“Baby Unplugged”/Blue Manatee Press Review

I generally try to keep evidence-based information on one “side” of the SquintMom site, and bloggier things on the other side. A book review would typically go on the blog side, but in this particular case, the concept behind Baby Unplugged and Blue Manatee Press is so well supported by scientific evidence that it’s going on the evidence-based parenting side.

The Baby Unplugged concept was developed by Dr. John Hutton, a pediatrician whose stated mission is “Uniting science and sense to be screen-free until age 3.” In addition to his blog, Dr. Hutton writes books and owns Blue Manatee Press, which publishes both his books and those of selected authors whose work espouses the same principles. The Blue Manatee Boxes storefront sells books from Blue Manatee Press and other publishers; the distinguishing feature of the business is that the books come packaged in an awesome, low-tech, plain ol’ cardboard box filled with biodegradable packing noodles, a sponge, a green crayon, an instructional insert that encourages creative play and environmentally sound behavior, and (of course) the books. As far as the packing noodles go, they’re pretty fabulous for two reasons. First, they’re much “greener” than styrofoam. Additionally, though, kids can use them to play. They break down when exposed to lots of water, but just a little bit of water — applied with the conveniently included sponge — makes them perfectly sticky, explains the instructional insert:

As for the green crayon, the box insert suggests using it to color the box like a turtle shell for playing dress-up. Of course, there are lots of ways to use a box and some packing noodles, and the idea behind the insert is to provide inspiration for kids and parents who need a little help getting their imaginations fired up.

Once everyone’s done playing with the box, it makes a great biodegradable planter, explains the box insert. I love this idea; W’s really into garden stuff, and I’m planning to let her plant flowers in the box, watch them grow inside for a while (where they’ll be sheltered from the still-blazing-hot sun), then plant them — box and all — in the garden, where the box will break down.

As much as W and I love the Blue Manatee Box and its packing noodle contents, we love the books that were inside even more. We got three of Dr. Hutton’s books (Ball, Pets, and Yard), and one book by Sandra Gross and Leah Busch called Toast To Counting, also published by Blue Manatee Press. Hutton’s books feature simple language and illustrations, and all share the same basic message: playing and being creative (and active) is way, WAY cool. From Pets:

Robot dogs are cool and all, but they’ve got nothing on a real puppy, hamster, or fish.

W enjoys all three of Dr. Hutton’s books, but Pets is definitely her favorite. We got two cats (the first pets we’ve ever owned) about three weeks ago, and she’s absolutely in love with them. She gets a kick out of reading about other kids and their pets.

Toast to Counting is a little different; there are no words at all until the last page of the book. Instead, the pictures speak for themselves (and parents can make up their own words, which makes the book ultra-interactive). In the book, a piece of bread becomes a cute little face with egg eyes, a butter nose, and so forth, where each piece of the face added to the toast introduces a number (1 piece of toast, 2 eggs, etc):

I just love the little toast guy!

As an awesome bonus, the images in Toast To Counting are all made of glass; the authors, in addition to being teachers, are glass artists. Neat!

Both W and I are now committed fans of Blue Manatee Boxes/Press and Baby Unplugged for their pro-environment business practices and their fun-to-read books that encourage open-ended play. The back cover of each of Dr. Hutton’s books sums up the message of Baby Unplugged nicely:

I think a Blue Manatee box is going to be my new go-to birthday gift for toddlers!

For the purposes of writing this review, I was given four books from Blue Manatee Press. All opinions are my own.

Spanking Associated With Development Of Mental Disorders, New Study Suggests

The American Academy of Pediatrics (AAP) is a relatively conservative organization, in the sense that they require a significant body of evidence before making a statement or changing a recommendation. For instance, they equivocate on infant circumcision, ignoring both the violent protestations of those who feel the practice is immoral as well as the body of evidence that suggests it’s of modest health benefit (see this post and this one for more discussion on this topic). One topic on which the AAP does take a firm stance, however, is that of corporal punishment and spanking. From the Healthy Children website (AAP):

The American Academy of Pediatrics does not recommend spanking. Although most Americans were spanked as children, we now know that it has several important side effects.

  • Even though spanking may seem to “work” at first, it loses its impact after a while.
  • Because most parents do not want to spank, they are less likely to be consistent.
  • Spanking increases aggression and anger instead of teaching responsibility.
  • Parents may intend to stay calm but often do not, and then regret their actions later.
  • Spanking can lead to physical struggles and even grow to the point of harming the child.

It is true that many adults who were spanked as children may be well-adjusted and caring people today. However, research has shown that, when compared with children who are not spanked, children who are spanked are more likely to become adults who are depressed, use alcohol, have more anger, hit their own children, hit their spouses, and engage in crime and violence. These adult outcomes make sense because spanking teaches a child that causing others pain is OK if you’re frustrated or want to maintain control—even with those you love. A child is not likely to see the difference between getting spanked from his parents and hitting a sibling or another child when he doesn’t get what he wants.

Each of the statements made above is backed by solid scientific evidence (see, for instance, Bender et al, Berlin et al, Bradley et al, Gershoff, E., Knox, M., Slade et al, Strassburg et al, Strauss et al, Taylor et al).

It’s known that physical and emotional abuse and neglect are associated with certain mental disorders, including major depression and other mood disorders, schizophrenia, obsessive compulsive disorder, and the like (see, for instance, Fergusson et al, Kessler et al, MacMillan et al, Scott et al). One question that has remained unanswered, however, is whether children who are spanked are more likely to experience these same types of mental disorders during adulthood than those who are not spanked.

A new study examined the relationship between spanking (and similar punishments, all in the absence of more serious abuse or neglect) and mental disorders in an attempt to answer this question (Afifi et al). The study involved an examination of a large quantity of data that included information on more than 34,000 individuals. Participants who reported having been spanked, slapped, or similar were compared to those who reported not having been physically punished. Individuals who were spanked but who also reported having been physically, sexually, or emotionally abused or neglected were discarded from the data set, leaving a total of about 20,500 individuals whose data were analyzed.

