Pinterest Bars Vaccination Searches in Move to Control the Conversation

Published in The Wall Street Journal, U.S. Edition, on February 27, 2019, by Robert McMillan and Daniela Hernandez:  Original Article

Pinterest has stopped returning results for searches related to vaccinations, a drastic step the social-media company said is aimed at curbing the spread of misinformation but one that demonstrates the power of tech companies to censor discussion of hot-button issues.

Most shared images on Pinterest relating to vaccination cautioned against it, contradicting established medical guidelines and research showing that vaccines are safe, Pinterest said. The image-searching platform tried to remove the antivaccination content, a Pinterest spokeswoman said, but has been unable to remove it completely.

Pinterest described the search ban—which the company hasn’t previously publicly discussed but which went into effect late last year—as a temporary but necessary measure until it can develop better strategies to sift through what it calls “polluted” content. The company made a similar decision last year to block searches for dubious cancer therapies.

Users can still pin vaccine-related images to their online boards, which could lead to suggestions for similar content, but the posts no longer show up in searches. “It’s better not to serve those results than to lead people down what is like a recommendation rabbit hole,” said Ifeoma Ozoma, Pinterest’s public policy and social manager. The technology industry is grappling with the thorny issue of how and when to take responsibility for information on its platforms. Companies including Twitter Inc. and Facebook Inc. have begun to police hate speech, violence, terrorism-recruitment campaigns and sexual harassment on their services, shutting down millions of accounts. But those actions have sparked counter-complaints about everything from political bias and censorship to a lack of transparency in the process.

“There’s a secretive process with no real appeal where people are making extremely difficult subjective calls that have to do with politics, culture and religion,” said Jennifer Granick, an attorney with the American Civil Liberties Union. “This example shows why it is dangerous. If I want to find good information about vaccines, I can’t find it.”

The aggressive move by Pinterest marks another change in the way large tech companies are trying to handle the responsibility of monitoring the flow of information.

“Until recently, social-media companies have drawn a line in the sand saying they’re not arbiters of truth; that they are passive purveyors of information,” said Samuel Woolley, a researcher who studies social-media disinformation at the Institute for the Future think tank.

“There’s been pressure on them for a long time to respond to this because the reality of this is the spread of misinformation— especially around vaccines— leads to extremely bad consequences, including death,” he said.

Last week, Rep. Adam Schiff (D., Calif.) wrote to Google and Facebook, expressing his concern that the tech giants’ algorithms were recommending messages that would discourage parents from vaccinating their children.

In response, Facebook said Friday that it was considering changes to the way its algorithm recommends health-related information, including demoting or ceasing recommendations of antivaccine material. Over the past few years Google, a unit of Alphabet Inc., has introduced measures to improve the quality of its health-related search results, such as “knowledge panels” that pop up with authoritative information on searches for medical conditions. These panels are sourced from places such as the Mayo Clinic and are reviewed by medical professionals.

YouTube said it is working with experts to provide more context, including information panels, in its search results, and the company has pledged to improve its search and recommendations when it comes to medical content.

Misinformation about health-related issues can be particularly pernicious because it can affect people’s well-being, physicians said. In Washington state’s Clark County, a measles outbreak this winter has infected 62 people, most of them unvaccinated children. Dr. Alan Melnick, the county’s public-health director, said “the onslaught of fairly sophisticated but nonsense messages on social media” has contributed to the problem. Amid the outbreak, the county’s Facebook page was littered with comments falsely claiming that vaccinated children could spread the disease to others and links to a YouTube video falsely claiming a link between autism and the vaccine used to fight measles, mumps, and rubella, he said.

Pinterest also has begun to block certain cancer-related searches, content and accounts related to dubious cancer therapies, which are another source of misinformation, according to the company. A Pinterest spokeswoman said the company is working on new ways of keeping misleading content out of its recommendations engine.

In December, Pinterest blocked multiple accounts that promote what it determined to be false cancer treatments or that linked to third-party websites selling supplements or other merchandise that haven’t been scientifically vetted, according to the company.

Its decision came following a collaboration with social-media intelligence firm Storyful, which identified cancer as “one of those areas where there is more misinformation than not,” Ms. Ozoma said. Storyful is owned by News Corp, The Wall Street Journal’s parent company. Storyful confirmed the collaboration and said its assessment of cancer-related misinformation was ongoing.

Pinterest trains and uses human reviewers to make determinations about whether or not shared images on the site, called pins, violate its health-misinformation guidelines. Pinterest has felt blowback from users who feel that the removal of these posts is an overreach, Ms. Ozoma said.

Kevin Malone, 58 years old, who gets medical information from podcasts and Facebook, among other sources, said he would “hate to see [social media] totally censored.” In the past, traditional doctors haven’t been able to treat his ailments well, including infections and a heart condition, he said. Through friends and social media, he’s found therapies that work for him, he said. “I think it’s a disservice to the population who like me want to be proactive and want this knowledge,” said Mr. Malone, a physical therapist from Ocean Shores, Wash.

 

Flat Head Syndrome is fast becoming a pediatric epidemic

A pediatric epidemic: Deformational plagiocephaly / brachycephaly and congenital muscular torticollis

Published in Contemporary Pediatrics on February 1, 2019; Volume 36, Issue 2  (Re-posted from Original Article)
A pediatric epidemic is sweeping the country. The incidence of infant deformational plagiocephaly and brachycephaly (DPB) and congenital muscular torticollis (CMT) has been on an upward spiral since 1992 when the American Academy of Pediatrics (AAP) instituted the “Back to Sleep” campaign.1 Infants are spending more time supine and in reclined positions day and night and less time prone than in the past.2We postulate that the widespread increase in DPB and CMT is multifactorial, including frequent use of and/or sleeping in reclined positioners and chairs such as bouncy seats, reclined rockers, swings, and car seats, and dramatically decreased tummy time.
Clinics and pediatrician offices have become inundated with patients exhibiting DPB and CMT, leading to a substantial escalation in costs to the healthcare system. Other repercussions from these diagnoses are an increased need for physical therapy (PT) services and use of helmet therapy (HT), which place additional stress on a family’s time and financial resources. Most community- and government-funded programs (Birth-to-3, early intervention) are strained to accommodate expanding demand for these services.
The aim of this article is to heighten awareness of this epidemic. Pediatric healthcare providers are on the front lines to intervene early in its evolution, allowing them to identify, prevent, and/or treat DPB and CMT with conservative measures. Hopefully, these measures will reverse the process and decrease or eliminate associated exorbitant healthcare costs.
DPB and CMT

Deformational plagiocephaly/brachycephaly occurs from prolonged pressure on the baby’s skull in utero or soon after birth, causing an asymmetric (plagiocephaly) and/or wide (brachycephalic) head shape. The skull is soft and malleable until ossification begins at age 5 to 6 months. When a baby develops a preferred position, the skull will flatten in that area. If the misshapen area is unilateral, the ear, forehead, and cheek will shift anteriorly and impact cosmesis. If the misshapen area is bilateral, the back of the head will widen and may look tall or turricephalic. Incidence of DPB ranges from 18% to 19.7%.3

Congenital muscular torticollis occurs when the sternocleidomastoid (SCM) muscle becomes shortened or restricted unilaterally. The head then turns to the opposite side and/or tilts downward to the same side, resulting in a preferred head position. It becomes difficult for the infant to independently alter head position, and prolonged pressure on the same area occurs when the infant is in a reclined position or sleeping. Also, CMT may develop prenatally due to restricted intrauterine positioning, during delivery, or because of DPB or other external forces. This strains the SCM and surrounding neck musculature causing cervical muscle imbalance and positional preference. The 2 diagnoses usually occur together, creating a synergistic effect.4 Additionally, DPB is strongly associated with CMT—as high as 70% to 95%.3

