Pertussis Vaccination in Every Pregnancy: Is it Safe and Effective?

I’m now 37 weeks pregnant, and it blows my mind how quickly this pregnancy has flown by. Now the days are ticking by faster than I can tick things off of my to-do list, and I can feel my body warming up for birth with increasing Braxton Hicks contractions and the baby dropping into my pelvis.

Preparing for a new baby means lots of things to me. There is the physical preparation of washing and folding tiny clothes and setting up baby’s space for changing and sleeping (in our bedroom for now). There is the arduous task of coming up with names – two of them, since we don’t know the baby’s sex. There is the mental preparation of imagining life with a new baby, trying to map out a few strategies for coping with wakeful nights and baby-filled days. There are the talks with Cee about how things will change and how they will stay the same, how she can help us with the baby, and how we’ll help her to adapt to the change in her life.

There’s also the very important aspect of making sure that we do everything we can to protect our new baby’s health, especially before the first round of immunizations at 2 months. This baby will be born during the season of flu and cold viruses, and this year is predicted to be a pretty bad one for the flu. Just south of our home in Oregon, California has so far recorded nearly 10,000 cases of pertussis, also known as whooping cough, this year, more than they’ve seen in 70 years. Cee will be exposed to a range of pathogens in preschool, and my husband will encounter them in his job in healthcare. We’ll do our best to protect our baby by leaving our shoes at the front door, changing clothes when needed, and washing our hands frequently. I also plan to breastfeed, which should confer some passive protection to the baby. However, some of the most important protection has hopefully already been given to this baby during pregnancy, because I’ve been vaccinated for both the flu (as soon as the vaccine was available this season, around 26 weeks) and pertussis around 34 weeks.

Getting vaccinated for flu and pertussis during pregnancy can protect your baby from these serious illnesses during early infancy.

Getting vaccinated for flu and pertussis during pregnancy can help protect your baby from these serious illnesses during early infancy.

The flu vaccine was first recommended for pregnant women in 1964,1 and there is a large body of research showing that the flu shot is safe in pregnancy and an effective way of preventing flu infections in expecting moms, which can pose a significant risk to the fetus. There’s also good evidence that influenza antibodies are transferred to the baby in utero,2 reducing baby’s chances of infection and hospitalization with the flu in early infancy.3,4 (Several of the above links direct you to evidence-based articles written by Tara Haelle on her blogs at Red Wine and Apple Sauce and Forbes. If you want to keep up with vaccine and other health news, Tara is an excellent blogger and science journalist to follow.)

The latest news on this year’s flu season is showing that most of the cases seen so far have been identified as being caused by seasonal influenza A H3N2, a nasty strain, and about half of these are a new subtype that isn’t well-covered by this year’s flu vaccine. If you haven’t yet gotten a flu shot this season, don’t let this news deter you. The flu vaccine will still protect you from the older strains of the flu and might decrease the severity of an infection with the newer type. The vaccine is very safe and still offers the best protection against the flu for you and your baby.

The recommendation that women be vaccinated against pertussis in every pregnancy – using the Tdap vaccine here in the U.S. – was new in 2012. It wasn’t recommended when I was pregnant with Cee in 2010, although I had recently gotten a Tdap booster for my job at the time. Several pregnant friends and readers have emailed me this fall asking if Tdap in pregnancy is safe and if they really need it, particularly if they were just vaccinated in the last couple of years. The good news is that there have been quite a few studies published on these questions in just the last year or two, and I’ll focus the rest of this post on the evidence for the Tdap shot in pregnancy.

What is the concern about pertussis in young infants?

We’ve seen big increases in pertussis recently, especially over the last decade. In 2012, there were more than 48,000 cases reported in the U.S., making it the worst year since 1955. Pertussis hits young infants the hardest. Among the 20 deaths from pertussis in the U.S. in 2012, 15 were in infants less than 3 months of age [PDF]. The first dose of pertussis vaccine is usually given with the DTaP shot at 2 months of age, and before this time, infants are particularly vulnerable to the disease. The 2012 recommendation that women be vaccinated with Tdap in the third trimester of every pregnancy came in response to these infant deaths, the hope being that maternal antibodies to pertussis could help protect infants during those first few months of life.