Of these, just over 19,000 reported not experiencing physical punishment, while 1258 did experience such punishments. Once the data were corrected to remove possible confounding variables (such as parents with mental disorders, which would predispose children to mental disorders), the prevalence of mental disorders was approximately 2-7% higher among adults who’d been spanked as children as compared to those who had not.

Unfortunately, while I’m intellectually inclined to believe that there may be an association between physical punishment during childhood and adult mental disorder, I have a number of concerns about this study and its methodology. First, it’s notable that of over 34,000 original records, only 20,500 remained once the authors removed individuals who had been physically, sexually, or emotionally abused or neglected. This is a tremendous portion of the original population, and simply doesn’t make intuitive sense. On further examination, I find two potential explanations. First, the data were pulled from the National Epidemiologic Survey on Alcohol and Related Conditions, which despite the implications of its name, surveyed a large group of individuals who were more-or-less representative of the general population for information about substance use/abuse habits and mental disorders (Grant et al). Grant does note that the survey over-sampled certain minority demographics, and further, the survey was voluntary and depended upon self-report of information (with an approximate return rate of 81%). As such, it’s possible that individuals who were resentful of the way they’d been parented (and who were perhaps more likely to report a mental disorder) were also more likely to return the survey. Unfortunately, there’s no way to know whether this is a significant factor.

Far more likely to produce the startling proportion of survey respondents who were not included in this study because of abuse and/or neglect is the definition of abuse used by Afifi et al. Per the authors, individuals who were removed from the study population were those who (among more traditional definitions) were hit hard enough to leave marks, had objects thrown at them, were sworn at, and/or were made afraid during or by punishments. It’s not difficult to imagine, given this definition, that there would be very few individuals left in the physical punishment category once those in the abuse category had been removed.* Whether the authors’ definition of abuse is appropriate or not, the exclusion from the study of many individuals who were physically punished in ways that would not be considered abuse in the traditional sense weakens the study by reducing the number and the type of participants. It would be interesting to see what the data would reveal if the definition of abuse were more narrow (and more traditional), allowing inclusion of a larger group of those who’d been physically punished in “non-abusive” ways.

*Note that here I do not express either agreement or disagreement with the authors’ definition of abuse; I merely suggest that per the given definition, it’s not surprising that there were relatively few participants left in the punishment condition.

Along these same lines, the authors apparently fail to recognize the effect that the elimination of this large group of participants might have had on their data, leading them to make some bizarre observations. For instance, they note that physical punishment is more likely in families in which parents are better educated (39.2% of physically-punished children had a parent with a post-secondary degree) than in less-educated families (8.8% of physically-punished children had parents who hadn’t completed high school). The authors expressed surprise at this finding, as would I were I faced with the raw data. However, a more reasonable explanation (and of course, without the 14,000 records that were not included in the study, this is purely speculative) is that individuals from lower-education families were more likely to be punished physically in a way the authors deemed abusive, and were thus thrown out of the study. From a scientific perspective, the lack of awareness of these sorts of possibilities on the part of the authors distresses me; generally speaking, scientists value the work of other scientists more highly when the researchers are aware of potential confounding factors and methodological limitations.

Another concern I have with the study is that the authors make the mistake of confusing (at least in their language) correlation with causation. In the abstract results, they state:

Approximately 2% to 5% of [one category of mental] disorders and 4% to 7% of [another category of mental] disorders were attributable to harsh physical punishment.

Based upon the study design, it’s impossible to say that the disorders were attributable to harsh punishment; the design allows only the statement that harsh punishments were positively correlated with mental disorders. Regardless of this error, however, the findings nevertheless somewhat strengthen the (already considerable) body of evidence suggesting that spanking and other corporal punishments aren’t effective, and are likely harmful.

As a scientist, I’m not particularly impressed by this new research; I’d want to see what sort of data the very large group of survey respondents (about 14,000 in all) who were thrown out for abuse might have contributed if the definition of abuse had been a bit more in keeping with traditional usage. Again, I want to make it clear that just because a punishment isn’t classically defined as “abuse” doesn’t make it right. In classical terms, however (and here I refer, for instance, to the social mores regarding appropriate discipline techniques in the 50s, 60s, 70s, and 80s) “spanking” was one thing, and “abuse” was another. Clearly, the delineation between the two isn’t absolute, but I nevertheless feel that by defining “abuse” too broadly, we lose the opportunity to extract potentially valuable information about the damage done by “non-abusive” physical punishment.

The weaknesses of this particular study aside, there is nevertheless a tremendous body of compelling science that shows spanking and other physical punishments are simply not effective, and likely contribute to at least some lasting negative effects through childhood and into adulthood. In lieu of spanking and corporal punishment, the AAP recommends techniques such as natural consequences and time-out. For those who don’t mind a slightly more technical read, there’s an interesting paper by the AAP’s Committee on Psychosocial Aspects of Child and Family Health here. Those looking for a less technical guide to effective and positive discipline may find some good information in Elizabeth Pantley’s The No-Cry Discipline Solution (McGraw-Hill), which has suggestions for children of all ages, and Harvey Karp’s The Happiest Toddler On The Block (Bantam), which focuses on children aged 12 months to 4 years.

Science Bottom Line:* The new study of physical punishment and mental disorders in adults doesn’t establish a strong link due to flawed methodology and interpretation, but the existing body of research that discredits spanking as a viable discipline technique is large enough to be compelling without the addition of these results.

 

How do you feel about spanking children?

