Monday, May 18, 2015

A History of Sleep Deprivation

I've been enjoying the TimeHop app on my phone. It's fun to see old Facebook posts about things my kids said, or pictures of them, or other random happenings, or information I came across and wanted to share.

What has struck me, though, is just how many of those posts are about sleep, and how I wish I could get more of it.

Since I've been on Facebook for about seven years, give or take, some of these posts go back pretty far, at least to S's infancy. And almost daily, one of the posts from one of the years going back to when S was a baby has said something along the lines of, "I hope [whichever baby] lets me sleep tonight," or "WHY is [baby] not asleep yet?" or "I need more coffee," or "[Baby] actually slept through the night last night!"

And I'm still feeling that way, with Y approaching 19 months. Sleep is such a feature when it comes to babies and toddlers, it's such a central theme. I've had a baby or a toddler in my life nonstop for 8-1/2 years now, and in all that time, I've had just a few months here and there in which everybody in the house was sleeping through the night. This is not an exaggeration. It's simple truth. My Facebook history is witness to that.

Sleep is such an issue that there is a whole growing industry of "sleep consultants" who will meet with you in person or virtually, assess your baby's sleep habits and environment, and give you a personalized plan to get your baby sleeping through the night. A consultation and plan, with follow up, can run in the hundreds of dollars, and I imagine many parents feel it is money well spent. I feel like I know enough about infant sleep that if I had the will and the strength, I could do all this myself and have my kids sleeping through the night. But since I don't have that willpower, I don't think I could bring myself to follow someone else's plan, either. I'm not saying you shouldn't use a sleep consultant if you think it will help. I'm just saying I don't think it's the answer for my family.

The problem is that there is such a wide range of advice and rhetoric around infant and toddler sleep. At one end of the spectrum are those who say that by three to four months of age, you should put your baby in a crib in a dark room at a set bedtime, shut the door, and walk away, and don't return until the time he is "allowed" to wake up. No amount of crying from him should sway you to comfort him or in any way appear to be giving in to him. Because, they say, babies need to learn to sleep on their own, and if they don't learn it young, it will be harder and harder to learn it as they get older!

At the other end of the spectrum are those who say that a baby needs what she needs, and you should respond every time she asks for you. Indeed, if she needs to sleep in bed with you and suckle at your breast all night, then that's what you should do so that she feels safe and protected and secure, and so she knows that you will always be there for her. Some kids will need to sleep with you until they're five or six, but most will ask for their own bed at some point. After all, they say, in other cultures, the whole family sleeps together in one big bed anyway, so why do we in the West think it's wrong?

With this kind of contradictory advice about what you "should" be doing for your baby, and what your baby "should" be doing, what is a new parent to believe? Who's right?

I think both are right. And neither. I think parents and baby have a right to a good night's sleep, have a right to their needs being met, and have a right to negotiate the best possible sleep for everybody. I adamantly disagree that if you don't "teach" a baby to sleep through the night when he's six months old, then he'll be waking at night for years. I also adamantly disagree that if parents are simply uncomfortable allowing a baby or toddler to sleep in their bed, they should do it anyway for the best interests of their child.

How you go about finding this middle ground will vary depending on your personality and parenting style. I'm a hands-off type, and after four kids, I've learned that eventually you hit a wall and have to make a change, and usually at that point it's easier than you expected it to be to make that change. I'm also lazy about enforcing a schedule or pattern, and I am pulled in too many directions at night to focus so strongly on just one of the kids. Usually I get a sense of what I need to do, then find a way to work up to it, and then suddenly implement the new rule, which takes a few nights or weeks to stick. I tend to take things in stages. First, put him in his own bed (as opposed to mine). Next, wean him from needing to nurse at night (in the hope that if he doesn't have that to wake up for, he won't bother waking up). Finally, if he is still waking for comfort even if he's not nursing, help him learn self-soothing techniques so he can put himself back to sleep instead of calling for me. This was the general process I did with G starting at about 15 months, and it took about eight months until he was totally falling asleep on his own, in his own bed, and sleeping through until morning without waking me.

I have the benefit of knowing that they do eventually sleep through the night. My 8 and 6-year-olds take their own bath or shower, get themselves in PJs, and read to themselves in bed, then put themselves to sleep and sleep through until morning (barring illness, bathroom, or nightmares, of course). Neither was always that way, and indeed both woke me many, many, many times at night until I finally decided to attempt a change. Change is slow but inexorable, and eventually you realize, hey, it's been a while since I needed to tend to him at night!