Previous to the recommendation to vaccinate during pregnancy, pertussis prevention strategies were focused on “cocooning” infants. That meant vaccinating women just after giving birth and also trying to vaccinate family members and others around them to decrease newborns’ exposure to pertussis. While this strategy made sense, research has shown that it isn’t particularly effective at protecting infants from pertussis. It can take several weeks for pertussis antibodies to peak in moms after vaccination, leaving mom and baby vulnerable during the first few weeks postpartum, and it can be challenging (and expensive) to get everyone in contact with the baby vaccinated. It certainly doesn’t hurt to ensure that the family is up-to-date on their pertussis vaccines, and some studies suggest that it helps a little, but overall, it’s turned out to be a pretty inefficient strategy. Tara Haelle reviewed some of the latest research on cocooning here.

Is there evidence that Tdap vaccination in pregnancy can protect babies from pertussis?

The strategy of vaccinating moms during pregnancy takes advantage of the natural transfer of mom’s antibodies to the fetus across the placenta. Several recent studies show that this is an effective way to boost baby’s immunity. Given the pertussis outbreaks in recent years and the finding that cocooning offers only minor protection, this is pretty great news.

A small randomized controlled trial led by Flora Munoz of Baylor College of Medicine, published in JAMA in May of this year, gave 33 women Tdap and 15 women a placebo at 30-32 weeks of pregnancy.5 After giving birth, the treatments were crossed over so that the women receiving the vaccine during pregnancy received the placebo postpartum and vice versa. Predictably, the moms who received the vaccine during pregnancy had higher antibody levels in their blood at the time of delivery, and this was also reflected in their infants at birth and at 2 months of age. Researchers measured antibodies to 4 different proteins produced by the Bordatella pertussis bacterium, and depending on the protein, levels were 5x-36x higher in infants whose moms were vaccinated in pregnancy compared to those who weren’t.

Although the Munoz study was small, it very convincingly demonstrated that vaccination in pregnancy confers greater anti-pertussis antibodies to infants. What it couldn’t do was tell us whether these antibody levels actually protect infants from pertussis infection in the first few months of life. To answer this question, we need much larger groups of study subjects, which means turning to epidemiological studies.

That’s where a study from the U.K., published in the Lancet in October of this year, comes in.6 As in the U.S., there was a huge pertussis outbreak in the U.K. in 2012, during which 14 infants died. In September of that year, the U.K. Department of Health recommended that pregnant women receive the acellular pertussis vaccine between 28 and 38 weeks of pregnancy. In the subsequent year, about 60% of pregnant women were vaccinated.

The Lancet study tracked confirmed pertussis cases occurring in infants younger than 3 months before and after this new recommendation and then looked back at their mothers’ vaccination records to see if vaccination in pregnancy affected their chances of infection.6 The results were impressive. Of 82 pertussis cases in young infants, most were born to women who didn’t receive the vaccine during pregnancy. Only 12 of them (15%) were born to mothers vaccinated at least one week before giving birth. The researchers calculated that the pertussis vaccine was 91% effective in preventing pertussis in young infants, so long as it was given at least 7 days before birth. If the vaccine was given less than 7 days before birth or in the immediate postpartum period, vaccine effectiveness dropped to 38%.

This last part about the timing of the vaccine is important, and it explains in part why the recommendation is to receive the vaccine during the third trimester of every pregnancy. After vaccination, it takes a couple of weeks for anti-pertussis antibodies to peak in the mom,7,8 which is why it is important to vaccinate well before your due date. However, it’s also important not to vaccinate too early. After the antibody peak, circulating pertussis antibodies seem to drop pretty quickly. When women are vaccinated before pregnancy or early in pregnancy, the pertussis antibody concentrations found in cord blood appear to be too low to provide much protection to the infant and are much lower than those found in women vaccinated in the third trimester.5,9 (This doesn’t mean that mom can’t mount an effective immune response to pertussis if exposed, just that circulating antibodies available to cross the placenta are low.) In general, maternal IgG antibodies are not transported across the placenta very efficiently until the third trimester, so to optimize placental transfer to the baby, we want mom’s antibody concentrations to peak during that time.10

Maternal vaccination during pregnancy is an elegant solution to the problem of this deadly disease in newborns. It allows us to give mom a small, controlled dose of inactivated pertussis toxoids at an optimal time in late pregnancy, and the baby gets the benefit of being born with at least temporary immunity to pertussis, enough to protect her during early infancy until she can receive her own vaccine around 2 months.

Is there evidence that Tdap vaccination in pregnancy is safe for the mom and baby?