 

References:

Afifi et al. Physical Punishment and Mental Disorders: Results From a Nationally Representative US Sample. Pediatrics. 2012 Jul 2. [Epub ahead of print]

Bender et al. Use of harsh physical discipline and developmental outcomes in adolescence. Dev Psychopathol. 2007;19(1):227–242

Berlin et al. Correlates and consequences of spanking and verbal punishment for low-income white, African American, and Mexican American toddlers. Child Dev. 2009;80(5):1403–1420

Bradley et al. The home environments of chil- dren in the United States part II: relations with behavioral development through age thirteen. Child Dev. 2001;72(6):1868–1886

Fergusson et al. Exposure to childhood sexual and physical abuse and adjustment in early adulthood. Child Abuse Negl. 2008;32(6):607–619

Gershoff, E. Corporal punishment by par- ents and associated child behaviors and experiences: a meta-analytic and theoret- ical review. Psychol Bull. 2002;128(4):539–579

Grant et al. Prevalence, correlates, co-morbidity, and comparative disability of DSM-IV generalized anxiety disorder in the USA: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Psychol Med. 2005;35(12):1747–1759

Kessler et al. Childhood adversity and adult psychiatric disorder in the US National Comorbidity Survey. Psychol Med. 1997;27(5):1101–1119

Knox, M. On hitting children: a review of corporal punishment in the United States. J Pediatr Health Care. 2010;24(2):103–107

MacMillan et al. Childhood abuse and lifetime psychopathology in a community sample. Am J Psy- chiatry. 2001;158(11):1878–1883

Scott et al. Prospectively ascertained child maltreatment and its association with DSM-IV mental disorders in young adults. Arch Gen Psychiatry. 2010; 67(7):712–719

Slade et al. Spanking in early childhood and later behavior problems: a prospective study of infants and young toddlers. Pediatrics. 2004;113(5):1321–1330

Strassburg et al. Spanking in the home and children’s sub- sequent aggression toward kindergarten peers. Dev Psychopathol. 1994;6(3):445–461

Strauss et al. Spanking by parents and subsequent anti- social behavior of children. Arch Pediatr Adolesc Med. 1997;151(8):761–767

Taylor et al. Mothers’ spanking of 3-year-old children and subsequent risk of children’s aggressive behavior. Pediatrics. 2010;125(5)

Chemicals and Toxins — What Is Safe?

One of the most common questions I get from SquintMom readers is along the lines of is item/substance/compound XYZ toxic? I’d like to go ahead and answer this once and for all: YES, it is.

Now let me explain what I mean, and how I can answer this very generic question in a catch-all way without specifying the item/substance/compound to which I refer. Because he said it so well that it doesn’t need rephrasing, I’ll quote the Renaissance-era botanist Philippus Aureolus Paracelsus, who said:

All substances are poisons; there is none that is not a poison. The right dose differentiates a poison from a remedy.

Phrased more generally, this is simply that any substance can be either safe or toxic; the dose (quantity) to which one is exposed is what makes the difference. I’ve mentioned in previous posts (like this one about oxybenzone in sunscreen) that the notoriously jumpy Environmental Working Group (EWG) systematically fails to recognize this particular principle; they have a tendency to vilify anything that proves toxic in any dose, under any conditions. This attitude, however well intentioned, leads us to some interesting places. Pause for a moment and check out the cautionary website DHMO.org. Note that the highly toxic dihydrogen monoxide (DHMO) is associated with cancer (it’s found in every tumor ever identified), has serious environmental impact (it’s a major greenhouse gas and overexposure is associated with thousands upon thousands of deaths every year), and, per the website:

[DHMO’s] basis is the highly reactive hydroxyl radical, a species shown to mutate DNA, denature proteins, disrupt cell membranes, and chemically alter critical neurotransmitters.

Sounds horrid, doesn’t it? No doubt we should ban it. Except that…DHMO.org is a joke website, and dihydrogen monoxide is the almost never-used, formal chemical name for water.

None of the information on DHMO.org is false, which is what makes it both amusing and apropos to this discussion. Water does, in fact, directly result in many deaths. Not only through “overexposure” via flooding and/or drowning, but also through overconsumption. For instance, in 2007, a radio station held a contest (“Hold your wee for a Wii”), the idea of which was to drink as much water as possible without a bathroom break; the caller who drank the most would win a coveted Wii game console. Contestant Jennifer Strange won (and then lost) by consuming more than 2 gallons of water in the space of less than an hour. She died shortly thereafter of hyponatremia, a condition in which there is an insufficient concentration of sodium in the body fluids to support life (sodium is critical to cellular function, neural conduction, muscular contraction, brain function, and so forth). This is not the only incident of water toxicity on record; similar cases have resulted from fraternity hazings, bizarre diet plans, and overconsumption of water during endurance sporting events like marathons.

On the other hand, there are substances that we typically consider highly toxic that are, in the right dose, of great medicinal utility. Clostridium botulinum is a species of bacteria that produces botulinum toxin, generally considered the deadliest substance on Earth. The average 150 pound man would have a 50:50 chance of survival if exposed to merely 341 ng (that’s less than a millionth of a gram) of pure botulinum toxin. Regardless, marketed under the trade name Botox, botulinum toxin is used for cosmetic purposes (wrinkle treatment and prevention). Of perhaps greater medical importance, it’s also used to ease the painful symptoms of temporomandibular joint syndrome (TMJ) and other spasmodic disorders, and mitigate the symptoms of diabetic neuropathy (damage to peripheral nerves, often in the feet, due to diabetes).

Further complicating matters, our perception that “natural” substances are somehow safer or better for us than “artificial” substances is misinformed. A simple example is the flavoring agents found in many foods. While the common perception is that natural flavors come from the food of which they taste (strawberry flavor, for instance, comes from strawberries), nothing could be further from the truth. In reality, natural and artificial flavors are generally identical chemicals, collected or produced in different ways.* Natural almond flavor, for instance, isn’t a mixture of “natural substances” that come from almonds. Instead, it’s a chemical called benzaldehyde that is extracted from peach pits. Artificial almond flavor is also benzaldehyde, but unlike natural almond flavor, the artificial stuff is made in the lab. Funnily enough, it’s possible to get benzaldehyde made in the lab much more pure than that extracted from peach pits. Further, the stuff that comes from peach pits — the natural almond flavor, remember — contains small amounts of deadly cyanide that occurs naturally in those same peach pits (one of many reasons it’s not wise to eat the pits of stone fruit).