In the United States, CMT is the third-most common orthopedic diagnosis in infants. Like DPB, its incidence has increased, with a reported range of 0.4% to 1.9% in earlier studies.1,5-9 A rate as high as 16% was reported by 2008.10 Also, CMT has been associated with comorbidities including DPB, facial asymmetries, mandibular asymmetry (MA), developmental hip dysplasia, and gross motor skill asymmetries. Children diagnosed with CMT are treated with skilled PT services to address weakness, range-of-motion limitations, postural deficits, and altered gross motor skill acquisition. A course of PT successfully resolves 90% to 99% of CMT. Surgical intervention (eg, SCM release) is rarely necessary.1,11

Congenital muscular torticollis has an association with MA that can lead to long-term facial asymmetry.1,12 Unilateral ramal height growth restriction, causing jaw asymmetry, results from CMT due to abnormal muscle forces. Mandibular asymmetry can be identified by approximating the mandible to the maxilla. The mandible will cant upward on the side of the head tilt. Physical therapy for the torticollis will address the MA, which is important because MA can affect feeding, especially the ability to achieve latch and adequate suction for breastfeeding.13 Addressing MA early means a greater potential for improvement and resolution. Craniofacial asymmetries, including MA, can become more severe with age when treatment of CMT is delayed or if CMT remains untreated.14

Identifying the problem

Most parents notice the flattening or misshaping of their infant’s head shape between age 1 and 2 months. Parents and primary care physicians (PCPs) do not always recognize CMT because presentation may be subtle. Parents tell us they mention their concern about abnormal head shape and/or positional preference to their PCP but are told it will spontaneously improve once the infant is rolling over and sitting upright. They are discouraged when this does not happen. Although many PCPs believe what they are telling concerned parents about spontaneous improvement, this is typically not the case unless interventions are initiated much earlier in infancy.

In the United States in 2017, 3.8 million babies were born. As noted earlier, incidence of DPB ranges from 18% to 19.7%—about 720,000 infants per year born with DPB.3 About 100 US pediatric plastic surgery/cleft-craniofacial centers each see nearly 100 patients with these diagnoses per month. This does not account for other providers including neurosurgeons or pediatricians. Only about 100,000 of 720,000 infants per year are currently being identified and treated, leaving 86% (620,000) unidentified and untreated. Given long-term, often irreversible, sequelae, this is a serious problem.

Our center’s experience

At our institution, the University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh, Pennsylvania, the cleft-craniofacial center is embedded in the pediatric plastic surgery department. With more than 100 new patients referred to us monthly, most of whom having both DPB and CMT, we developed a multidisciplinary clinic in 2010. Our comprehensive team evaluation and treatment approach includes a nurse practitioner and a physical therapist. With this approach, we are able to institute PT and aggressive repositioning (AR) management at the initial appointment, beginning these conservative measures as soon as possible. Combining these services saves time and money for parents and/or guardians by eliminating the need to schedule a separate PT appointment.

Patients receive a wealth of information during a medical appointment, of which about 80% is not retained once they leave the office.15 To reinforce our recommendations and instruction, we have developed printed patient-education materials to increase understanding and compliance. Handouts include information sheets on DPB and AR techniques as well as brochures about tummy time and torticollis that describe home exercises for CMT.

We also provide community outreach to our regional PCPs and pediatric therapists. Our purpose is to increase awareness of these diagnoses and emphasize the small but critical time frame available to institute conservative measures to treat DPB.

Diagnosis and evaluation

Diagnosis of DPB is determined by physical exam. The cranial exam is performed by having the parent/guardian hold the infant in his/her lap while the nurse practitioner examines the baby from the vertex view (Figure 1). This exam ascertains whether the DPB is unilateral or bilateral. Unilateral DPB most frequently manifests in a parallelogram shape of the head (Figure 2). The flattened side of the head displaces the ear forward anteriorly, causing forehead bossing and fullness of the cheek on the affected side. The orbital opening may be larger on the affected side. Bilateral DPB results in significant brachycephaly (Figure 3). Facial features are not as affected in brachycephalic patients unless both brachycephaly and asymmetry are demonstrated.

When assessing the cranial vault, a hand caliper is used to measure the cranial index (CI), also referred to as the cephalic ratio, defined as the width divided by the length. The oblique diagonal difference (ODD) is a measurement of the asymmetry of the cranial vault. The CI and ODD provide objective guidelines with which to determine DPB severity (Figure 4). Criteria for cranial vault measurements have not been standardized, but an ODD equal to or greater than 12 mm (and/or confidence index [CI] ≥1.0) has been used to denote DPB as severe. These measurements guide treatment decision-making; eg, mild DPB is treated conservatively with AR and PT.

If the baby is aged 4.5 to 5 months or older and has moderate or severe cranial vault measurements, the parent/guardian is offered HT as a choice. The infant must show adequate head and neck control. We verify this developmental achievement by performing a pull-to-sit test to ensure a strong chin tuck is present and there is no head lag (Figure 5). If head lag exists, we recommend increasing tummy time to achieve improved head and neck control and a return visit once adequate head and neck control is achieved. Helmets weigh about 8 ounces, which is a significant weight to place on an infant’s head. Infant safety must be ensured with HT as poor head and neck control combined with the weight of a helmet could potentially compromise respiratory status.

Differential diagnosis

When evaluating these patients, differential diagnoses including craniosynostosis, macrocephaly, hemifacial microsomia, and hydrocephalus must be considered. The occipital frontal circumference is obtained to evaluate for macrocephaly. If there are concerns about head size, we refer to neurosurgery for further evaluation. Cranial sutures are evaluated via palpation for any indication of suture ridging, which can be suggestive of craniosynostosis (fusion or premature closure of skull sutures). If cranial suture ridging is identified and findings are consistent with craniosynostosis, a 3-dimensional computed tomography (3D CT) scan is indicated and HT deferred until it is completed.

Skull x-rays are rarely indicated or helpful. If the 3D CT scan shows craniosynostosis, the patient is referred to a craniofacial surgeon. If the scan does not indicate craniosynostosis, HT can be considered. Some asymmetric facial features observed in children with mild hemifacial microsomia may also be seen in children with DPB and CMT. Children with hemifacial microsomia, however, typically do not present with DPB and/or CMT.

Role of the physical therapist

The physical therapist evaluates the patient’s neck, spine, hips, feet, and provides gross motor skill screening. If the infant has CMT, parents and/or guardians are educated about it, taught exercises to begin immediately, and counseled on initiating PT services via outpatient or early intervention (Birth-to-3). In our state, parents/guardians often opt for early intervention because the state-funded programs do not require insurance and provide the convenience of a physical therapist coming to the home, daycare, or sitter’s home. Such services can take up to a month to initiate, so exercises must start right away. Frequency of PT is weekly or every other week, becoming less frequent as the infant improves. Standard of care for CMT is to continue with PT until the child is walking independently to ensure gross motor milestones are achieved and performed symmetrically.11

Up to 99% of CMT resolves with PT and less than 0% to 1% requires surgical intervention.11 Often CMT manifests with soft tissue restriction of the neck and shoulders, including fibromatosis colli within the SCM in 10% to 50% of cases.1 Families are taught massage for the soft tissue restrictions, which can take months to resolve. Also, a 10% to 14.9% correlation of CMT with developmental hip dysplasia has been documented.1,16,17 The physical therapist undertakes a clinical hip evaluation, and if there are any concerns, the patient is referred to a pediatric healthcare provider or to orthopedics.