I'll be starting the next stage of this process with Y soon. He's already sleeping in his own bed, but, unfortunately, I usually end up sleeping there with him most nights. He also nurses several times a night and nurses to sleep for naps and bedtime as well. My next project will be to night-wean him, so that he no longer needs or asks to nurse at bedtime or throughout the night. I hope that he will simply start sleeping through the night at that point, but, judging from my experience with G, I will probably have to tend to night-wakings for a few more months, and possibly do some light sleep training, before everyone in the house goes to bed, goes to sleep, and sleeps through until morning.

What a luxurious time that will be!

Maybe a few years from now, when I look at my TimeHop or my Facebook history, I won't be inundated with complaints about my babies' sleep. Instead, I'll be relatively well-rested, alert, and able to focus more of my energies on living life, instead of craving sleep.

I wish you all good nights and good sleep.

If you have any questions about infant sleep, I've written on this subject many times. Check out the sleep tag for lots of stories and information.

Wednesday, May 13, 2015

Socks for Mother's Day

I wear socks All The Time. I hate walking around barefoot, but I also hate wearing shoes indoors, so I tend to kick off my shoes when I get in the house and then walk around in my socks all day. (I'm in my house almost all day, most days.) The unfortunate consequence of this habit is that my socks wear out pretty quickly and need replacing.

The problem is, one of the last things I would think to buy for myself is socks. There's always something else that needs buying. The kids need new clothes and shoes. There's a field trip coming up. Everyone needs haircuts. We need groceries, diapers, baby wipes. This bill or that bill is due. Socks? Who would put socks on the list when there are so many more immediate needs to fill?

And so, on Mother's Day three years ago, my husband left me to spend the day with my mother and G, who was a baby at the time. He took N and S, the two older boys, off to have lunch and go shopping. When we reunited later that afternoon, he handed me two big packages of socks that he and the boys had picked out for me. One set had various types of smiley faces on them. Another was colorful with various patterns. No boring socks around here!

I thought it was such a great idea, to get me socks. It's not an extravagant gesture, but I don't need or want extravagance. I feel guilty when I spend our money on myself, and something expensive and overwhelming would make me wonder what bill I now couldn't pay because of money spent on something I didn't really need. But socks are useful, and I could tell he had picked out ones he knew I would like.

This quickly became a tradition, and now every year on Mother's Day, I receive several pairs of fun new socks to replace the ones that are wearing out.

This year, my husband outdid himself and entered into a conspiracy with my aunt to purchase not only socks but a pair of slippers, to be delivered to her house and paid for with her credit card (he reimbursed her with a check) so that I couldn't see the charge on our bank activity! I had mentioned in passing a while back that I should get some slippers, and he remembered and sought out a pair for me.

Mother's Day is about honoring the mother or mothers in your life. It's about thinking of them, and letting them know you're thinking of them. Even though it's a small thing, socks for Mother's Day, to me, means, "Here, you deserve to take care of yourself first once in a while." It means, "I noticed your socks all had holes in them, and that can't be comfortable to walk around in!" And it means, "I remembered that you wanted slippers, so I got you some."

What are your "socks" for Mother's Day?

Friday, May 1, 2015

More on Vaccination: A Simple Risk-Benefit Analysis Regarding the Measles Vaccine

The other day, I took my perfectly healthy, 18-month-old son to the doctor. The nurse weighed him and measured his height (27lbs., 4oz., and 33.25"). The doctor looked in his eyes, nose, mouth, and ears, felt his abdomen, listened to his heart and lungs, asked some questions about his development. Then the nurse came back, and I held him still for a minute while the nurse swabbed his bare thigh with some alcohol and jabbed him with a needle. My son cried indignantly. I put his pants on, thanked the nurse and doctor, declined to make a further appointment at the moment (his next checkup will be when he turns two), and left the office. I buckled him and his brother into their car seats (checking to make sure their straps were properly tightened and their chest clips were aligned with their arm pits), then drove them to the park, where they played for an hour with a babysitter while I went to appointment of my own. It was a sunny, gorgeous, perfect day, and the boys had fun going down the slides, swinging, and eating a snack. I picked them up, buckled them carefully into their car seats again, and drove to McDonald's, where they ate a special lunch. Then we got back in the car and drove home, following traffic laws. I nursed the toddler in his bed, and he fell asleep and took a nap while his brother watched TV. The rest of the day was similarly uneventful.

The next day while getting the toddler dressed, I checked his thigh where he had been given the shot and couldn't find the spot where the needle went in.

Today, he is cheerfully playing with his brother in the living room. We're going to the supermarket soon. Later, we'll go see the oldest in the school talent show and have tacos for dinner.

If you're waiting for some kind of dramatic, "AND THEN," you're not going to get one. And that's the point.