*Eric Schlosser’s excellent book Fast Food Nation contains a very interesting chapter on this topic, for further reading.

Where does this leave us, in trying to avoid toxins? First, as a chemist, let me just say that the word toxin is very often misused in popular sources and conversation, and the word chemical is almost always misused. “Chemicals” are not bad things that cause harm and should be avoided. Instead, they are matter; they are what makes up the physical universe. Nothing that has mass and occupies space — nothing we touch, eat, drink, breathe — is not chemical. There’s no such thing as chemical-free bread, shampoo, or paint. Water is a chemical (and — let’s not forget — a toxic one at that). With regard to toxins, the word is used too often in a vague, handwaving sense on the Interwebs. I see pop-authors (who are generally trying to sell something) write about how Product X contains “toxins,” and should therefore be avoided, or Product Y (which they’re selling) contains no toxins.* I’m not sure what these folks mean when they say “toxins” (and since they rarely name said toxins, I’m not sure they know either); after all, let’s not forget that all substances are toxic in the right dose.

*Or worse yet, Product Y (which they’re selling) is a detoxifying agent. This is ridiculous; almost all humans (with the exception of a few with significant disease) are possessed of one of the most powerful detoxifying mechanisms known to man — a liver. Livers work really well, particularly when they’re left alone to do their job.

This is not to say that we should all go about our business with no concern whatsoever for the things we touch/eat/drink/breathe; it’s simply to say that we simultaneously worry too much and worry too little about “chemicals.” To take one particular example, a few scare-articles about bisphenol A (BPA) have some of us so worried (and confused) that we’re willing to shell out extra cash for BPA-free diaper wipe containers, toys, and even a bath toy organizer. In reality, if BPA has any effect at all in doses to which we’re routinely exposed (which has not yet been established), it would require significant physical contact with the compound to absorb it. Holding, playing with, or storing one’s bath toys in a BPA-containing item would not be a problem, particularly given that while the absorption rate of BPA through human skin hasn’t been thoroughly evaluated or established, it nevertheless appears to be significantly lower than the (already modest) rate of absorption through the skin of other animals (Marquet et al). Based upon the current research, might it be worth avoiding storing food in BPA-containing plastics? Possibly. This is because food might leech BPA out of the plastic in sufficient quantities to possibly have some effect on people (because we eat the food, which gives it an easy route into the system). Is it worth it to avoid all BPA in our houses, however? Simply, no. And on that note, it particularly amuses me to watch women with painted nails shopping for BPA-free toys for their daughters (also with painted nails), given that the exposure to potentially harmful substances (like toluene) is much greater when one physically paints said chemicals on one’s body.*

*For those who are curious, I do paint my nails, because I really don’t think this is that big a deal. But it’s certainly a more significant exposure to chemicals (ew! chemicals!) than touching a rubber ducky in the tub.

So, we worry too much. But we also worry too little. In our desire for the “natural” (whatever that means), we choose the cyanide-laced flavoring agent over the one made under strict conditions and control in the lab. We go to the natural foods store and buy herbs to treat our ailments — which are essentially unregulated for either safety or efficacy, and which may interact unsafely with prescription and over-the-counter drugs or be toxic in their own right — rather than using the “unnatural chemicals” prescribed by medical professionals, despite the fact that the latter have undergone many years of pre-marketing research, followed by decades of post-marketing surveillance. We’re more willing to expose our children to the 1/330 risk of death due to the measles than the 1/3000 risk of a moderate side effect of measles vaccination (e.g. seizure with no permanent effects, mild rash), and immeasurably small risk of serious side effect. We further eschew the vaccination because, in a complete failure to understand the mechanics of human immunity, we have come to believe that “natural” immunity from disease is superior to “artificial” immunity from vaccination. When it comes to the “natural” versus the “toxic” and/or “chemical,” we’re chasing flies out of the chicken coop while the foxes sneak in.

So what do we do about it? This is difficult. We know that all substances are toxic in the right (wrong?) dose, but when it comes to many substances, we still don’t know what that dose is. Some exposures are unavoidable (by virtue of living in a city, for instance, one is going to be exposed to a certain amount of benzene from exhaust, industrial processes, etc). Some exposures are avoidable, but avoiding them reduces quality of life (no one HAS to eat foods containing coloring agents, for instance, many of which are of questionable safety, but the complete avoidance of these would make for a stoic existence, particularly for children). In most cases, when it comes to toxic chemicals (and once more, all substances are chemicals, and all chemicals are toxic when one is exposed to them…all together now…in the right dose), one must do a risk-to-benefit analysis. Some cases are relatively clear. Is codeine toxic? Yes, in the right dose. Is it worth the risk to take codeine for recreational purposes? Probably not. Is it worth the risk to take codeine after a painful surgery? Probably. Is water toxic? Yes, in the right dose. Is it worth the risk to drink water when one is thirsty? Absolutely. Is it worth the risk to drink water to win a contest? Probably not. Some cases are less so, as with the previous example of BPA. With the evidence still equivocal, financial means and convenience likely become a large part of the decision. Those of greater means or with greater willingness to be inconvenienced might buy the BPA-free rubbery ducky, the BPA-free cabinet safety locks. Others might decide to buy the BPA-free food storage, but be content with the plain old, BPA-containing bath caddy. Regardless of these personal decisions when it comes to substances of yet-unknown safety, it’s worth remembering that the media, the product manufacturers, and the fad-authors capitalize upon the lucrative combination of public confusion and fear, and that the words “chemical,” “toxic,” “artificial,” and “natural” are as powerful as they are misused and misunderstood.

References:

Marquet et al. In vivo and ex vivo percutaneous absorption of [14C]-bisphenol A in rats: a possible extrapolation to human absorption? Arch Toxicol. 2011 Sep;85(9):1035-43. Epub 2011 Feb 2.