Critical importance of tummy time

Initiating awake prone time immediately is crucial in the newborn period. Although parents are well educated about the Back to Sleep campaign to prevent sudden infant death syndrome, they rarely receive sufficient information on the benefits and techniques of tummy time. Our brochure on tummy time reviews techniques for families to use to achieve the goal of 81 minutes by age 4 months.2

Tummy time strengthens the infant’s neck and core and relieves pressure from the head. It is inexpensive, easy to do, and does not require additional products or have associated costs. It would be most beneficial if tummy time were reviewed by the pediatrician or healthcare personnel within the practice during the first newborn appointments. The slogan “Back to sleep, tummy to play” establishes a simple but important message.

Impact of aggressive repositioning

If patients are referred early, between age 0 and 4 months, we initiate the conservative measures of AR and PT. Such techniques are effective then because the skull is soft and malleable until age 5 to 6 months. We strongly support the AAP recommendations of sleeping on a flat, firm surface. Many families have their babies sleeping in reclined chairs, which we believe exacerbates DPB and CMT. In an effort to minimize pressure on the misshaped side of the head, we teach families to use AR. We use a receiving blanket rolled up like a log and tucked behind the affected side of the head, shoulder, waist, and hip when the baby is resting, especially in reclined chairs (eg, bouncy, Fisher Price Rock ‘n Play, or swing chairs). The goal is to minimize reclined positioning and increase upright seating when developmentally appropriate.

Upright chairs for emerging sitters (eg, Bumbo, Fisher Price Sit-Me-Up, Summer Infant, BebePod) are recommended at age 3 to 4 months. These chairs provide necessary back support but allow pressure to be removed from the head. They should be introduced in short intervals, increased as the baby adjusts, and placed on the floor, never on a table or counter due to concern over fall risk. Parents are encouraged to use front carriers in their daily activities to remove pressure from the baby’s head.

Feeding techniques for both bottle-feeding and breastfeeding are provided to support the head and neck, reducing pressure on the affected side of the skull. It is important to reduce laying the baby’s affected side of the head on an arm or items like a pillow. Visual stimulation encourages the baby to look to the opposite side from the DPB.

We use AAP guidelines and state trooper guidelines for car-seat positioning.18 These guidelines require the infant be safely buckled into the car seat and the blanket roll tucked behind the affected side of the head, shoulder, and hip outside of straps and buckles. The family is taught to take the infant out of the reclined car seat upon reaching their destination to prevent further pressure on the affected side of the head. This can be done by holding the baby, using a front carrier, or, when developmentally appropriate, the stroller. We offer a prescription for AR if the baby is enrolled in daycare.

Cranial remolding helmet therapy

Patients return for further evaluation between age 4.5 and 5 months. If conservative techniques have been effective in improving or halting progression of DPB and its severity does not meet criteria for HT, we recommend continuing AR and PT. If between 4.5 and 5 months infants still show significant DPB and meet criteria, we offer HT and many parents agree to it. Again, HT has proved most effective when the skull is still malleable, brain growth is robust, and when initiated prior to the ossification process.19We inform families that DPB is a functional cosmetic issue because patients need to fit into safety helmets properly when they begin to ride bikes or play helmeted sports. Risk of concussion should not be increased by an ill-fitting helmet due to an abnormal head shape.

Although highly effective, HT can be time consuming and stigmatizing. Often, mothers tell us they feel they have done something to cause this problem. Many cultures are not open to HT. The potential adverse effects of HT include skin issues; ie, rashes, pressure areas, wounds, contact dermatitis, and exacerbation of eczema, seborrhea, or cradle cap. Infants also can become overheated when wearing helmets. Loss of work due to follow-up appointments for adjustments can impact the family. Finally, HT can be very expensive and insurance coverage may be lacking.

Of note, the AAP clinical report from 2011 found no evidence that molding helmets work any better than repositioning for mild or moderate skull deformity.20 Based on studies available then, the best use of helmets for severe deformity is at age 4 to 12 months because of the greater malleability and rapid brain growth. Since 2011, however, newer, larger studies have been completed on the efficacy of HT.

In 2014, a prospective, nonrandomized study recommended treating mild plagiocephaly with repositioning and that HT be the treatment of choice for moderate-to-severe plagiocephaly.21 Another study of 4378 patients found that both conservative treatment and HT were effective.22Recommendations included repositioning first and HT if repositioning was not effective, or if the baby was older or the condition more severe. A 2015 long-term outcome study comparing those who used helmets versus repositioning found HT provided greater improvement in skull shape than the conservative measure.23 In contrast to other recent findings, a 2016 study found clear improvement in nonsynostotic head deformity treated with a molding helmet and no clear evidence of improvement of absolute measurements in untreated cranial deformity within a 5-year follow-up.24

Although recent review/guidelines from the Congress of Neurological Surgeons (CNS) on HT for patients with positional plagiocephaly indicate AR and PT are important, the report stresses that HT is more effective in reshaping the plagiocephaly.25 It concludes that a body of nonrandomized evidence has shown “more significant and faster improvement of cranial shape in infants with positional plagiocephaly treated with a helmet in comparison with conservative therapy, especially if the deformity is severe, provided that helmet therapy is applied during the appropriate period of infancy.”

We propose, however, that AR and PT initiated early enough have the potential to be as effective as HT in addressing DPB. Patients are rarely referred to us in this early critical timeframe, but when they are, the conservative measures of AR and PT halt or reverse DPB, resulting in substantial improvement and even negating the need for HT. Although it has not been our experience, concerns exist about the overprescribing of HT, but that issue is beyond the scope of this article’s focus.

The epidemic of DPB and CMT has caused a significant financial burden on the healthcare system, especially when HT is used. As the majority of infants are referred too late to institute conservative measures, HT becomes the only option, one that we estimate costs $3.6 million at our center for approximately 900 patients per year.

The United States has over 100 craniofacial centers, and certainly specific costs attributed to this problem vary among them. Nevertheless, referencing our costs for HT as well as plastic surgery consults and PT evaluations and sessions, and multiplying it by 100 centers across the country, the rough gross estimate for costs nationwide quickly reaches more than $1 billion. As well, this estimate does not include costs for patients treated by neurosurgery centers or other providers, missed work, or transportation.

Prevention

Few medical issues occur with this prevalence in otherwise healthy infants, and little attention has been paid to prevention or early treatment in light of the increased numbers of infants with this diagnosis since 1992. Research supporting effective prevention strategies is scant. We recently completed a pilot study approved by the Institutional Review Board that demonstrated support of early referral resulting in less-frequent HT. A Finnish study also has shown that initiating preventive education in the maternity ward from the time infants are born provides significant reduction in the number of infants who develop deformational plagiocephaly or require HT.4

Conclusion

Pediatric healthcare providers are in the best position to identify and manage DPB and CMT. Evaluation of the infant’s head shape and range of motion of the neck should be incorporated into the 1- and 2-month well-child appointments. If any concerns are noted, AR and referral to PT should be initiated immediately.

Lack of intervention or suggesting it will resolve once the baby is rolling and sitting is usually a fallacy. Conservative measures are most effective when the skull is still malleable prior to onset of ossification. If no improvement is observed by the 4-month well-child appointment, referral to a specialist is recommended. Early identification and treatment are critical. They can dramatically improve the patient’s course and provide the momentum to begin to minimize, and hopefully reverse, this epidemic.