Two studies out this year provide reassuring data on the safety of Tdap in pregnancy. Tara Haelle (again!) wrote about both of these here and here, so I’ll mention these findings only briefly. A U.K. study, published in the BMJ in July, compared pregnancy and birth outcomes in more than 20,000 women who received the pertussis vaccine in the third trimester to a matched group of unvaccinated pregnant women.11 There were no differences between the vaccinated and unvaccinated groups when it came to risk of stillbirth, maternal or neonatal death, pre-eclampsia or eclampsia, hemorrhage, fetal distress, uterine rupture, placenta or vasa previa, cesarean birth, low birth weight, or neonatal renal failure.

A more recent study, published last month in JAMA, looked back at more than 123,000 women in California’s Kaiser health system, 21% of whom had received Tdap during pregnancy.12 In this study, there were no differences in risk of small-for-gestational age birth, preterm birth, or hypertensive disorders in pregnancy between vaccinated and unvaccinated women. Vaccinated women were slightly more likely to be diagnosed with chorioamnionitis (6.1%), a bacterial infection of the fetal membranes, compared with unvaccinated women (5.5%). Tara Haelle explained why we shouldn’t freak out about that finding in her post on the study (the association is likely due to confounding factors that weren’t considered in the study).

Finally, the randomized controlled trial conducted by Munoz et al, which included the antibody data mentioned earlier, also included a detailed assessment of reactions to the vaccine as well as birth and baby outcomes.5 This study found no difference in birth weight, gestational age, Apgar scores, neonatal exams, birth complications, or the baby’s growth and development later in infancy. Pain at the injection site of Tdap was common – occurring in about 3 out of 4 women – and more frequent than found in the placebo group, but symptoms were generally mild and resolved on their own within a few days. (This was also my experience – a sore arm for a couple of days.)

What’s the bottom line? Receiving the Tdap vaccine during the third trimester of pregnancy is our best chance at protecting young infants from pertussis, a disease that can be particularly dangerous during the first few months of life. Research shows that vaccination in late pregnancy gives newborns the gift of pertussis-specific antibodies at birth and is safe for both mother and baby.

References:

  1. Keener, A. B. Efficacy studies build up the case for prenatal immunization. Nat. Med. 20, 970–972 (2014).
  2. Steinhoff, M. C. et al. Influenza Immunization in Pregnancy — Antibody Responses in Mothers and Infants. N. Engl. J. Med. 362, 1644–1646 (2010).
  3. Zaman, K. et al. Effectiveness of Maternal Influenza Immunization in Mothers and Infants. N. Engl. J. Med. 359, 1555–1564 (2008).
  4. Benowitz, I., Esposito, D. B., Gracey, K. D., Shapiro, E. D. & Vázquez, M. Influenza Vaccine Given to Pregnant Women Reduces Hospitalization Due to Influenza in Their Infants. Clin. Infect. Dis. 51, 1355–1361 (2010).
  5. Munoz FM, Bond NH, Maccato M & et al. Safety and immunogenicity of tetanus diphtheria and acellular pertussis (tdap) immunization during pregnancy in mothers and infants: A randomized clinical trial. JAMA 311, 1760–1769 (2014).
  6. Amirthalingam, G. et al. Effectiveness of maternal pertussis vaccination in England: an observational study. The Lancet 384, 1521–1528 (2014).
  7. Kirkland, K. B., Talbot, E. A., Decker, M. D. & Edwards, K. M. Kinetics of Pertussis Immune Responses to Tetanus-Diphtheria-Acellular Pertussis Vaccine in Health Care Personnel: Implications for Outbreak Control. Clin. Infect. Dis. 49, 584–587 (2009).
  8. Halperin, B. A. et al. Kinetics of the Antibody Response to Tetanus-Diphtheria-Acellular Pertussis Vaccine in Women of Childbearing Age and Postpartum Women. Clin. Infect. Dis. 53, 885–892 (2011).
  9. Healy, C. M., Rench, M. A. & Baker, C. J. Importance of timing of maternal combined tetanus, diphtheria, and acellular pertussis (Tdap) immunization and protection of young infants. Clin. Infect. Dis. Off. Publ. Infect. Dis. Soc. Am. 56, 539–544 (2013).
  10. Glezen, W. P. & Alpers, M. Maternal immunization. Clin. Infect. Dis. Off. Publ. Infect. Dis. Soc. Am. 28, 219–224 (1999).
  11. Donegan, K., King, B. & Bryan, P. Safety of pertussis vaccination in pregnant women in UK: observational study. BMJ 349, g4219–g4219 (2014).
  12. Kharbanda EO, Vazquez-Benitez G, Lipkind HS & et al. Evaluation of the association of maternal pertussis vaccination with obstetric events and birth outcomes. JAMA 312, 1897–1904 (2014).