Updated Policy on LATCH Use For Securing Car Seats

Since 2001, the National Highway Traffic Safety Administration (NHTSA) has required that car manufacturers comply with Lower Anchors and Tethers for Children (LATCH), a system that relies upon a universal anchor system to which car seat tethers can be attached. However, as of 2014, the NHTSA will be requiring child seat manufacturers to inform parents NOT to use the lower LATCH anchors if the combined weight of seat and child is more than 65 pounds, on the grounds that the anchors could fail in the event of a car accident.

The problem, according to the Alliance of Automobile Manufacturers, is that the original legislation did not take the weight of a car seat into account when stipulating strength limits for LATCH anchors, which are consequently required to be tested to only 65 pounds. Combined with the weight of a seat, however — one of which weighs an incredible 33 pounds — a child as light as 32 pounds could be unsafe in a LATCH-tethered seat.

While the LATCH system is a convenient way to tether a car seat in a vehicle, a LATCH-secured child seat is no safer than one properly secured using the vehicle’s seat belts. Given the potential for LATCH failure, then, parents who need to secure a seat-plus-child combination weighing 65 pounds or more should use the vehicle’s seat belts per the car seat manufacturer-provided instructions.

There’s been increasing attention paid to car seats for larger and heavier children as a result of the American Academy of Pediatrics’ (AAP) recent car seat policy changes. The current recommendations include the following (Durbin et al):

  •  Children should ride in a rear-facing car seat until age 2 or until reaching the maximum height/weight allowed by the seat manufacturer for rear-facing travel
  • Children 2 and older should ride in a forward-facing car seat with a harness until reaching the maximum height/weight allowed by the seat manufacturer
  • Children who have outgrown forward-facing seats with harnesses should ride in a belt-positioning booster until they are at least 4′ 9″ in height (8-12 years of age)
  • Children younger than 13 should ride in the vehicle’s rear seat at all times

This post contains a discussion of some of the research that supports the AAP’s policy changes.

 

Science Bottom Line:* If the combined weight of your child and your child’s car seat is 65 pounds or more, secure the seat using the vehicle’s seat belts; do NOT use the lower LATCH anchors.

 

Do you use the LATCH anchors, or do you prefer to secure your child’s seat with the vehicle seat belt?

 

References:

Durbin et al. Child passenger safety. Pediatrics. 2011 Apr;127(4):e1050-66. Epub 2011 Mar 21.

Are Bubble Baths Safe For Girls, Or Do They Cause UTIs?

Got another great question recently (keep them coming, readers; I love answering these!):

I’ve heard that girls shouldn’t take bubble baths because they can get urinary tract infections. I have some around the house, though, and in a moment of weakness, I let my toddler use it. Now she wants a bubble bath all the time! The package says it’s “safe for girls” but I am not sure what chemical it is that gives them UTIs so I find the whole thing confusing. Is it safe to use bubble bath for a girl?

This is an interesting case of some old and erroneous research that’s been propagated in the medical field (and among women) for several decades. Back in the 1960s and 70s, a few studies suggested that bubble baths caused urinary tract infections (UTIs) in girls (see, for example, Neumann et al). This belief has continued to show up in more recent journal articles for medical professionals. The truth is that while it’s certainly possible for soaps, fragrances, and other chemicals in bubble bath to irritate the vulva (Modgil et al) and urethra (see, for example, Johnson et al, Santen et al), there isn’t any scientific support for them causing UTI.

A study of college-age women examined a number of potential risk factors for UTI (including bubble baths, diaphragm use, tampon use, sexual activity, and various hygiene practices), and concluded that only diaphragm use was reasonably correlated with increased urinary infection risk (Strom et al). A 2006 meta-analysis (study of studies) revealed that while many pediatricians advise parents to avoid bubble baths for female children, there is no reasonable scientific support for the notion of a connection between the two (Modgil et al). Indeed, despite the lack of scientific evidence, a survey of health care professionals and women noted that both groups believed there was a link between bubble baths and UTIs (Rink).

It’s possible that the mistaken belief about bubble baths and urinary infections comes from the tendency of some healthcare practitioners and researchers to view children as “little adults” (Todd). In fact, however, signs and symptoms of UTIs are not the same in little girls as they are in adult women; one of the most notable differences is that while adult women often experience dysuria (painful urination) with UTI, most girls do not (Santen et al). The ability of frequent bubble baths to cause urethral or vulvar irritation in some girls and women, which can in turn lead to painful urination, combines with the mistaken belief that painful urination typically indicates a UTI in a young girl to produce the erroneous notion of a bubble bath/UTI link. In the end, however, with no reasonable scientific support for a link, Modgil et al sum up the risk-to-benefit analysis nicely, in saying:

We believe that the enjoyment of bubble baths outweighs the limited evidence of their proposed harm.

There is, of course, the question of whether some bubble bath products might produce less skin, vulvar, and urethral irritation than others. Very sensitive children and those with allergies to specific chemicals may be more likely to react to any given product. Still, some bubble baths are milder than others, with fragrance-free varieties almost always ranking milder than those containing fragrance. The Environmental Working Group (EWG) is a somewhat reactionary organization that likely overestimates the toxicity of and risk associated with chemicals, as I discuss in this post. Still, they provide a nice guide to various personal care products — bubble bath included — that at the very least can be used to determine which of the bubble baths on the market are most mild.

Science Bottom Line:* There is simply no scientific evidence to support the notion that bubble baths increase a girl’s risk of urinary tract infection. Children with sensitivities may do better with a milder product, however, as well as less frequent use. Because bubble baths can cause irritation to the skin and female genitals, it may be reasonable to consider rinsing with plain water after a bubble bath.

 

Do you let your little girl take bubble baths? What’s your favorite type?

 

References:

Johnson et al. New advances in childhood urinary tract infections. Pediatr Rev. 1999 Oct;20(10):335-42; quiz 343.