References:

1. Karmel-Ross K. Congenital muscular torticollis. In: Campbell SK, Palisano RJ, Orlin MN, eds. Physical Therapy for Children. 4th ed. St. Louis, MO: Elsevier Saunders; 2012:292-312.

2. Dudek-Shriber L, Zelazny S. The effects of prone positioning on the quality and acquisition of developmental milestones in four-month-old infants. Pediatr Phys Ther. 2007;19(1):48-55.

3. Rogers GF. Deformational plagiocephaly, brachycephaly, and scaphocephaly. Part 1: terminology, diagnosis, and etiopathogenesis. J Craniofac Surg. 2011;22(1):9-16.

4. Aarnivala H, Vuollo V, Harila V, Heikkinen T, Pirttiniemi P, Valkama AM. Preventing deformational plagiocephaly through parent guidance: a randomized, controlled trial. Eur J Pediatr. 2015;174(9):1197-1208.

5. Cheng JC, Au AW. Infantile torticollis: a review of 624 cases. J Pediatr Orthop. 1994;14(6):802-808.

6. Cheng JC, Tang SP, Chen TM. Sternocleidomastoid pseudotumor and congenital muscular torticollis in infants: a prospective study of 510 cases. J Pediatr. 1999;134(6):712-716.

7. Cheng JC, Wong MW, Tang SP, Chen TM, Shum SL, Wong EM. Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis in infants. A prospective study of eight hundred and twenty-one cases. J Bone Joint Surg Am. 2001;83-A(5):679-687.

8. Do TT. Congenital muscular torticollis: current concepts and review of treatment. Curr Opin Pediatr. 2006;18(1):26-29.

9. Tatli B, Aydinli N, Caliskan M, Ozmen M, Bilir F, Acar G. Congenital muscular torticollis: evaluation and classification. Pediatr Neurol. 2006;34(1):41-44.

10. Stellwagen L, Hubbard E, Chambers C, Jones KL. Torticollis, facial asymmetry and plagiocephaly in normal newborns. Arch Dis Child. 2008;93(10):827-831.

11. Kaplan S, Coulter C, Sargent B. Physical therapy management of congenital muscular torticollis: a 2018 evidence-based clinical practice guideline from the APTA Academy of Pediatric Physical Therapy. Pediatr Phys Ther. 2018;30(4):240-290.

12. Kawamoto HK, Kim SS, Jarrahy R, Bradley JP. Differential diagnosis of the idiopathic laterally deviated mandible. Plast Reconstr Surg. 2009;124(5):1599-1609.

13. Wall V, Glass R. Mandibular asymmetry and breastfeeding problems: experience from 11 cases. J Hum Lact. 2006;22(3):328-334.

14. Jeong KY, Min KJ, Woo J, Yim SY. Craniofacial asymmetry in adults with neglected congenital muscular torticollis. Ann Rehabil Med. 2015;39(3):440-450.

15. Bass PF. 3 steps to boost health literacy. Contemp Pediatr. 2018;35(1):13-14.

16. Jackson JC, Runge MM, Nye NS. Common questions about developmental dysplasia of the hip. Am Fam Physician. 2014;90(12):843-850.

17. Kim SN, Shin YB, Kim W, et al. Screening for the coexistence of congenital muscular torticollis and developmental dysplasia of hip. Ann Rehabil Med. 2011;35(4):485-490.

18. American Academy of Pediatrics. Car seats: information for families. HealthyChildren.org website. Available at: https://www.healthychildren.org/English/safety-prevention/on-the-go/Pages/Car-Safety-Seats-Information-for-Families.aspx. Updated August 30, 2018. Accessed January 23, 2019.

19. Kluba S, Kraut W, Reinert S, Krimmel M. What is the optimal time to start helmet therapy in positional plagiocephaly? Plast Reconstr Surg. 2011;128(2):492-498.

20. Laughlin J, Luerssen TG, Dias MS; Committee on Practice and Ambulatory Medicine, Section on Neurological Surgery. Prevention and management of positional skull deformities in infants. Pediatrics. 2011;128(6):1236-1241. Erratum in: Pediatrics. 2012;129(3):595.

21. Kluba S, Kraut W, Calgeer B, Reinert S, Krimmel M. Treatment of positional plagiocephaly—helmet or no helmet? J Craniomaxillofac Surg. 2014;42(5):683-688.

22. Steinberg JP, Rawlani R, Humphries LS, Rawlani V, Vicari FA. Effectiveness of conservative therapy and helmet therapy for positional cranial deformation. Plast Reconstr Surg. 2015;135(3):833-842.

23. Naidoo SD, Skolnick GB, Patel KB, Woo AS, Cheng AL. Long-term outcomes in treatment of deformational plagiocephaly and brachycephaly using helmet therapy and repositioning: a longitudinal cohort study. Childs Nerv Syst. 2015;31(9):1547-1552.

24. Wilbrand JF, Lautenbacher N, Pons-Kühnermann J, et al. Treated versus untreated positional head deformity. J Craniofac Surg. 2016;27(1):13-18.

25. Flannery AM, Tamber MS, Mazzola C, et al. Congress of Neurological Surgeons systematic review and evidence-based guidelines for the management of patients with positional plagiocephaly: executive summary. Neurosurgery. 2016;79(5):623-624.

Groundbreaking CMS study shows better outcomes and lower costs at birth centers

The Centers for Medicare & Medicaid Services study confirms what we have experienced in our practice for many years, but on a national scale – that women who get their care at birth centers experience better outcomes, on average. – Ann McCarthy, CNM, MSN, Clinical Director of The Midwife Center, 01/30/2019

The results of a recent groundbreaking study are in: birth centers are coming out on top!

According to the Center for Medicare & Medicaid Services (CMS) study, Strong Start for Mothers and Newborns, individuals with Medicaid who received prenatal care in birth centers like The Midwife Center experienced better birth outcomes compared to the rest of the nation, on average.

Why this study is important

Right now, the U.S. maternity care system is failing our mothers and newborns. We spend more on healthcare than any other country, yet women and newborns experience significant disparities associated with race, poverty, and access to quality care.

  • One in ten births is premature, and Black babies have a higher risk of prematurity
  • Maternity care is one of our nation’s largest healthcare expenditures
  • Preterm birth alone costs over $26 billion per year

Key stats

Researchers collected data on individuals receiving care within enhanced prenatal care models.* The study looked at 8,806 individuals enrolled in Strong Start Birth Centers.**

  • All had Medicaid
  • 10% had a previous preterm birth
  • 33% exhibited symptoms of depression, anxiety, or both

Individuals enrolled in Strong Start Birth Centers experienced better health outcomes, on average, compared to the rest of the nation:

Primary c-section rate is for first baby only (Osterman, 2014). Other US numbers are from 2016 (Martin, 2018). Total c-section rate includes repeat c-sections.

What’s next?

As midwives and birth center professionals, the study confirmed what we already knew – that birth center clients experience better outcomes, and the maternity care system as a whole experiences lower costs. We are thrilled to see this confirmed by the CMS study. We hope that policymakers at the state and national level will work to improve health outcomes by expanding access to birth center care.

We at The Midwife Center were honored to play a significant role in the study. Due to the success of the study, we have continued to provide information and resource counseling to our clients in addition to new and expanded services like behavioral health and wellness.

More information:

– CMS’s “Findings at a glance” (PDF)

– Full findings at CMS.gov

– Original Blog by Ann McCarthy, CNM, MSN

Vitamin D deficiency tied to miscarriages, study says

by Sonja Haller, USA Today, May 31, 2018

Miscarriage is so common that it happens to up to 25 percent of all pregnancies, according to the American Pregnancy Association.