I have "come out," as it were, as pro-vaccination. I believe that vaccinations are one of the greatest medical advancements and discoveries of the past several centuries. I have seen the data and charts and listened to the expert researchers. I have read articles by people who believe vaccinations are in some way harmful and do not find their arguments to be convincing. All four of my children are and will continue to be vaccinated according to the schedule recommended by the CDC and their pediatrician. The only vaccination I refuse is the hepatitis B shot at birth, because I have done my research and learned that the purpose of the newborn hep B vaccination is to prevent vertical transmission of hepatitis B from the mother. Since I know I do not have hepatitis B, I feel it is unnecessary to give this vaccination immediately upon being born. My concern is that so much happens in the first day or two postpartum that I want to do as little as possible to disrupt my new baby's simple needs to be near me and breastfeed, while still taking the recommended courses of action when medically appropriate. Thus, my children begin the hep B series at their two-month checkup, along with several other shots.

You only hear stories about people who have a story to tell. When their day is as completely ordinary as mine was, it's not interesting. And since most of the millions of children who receive vaccines each year have completely ordinary days afterward, we don't hear their stories. See, it's easy to use scare tactics to drum up public outrage and support for your cause. And when you've personally witnessed a child who had a bad reaction to a vaccination, it's completely understandable that you would be scared that something like that could happen to your own child. I get that.

The problem is, what I encounter again and again when I see anti-vaccination rhetoric is a complete misunderstanding of statistics and how they work.

For example, someone might say: "Measles was on the decline before the vaccine was introduced." But that is not a correct interpretation of the statistics. Measles deaths were on the decline, due to better sanitation and medical care, but measles cases were still quite frequent, and so were complications of measles. According to the CDC: "In the decade before 1963 when a vaccine became available, nearly all children got measles by the time they were 15 years of age. It is estimated 3 to 4 million people in the United States were infected each year. Also each year an estimated 400 to 500 people died, 48,000 were hospitalized, and 4,000 suffered encephalitis (swelling of the brain) from measles" [my emphasis]. However, "Widespread use of measles vaccine has led to a greater than 99% reduction in measles cases in the United States compared with the pre-vaccine era."

Another misuse or misunderstanding of statistical information I see frequently is the assertion that while measles has caused no (or less than a handful) of deaths in the past 15 years, the measles vaccine has caused over 100. This represents a clear misunderstanding of how statistics and risk-benefit assessments work. Consider the number of measles cases there were in 15 years, and divide the number of deaths by that relatively small number. Your result is the risk of dying from measles in this century. The number of measles cases in the United States in 2014 was almost 600, and so far in 2015 is close to 200. So let's say there were 800 measles cases in the last year and a half (in the United States - there are millions of cases of measles yearly in other parts of the world and tens of thousands die from it). As far as I can tell there have been no deaths from measles in that same period - in the United States - or perhaps one. A toddler did die of measles in Germany recently (also a First World country with good sanitation and health care). If we say one death out of 800 cases of measles, we get a risk of 1/800 = 0.00125 or about 0.1% (which was also the risk of death from measles before the vaccine was introduced). Indeed, according to studies, the general risk of dying from measles is about 0.1 to 0.2%, or 1 to 2 out of 1000. Now, the only reasonable comparison to make with this is the risk of death from the measles vaccine. To find out the risk of dying from a measles vaccine, we need to know how many measles vaccines were administered in 2014 and how many died from receiving that vaccine, and do the same math. That number is harder to come by, but we can estimate. There are close to 4 million babies born in the United States each year. About 98% of these babies will receive an MMR vaccine at age 12 - 15 months. 98% of 4 millon = 3,920,000 (3.9 million). I can't find data on how many deaths are attributed to the measles vaccine in a given year, but for the sake of argument, let's take the CDC's report that there were possibly 3 deaths from encephalitis that apparently was caused by the MMR vaccine. (If I'm reading this correctly, that's three deaths ever, not three deaths per year, so I may be considerably overestimating this number. But, for the sake of argument, let's use it anyway.) So if three infants die because of receiving the MMR vaccine, out of 3.9 million who received it, that's a risk of death of approximately 0.000001, or 0.0001%. That's much smaller than the risk of dying from measles itself. If people stop vaccinating because they believe that the vaccine is more dangerous than the disease, then we will begin seeing deaths in the hundreds again, once mass outbreaks start occurring with the regularity they did in the 1950s and 1960s.

Of course, measles deaths aren't the only concerns. There are plenty of other complications possible from measles, not the least of which is that your child will have to stay out of school for a week or two, as will all of your other children as they almost inevitably come down with measles as well. This is an economic risk more than a health risk, but it's worth considering!

Now, I understand that if your baby was one of those three that died of MMR-related encephalitis, it is no laughing matter, and knowing the stats is no comfort. But sometimes, even if we do a proper risk-benefit analysis, and we make the obviously safer choice, we might still fall into the unfortunate, tiny percentage. That's true in many areas of life.