 

Can Fetal Movements Predict a Baby’s Sex or Temperament?

I’m now 31 weeks pregnant. The weeks are flying by, and for the most part, I’m relishing all the physical changes in my body and the preparations for this baby. We waited a long time for this pregnancy, and it will probably be my last. I curl around my belly at night and think about the baby growing inside me. I wonder about the person that he or she will become and how our little family will adapt to welcome a second child. (We’ve chosen not to learn the sex of this baby until its birth.)

When I was pregnant with Cee and about to become a mom for the first time, I thought a lot about what kind of mother I would be and how this big life transition might alter my identity, my career path, my marriage, and my daily life. The baby-to-be was kind of a vague amalgamation of all the babies I’d known.

This time around, having been around many more babies, I recognize the individuals that babies are from the first days of life – and even in utero – and I spend a lot more time wondering about this baby’s temperament and personality. Introverted and contemplative, like Cee? Or totally different?

Filling me with wonder, this baby moves around in utero a lot, and this feels very different from my experience carrying Cee. I didn’t feel movement from Cee until around 23 weeks, but I began to feel this baby move at 16 weeks. And this baby continues to be very active, more than I remember with Cee, especially making big, dramatic movements in the evening hours but also having significant activity bouts throughout the day (and sometimes in the middle of the night, of course).

Because we don’t know the sex of this baby, I’m often asked if I have any predictions on that front. How would I know, I think? I don’t feel like I have any kind of gut instinct for this kind of thing, and I don’t buy into any of the old wives tails. But if I’m pushed to make a guess, I guess that this baby is a boy. And when I ask myself why that is, it comes down to this observation about more fetal movements. This baby feels different from Cee, and my brain makes a jump to sex as a possible explanation. And then I stop, remind myself that I’m perpetuating a total gender stereotype, and feel embarrassed.

One day, I repeated all of this to a friend as we walked together (complete with an apology for the gender stereotype), with Cee riding her bike within hearing distance. A couple of weeks later, my mom was talking to Cee on the phone and asked her if she thought the baby would be a boy or a girl. Cee answered in what seemed like a verbatim copy of my own explanation: “Well, Mom thinks that it’s a boy, because the baby moves around a lot inside of her, and I didn’t move very much.” Yikes. From now on, I’m keeping my mouth shut. And for the record, Cee is really hoping for a little sister.

All of this left me wondering if fetal movements can actually predict anything about the baby, whether sex or temperament, in postnatal life. I happened to be corresponding with Jena Pincott, author of Do Chocolate Lovers Have Sweeter Babies?, a few weeks ago, and I asked her if she knew of any research on this. She wrote back, “As for ‘in utero’ forecasts, my prediction is that your 2015 is going to be very, very busy!” and sent me a few research articles. I dug around and found quite a few more studies of this question. Finally, I could stop speculating and start talking science! Here’s what I found:

How is this question studied?

Most studies use ultrasound or a Doppler transducer placed on the mother’s belly to us baby profile croppedmeasure fetal movements. Most are conducted over a period of about an hour, during which the moms are asked to rest, and the best studies take several of these measurements over the course of the pregnancy. Studies of postnatal temperament then use standardized behavioral observations or questionnaires to describe aspects of the baby’s behavior.

Is it true that some fetuses are more active than others?

I wondered if my perception that I was carrying a more active fetus is this pregnancy was really true or if it was influenced by other factors? Continue reading

The Whole Truth About Infant Cereals: 7 Science-Based Tips

I recently received an email from a reader with a question about baby cereals:

“My wife and I are expecting a baby this October. We are planning to breastfeed but have lots of questions about introducing solid foods, particularly cereals. Do we have to feed the baby commercial baby cereals? I am concerned about all the extra crap that is put into commercial food, including unnecessary sugars and possible GMOs. Is there another product or whole food option that we could use to introduce grains to our baby instead of a commercial cereal product?”