In the face of this heartbreak, doctors can often only tell women trying to conceive to wait 10-12 weeks and try again. 

The news this week out of the National Institutes of Health is that Vitamin D can reduce the risk of another miscarriage. That is positive news. 

Researchers found that women with sufficient levels of Vitamin D were 10 percent more likely to become pregnant and 15 percent more likely to have a live birth after miscarriage. (A miscarriage is the loss of a pregnancy within the first 20 weeks.)

“Our findings suggest that vitamin D may play a role in pregnancy,” said the study’s principal investigator Sunni L. Mumford, in the Epidemiology Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. 

The study was published in The Lancet Diabetes & Endocrinology. 

The study tested Vitamin D blood levels of 1,200 women before pregnancy and again at the eighth week of pregnancy. Vitamin D levels in the eighth week of pregnancy were not linked to pregnancy loss. Researchers defined Vitamin D levels of below 30 nanograms per milliliter as insufficient.

Researchers noted that the study does not prove cause and effect.

More study is needed to determine whether giving vitamin D supplements to women at risk for pregnancy loss could increase their chances of pregnancy and live birth.

Authors of the study noted that research has shown that women who have higher levels of Vitamin D before undergoing in vitro fertilization have higher pregnancy rates than those with lower levels.  

Fish oil and probiotic supplements for pregnant mothers may decrease children’s risk of getting allergies, study says

Major analysis is being considered by UK government to inform future dietary guidelines for expectant mothers

by Alex Matthews-King, Health Correspondent, February 28, 2018

Fish oil supplements and probiotic yoghurts during pregnancy may decrease children’s risk of developing allergies, a major evidence review has found. 

The study on how childhood allergies are influenced by mothers’ diet also found that avoiding key foods like peanuts, eggs and dairy had little impact on future allergies or eczema.

The findings are now being considered by the British Government and could influence new dietary guidance for expectant mothers and infants.

“Food allergies and eczema in children are a growing problem across the world,” said lead author Dr Robert Boyle from the Department of Medicine at Imperial College London.

“Although there has been a suggestion that what a woman eats during pregnancy may affect her baby’s risk of developing allergies or eczema, until now there has never been such a comprehensive analysis of the data.

“Our research suggests probiotic and fish oil supplements may reduce a child’s risk of developing an allergic condition, and these findings need to be considered when guidelines for pregnant women are updated.”

Food allergies affect around one in 20 children in the UK. 

These are caused by the immune system becoming sensitive to harmless chemicals in foods like peanuts or dairy and over-reacting. Then this triggers the body’s defence response that includes rashes swelling, and the closing off of the airways.

Eczema, a condition causing cracked, dry and itchy skin, affects 20 per cent of UK children. It is also linked to children having a higher risk of food allergies, although it’s not clear why. 

The Imperial team reviewed over 400 studies, covering 1.5 million people, on the link between maternal diet, allergies and breast feeding, for the research – which is published in PLOS Medicine. It was funded by the Food Standards Agency.

Pooling multiple studies in this way means results are less likely to be statistical one offs.

The studies on probiotics and fish oil were all controlled trials where mothers were randomly assigned to a particular diet instead of just reporting what they ate, which also lends credibility to the results.

Looking at 19 studies where mothers took a daily fish oil capsule, they found there was evidence to suggest the daily omega-3 supplement from 20 weeks of pregnancy, and in the first three to four months of breast feeding, decreased the risk of allergies.

These studies tested infants for an egg sensitivity as a proxy for developing other allergies in future.

There was also some evidence to suggest omega-3 could reduce peanut allergies, by as much as 38 per cent. However this was only identified in two studies and therefore not as reliable.

The 30 per cent reduction amounts to around 31 fewer children with an egg allergy for every 1,000 mothers following this regime.

It also looked at 28 trials, covering 6,000 women, taking a variety of probiotic supplements 0 though most of them contained a bacterium called Lactobacillus rhamnosus.

While probiotic yogurt drinks are one source of these sort of gut boosting bacteria, most don’t contain a high enough concentration of helpful bacteria and these studies mostly looked at pill or powder supplements.

The analysis found taking probiotics in the last few weeks of pregnancy and in the first three to six months of breastfeeding, was related with a 22 per cent decrease in eczema cases in children – around 44 fewer cases in every 1,000.

Researchers found some limited evidence to support the suggestion that maternal breast feeding  alone helped reduce eczema rates, and could also have benefits for lowering the risk of type one diabetes.

But there was not enough evidence to support other supplements, or leaving out certain foods.

“This is an important, well conducted piece of research, which adds to the growing evidence suggesting that nutrient supplementation during pregnancy and lactation may have the potential to prevent childhood allergy and allergic disease,” said Seif Shaheen, professor of respiratory epidemiology at Queen Mary University of London, who was not involved with the study.

Body Image and Baby Jesus: Seeing Deeper Love in Scars and Sagging

Article by Liz Wann, Regular Contributor, Published in desiringGod, December 6, 2017

Before getting pregnant with my third child I worried about my body image. Will I be able to lose the baby weight a third time? Will there be more sagging? More stretching and scars? My postpartum body just doesn’t measure up to images on social media or the magazine aisle at checkout.

The cultural and social pressure out there is tough on our bodies, especially for women. Fat is stigmatized, muscle should be toned, and beach body ready by summertime. If the view of our bodies is reduced to only a scale number and a certain “fit look” then we are missing out on God’s design for our bodies.

God declares our bodies good. They are a temple of the Holy Spirit, which he bought at a great cost (1 Corinthians 6:19–20). Since our bodies are good and not our own, we are called to cherish and care for them and use them in service and sacrifice (Romans 12:1).

Although tempted to believe otherwise when I look in the mirror, my pregnant body is good and my postpartum body is good. Scars and sagging skin are the marks I bear on my body in service of others, like when Jesus showed the disciples the nail scars in his hands. It was good for him to sacrifice his body for me, and it’s good for me to sacrifice my body for another.

King of Kings, Yet Born of Mary

Before the nail scarred hands, someone had to agree to volunteer their own body to bear the Savior. When the Virgin Mary was approached by the angel Gabriel and she submitted to the call on her life, she was not only sacrificing her reputation and social standing, but also her body (Luke 1:26–38). She was agreeing to carry a baby she didn’t ask for, and God himself was willing to grow inside her body.

Mary’s body was used for God’s purposes. For God to inhabit a human body he developed it inside of her womb. The one who is spirit took on flesh for all eternity. As C.S. Lewis says in Mere Christianity, “It is really, I suggest, a timeless truth about God that human nature, and the human experience of weakness and sleep and ignorance, are somehow included in his whole divine life.”

Jesus had to be made like us in every way (Hebrews 2:17). His body is not insignificant.

Jesus’s Was Body Broken

His body came out of the birth canal and as it grew Mary nourished him with her own body. Then Jesus himself was able to care for and nourish his body on his own. He slept, he rested, he ate good food, and he worked hard in manual labor and ministry. He ministered to people’s bodies — not just their souls — through healings and miracles. He fed people’s minds and hearts, but also fed their bodies (Matthew 14:13–21).

Then, as the culmination of bodily service to God and others, Jesus’s body was killed. His body broke on a tree just like when he broke a loaf of bread in half with his disciples (Luke 22:19). He told them he was going to break his body for them. And as he poured wine for them, he told them he would spill his blood for them (Matthew 26:27–28). The hymn, Let All Mortal Flesh Keep Silence, depicts Christ’s birth resulting in the giving of his body and blood for our eternal nourishment:

King of kings, yet born of Mary,
As of old on earth he stood,
Lord of lords, in human vesture,
In the body and the blood;
He will give to all the faithful
His own self for heavenly food.

