breast Milk For Pain Relief

Image from Melimama, Wikimedia Commons

There are two interesting studies on breast milk as an analgesic (pain reliever) in this month’s issue of Pediatrics. Each compares the effects of breast milk to those of oral sugar (either glucose or sucrose) for relieving pain during the ubiquitous neonatal heel stick procedure.

The first study looked at late preterm infants (gestational age 34-36 weeks), and measured pain as indicated by crying and pain response (evaluated using the Premature Infant Pain Profile [PIPP] scale) [1]. All infants were being breastfed and were fed at least an hour before the procedure. They were randomized into two groups, one of which received expressed breast milk (from the infant’s mother) and one of which received a solution of glucose. (Glucose is a type of sugar; it’s exceedingly common in nature and in food, but is only about 70% as sweet as table sugar. Sugar solutions have been well established as a method of delivering pain relief to neonates [2]). The researchers found that infants given glucose displayed significantly less discomfort during and after the procedure compared to those given expressed breast milk. Interesting though these results are, they don’t particularly excite me. They can be taken to mean oral glucose is a superior analgesic to oral breast milk in late preterm newborns, but they can’t be taken to mean oral glucose is a superior analgesic to breastfeeding in late preterm newborns. This is because breastfeeding consists of more than simply oral administration of breast milk.

I’m more interested in the findings of a second study, also conducted on late preterm infants undergoing heel stick [3]. In this study, breastfed infants were randomized to one of three conditions: oral sucrose (table sugar) solution, expressed breast milk, or breastfeeding. Infants were fed or given sucrose during the heel stick procedure. Those being breastfed were held in their mother’s arms, while those receiving expressed breast milk or sucrose were held by a nurse. As in the first study, the researchers measured crying and pain response via PIPP. There was no significant difference in PIPP score for infants receiving breast milk versus those receiving sucrose. Interestingly enough, this was true for both the expressed breast milk group AND the group being breastfed. I have to admit to being surprised by the results; I would have guessed that there would be no difference between sucrose and expressed breast milk (or possibly that sucrose would be more effective), but that breastfeeding would provide superior analgesia!

Note that these results apply only to neonates (and, to be rigorous, only to late preterm neonates). It’s entirely possible that the establishment of a solid breastfeeding relationship over the course of the first weeks or months of life would change the relative efficacy of sugar solution versus expressed breast milk versus breastfeeding as analgesics (follow-up post on this issue forthcoming).

One final note — in the discussion portion of the second study (where the researchers talk about what their results mean and what they noticed while doing the study), there was a line that jumped out at me. The researchers were apparently, like me, surprised that they didn’t discover that breast milk was a superior analgesic. They suggested that one reason could have been that preterm infants have an “immature competence for sucking,” which could have reduced their ability to take enough milk to make a difference. Further, they noted (and this is what caught my eye), “We observed that these [preterm] newborns are more easily annoyed than term neonates…” Alrighty then!

 

Science Bottom Line:* In late preterm newborns, sugar solutions provide pain relief for procedures such as a heel lance. Breast milk, either expressed or obtained via breastfeeding, may provide similar pain relief, though some evidence suggests that breast milk is not as effective as sugar.

 

Do you think breast milk helps relieve pain?

 

References:

1) Bueno et al. Breast milk and glucose for pain relief in preterm infants: a noninferiority randomized controlled trial. Pediatrics. 2012 Apr;129(4):664-70. Epub 2012 Mar 5.

2) Harrison et al. Efficacy of sweet solutions for analgesia in infants between 1 and 12 months of age: a systematic review. Arch Dis Child. 2010 Jun;95(6):406-13. Epub 2010 May 12.

3) Simonse et al. Analgesic effect of breast milk versus sucrose for analgesia during heel lance in late preterm infants. Pediatrics. 2012 Apr;129(4):657-63. Epub 2012 Mar 5.

Sleep Training and Night Weaning a Breastfed, Co-Sleeping Toddler — Part 1

We have sleep problems, as I’ve mentioned before. I’ve been sitting on the fence about sleep training for quite a while, and have been reading Alice’s posts on the topic (like this one) over at Science of Mom. I’m totally convinced that there are good reasons to sleep train W, which include (but are not limited to) these:

1) I have not gotten a full night’s sleep since W was born. There was one night back when she was 5 months old that she actually slept all night long, but it freaked me out so much I spent the night waking every 20 minutes to make sure she was still breathing.

