Tag Archives | Pediatrics

Breastfeeding Center of Pittsburgh’s Dr. Nancy Brent Named A “Pediatric Hero”

Dr. Nancy Brent, Medical Director of the Breastfeeding Center of Pittsburgh and a pediatrician at Kids Plus Pediatrics in Pittsburgh, has been named one of Baby Talk magazine’s seven national Pediatric Heroes for 2012. The award, announced at the recently concluded American Academy of Pediatrics National Conference and Exhibition in New Orleans, honors “the most innovative and inspiring doctors” in the country.

Dr. Brent was honored as a Pediatric Hero for her nationally acclaimed work in promoting and supporting breastfeeding, and in training physicians to do the same. A board-certified pediatrician since 1984 and an International Board Certified Lactation Consultant (IBCLC) since 1990, Dr. Brent has spent more than two decades at the forefront of Breastfeeding Medicine, leading the way both locally and nationally to bring critical, often hard-to-find services and support to breastfeeding mothers and babies, as well as to the doctors who care for them.

Ellen Rubin, an IBCLC who works at the Breastfeeding Center says,

“As a relatively new IBCLC, I could not have asked for any better opportunity than to work with Dr. Nancy Brent. She’s an an IBCLC-Pediatrician and an amazing teacher who always takes the time to share her knowledge and experience with me and the many residents and medical students who visit our clinic. Dr. Brent’s approach to breastfeeding is very well-rounded. While addressing each baby’s needs and well-being, she also takes into account each mother’s experience in the nursing relationship. Her medical expertise is a great asset, especially when babies are not gaining weight or are consistently fussy. So many complications are erroneously blamed on breastfeeding, and it makes a big difference when a medical professional can get to the root of a problem before breastfeeding is disrupted.”

Since 2006, Dr. Brent has served as the Medical Director of the Breastfeeding Center of Pittsburgh, the region’s leading resource for front-line breastfeeding medicine, support, and clinical care. Dr. Brent’s hard work and leadership have helped make the Breastfeeding Center of Pittsburgh a nationally recognized model in lactation services, and the first and only Advisor to the United States Breastfeeding Committee. Before joining Kids Plus Pediatrics and helping to create the Breastfeeding Center of Pittsburgh, Dr. Brent worked for 20 years in the department of Pediatrics at Mercy Hospital. During her time at Mercy, she created and directed the Maternal Infant Lactation Center, which provided patient care, research, and professional education for pediatric residents. Many of the pediatricians she trained in her time at Mercy are now her colleagues at Kids Plus: IBCLC pediatricians and a staff of Lactation Consultants who, under her direction, provide consults and medical care through the Breastfeeding Center of Pittsburgh.

Dr. Brent is a member of ILCA, the American Academy of Pediatrics, the Academic Pediatric Association, the Pittsburgh Pediatric Association, and the Academy of Breastfeeding Medicine. She is co-chairperson of the Allegheny County Breastfeeding Coalition and a member of the Pennsylvania Breastfeeding Coalition.

Join us in congratulating Dr. Nancy Brent, IBCLC for the stellar work she is doing to support mothers and babies!

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American Academy of Pediatrics Section on Breastfeeding Launches New Facebook Page

By Jennifer Thomas, MD, MPH, IBCLC, FAAP, FABM

The internet has increasingly become a tool for people seeking health By Jennifer Thomas, MD, MPH, IBCLC, FAAP, FABM
information. A Pew Internet and American Life survey in 2011 showed that 80% of internet users have visited a website for information or support for a specific health problem, 19% of whom searched for information on pregnancy and childbirth.

Social media has increasingly become a tool for organizations, such as the American Academy of Pediatrics (AAP), to share information pertinent to the goals, mission, vision, publications and achievements. It has become a way to promote new products. It increases awareness about current issues, and can, unfortunately, generate misinformation which can be quickly disseminated widely. As the AAP is the recognized authority on the care of children, in addition to provide accurate information to physicians and breastfeeding mothers, we see this misinformation as a problem which needs to be addressed.

The American Academy of Pediatrics Section on Breastfeeding recently launched a new Facebook page.  It was created to:

    • Raise awareness of activities, products, and resources produced by the Section on Breastfeeding.
    • Highlight our members achievements.
    • Recruit new pediatricians to our membership.
    • Highlight pertinent evidence-based practices and publications.
    • Present evidence-based information in response to trends on social media which may be detrimental to the experience of new breastfeeding mothers.
    • Join in the discussions, currently occurring in social media about breastfeeding.

The Facebook page has the potential to be many things but it will not be a place for our section’s members to offer clinical advice.  It will be for the dissemination of information only. 