Jesus was the perfect sacrifice, because he had an untainted soul, but also because he had a body. His blood would spill like the blood smeared all over the High Priest in the tabernacle. His body could be broken and die like the ram given to Abraham in exchange for the life of his son (Genesis 22:9–14). His body developed in the body of a woman, so his body could be crushed for us.

Scarred to the Glory of God

This is why his body is not insignificant, why my body is not insignificant even when it’s swollen in pregnancy and sagging in its postpartum state. His body is not insignificant because he calls us to remember his body in the Lord’s Supper. With a cracker and a cup of juice we remember his body sacrificed for us. And he still bears the bodily scars of his sacrifice and service, even in his resurrected body.

Charles Spurgeon imagines the angels in heaven wondering at the scars of Christ:

They were enabled to behold for themselves in heaven the man who suffered, and they could see the wounds which were produced in his body by his sufferings; and I can readily imagine that this would cause them to lift their songs higher, would prolong their shouts of triumph, and would cause them to adore him with a rapture of wonderment, such as they had never felt before. And I doubt not that every time they look upon his hands, and behold the crucified man exalted by his Father’s side, they are afresh wrapt in wonder, and again they strike their harps with more joyous lingers at the thought of what he must have suffered who thus bears the scars of his hard-fought battles.

If Christ’s scars have meaning, maybe my scars on behalf of another life have meaning too. God can be exalted in my pregnant and postpartum body (Philippians 1:20).

As I remember the body and blood of Christ, I recall that he ransomed my body, as well as my soul, to belong to him forever. This is the reason I offer up my body to him (Romans 12:1), as I carry another body in my womb. We both are fearfully and wonderfully made. I give up my body so my future daughter can be knitted in my womb by God himself. God is exalted in this body and he will keep it blameless until he comes again (1 Thessalonians 5:23) to give me an even more glorious body at the resurrection of the dead (1 Corinthians 15:42–44).

Liz Wann (@liz_wann) lives in Philadelphia with her husband and two sons. She is a stay-at-home mom and editor in chief of Morning by Morning and writes at lizwann.com.

Hormonal contraception and breast cancer: Is there a link?

Published in Contemporary OB/GYN, December 14, 2017

Results of a prospective cohort study by Danish investigators suggest that current or recent use of hormonal contraceptives may be associated with an increased risk of breast cancer. The researchers caution, however, that the risk is low and must be weighed against the important benefits of taking the drugs, including their efficacy and reduced risks of ovarian, endometrial, and perhaps colorectal cancer.

Published in The New England Journal of Medicine, the findings reflect data from 1.8 million women aged 15 to 49 who were followed for 10.9 years, or equal to 19.6 million person-years of use of contraception. During that time, 11,517 cases of breast cancer were diagnosed in the cohort.

A relative risk (RR) of breast cancer of 1.20 was seen among all current and recent users of hormonal contraception (95% confidence interval [CI], 1.14 to 1.26) compared with women who had never used the drugs. The RR increased from 1.09 (95% CI, 0.96 to 1.23) with < 1 year of use to 1.38 (95% CI, 1.26 to 1.51) with > 10 years of use (P = 0.002).  After discontinuation of hormonal contraception, risk of breast cancer was still higher among women who had used hormonal contraception for 5 years or more than in those who had not used the drugs.

RRs for breast cancer associated with triphasic and monophasic levonorgestrel-containing oral contraceptives (OCs) were similar (1.21 and 1.45, respectively). No major differences were seen when the authors compared various combined OCs and after adjustment for multiple testing, they were no longer significant. Contraceptives studied included norethisterone, levonorgestrel, norgestimate, desogestrel, gestodene, drospirenone and cyproterone combined with 20 to 40 µg estradiol, the progestin-only implant, depot medroxyprogesterone acetate, and the levonorgestrel-releasing intrauterine device (IUD).  Adjustment of analyses for estrogen dose attenuated overall relative risk of breast cancer with current or recent use.

The data, taken from nationwide registries, were fully adjusted for level of education, parity, polycystic ovary syndrome, endometriosis, and family history of breast or ovarian cancer. Adjustment also was made for body mass index (in parous women only), smoking status, and age of the women at first delivery when this information was available for parous women. The authors were not able to adjust for age at menarche, breastfeeding, alcohol consumption or physical activity.

“Our results,” the authors said, “suggest the rapid disappearance of excess risk of breast cancer after discontinuation of use among women who have used hormonal contraceptives for short periods, whereas the risk among women who have used these contraceptives for longer periods may persist for a least 5 years after discontinuation.”

Expert Perspective

“This study provides important information regarding the risks of breast cancer associated with newer, low-dose combination OCs (notably lower doses of estrogen), non-oral hormonal contraception such as implants, the vaginal ring, and the levonorgestrel IUD, and different formulations of progestins.  Older studies have suggested that there is an association between the older formulations of OCs and breast cancer risk, but there has been little data on the newer, and non-oral forms of hormonal contraception. The new findings suggest that contemporary hormonal contraception does not decrease the risk of breast cancer and there is a dose-response effect with higher risk associated with longer use. The study does not adjust for some of the important factors that affect breast cancer risk, such as physical activity, breastfeeding or alcohol use. It also does not report on long-term risk of breast cancer > 10 years after discontinuation of use of hormonal contraception, which are important data, given the young age of women using hormonal contraception and the older age at which most women are diagnosed with breast cancer.  Nonetheless, the data suggest that current hormonal contraception, both with lower doses of hormones and non-oral formulations, are associated with a small, but significant risk of breast cancer.”  

~ Ilana Cass, MD, Editorial Board Member, Contemporary OB/GYN

A Striking Rise in Serious Allergy Cases

By Sumathi Reddy, The Wall Street Journal, Updated Aug. 21, 2017 11:12 a.m. ET

The rate of reports of severe allergic reactions to foods like peanuts has increased by nearly five times over the past decade, according to a new analysis of private insurance claims.

The analysis looked at private insurance claims with a diagnosis of an anaphylactic food reaction from 2007 to 2016. Anaphylaxis is a systemic allergic reaction in which the immune system affects multiple parts of the body at the same time, often leading to trouble breathing. It can be fatal if not treated promptly and requires an injection of epinephrine and a trip to the emergency room.

The analysis was conducted by FAIR Health, a New York City-based, independent nonprofit that has a database of 24 billion medical and dental claims from 150 million privately insured people.

“This is an incredibly important study,” says James Baker, chief executive officer and chief medical officer for the Food Allergy Research & Education (FARE), a Virginia-based advocacy group. “Clearly our own information suggests that not just the frequency of people having food allergy but the severity of food allergy in individuals has increased dramatically.”

The proliferation of food allergies in the western world, particularly to peanuts, has baffled medical experts who struggle with how to advise parents and children for a condition with no permanent cure. Studies have found that as many as 8% of children have a food allergy, with nearly 40% having a history of severe reactions.

The increase could be related to the increasing use of antibiotics, rising rates of C-sections that affect the microbiomes of babies, and an increasingly sterile environment, says Hugh Sampson, director of the Jaffe Food Allergy Institute at the Icahn School of Medicine at Mount Sinai in New York City. All have altered the good bacteria in our intestinal tracts, which alters the programming of our immune systems.

Many years of medical advice telling parents to avoid highly allergenic foods such as peanuts when children are babies may have contributed to increasing allergy rates, he says. Earlier this year medical organizations changed their advice recommending that babies at high and moderate risk of developing a peanut allergy, such as those with eczema, be introduced to the foods by six months.