2) She really has no “self-soothing” skills, and she’s old enough now, at nearly 14 months, that I think they might begin to come in handy.

3) I’m sure that the frustration of dealing with our sleep troubles (sometimes we spend 4 hours trying to get 40 minutes worth of nap, and sometimes it takes 3 hours to put her to bed) is affecting how much fun I am the rest of the time.

4) I have to work, so once we take mama’s work time out of the day, and then subtract the “mama and W are fighting about sleep” time, there’s not much day left. And that sucks for both of us, because she is SUCH a fun little toddler.

I read the book Bedtiming, by Drs. Marc D. Lewis and Isabela Granic, and thought it was AMAZING. The book’s bottom line is that it doesn’t matter so much how you sleep train, as when. There are certain developmental windows, they assert (and back up with solid evidence), that lend themselves better to sleep training. Lo and behold, we’re in one of those windows. W is past the first bout of separation anxiety, and is an emotionally stable little trooper for the time being. We have a solid bond. I have no concerns that sleep training her at this point will “damage” her in any way. So yesterday afternoon, I set up a cozy bed for her, nursed her, explained the bed, and told her that mama would sit with her while she went to sleep. She cried. I patted her back, ran my fingers through her hair…she cried. After about an hour, it was clear that she wasn’t going to sleep with me there, so I left. I came back and checked on her periodically. She cried a LOT, but I felt ok about it. It was clear she was mad, not scared, and that made all the difference to me. Long story short, it took us 2.5 hours of crying to achieve a 30-minute nap. Sigh.

Today, I nursed her before nap and once again explained the bed. I put her in, and she started crying. I left for 5 minutes. When I came back to check on her {still crying}, I spoke to her softly and helped her lie back down. I stroked her hair. She sighed, curled up with her bear. Closed her eyes. I stroked her hair for a minute longer. If I’d stayed, stroking and whispering to her, she probably would have gone to sleep. However, I decided that wasn’t going to help us too much, since she’d just wake again 30 minutes later, and would find me gone…and that would be the end of nap. I reasoned that she needed to learn to soothe herself to sleep. I told her I loved her, and left. She started crying. Her crying escalated. I didn’t respond. Finally, she pulled out the big guns: “Mama! Mama! MAMA!” she yelled, sobbing.

That was it for me. I came running, scooped her up, cuddled her. She snuggled against me, sniffling. I sat down on my bed — our bed — the bed she’s slept in with me since she was two days old, and held her. She fell asleep against my chest. SO much harder to sleep train someone who can talk!

So I’m writing this now while she naps in our bed, curled up against my leg. We failed at sleep training for today. Funny thing, though; I don’t feel like a failure. The one previous attempt I made at sleep training (when she was about 10 months old) ended with us both in tears. I felt like a terrible mother for putting her through that. I felt like a terrible mother for failing to stick with it. I worried I’d damaged our relationship. I don’t think any of those things right now. Sure, this afternoon’s nap turned out differently than I’d hoped. And yes, I made a choice that caused my baby to cry — to cry out for me — and I am sad that she was sad. But I know I didn’t damage her.

Do enough reading or surfing the Internet, and you hear really bad things about sleep training. Like that it causes changes in a child’s brain, leads to fear, threatens attachment. None of this is supported by science. In fact, I wonder whether the ones who are most affected by sleep training…are us. The parents. See, if I’d left her in her crib this afternoon, she’d have gone to sleep eventually. She did yesterday, after all. And she would have woken up happy and ready to play, just as she did yesterday. And she would have forgotten the entire thing, just like yesterday.

But I wouldn’t have.

I would have put it out of my mind for the afternoon, and then tonight, while I was trying to go to sleep, I would have replayed it over…and over…and over. Despite knowing I’d done her no harm, and that she was completely fine, I would have heard her cry in my mind hour after hour as the night dragged on. Just like yesterday.

I didn’t pick her up because of her. I picked her up because of me. Because I was done with sleep training for the day. Because while she may be in a “developmentally appropriate” sleep-training window, clearly I’m not quite ready yet.

 

Have a sleep story to share?

 

 

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