~Brenda and Leah in San Diego, CA

Baby cereals have made a big swing in popularity over the last couple of generations. It wasn’t long ago that they were considered an essential first food, given to baby within the first months or even weeks of life. These days, in some circles, they’ve become a marker of lazy parenting, with conscientious parents choosing instead to prepare their own organic carrot purees or scrambling eggs with butter and breast milk. Cereals, meanwhile, get slammed in blog posts that call them over-processed, pointless, and even toxic. The movement towards more real foods for babies is definitely a good thing, but the scare-mongering about baby cereals is not. Brenda and Leah’s question is a great one, and it deserves an answer that is science-based, not sensationalized.

mother feeding her baby

1. You don’t have to feed a commercial baby cereal.

The reason infant cereals are typically recommended is that they are fortified with iron, and iron can become limiting during late infancy, particularly in breastfed babies. In early infancy, babies are mostly using stored iron that was transferred from mom during pregnancy, but by around 6 months, those stores run low, and they need to be getting some iron from solid foods. At this age, babies are growing and developing rapidly, and studies show that iron deficiency in infancy can cause developmental delays and lasting cognitive deficits.1–3 Breastfed babies are at greatest risk for iron deficiency,4,5 because breast milk is quite low in iron. (The iron in breast milk is efficiently absorbed, but there simply isn’t much of it.)

Commercial baby cereals are fortified with iron, effectively making it an easy way to deliver extra iron to lots of babies. In one study, among breastfed babies fed a fortified cereal daily, only 2.5% developed iron deficiency, compared with 14% of babies fed solids at their parents’ discretion.6 Infant formula is also fortified with iron, so babies that are formula-fed for at least half of their milk meals generally get enough iron that way.

However, there are other sources of iron that are actually better than fortified cereals. Meat, poultry, and fish all contain heme iron, which is more efficiently absorbed in the digestive tract than nonheme iron, the form found in plants like spinach and beans, as well as fortified cereals. Including a source of heme iron in a meal also increases the absorption of nonheme iron, so serving baby a little chicken with lentils actually increases the bioavailability of iron from the lentils. Baby cereals are often recommended as first foods, but this is based more on tradition and culture than on any scientific evidence. There is no reason why you can’t introduce those great heme sources of iron (meat, poultry, fish) as first foods, and in fact, this is now recommended by the AAP. If your baby is consuming 1-2 small servings of meat per day, plus other sources of non-heme iron, then there’s no reason that you have to supplement with an iron-fortified cereal. See more of my tips on ensuring that your baby gets enough iron in this post: 5 Practical Ways to Increase Iron in Your Baby’s Diet. Also, note that your pediatrician should test your baby for anemia around 12 months, so this will at least alert you if your baby is very deficient in iron.

Many babies and their parents also opt to skip spoon-feeding entirely, doing some version of Baby-Led Weaning. Cee simply wasn’t interested in being spoon-fed pureed foods, but she loved feeding herself soft finger foods. That meant that she ate very little infant cereal, except what I baked into muffins or pancakes (mostly to use up the box, but I figured she could also use the extra iron). This route can be fun and appropriate for babies that are ready to self-feed by around 6 months; others may need spoon-feeding and may love the interaction of feeding with a tuned-in caregiver.8 There are lots of options here, and the most important thing is to offer iron-rich foods (cereal or otherwise) and to follow your baby’s lead with texture and timing.

2. Commercial baby cereals may not be as bad as you think.

Here’s the Nutrition Facts label and ingredient list for Gerber’s oatmeal cereal (this one happens to be an organic product, but the conventional version is otherwise the same):

gerber oatmeal label

What’s in baby cereals? Take a look at the ingredient list. Continue reading

New Research on Gluten Introduction to Infants and Risk of Celiac Disease

If you’re worried about your child’s risk of celiac disease and wondering when to introduce gluten-containing foods, then you’ll want to know about two new studies published in the New England Journal of Medicine this week.

Gluten is delicious to most of us, but it can be devastating to those with celiac disease. Photo by Adrian van Leen

Gluten is delicious to most of us, but it can be devastating to those with celiac disease. Photo by Adrian van Leen

Celiac disease is an immune response to gluten, a protein found in wheat, barley, and rye. It causes inflammation and damage to the small intestine, and while it can be successfully managed with a gluten-free diet, it is a lifelong disease. (Celiac disease is distinct from non-celiac gluten sensitivity, which is a murky and controversial condition that may not be related to gluten at all.)