The rate of food allergies to peanuts and tree nuts have doubled or even tripled over the past two decades in the U.S., Dr. Sampson says.

The FAIR Health analysis found that peanuts were the most common cause of anaphylaxis, making up 26% of claims. Tree nuts, such as walnuts and pistachios, and seeds accounted for 18% of claims, followed by eggs, crustaceans, and dairy. About 33% of claims were due to unspecified or unknown foods.

The analysis also showed a greater increase in claims in rural areas than in cities. “The one thing that surprised me was the bigger change occurring in rural areas as opposed to urban areas,” Dr. Sampson says.

The urban and rural area designations were based on the U.S. Census, says Robin Gelburd, president of FAIR Health.

The group will dig deeper into the data in a white paper to be released in October, she says, looking at geographical and gender variations and costs of services, among other factors.

About 34% of claims were in people over 18, she says.

“I think a lot of people assume children grow out of these allergies, and the fact that we’re seeing about a third of the claims attributable to those over 18-years-old is something that raises some interesting questions and invites some further study,” Ms. Gelburd says.

Kristin Osborne, a mother to three boys in Virginia Beach, Va., knows the fear of anaphylaxis. Her sons—ages 15, 11 and 5—all have multiple food allergies.

Her middle son, David Osborne, is allergic to peanuts, tree nuts, wheat, dairy and eggs. He has had two anaphylactic reactions in the past 12 months. The most recent was at the grocery store, when she suspects he was exposed to an allergen on the conveyor belt at the checkout line.

“He started wheezing and coughing and couldn’t breathe, so I administered epinephrine and rode to the emergency room,” recalled the 36-year-old, who works as a disability advocate.

“It’s extremely scary,” she says of the reactions. “It’s kind of like a roller coaster. We really prepare and try to be as proactive as possible, but when it happens, you never really know what the end result is going to be. We just hope to get to the ER in time.”


The Politicization of Motherhood

Conservatives cheer and liberals jeer New York psychoanalyst Erica Komisar’s book on the science of early childhood development.

Motherhood used to be as American as apple pie. Nowadays it can be as antagonistic as American politics. Ask Erica Komisar.

Ms. Komisar, 53, is a Jewish psychoanalyst who lives and practices on the Upper West Side of Manhattan. If that biographical thumbnail leads you to stereotype her as a political liberal, you’re right. But she tells me she has become “a bit of a pariah” on the left because of the book she published this year, “Being There: Why Prioritizing Motherhood in the First Three Years Matters.”

Christian radio stations “interviewed me and loved me,” she says. She went on “Fox & Friends,” and “the host was like, your book is the best thing since the invention of the refrigerator.” But “I couldn’t get on NPR,” and “I was rejected wholesale—particularly in New York—by the liberal press.” She did appear on ABC’s “Good Morning America,” but seconds before the camera went live, she says, the interviewer told her: “I don’t believe in the premise of your book at all. I don’t like your book.”

The premise of Ms. Komisar’s book—backed by research in psychology, neuroscience and epigenetics—is that “mothers are biologically necessary for babies,” and not only for the obvious reasons of pregnancy and birth. “Babies are much more neurologically fragile than we’ve ever understood,” Ms. Komisar says. She cites the view of one neuroscientist, Nim Tottenham of Columbia University, “that babies are born without a central nervous system” and “mothers are the central nervous system to babies,” especially for the first nine months after birth.

What does that mean? “Every time a mother comforts a baby in distress, she’s actually regulating that baby’s emotions from the outside in. After three years, the baby internalizes that ability to regulate their emotions, but not until then.” For that reason, mothers “need to be there as much as possible, both physically and emotionally, for children in the first 1,000 days.”

The regulatory mechanism is oxytocin, a neurotransmitter popularly known as the “love hormone.” Oxytocin, Ms. Komisar explains, “is a buffer against stress.” Mothers produce it when they give birth, breastfeed or otherwise nurture their children. “The more oxytocin the mother produces, the more she produces it in the baby” by communicating via eye contact, touch and gentle talk. The baby’s brain in turn develops oxytocin receptors, which allow for self-regulation at a later age.

Women produce more oxytocin than men do, which answers the obvious question of why fathers aren’t as well-suited as mothers for this sort of “sensitive, empathetic nurturing.” People “want to feel that men and women are fungible,” observes Ms. Komisar—but they aren’t, at least not when it comes to parental roles. Fathers produce a “different nurturing hormone” known as vasopressin, “what we call the protective, aggressive hormone.”

Whereas a mother of a crying baby will “lean into the pain and say, ‘Oh, honey!’ ” a father is more apt to tell the child: “C’mon, you’re OK. Brush yourself off; let’s go back to play.” Children, especially boys, need that paternal nurturing to learn to control their aggression and become self-sufficient. But during the first stages of childhood, motherly love is more vital.

Ms. Komisar’s interest in early childhood development grew out of her three decades’ experience treating families, first as a clinical social worker and later as an analyst. “What I was seeing was an increase in children being diagnosed with ADHD and an increase in aggression in children, particularly in little boys, and an increase in depression in little girls.” More youngsters were also being diagnosed with “social disorders” whose symptoms resembled those of autism—“having difficulty relating to other children, having difficulty with empathy.”

As Ms. Komisar “started to put the pieces together,” she found that “the absence of mothers in children’s lives on a daily basis was what I saw to be one of the triggers for these mental disorders.” She began to devour the scientific literature and found that it reinforced her intuition. Her interest became a preoccupation: “My husband would say I was a one-note Charlie,” she recalls. “I would come home and I would rant and I would say, ‘Oh my God, I’m seeing these things. I’ve got to write a book about it.’ ”

That was 12 years ago. She followed her own advice and held off working on the book because her own young children, two sons and a daughter, still needed her to be “emotionally and physically present.”

She uses that experience as a rejoinder to critics who accuse her of trying to limit women’s choices. “You can do everything in life,” she says, “but you can’t do it all at the same time.” Another example is Nita Lowey, a 15-term U.S. representative from New York’s northern suburbs: “She started her career when she was in her 40s, and she said to me she wished she’d waited longer. She said her youngest was 9.”

Ms. Lowey is a liberal Democrat, but she was born in 1937 and thus may have more traditional inclinations than women of the baby boom and later generations. Ms. Komisar tells of hosting a charity gathering for millennials at her apartment. One young woman “asked me what my book was about. I told her, and she got so angry. She almost had fire coming out of her eyes, she was so angry at my message. She said, ‘You are going to set women back 50 years.’ I said, ‘Gosh, I wouldn’t want to do that.’ ”

Male attitudes have changed as well, Ms. Komisar says: “A lot of young men, particularly millennials, have been raised to believe that it’s even-steven; that women are to bring in as much money, and they’re always going to work.” Young women “make promises to their partners, these young men: ‘I’m going to work forever, I’m going to make as much money as you; maybe I’ll make more than you.’ It’s almost like a testosterone kind of competition.”

The needs of children get lost in all this—and Ms. Komisar hears repeatedly that the hostility to her message is born of guilt. When she was shopping for a literary agent, she tells me, “a number of the agents said, ‘No, we couldn’t touch that. That would make women feel guilty.’ ” Another time she was rejected for a speaking gig at a health conference. She quotes the head of the host institution as telling her: “You are going to make women feel badly. How dare you?”