Modgil et al. Should bubble baths be avoided in children with urinary tract infections? Arch Dis Child. 2006 Oct;91(10):863-5.

Neumann et al. Constipation and urinary tract infection. Pediatrics. 1973 Aug;52(2):241-5.

Rink, E. Risk factors for urinary tract symptoms in women: beliefs among general practitioners and women and the effect on patient management. Br J Gen Pract. 1998 Apr;48(429):1155-8.

Santen et al. Pediatric urinary tract infection. Emerg Med Clin North Am. 2001 Aug;19(3):675-90.

Strom et al. Sexual activity, contraceptive use, and other risk factors for symptomatic and asymptomatic bacteriuria. A case-control study. Ann Intern Med. 1987 Dec;107(6):816-23.

Todd, J. Management of urinary tract infections: children are different. Pediatr Rev. 1995 May;16(5):190-6.

Sunscreen Safety and Oxybenzone

Is oxybenzone in sunscreen safe? From Squintmom/Beautiful EntropyI love getting questions about science-related issues from readers. I particularly love it when a question intersects with an issue I myself am curious about, as happened when a reader got in touch with me last week:

I need some advice about sunscreen. I just read some articles on CNN about new FDA guidelines and the Environmental Working Group’s 2012 sunscreen review. Of particular concern is oxybenzone. The FDA claims it’s safe and very effective at protecting against UVA and UVB rays. However, the EWG says that oxybenzone is carcinogenic. Hmm… use sunscreen to prevent skin cancer, but sunscreen causes… skin cancer? That seems like a big time conundrum to me. The other thing I wonder about is who is the EWG? All I really know is they came up with the “Dirty Dozen” foods you should always buy organic. So what’s the deal? Should I toss all of last year’s sunscreen with oxybenzone and buy new? Is the EWG generally a trustworthy, “non-woo” authority?

The oxybenzone molecule

Let’s start with my professional opinions of the Food and Drug Administration (FDA) and of the Environmental Working Group (EWG). The FDA is routinely accused by consumer groups and conspiracy theorists of being “in bed with Big Pharma,” engaging in cover-up operations, putting profit ahead of consumer health, and so forth. I really don’t agree with this take on the organization, as I discuss in this post. The FDA’s history in the US is one of a largely appropriate trajectory. They’re a behemoth organization, and as such, they move slowly. They’re slow to approve new drugs because they insist on rigorous testing; this is one of the things that pisses off consumers who want to see new drugs come to market quickly. They’re relatively quick to warn consumers if there’s evidence that a pharmaceutical or substance is harmful, though they’re not alarmist and rarely respond to the results of an isolated study. The FDA is, to put it simply, stuck performing an impossible balancing act: they’re under public pressure to approve substances quickly, while they’re simultaneously under public pressure to keep anything that could potentially be harmful off the market. These missions are mutually exclusive, and I have to say that for the most part, the FDA handles their task as elegantly as a behemoth government organization can do. Have they made mistakes? Absolutely. But what I appreciate about the FDA is that they correct over time, such that their trajectory is generally appropriate and stable.

The EWG, on the other hand, is far more alarmist than the FDA. They’re not a government organization, but are rather a research and lobbying group made up of citizens and scientists. A survey of toxicologists (unaffiliated with the organizations about which they were questioned) revealed that most felt the EWG overstates risks associated with products. Specifically, toxicologists gave the EWG an accuracy score of 4.2 (1 = significantly understates risks, 3 = accurately states risks, 5 = significantly overstates risks). By comparison, the FDA got a 3 from the toxicologists, indicating that they felt the organization was accurate in assessing and reporting risks. For those who are curious, the U.S. Centers for Disease Control and Prevention (CDC) and the American Medical Association (AMA) also scored near 3, reflecting accurate portrayal of risks, while Greenpeace got a 4.5 — the highest score given — for significant overstating of risks. The Pharmaceutical Research and Manufacturers of America (PhRMA), on the other hand, scored a 2.3 for being the most significant understater of risks. Note that PhRMA is not a government organization, and is not tied to the FDA, the CDC, or other government health regulators.

As far as the EWG goes, I think they have their place. They report on research, but often issue warnings on the basis of single studies or studies with limited applicability. Case in point, they warn consumers against sunscreen containing retinyl palmitate (vitamin A) on the basis of a 2009 study that looked at mice rubbed with the chemical and exposed to light. The vitamin A mice developed more tumors, leading the EWG to report a link between retinyl palmitate in sunscreen and cancer. However, there are significant issues that limit the study’s applicability. Most notably, sunscreen only ever contains a small amount of retinyl palmitate. Dose is very important in toxicology; any substance — even water — is toxic in sufficient quantity. As such, a pure retinyl palmitate rub applied to mice doesn’t provide information about the toxicity of small amounts of the compound in sunscreen. In the end, groups like the EWG help to promote research on issues pertaining to toxicology and public safety, but speaking for myself, I look for corroborating research or concern from more moderate institutions before acting on an EWG warning. In response to the question from the start of this post, I think we can safely say that the EWG is “non-woo,” but they are a little jumpy.

On to sunscreen safety. First and foremost, there’s a major risk-to-benefit analysis that one must conduct when determining whether to use sunscreen and what type to use. This is because the sun emits ultraviolet radiation (UV) that damages cells, leading to development of wrinkles, aging of tissues, and skin cancer. Sunburns are an indication of particularly severe cellular damage — just one or two sunburns before the age of 18 significantly increases risk of skin cancer later in life — but even a so-called “healthy” tan is a sign that damage has occurred. Sunscreen is a part of protecting the skin from sun damage, but it’s not the entire equation. In fact, staying out of the sun during intense radiation hours (midday) and using physical protection such as clothing, sunglasses, and hats provides the best protection from harmful UV radiation. No sunscreen provides complete protection. To this end, one of the new FDA regulations regarding sunscreen labeling is that sunscreens will no longer be allowed to refer to themselves as “sunblock,” on the grounds that this inappropriately overstates protection. While there’s been some muttering by the EWG and other groups about whether sunscreen truly helps to prevent skin cancer, these concerns are largely based upon use of sunscreens that protect from only one type of UV radiation (broad-spectrum sunscreens are best, but not all sunscreens are broad-spectrum) and inappropriate use of or reliance on sunscreen. The general consensus among medical and government organizations, including the CDC and the AMA, is that sunscreen is an important component of safe-sun behavior.