I reviewed the research on early infant feeding and risk of celiac disease on my blog about a year ago (Breastfeeding, Gluten Introduction, and Risk of Celiac Disease). I have since received lots of comments and messages from parents concerned about this, so I wanted to be sure to write about these important new studies.

These latest studies dramatically advance our understanding of this topic because they are randomized controlled trials. Both started with a group of babies already identified as being high-risk for celiac disease, randomly assigned them to different time of introduction of gluten, and then tracked their development of the disease. Previous studies were all observational, thus only able to identify associations between variables, and were limited by confounding factors and other sources of bias.

The first study was led by researchers in the Netherlands but included children born in 7 European countries and in Israel. 944 babies were identified as being high-risk for celiac based on a genetic predisposition (HLA genotype) and having a first-degree relative (parent or sibling) with celiac. The babies were randomized to two groups, and one group was given a small amount (100 mg) of gluten starting at 4 months of age, while the control group was given a placebo and instructed not to introduce gluten until 6 months, at which point parents in both groups were advised to gradually introduce gluten-containing foods. The incidence of celiac disease was tracked through 3 years of age, with all suspected cases confirmed with an intestinal biopsy. Overall, about 5% of the study participants developed celiac disease by age 3, and it made no difference whether gluten was introduced at 4 or 6 months. It also made no difference whether the babies were breastfed (exclusively or not) or currently breastfed at the time of gluten introduction.

The second study was conducted in Italy and had a similar design but instead compared gluten introduction at 6 vs. 12 months. Continue reading

Bed-sharing with Young Infants: Is It Safe After All?

Does bed-sharing with infants increase their risk of SIDS, even without known risk factors such as alcohol use, smoking, and co-sleeping on a couch or chair? A recent study makes what is probably the best attempt to date to answer this question. The study, led by U.K. researcher Peter Blair, was published last week in the journal PLOS ONE and is freely available to the public (yay!).1

mother and baby

How you bed share can make a big difference to safety. Co-sleeping on couches, alcohol use, and smoking are all very risky. The mom in the photo could keep her baby safer by removing the swaddle and ensuring that her baby sleeps on his back.

Many studies have found that co-sleeping is associated with an increased risk of SIDS, but most of this risk doesn’t come from co-sleeping per se, but rather doing so in particularly hazardous conditions, such as on a couch or with a parent who has been drinking. However, there’s an important, albeit controversial, caveat to this conclusion. Several studies have looked specifically at infants younger than 3 months and still found a significant risk of bed-sharing even in the absence of these other risk factors.2–6 The current study comes to conclusions much more reassuring to bed-sharing parents. In this study, bed-sharing without alcohol, smoking, or couch/chair co-sleeping was not associated with a significant SIDS risk in infants younger than 3 months and even seemed to be protective in older babies. Both of these findings run counter to previous studies and to the sleep recommendations of the AAP, so they deserve a close look.

How was the study conducted? Continue reading

Zero to Five: A Book Review and Giveaway

I received a review copy of a really cool book over the summer: Zero to Five: 70 Essential Parenting Tips Based on Science (and What I’ve Learned So Far) by Tracy Cutchlow. I loved the book and wanted to review it on my blog, and the publisher offered to give away 5 copies to Science of Mom readers! (If you’re curious about my policy on reviews and giveaways, check my About Me page.)

Author Tracy Cuthlow with her daughter, Geneva.

Author Tracy Cuthlow with her daughter, Geneva.

Zero to Five is a book of parenting advice starting with pregnancy and going up through age 5. Author Tracy Cutchlow is a former journalist at the Seattle Times and edited John Medina’s books Brain Rules and Brain Rules for Baby. Then she had a daughter, now 2, and was inspired to create a book that would bring together relevant, evidence-based parenting advice into an enjoyable and accessible format. I’d say she succeeded.

Each of the 70 parenting tips are explained in 2-4 page spreads summarizing the research in the area and accompanied by gorgeous candid photographs of children and parents. The tips are practical, and they’re explained simply, but they’re rooted in science.