In Ms. Komisar’s view, guilt isn’t necessarily bad. “My best patient is a patient who comes to me feeling guilty,” she says. “Women who feel guilty—it’s a ‘signal’ feeling, that something’s wrong, that they’re in conflict. If they go talk to a therapist or deal with the conflict head-on, they often make different choices and better choices.”

That’s “better,” not “perfect,” and Ms. Komisar is at pains to emphasize that “mothering is not about perfection.” She acknowledges, too, that staying at home isn’t right for all new mothers: Some lack the wherewithal to take time off work; some are depressed or distracted and “not really emotionally present.” When the mother can’t be there, Ms. Komisar says, the best alternative is a “single surrogate caregiver,” optimally a relative.

“The thing I dislike the most is day care,” she says. “It’s really not appropriate for children under the age of 3,” because it is “overstimulating” given their neurological undevelopment. She cites the “Strange Situation experiments,” devised in 1969 by developmental psychologist Mary Ainsworth, a pioneer of attachment theory: “A mother and the baby are on the floor playing. The mother gets up and leaves the baby in the room alone. The baby has a separation-anxiety response. A stranger walks in; the baby has a stressed reaction to the stranger.”

Researchers sample the infant’s saliva and test it for cortisol, a hormone associated with stress (and inversely correlated with oxytocin). In a series of such experiments in which Ms. Komisar herself participated, “the levels were so high in the babies that the anticipation was that it would . . . in the end, cause disorders and problems.” In a more recent variant of the experiment, scientists use functional magnetic resonance imaging to look directly at the brain of an infant reacting to photos of the mother and of a stranger.

You can see why tradition-minded conservatives welcome Ms. Komisar so warmly. Think about how they are stereotyped—as backward, superstitious, hostile to science. She shows that science validates what they know as common sense.

But although she returns their affection, she doesn’t share their distaste for contemporary mores. “We don’t want the ’50s to come back,” she tells me. “Women had children who didn’t want to have children. Women didn’t have other choices than having children, and women were ostracized if they didn’t have children. And women were ostracized if they went out into the world and worked.”

“What we do want,” she says, “is to be a child-centric society.” To that end, she offers a proposal many conservatives will find uncongenial: a government mandate that employers provide generous maternity benefits. “All mothers and babies should have the right to be together in the first year,” Ms. Komisar says. That means maternity leave at full pay, “and then the flexibility to be together as much as possible for the next two years—meaning mothers should have the ability to work flexibly and part-time.”

Ms. Komisar sounds very much like a liberal when she observes of the U.S. that “we’re the only civilized country that doesn’t have a maternity-leave policy.” I ask what she thinks of Ivanka Trump’s proposal to mandate six weeks’ paid leave for primary caregivers, regardless of sex. “It’s a start,” Ms. Komisar says. “It is not enough. Babies are just waking up from birth after six weeks, and even at three months they are incredibly vulnerable and not necessarily bonded with their mothers.”

But if most conservatives find Ms. Komisar’s solution too coercive or expensive, most liberals won’t even acknowledge the problem. “If we defend the idea that mothers are not necessary,” she asks, “what chance do we have to get a maternity-leave policy?” As important as her insights into child development are, her policy proposal seems destined for the political orphanage.

Mr. Taranto is the Journal’s editorial features editor.

Drinking Alcohol While Breastfeeding: Is It Safe?

By The Recovery Village’s Recovery Blog;

Link to original blog: Alcohol and Breastfeeding

Drinking Alcohol While Breastfeeding: Is It Safe?

There is a great deal of evidence regarding the dangers of drinking alcohol while pregnant, but the risks of drinking while breastfeeding aren’t as clearly defined. Doctors and other professionals have differing opinions on the issue, with some claiming breastfeeding alcohol to a baby is dangerous only if large amounts are consumed. Others argue that alcohol and breastfeeding simply don’t mix and that no amount of alcohol is safe for a baby. If you’re currently nursing, it’s important to be aware of the possible risks associated with drinking alcohol.

What Are the Dangers of Breastfeeding Alcohol to a Baby?

According to the American Academy of Pediatrics, studies indicate that there are many health benefits to breastfeeding for infants, including a reduced risk of asthma, allergies and type 2 diabetes. However, the Academy advises against habitually drinking alcohol while breastfeeding. One of the reasons is that this substance passes through breast milk, just as any other beverage or food that the mother consumes. Alcohol moves through breast milk at the same rate that it moves through the blood; the more that’s consumed, the longer it takes to clear from the bloodstream and breast milk.

In general, drinking alcohol in large amounts can be dangerous for anyone, but the following are some of the potential risks associated with drinking in excess while breastfeeding:Impaired motor development for the infant

        • •Impaired motor development for the infant
        • •Changes in sleep pattern for the infant
        • •Decreased milk production
        • •A reduction in consumed breast milk (20% less), since alcohol can change the taste of the milk
        • •Weakness in the infant
        • •Increased risk for pseudo-Cushing syndrome (see below)

Pseudo-Cushing syndrome (PCS) is a condition comparable to Cushing’s syndrome (a condition caused by excessive cortisol in the body), which is often characterized by weight gain, among other symptoms. According to an article from The Journal of Pediatrics, a 4-month-old breastfed infant developed pseudo-Cushing syndrome because of the mother’s chronic and heavy alcohol consumption (50 cans of beer weekly, in addition to other alcoholic beverages).  As a result of the syndrome, the infant had a diminished length, a bloated appearance and excessive weight gain while breastfeeding. These symptoms, fortunately, disappeared after the mother stopped drinking alcohol.

Alcohol and Breastfeeding Myths

Before making a decision about whether you’ll choose to drink alcohol while breastfeeding, it’s important to separate the myths from the facts. The following are some disproven myths:

Myth: Drinking alcohol will increase milk production

Fact: Although this a common belief, the opposite is true; drinking alcohol while breastfeeding can actually decrease milk production.

Myth: “Pumping and dumping” will remove the alcohol from breast milk.

Fact: Pumping and dumping breast milk does nothing to remove alcohol content from it. It’s typically done only to relieve discomfort from engorgement.

Myth: Alcohol helps with milk letdown.

Fact: This is another popular belief of nursing mothers, but drinking alcohol while breastfeeding does nothing to improve milk letdown.

Is It Ever Safe to Drink Alcohol While Breastfeeding?

The answer to this question depends on the amount of alcohol consumed and the amount of time that passes between the last drink and the time breastfeeding or pumping begins. With that in mind, yes, it can be safe to drink alcohol while breastfeeding, but only if a small amount is consumed and only after it has completely cleared from the breast milk.

The type of alcohol, the amount consumed and the mother’s body weight determine how long it takes for alcohol to clear from the bloodstream and breast milk. Typically, blood alcohol content peaks about 30–60 minutes after consumption, but it may take several hours for it to be eliminated from the body. In fact, it could take up to three hours for a 120-pound woman to eliminate one serving of beer or wine from her body, according to La Leche League. It could take four times longer for the same woman to eliminate a drink with a high alcohol content, like vodka, from her body.

If you plan to drink alcohol while breastfeeding, it’s best to take the following precautions to prevent breastfeeding alcohol to your infant (as recommended by the American Academy of Pediatrics and the National Health Service):

•Drink alcohol only immediately after nursing or pumping, instead of before.

•Allow at least two hours per drink (12-ounce beer, 4-ounce glass of wine or one ounce of hard liquor) before breastfeeding or pumping to allow the alcohol to clear from your system.

•Drink no more than two units of alcohol once or twice a week while breastfeeding.

If you’re struggling with an alcohol-related disorder, or any other substance use disorder, The Recovery Village® can help. Call today to speak with an intake coordinator to kick-start the healing process.

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