The active ingredients of a barrier sunscreen.

There are two major classes of sunscreens: barrier sunscreens containing minerals (like zinc oxide and titanium dioxide) that reflect light, and chemical sunscreens that absorb the light and prevent it from penetrating cells. There is essentially no risk of absorbing the barrier compounds through the skin, leading even the EWG to note that these sunscreens are likely the safest and most effective. In times past, barrier sunscreens were unpopular because they had a greasy white appearance on the skin (remember Zinka from the 80s?). Newer technology allows for smaller particles (nanoparticles) of barrier compounds, which are less visible on the skin, though some formulations may still be greasy. There’s also some question as to whether these nanoparticle formulations appropriately protect from UVA, one of the types of UV (UVB is the other type). Unfortunately, while the sunlight reaching Earth is made up of mostly UVA, the SPF rating on sunscreen applies to UVB protection only. The new FDA regulations propose a set of standards for reporting UVA protection, as UVA exposure also leads to skin cancer. With regard to barrier sunscreens, then, the most effective UV protection comes from the old-school stuff: greasy, white, and slathered on thick. The next most effective UV protection comes from a nanoparticle formulation combined with a chemical sunscreen containing oxybenzone or similar for enhanced UVA protection. Of course, protection from UV is only part of the equation when it comes to assessing sunscreen safety; the other part is the safety of the sunscreen ingredients themselves.

The active ingredients of a chemical sunscreen.

Oxybenzone is currently raising hackles at the EWG, and is one of the reasons that their Sunscreens 2012 report contains so few “approved” choices. The compound occurs in nature — it’s in flower pigments — and is incredibly common in personal care products. It’s not only a sunscreen, it’s also a fragrance enhancer, preservative, flavor enhancer, and so on. The CDC reports that a recent random sample of Americans revealed oxybenzone in 97% of urine samples (Calafat et al). However, the significance of this information has not yet been determined. The EWG calls oxybenzone a “potential hormone disruptor,” citing the European Commission on Endocrine Disruption (pdf) (ECED), which basically means that the EWG is saying they don’t like oxybenzone on the grounds that the ECED doesn’t like oxybenzone. As to why the ECED takes issue with it, they (like the EWG) are exceedingly cautious. The EWG cites two studies (Ma et al,* Ziolkowska et al) that show the potential for weak endocrine disruption. {Note that the Ma et al reference is incomplete on the EWG website, and I was able to find no evidence of it in the scientific literature}. The extent to which the results of these studies, conducted on cells with pure oxybenzone compound, are relevant to use of the compound in sunscreen are unknown. As the American Cancer Society points out:

Virtually all substances known to cause cancer in humans also cause cancer in lab animals. But the reverse is not always true – not every substance that causes cancer in lab animals causes cancer in people. There are different reasons for this.

First, most lab studies of potential carcinogens (cancer-causing substances) expose animals to doses that are much higher than common human exposures. This is so that cancer risk can be detected in relatively small groups of animals. But doses are very important when talking about toxicity. For example, taking a couple of aspirin may help with your headache, but taking a whole bottle could put you in serious trouble. It’s not always clear that the effects seen with very high doses of a substance would also be seen with much lower doses.

Second, there may be other differences between the way substances are tested in the lab and the way they would be used, such as the route of exposure. For example, applying a substance to the skin is likely to result in much less absorption of the substance into the body than would be seen if the same substance is swallowed, inhaled, or injected into the blood. The duration and dose of the exposure also help determine the degree of risk.

While the above refers to cancer risk, the same is true of other toxic effects of compounds that are revealed through laboratory and animal studies. With specific regard to cancer and oxybenzone, even the cautious EWG notes that there’s no evidence that oxybenzone is carcinogenic — or, more accurately, THERE IS evidence that oxybenzone IS NOT carcinogenic (non-mutagenic in 4 of 4 studies: CTFA, 1980; DHEW, 1978; Hill Top Research Labs, 1979; Litton Bioneics, 1979).

Taking all the information together and conducting a risk-to-benefit analysis, I think it’s fair to say that because of the limited data available and the availability of alternatives to oxybenzone, it may be worth avoiding it in sunscreen, but there’s no reason to get particularly excited about previous use or occasional future use. Given that it’s present in almost all chemical (non-barrier) sunscreens, this essentially leaves the barrier sunscreens containing zinc oxide and titanium dioxide. If one chooses to use the nanoparticle formulations with somewhat reduced UVA protection, one must then decide whether to use a chemical sunscreen for additional protection — but this once again leads to oxybenzone exposure.

One last thing: with regard to old sunscreen, if in doubt, throw it out. The CDC recommends that sunscreen be no more than three years old if there’s no expiration date on the bottle. If the bottle has an expiration date, abide by it. The protective chemicals in sunscreen break down over time, meaning that protection wanes.

Science Bottom Line:* Given that there is no sunscreen that provides complete protection, the evidence suggests that the safest choice (particularly for children) is the use of zinc oxide or titanium dioxide sunscreen (I prefer nanoparticle formulations for convenience and aesthetics), without a chemical sunscreen backup. This should be augmented through the judicious use of shade, clothing, sunglasses, and hats, particularly during the most intense periods of sunlight.

 

How do you protect your family’s skin outdoors?

 

References:

Calafat et al. Concentrations of the sunscreen agent benzophenone-3 in residents of the United States: National Health and Nutrition Examination Survey 2003–2004. Environ Health Perspect. 2008 Jul;116(7):893-7.