ZTF-guard-babys-sleep

The book is divided into 9 topics headings, listed below with examples of some of my favorite tips in parentheses:

  • Prepare (Bolster your friendships; Expect conflict as a couple)
  • Love (Create a feeling of safety; Comfort newborn with the familiar)
  • Talk (Talk to your baby a ton; Read together; Teach sign language)
  • Sleep, eat, and potty (Guard your sleep; Guard baby’s sleep, too; Let baby decide how much to eat)
  • Play (Let baby touch that; Save the box; Make music with baby)
  • Connect (Choose empathy first; Allow mistakes, discomfort, boredom)
  • Discipline (Be firm but warm; Label intense emotions; Teach instead of punish)
  • Move (Rock, jiggle, and swing; Keep moving)
  • Slow down (Be still; Don’t bother to compare)

Some of these tips are obvious, like talking to your baby. But they’re also really important, and that’s one of the things I love about this book. Continue reading

What’s so important – and stressful – about family dinner?

A recent study about the stress of getting family meals on the table has been getting lots of attention from both the media and moms. A Slate piece, “Let’s Stop Idealizing the Home-Cooked Family Dinner,” posted Wednesday, has already garnered 3.5K comments on the article itself and more than 26K Facebook shares. This has obviously struck a nerve. While feeding a family is a big and often stressful job, some perspective about why we do it and what matters most about family meals might be helpful to families feeling the mealtime crunch.

The study itself, titled “The Joy of Cooking?”, was published in Contexts, a publication of the American Sociological Association geared to be accessible to the general public. The paper itself is a really interesting read and freely available online.

Researchers in the sociology and anthropology departments at North Carolina State University conducted the study. This was a qualitative study, which means that the data came in the form of stories, generated from interviews with real people. From the paper:

“Over the past year and a half, our research team conducted in-depth interviews with 150 black, white, and Latina mothers from all walks of life. We also spent over 250 hours conducting ethnographic observations with 12 working-class and poor families. We observed them in their homes as they prepared and ate meals, and tagged along on trips to the grocery store and to their children’s check-ups. Sitting around the kitchen table and getting a feel for these women’s lives, we came to appreciate the complexities involved in feeding a family.”

These kinds of methods are common in sociology and anthropology research, and they allow researchers to understand the many complex variables that contribute to how people feel and why they feel that way. However, we have to be careful about interpreting these studies beyond the individual stories that they provide. For example, this study wasn’t a random sample of moms, and it can’t give us quantitative information like the percentage of moms who find cooking to be an unbearable chore versus rewarding or enjoyable. It doesn’t allow us to look at correlations between family income and nights of home-cooked meals per week, for example.

Here’s what it can tell us: Continue reading

Caffeine and Breastfeeding

If anyone needs a little caffeine, it’s a new mom. My labor with Cee took me through two mostly sleepless nights, and when she finally arrived, we took a little time to nurse and get to know one another, and then our whole little family took a long nap. When we woke up, the first thing I did was send my husband to get me a latte. The second thing I did was breastfeed my new baby again. That dose of caffeine felt like good therapy to me, but what about for Cee? Was it good for her?

caffeine structure

Source: Wikimedia Commons

A few weeks ago, I wrote about the safety of caffeine in pregnancy, and several readers wanted to know about the postnatal effects of caffeine – how mom’s caffeine intake might affect her breastfed baby. I promised to take a look at the literature and report back, and so here we are.

 

When you drink a cup of coffee, how much caffeine ends up in your breast milk?

Several studies have examined this question, and although they are small, they give us a general idea of the transfer of caffeine from mom’s blood to her milk. After a cup of coffee, caffeine is rapidly absorbed into mom’s blood and then passively diffuses across the epithelial layers of the mammary gland. Caffeine appears in milk within 15 minutes of consumption and peaks within an hour. The concentration of caffeine in breast milk ends up being about 80-90% of that in mom’s plasma. However, taking into account the amount of breast milk consumed and adjusting for body weight, studies have estimated that the infant receives no more than 10% of the maternal dose of caffeine, and likely much less (see here, here, and here).

Is this amount of caffeine safe for a baby?

