Hooray for vaccines

I saw this simple but illuminating infographic on the Forbes website, in an article by Matthew Herper. It was created by graphic designer Leon Farrant and shows the profound impact effective vaccines have had on a nation’s health. As Herper explains:

Below is a look at the past morbidity (how many people became sick) of what were once very common infectious diseases, and the current morbidity in the U.S. There’s no smallpox and no polio, almost no measles, dramatically less chickenpox (also known as varicella) and H. influenza (that’s not flu, but a bacteria that can cause deadly meningitis.

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Vaccine Infographic | Leon Farrant

I saw this not long after watching the British charity fundraiser Comic Relief, which supports aid and development projects in many African countries (amongst other things). One of the recurring themes in the telethon was the urgent need for vaccines in certain parts of Africa, and the devastation that preventable diseases are having on children’s lives.

Worthy, heart-wrenching and persuasive stuff.

But I couldn’t help feel even more frustration than I normally do that, despite having immediate access, many parents in developed countries like the UK and US still choose not to vaccinate their kids. As we have seen with a rise in whooping cough cases and measles in recent years, and as the infographic elegantly shows, a failure to properly protect the population can lead to serious health consequences.

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[And for a thorough rebuttal of antivaxers' scaremongering, read David Gorksi at Science-Based Medicine]

*Infographic is licensed under Creative Commons CC BY-NC-ND 3.0.

Does the sun make you sneeze?

This is a video I took of our little one, sitting in a chair watching telly. As I walk over to him the sunlight streaming in through window catches him full in the face, and a couple of seconds later he sneezes.

This happens to him fairly often, usually as we leave the house into the bright sunlight. I noticed this behaviour straightaway, as the exact same thing happens to me when I move from dark to bright light.

It turns out that this doesn’t happen to everyone, as I found out when I said casually to friends, “you know how the sun makes you sneeze, well…”, and was met with stony silence.

Then I found out I had a proper disorder. Gosh!

It’s called a photic sneeze reflex, or as some witty scientists labelled itAutosomal dominant Compelling Helio-Ophthalmic Outburst - ACHOO syndrome for short. It is estimated that 17-35% of the population have it, and it’s far more common in white people than in other ethnicities.

But no one knows why it happens. Despite it apparently being noticed by Aristotle and investigated by philosopher Francis Bacon, little research has been carried out. My search in the biomedical database PubMed turned up only 16 research papers since 1984.

The best guess at the moment is that it’s because the nerve cells that carry information from the eye and those that carry information from the nose run so close together. As the nerves from the eye are stimulated by bright light, usually to constrict the pupil, electrical signals ‘spillover’ and activate the nerves coming from the nose. This causes the brain to confuse a bright light with a nose irritation, and… ACHOO! In fact, the area of the brain responsible for processing visual information is overstimulated in photic sneezers compared with non-sneezers, which may underlie the spillover effect.

We do know that it appears to run in families – as it has seemingly done in our case – but the genes at the root of it are not known. Initial studies claimed that a child has a 50% chance of inheriting the ‘disorder’ from a photic sneezing parent, but there may be more than one ACHOO gene.

It’s a fairly harmless reaction, though the US air force were sufficiently concerned to fund research into whether this reflex could endanger jet pilots. It could, but was easily overcome with sunglasses.

You may be tempted to speculate as to whether it evolved for a purpose. In all likelihood it didn’t, it is a quirk thrown up by evolution but one that’s not disadvantageous enough to be selected against.

It is irritating, but at least it doesn’t happen during sex.

Should babies watch TV?

This question seems to trouble many parents, and can cause a lot of guilt too.

“Will the TV numb my baby’s brain?”

“Are they destined for a sedentary life?”

“AM I CONDEMNING THEM TO LIFE AS A MINDLESS AUTOMATON?!”

This is why an interview last week with psychologist Annette Karmiloff-Smith on the BBC’s The Life Scientific caught my ear (thanks to a pointer from mum-in-law, Jenny). It’s a fascinating insight into how babies learn to learn, and how their brains develop to understand the world around them. You can listen here: The Life Scientific.

But on TV watching, Prof Karmiloff-Smith, an expert in developmental disorders, argues that if the subject matter of the programme is carefully chosen and scientifically based, then the TV can be better for a child’s learning than even a book.

This was largely in response to advice reissued by the American Academy of Pediatrics (AAP) that babies under two shouldn’t watch any TV or DVDs. There are three main concerns: poorer language skills, a negative effect on sleep, and less time spent taking part in other types of unstructured play that are critical for the proper development of mental capabilities.

This is based on a growing body of scientific research. TV/DVD watching is common: in the US at least, by two years old over 90% of children regularly watch TV, spending an average of 1-1.5 hrs a day in front of the box. Very young babies (under 1.5 years old) cannot, however, really understand TV programmes, and are instead mainly attracted by obvious changes like applause or visual surprises.

Children learn new words or actions better when an adult is teaching it to them live, rather than via a television screen, and the worry is that parents talk to their kids less when the TV is on. And a growing number of studies suggest that children who spend longer watching TV/DVDs have delayed language development, at least in the short-term, and may also develop a worse attention span.

A child’s play may also be hindered by the distraction of a TV that’s on in the background, so the AAP advise to turn it off altogether. Many parents also use TV/DVDs as a sleep aid, but there is evidence that bedtime viewing may lead to more disturbed and shorter sleep.