Here's a good example of how that kind of thinking works: Let's talk about seat belts. You won't find many people who would say that you're safer if you don't wear a seat belt, right? I mean, really, almost everyone agrees that you should wear a seat belt when you're in the car and that seat belts save thousands of lives every year. Most states have laws requiring some or all of a car's occupants to wear a seat belt when the car is in motion. Very, very rarely, we hear of a case in which a person's life was saved by the fact that they were not wearing a seat belt. Perhaps the car hit a guard rail and then went into a river, and if the driver had been wearing their seat belt, they would have gone into the water, but because they were ejected from the car on the first impact, they didn't drown. Most reasonable people would agree that there is a minuscule chance of being saved by not wearing a seat belt, and this is not a reason to quit wearing your seat belt regularly. There are far, far, far more cases in which people are saved because they were properly restrained, or, tragically, they died because they were not wearing their seat belt.

If you knew that one-in-a-billion person who was saved by not wearing a seat belt, you might be inclined to think that seat belts aren't as safe as the "experts" say they are, that wearing a seat belt is actually dangerous because it can cause bruising, or that wearing your seat belt means you'll be trapped in the car after a bad crash. You might be inclined to think that because your friend survived by not wearing a seat belt, this might happen to other people, too, and you wouldn't want to be the one who keeps wearing a seat belt and put yourself in danger of dying in a similar situation to the one your friend survived.

That all sounds ludicrous, right? The same type of arguments are made with regard to vaccines. Yes, unfortunately, tragically, some children suffer adverse effects from vaccines. A very, very small percentage of babies and children have experienced severe side effects related to receiving a vaccine. (Note: Study after study has failed to identify any risk of autism from vaccines. But other vaccine injuries do occur and are noted by the CDC on their website as possible complications.) I don't take this lightly. Indeed, I think more research needs to be done to try to identify individuals who are at risk of complications so they can be protected.

A final thought on this for the day.

If my car is broken, I take it to a mechanic to fix it. I might do some quick research on the internet to find out what the likely problem is and how much I can expect to pay to fix it. I might even look to see if it's something I can try to fix myself. But it is often the case that I need someone who knows more about cars than I do to investigate the problem and fix it. Sure, I could spend weeks learning all there is to know about my Toyota, find a supplier for the parts I need, and have a go at it, but most likely I would not do as good a job as someone who is an expert in the field. I haven't seen hundreds of Toyotas with this problem. I haven't fixed it dozens of times. I don't know all the pitfalls and tricks and shortcuts that can make the task easier, more efficient, and safer. And I might end up doing more harm than good if there's actually something else going on.

People specialize in various fields and become experts in those fields. Most people cannot be experts in everything. When we need information or action regarding a field we are not as familiar with, we consult someone who lives and breathes that subject. If we don't like what they have to say, we find another expert and get another opinion from someone who also lives and breathes that subject. If I don't like the quote the first contractor gave me for replacing the floor in my kitchen, I'll call another one. I don't know how to lay flooring and I don't think I'd do a good job. If I don't like the landscape design the first gardener proposed for my front yard, I might call another gardener and get his thoughts. I don't know anything about gardening and design, or irrigation systems, or native plants, so I wouldn't trust myself to do a good job.

In a similar vein, I can do some reading on the internet about vaccines, how they work, risks and benefits, and so on, but I don't trust myself to be able to completely assimilate all of this information because I don't understand all of it. I haven't spent years studying biology, epidemiology, immunology, statistics, anatomy, physiology, and so on. The best I can do is some shallow research, learn what questions I'd like to ask, and then ask the people who have spent years studying those things, and who live and breathe this kind of work, to explain it to me as best they can. And when those experts recommend a course of action - and not just one of them, but something close to all of them - then it makes sense to me to follow that advice.

This is also my stance when it comes to other aspects of life. For example, overwhelming evidence from decades of research has concluded that breastmilk is the optimal nutrition for babies and that breastfeeding results in healthier babies and a healthier population. Thus, I advocate for breastfeeding, breastfeeding education, and breastfeeding support.

When there is more ambiguity in the research results, such as those that report on various types and effects of diet and exercise, then I read what I can and make a decision I feel comfortable with based on what we know so far. I may also consult people whose opinions I trust for what they recommend or understand about the subject.

I understand enough about statistics to look at the statistics I'm given even by people who are against vaccination and make an informed risk-benefit analysis. I am comfortable - very comfortable - with my decision to administer vaccines to my children and to have appropriate ones administered to me as well. And, from the standpoint of public health, I understand enough about how disease spreads to know that it's important for as many people as possible to receive those vaccinations.