Just because levels of caffeine in breast milk are low relative to what adults normally consume doesn’t mean that these amounts are necessarily safe to a baby. Another important factor is how efficiently a baby can metabolize caffeine, and it turns out that newborn caffeine metabolism is really slow. Whereas the half-life of caffeine in adults is around 2-6 hours, it is an average of 3-4 days in newborns and can be even slower in premature babies. In other words, a morning cup of coffee for mom will easily clear her blood by bedtime, but caffeine may linger in her breastfed newborn for much longer. Metabolism gradually ramps up as the baby matures and the necessary enzyme levels come on board, and most babies can metabolize caffeine at rates similar to adults by 5-6 months of age. Continue reading

How My 3-Year-Old’s Sleep Fell Apart

A couple of weeks ago, I wrote that after I finished my book, I needed a sort of parenting reset with Cee. One of the big areas that we needed to work on was sleep. Bedtime had become a battle, and it was taking Cee a long time to fall asleep. This was leaving us all frustrated at the end of the day, and Cee was waking up grumpy in the mornings. I didn’t have the energy and attention to work on it while I was trying to finish my book, although in hindsight I’m not sure why we waited this long. Over the last couple of weeks, we’ve made some big changes to get us back to happy bedtimes.

Let me back up and tell you how we got into trouble with sleep in the first place. Last August, we moved to a new house. By this time, Cee had been in a toddler bed for almost a year, but she had no problem staying in it at bedtime or through the night. We had a sweet bedtime routine that ended with kisses goodnight, turning off the light, and then good sleep for Cee. After we moved, Cee started talking about being afraid of things like the deer and turkeys that wandered through the yard of our new house. We talked about these fears, got her a night light, and spent a little more time with her before saying goodnight, singing a couple of rounds of Twinkle, Twinkle and rubbing her back for a few minutes. All of that was fine.

Then Cee started getting out of her bed after we left her room for the night. She’d pad into the living room or my office to find me. I’d walk her back to bed and tuck her in again, but some nights this happened over and over. I would be shocked to see her in my office door at 9:00 or 9:30 PM, long after her 8:00 bedtime. She was also waking up during the night, coming into our room, and patting my shoulder until I woke up. I would walk her back to her room, often lying down next to her until she went back to sleep. Alternatively, I’d pull her into bed with me, but neither of us slept very well this way. All of this was adding up to fewer hours and less restful sleep for both of us.

When did the sweetness of a good nap become something to resist?

When did the sweetness of a good nap become something to resist?

Things seemed to get worse around the holidays. Cee was getting out of bed more and more after bedtime, and she was having a hard time separating when we tucked her back in. She started asking us to sit with her while she fell asleep, and this actually seemed like a reasonable solution. At least if we sat in her room we could make sure that she stayed in her bed, and maybe she would fall asleep easier and get more rest this way. I reminded myself that she was just 3, and if she was asking for more support in her transition to sleep, why shouldn’t we give that to her? (Never mind that she had been falling asleep on her own since she was a baby.)

There was something else going on at this time, too. I thought that maybe Cee’s struggles with sleep were because I wasn’t there enough for her in the day. I was going through a really tough period, approaching the 1-year anniversary of our first miscarriage and beginning some fertility testing. Continue reading

Caffeine Safety in Pregnancy

My first trimester of pregnancy coincided exactly with the last three months before my book deadline. I was lucky to have only mild nausea during this time, but I was really, really tired, especially in the afternoon. I tried hard to get enough sleep at night, but my body also seemed to want a 2-hour nap after lunch, when I just couldn’t stay awake, much less think and write. Pre-pregnancy, I responded to a post-lunch slump by pouring myself a cup of coffee or, even better, spending the afternoon at my favorite coffee shop, where a latte and the people around me helped keep me focused for a productive afternoon. A cup of herbal tea in the same atmosphere just made me want to curl up in one of the comfy chairs and take a nap, even as my caffeine-fueled coffee shop friends typed energetically around me.

But now I was pregnant, after 18 month of trying and several miscarriages, and I wanted to do all I could to minimize the risks of losing this pregnancy. In previous pregnancies I’d just given up most caffeine, and that wasn’t that hard to do. In this one, I was more afraid than ever of a miscarriage, but I also needed the caffeine boost more than ever to finish my book. I wanted to know what the research says about the safety of caffeine in pregnancy so that I could make an informed decision about whether to consume caffeine, and if so, how much.

Photo by Kevin Tuck

In her book, Expecting Better, Emily Oster includes an excellent discussion of caffeine in pregnancy. I consulted this for a quick answer to my question, and her analysis of the research on this topic helped me feel comfortable strategically drinking a little coffee in the afternoon. However, as much as I respect and highly recommend Oster’s book, I’ve also found that my approach to risk in pregnancy is a bit more conservative, and as soon as I had the chance, I wanted to look at the studies myself. Continue reading