Ziolkowska et al. Endocrine disruptors and rat adrenocortical function: studies on freshly dispersed and cultured cells. Int J Mol Med. 2006 Dec;18(6):1165-8.

Should A Toddler Wear A Helmet On A Tricycle?

A sweet trike and helmet for a sweet girl!

My husband and I are both avid cyclists, recreationally and for commuting purposes. We both owe our lives, several times over, to helmets. Some of our crashes have been due to, shall we say, “operator error,” while others have been the result of collisions with vehicles. Aside from those crashes that were severe enough to have been potentially life-threatening, we’ve also both been in a number of crashes that would have likely caused traumatic brain injury (commonly called concussion) had we not been wearing helmets. It’s easy to dismiss the importance of wearing a helmet on a bicycle, scooter, or similar non-motorized vehicle, particularly if one doesn’t believe the risk of death is significant in the event of a crash (e.g., I’m just riding a cruiser down the sidewalk; I won’t die if I crash). Nevertheless, any time a person is thrown or falls from a moving bike or similar, there’s the significant risk of head injury. Further, there’s a growing body of research that links even mild traumatic brain injury to depression, cognitive impairment, and early-onset dementia (see, for instance, Guskiewicz et al [2005 and 2007], Kiraly et al). Even people who don’t ride a non-motorized vehicle in a way that makes death a significant risk in the event of a crash are at risk for traumatic brain injury, and its associated complications.

There’s some concern among physicians that the use of the term “concussion” confuses parents and downplays the seriousness of this injury (DeMatteo et al). It should be noted that a concussion is a traumatic brain injury, is associated with alterations in brain blood flow in children (Maugans et al), and can cause developmental delays and functional losses that persist months to years post-injury (Rivara et al). Traumatic brain injury is one of the leading causes of disability and death in children (Keenan et al.)

Last week, we decided W was old enough for her first tricycle. I found a really cool company called Wishbone that makes a 3-in-1; it converts from a low-rider trike for the toddler set to a low-rider bike, and finally to a taller bike for older children. Best of all, it has no pedals; it’s a so-called “run bike,” which allows little ones to work on refining balance and steering before having to coordinate pedaling action. And I love the company’s ethics and commitment to sustainability. Anyway, with the bike on order, we went and bought W a helmet. For a toddler. Riding a trike. With no pedals. No joke. There were a few reasons for this. First, while it might seem suspect that a toddler could fall off a trike and do any significant damage, there are actually many reports of serious trike injuries (see, for instance, Powell et al [1997 and 2000], Sacks et al, Sosin et al). Toddlers and preschoolers who fall off tricycles sustain head, face, and mouth injuries with great frequency, and researchers strongly recommend helmets for this group. Secondly, among toddlers, it’s not just accidents while riding that account for tricycle injuries; these not-yet-stable walkers can fall and sustain a head injury while attempting to mount or dismount a tricycle. The final reason we bought W a helmet was simply to get her in the habit early on, which has been quite successful even over the course of just a few days; if she wants to ride her trike, she points to her helmet. I’m happy to be getting her into this habit early, because the kid will be wearing a helmet every time she gets on a trike, bike or similar, rides a skateboard, or skis. Every time. And her parents will too, both because it sets a good example, because we know from experience, and because, as an article published in the Journal of the American Medical Association (Sacks et al) put it:

From 1984 through 1988, bicycling accounted for 2985 head injury deaths (62% of all bicycling deaths) and 905,752 head injuries (32% of persons with bicycling injuries treated at an emergency department). Forty-one percent of head injury deaths and 76% of head injuries occurred among children less than 15 years of age. Universal use of helmets by all bicyclists could have prevented as many as 2500 deaths and 757,000 head injuries, ie, one death every day and one head injury every 4 minutes.

 

Science Bottom Line:* Use a brain bucket. Wear a skid lid. Invest in some skull insurance. Don’t crack your melon.

 

Do you wear a helmet when you ride a bike? Do you make your kids wear one?

 

References:

DeMatteo et al. “My child doesn’t have a brain injury, he only has a concussion”. Pediatrics. 2010 Feb;125(2):327-34. Epub 2010 Jan 18.

Guskiewicz et al. Association between recurrent concussion and late-life cognitive impairment in retired professional football players. Neurosurgery. 2005 Oct;57(4):719-26; discussion 719-26.

Guskiewicz et al. Recurrent concussion and risk of depression in retired professional football players. Med Sci Sports Exerc. 2007 Jun;39(6):903-9.

Keenan et al. Epidemiology and outcomes of pediatric traumatic brain injury. Dev Neurosci. 2006;28(4-5):256-63.

Kiraly et al. Traumatic brain injury and delayed sequelae: a review–traumatic brain injury and mild traumatic brain injury (concussion) are precursors to later-onset brain disorders, including early-onset dementia. Scientific World Journal. 2007 Nov 12;7:1768-76.

Maugans et al. Pediatric sports-related concussion produces cerebral blood flow alterations. Pediatrics. 2012 Jan;129(1):28-37. Epub 2011 Nov 30.

Powell et al. Bicycle-related injuries among preschool children. Ann Emerg Med. 1997 Sep;30(3):260-5.

Powell et al. Cycling injuries treated in emergency departments: need for bicycle helmets among preschoolers. Arch Pediatr Adolesc Med. 2000 Nov;154(11):1096-100.

Rivara et al. Disability 3, 12, and 24 months after traumatic brain injury among children and adolescents. Pediatrics. 2011 Nov;128(5):e1129-38. Epub 2011 Oct 24.

Sacks et al. Bicycle-associated head injuries and deaths in the United States from 1984 through 1988. How many are preventable? JAMA. 1991 Dec 4;266(21):3016-8.

Sosin et al. Pediatric head injuries and deaths from bicycling in the United States. Pediatrics. 1996 Nov;98(5):868-70.

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