We invite IBCLCs and other breastfeeding professionals and volunteers to come “like” our page and engage in the conversation with us. A strong collaboration between pediatricians and other members of a baby and their family’s health care team is vital to their breastfeeding success.

Click HERE to connect with the American Academy of Pediatrics Section on Breastfeeding’s new Facebook page.

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First, Do No Harm: A Critique of Recent Research on “Controlled Crying” (Part 2)

Earlier in the week, we presented Part 1 of a commentary from Kathleen Kendall-Tackett on a recent study about the long-term effects of controlled-crying for infants. As infant sleep and breastfeeding are so closely tied together, we are so glad to share both Part 1 and Part 2 with our readers.  

By Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA 

Does Controlled Crying Cause Long-term Change to Cortisol Levels?

Critics of controlled crying have expressed concern that this technique alters infant cortisol level. To address this concern, the authors assessed the children’s cortisol levels at age 6 and found no significant difference between the intervention and control groups. Unfortunately, these findings alone do not mean lack of physiological harm. We need to look at short-term effects.

The question we need to ask is what happens to babies when their mothers do not respond to them? One way this has been studied is by examining the impact of maternal depression on infants. Maternal depression impairs mothers’ ability to respond to their infants’ cues, and raises Infant cortisol levels (Feldman et al., 2009). Even when non-response is temporary, babies still find it stressful. In the still-faced mother paradigm, mothers are asked to not respond to their infants’ cues in a laboratory setting. This research is designed to mimic the effects of maternal depression. The still-faced-mother experiments increase babies’ cortisol levels (Grant et al., 2009).

So why the concern about cortisol? Mainly, it’s this: cortisol is quite toxic to brain cells. If cortisol is elevated for short time, it likely causes no damage. But if cortisol levels are repeatedly elevated because the infants are experiencing long and repeated incidents of being ignored when they cry, it can be a problem. The brain is at its most vulnerable in the first five years, so soaking the developing brain in cortisol is not a good idea (Buss et al., 2012).

The lack of difference between the groups at age 6 does not mean lack of harm. Cortisol levels likely returned to normal in the intervening five years, unless there was ongoing adversity. Unfortunately, cortisol elevated in infancy could have still affected vulnerable brain cells, even if current levels are normal. The authors would need to use more sensitive measures to assess these potential changes.

What About Breastfeeding?

Photo by Alessandro Pinna via Flickr Creative Commons

The final limitation of this study is rather stunning. Price et al. did not measure the effect of infant feeding method on sleep or maternal depression. Yet feeding method has a direct effect on both maternal sleep and postpartum depression, which are the two main factors the authors claim to address with their sleep intervention. Exclusively breastfeeding mothers get more sleep and are less likely to be depressed than their mixed- or formula-feeding counterparts (Doan, Gardiner, Gay, & Lee, 2007Dorheim, Bondevik, Eberhard-Gran, & Bjorvatn, 2009a2009bKendall-Tackett, Cong, & Hale, 2011).

Given these findings, isn’t it strange that breastfeeding was not even enquired about? If the study was conducted in a country with low breastfeeding rates, this omission would be somewhat understandable. But it makes no sense coming from a country like Australia, which has one of the highest breastfeeding rates in the world.

Conclusion

So what can we take away from the Price et al. study? Should we recommend the controlled-crying technique to parents? Based on the limitations of this study, I do not recommend this approach. The sample size is small, the follow-up sample is missing the children most likely to be negatively affected, their assessment of the intervention did not account for the Hawthorne/placebo effect, they have not measured dose of the intervention, nor have they accounted for feeding method, which recent research has soundly demonstrated as being related to both variables that are of key interest: maternal fatigue and postpartum depression.

My objections to this approach are not new. When I first encountered the Price et al. study, I remembered a study that this same group of researchers published 10 years ago in the British Medical Journal demonstrating that controlled crying lessened the risk of postpartum depression (Hiscock & Wake, 2002). I was specifically struck by this response from a German physician (Perl, 2002):

“As a German, I am unhappy to find fairly undiluted ideas of militaristic Nazi infant care uncritically repeated by these Australian care providers. The Nazis understood very well the crucial effect of letting young babies cry on their future development and made this a central theme in their child care. As a scientist, I find it hard to believe that all of the results of mother-infant sleep research of the 1990s completely escaped the authors’ notice.” 

In closing, Price et al. stated that organizations, such as the Australian Breastfeeding Association, were unduly negative towards controlled-crying techniques and need to update their recommendations based on more current research. Given recent findings in neuroscience, childhood trauma, breastfeeding, and maternal sleep, which are not accounted for in the Price et al. study, I’d respectfully advise the authors to do the same. I’d further urge healthcare providers who are considering recommending controlled crying to consider the limitations to the current study and alternative approaches that can meet the needs of both mother and baby.


Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA is a health psychologist and board-certified lactation consultant. She has authored or edited 22 books and more than 320 articles on family violence, postpartum depression, breastfeeding, and women’s health. Dr. Kendall-Tackett is a research associate at the Crimes against Children Research Center at the University of New Hampshire and a clinical associate professor of pediatrics at Texas Tech University School of Medicine in Amarillo, Texas. She is a Fellow of the American Psychological Association, and is president-elect of the APA Division of Trauma Psychology. You can view her website at www.KathleenKendall-Tackett.com

 

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First, Do No Harm: A Critique of Recent Research on “Controlled Crying” (Part 1)

Today, we present Part 1 of a commentary from Kathleen Kendall-Tackett on a recent study about the long-term effects of controlled-crying for infants. As infant sleep and breastfeeding are so closely tied together, we are so glad to share this with our readers. Check back on Thursday for Part 2.

By Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA 

A recent article in Pediatrics (Price, Wake, Ukoumunne, & Hiscock, 2012) reported on the long-term effects of a controlled-crying intervention for parents of infants 8 to 10 months old. The children were assessed five years post-intervention and showed no apparent harm. The media response to these findings has been overwhelming. Could this be the answer that weary parents have been waiting for? The authors certainly thought so. In fact, they concluded that practitioners could “confidently” recommend this approach.

Before we proceed, let’s step back and consider whether this recommendation is warranted. We must critically evaluate both the current study and where it fits within the larger literature in maternal-child health. In my view, there are a number of serious limitations to this study that call into question whether we should recommend this practice to parents.

Study Limitations

The Cumulative Effect of Childhood Adversities

Context is important to consider when evaluating potential harm caused by a parenting technique. In other words, how many parental missteps does it take for children to show evidence of lasting harm? Fortunately, children are resilient and don’t require perfect parenting. However, chronic bad parenting does harm children and the effects are cumulative (Centers for Disease Control and Prevention, 2010).

So does controlled crying cause infant harm? If it occurs in families with generally warm, responsive, and loving parents, probably not. I am more concerned about the impact of controlled crying when it takes place in high-risk families. A full 31% of the Price et al. original sample was lost to follow-up, most of them “high disadvantage.” In other words, the group most likely to be negatively affected by controlled crying was not in the follow-up study.

Assessing “Dose”: The Chronicity and Severity of the Experience

When assessing potential harm of a practice, it’s also important to consider chronicity and severity. This is a way of factoring in “dose” of an intervention. In terms of infant sleep, we need to know how often controlled crying was used in an average week, how many weeks or months that the parents employed these techniques, and in an average episode how many minutes elapsed before the parents responded to their babies. The longer they used it, the more pronounced the effects.

Information about “dose” was totally absent from the Price et al. study. From their article, we know little about what the parents actually did in either the intervention or control group. Even beyond the research protocol, parents could have implemented a controlled-crying program for themselves. We have no way of knowing. Given the wide range of practices that likely occurred in both the “intervention” and “control” groups, I am again not surprised to see no significant difference between groups.

Was the Intervention Actually Effective, Even in the Short Term?

Another problematic aspect of this study has to do with the research design’s inability to account for the Hawthorne Effect. The Hawthorne Effect was first noted by industrial psychologists who were testing the impact of minute changes in illumination on productivity in factory workers. When they raised the level, productivity increased. When they lowered the level, productivity also increased. In other words, any intervention was described as helpful. It’s basically a placebo effect for behavioral interventions.

The Hawthorne Effect could also be behind the positive results for the controlled-crying intervention. In earlier articles, the authors reported that controlled crying lowered rates of maternal depression and improved infant sleep. Did it? Perhaps it was simply a matter of the mothers having someone to listen to their concerns. A better test would have been to compare it to another intervention (such as educating mothers about the developmental normality of infant waking at 8 to 10 months, and brainstorming about ways the mothers could get more rest and cope with fatigue).

Check back on Thursday for Part 2 of this commentary. 


Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA is a health psychologist and board-certified lactation consultant. She has authored or edited 22 books and more than 320 articles on family violence, postpartum depression, breastfeeding, and women’s health. Dr. Kendall-Tackett is a research associate at the Crimes against Children Research Center at the University of New Hampshire and a clinical associate professor of pediatrics at Texas Tech University School of Medicine in Amarillo, Texas. She is a Fellow of the American Psychological Association, and is president-elect of the APA Division of Trauma Psychology. You can view her website at www.KathleenKendall-Tackett.com.

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