Karmiloff-Smith, on the other hand, argues that we live in a media saturated world and it’s unrealistic to expect parents to shut down all media use. This view has support from some of the evidence cited in AAP report itself. Despite the original recommendation in 1999 that parents should be discouraged from letting their babies watch TV/DVDs, over 90% of them in the US currently do so by the time their child is two years old. What’s more, the average age that TV is introduced is 9 months, so the advice is clearly not striking a loud enough chord.

From my experience, I can certainly appreciate this. The AAP report says that many parents use the TV so that they can have a shower or cook dinner. Absolutely! Even these seemingly mundane activities can feel like an exercise in military-like efficiency when you’re looking after a child. A 10-minute respite when they’re quiet and content gazing at a TV or prodding an iPad can be just too tempting.

It’s also interesting to consider that throughout history many new technologies have been treated with caution. Dr Vaughan Bell, a psychologist based at King’s College London, has highlighted how the printing press, popularisation of the radio, and now the Internet have been damned for ruining kids’ brains.

Karmiloff-Smith goes on to say that, rather than banning TV for babies, TV programmes just need to be made better and based on science developments. For instance, the visual system is attracted by movement, but most kids’ TV programmes have their focus on the centre of screen. Instead, objects and features that come in from the sides, move across screen and encourage the child to interact promotes the active participation that’s good for mental development. For very young babies, moving image media may even have advantages over books, which are static and whose main attraction is the rustling of the pages.

The caveat in this is that Karmiloff-Smith reveals herself to be a scientific consultant to a DVD company that is designing such programmes. This could cause suspicion of a financial conflict of interest. But her honesty and gusto make me suspect that she became a consultant so that she could promote these ideas, rather than the other way around.

She finished the interview by emphasising that parents still need to interact with their children and the TV shouldn’t be used as a babysitter. But we should think more carefully about which types of media can stimulate the visual and auditory systems, so as to help train the attention and memory systems early.

I’ve written before about the various kinds of programmes and the various contexts in which kids can watch TV, which may have different effects on child development. And some of the evidence cited in the AAP report highlights these complexities. The effects on children’s attention, for instance, seem to depend on the programme content and style, with problems seen not when the content is deemed educational but only when it’s geared towards entertainment. And when a parent watches a programme with an infant and talks them through it, the child tends to become more attentive and responsive. The AAP report also points to evidence that watching Sesame Street can have a negative effect on expressive language in children under two. But the same study showed that watching other programmes, such as the North American-based shows Dora the Explorer, Blue’s Clues, Arthur, Clifford, or Dragon Tales, was associated with greater vocabularies and higher expressive language scores. So it appears that not all ‘screen time’ is equal.

The AAP report seems to fall into the trap of treating all TV and DVD viewing as the same:

For the purposes of this policy statement, the term “media” refers to television programs, prerecorded videos, Web-based programming, and DVDs viewed on either traditional or new screen technologies.

Another major limitation of the AAP report is that all of the cited studies are, by necessity, observational. These investigations are good at highlighting whether two factors are associated with each other, but they cannot tell you whether one causes the other. As the report itself asks, are children with poor language skills simply placed in front of the TV more? Are children with shorter attention spans more attracted to screens? Are parents who are less attentive on the whole, more prone to resort to screen time? If so, then turning the TV off would not necessarily lead to more parent-child interactions.

And some results are just contradictory. One study in the US showed that when the mother’s educational status and household income were taken out of the equation, the association between TV viewing and poor language development disappeared. This appears to have been glossed over by the AAP.

So how do I answer my original question?

The AAP are right to caution against a lot of TV for under twos (over four hours a day, say), as this is when the damaging effects are really apparent. But Karmiloff-Smith is also right to say it’s unrealistic to expect no TV at all, and that the right programme in the right environment is fine and potentially beneficial.

And I’ll leave you with this quote in Time from Dr Dimitri Christakis, a paediatrician at Seattle Children’s Hospital:

Ask yourself why you’re having your baby watch TV. If you absolutely need a break to take a shower or make dinner, then the risks are quite low. But if you are doing it because you think it’s actually good for your child’s brain, then you need to rethink that, because there is no evidence of benefit and certainly a risk of harm at high viewing levels.

Parenting science: 12 top stories of 2012

It’s that time of year when we’re flooded with ‘best of’ lists, so allow me to jump on the bandwagon. 2012 has been a great year for science – the discovery of the Higgs Boson, the landing of Curiosity rover on Mars, and the ‘encyclopaedia of DNA’ that has given us the deepest insights into the human genome.

Here, I’ve picked out some of the stories that might interest parents, covering areas such as child learning and development, reproductive technologies, embryology, genetics, and even a bit of public policy thrown in. I’m sure I’ve missed some interesting ones too, so please add yours in the comments!

Mouse eggs created from stem cells for the first time (New Scientist)

Once a fully functional body cell develops from a ‘parent’ stem cell, it’s thought there is no going back to the previous state. A team of scientists in Japan, however, used a cocktail of signalling molecules to reprogram skin cells to become immature egg cells in mice (they had already done this to create sperm cells). What’s more, these cells could be fertilised and, in some cases, led to healthy mouse pups. This was a stunning feat of biological engineering that will help in the study of mammalian development and also hold promise in treatment of infertility. In a related story, controversy over whether biology textbooks need to be re-written took a turn when more convincing evidence was published that the number of eggs in a female isn’t fixed for her lifetime but can instead by replenished from a stem cell stock.

‘Chimera’ monkeys created in lab by combining several embryos into one (The Guardian)

The headline is pretty self-explanatory and the article itself is a fascinating read, so I won’t re-invent Ian Sample’s superbly crafted wheel. So if you want to know more about the controversial technique of creating normal, healthy monkeys with cells from more than one embryo and why it might benefit stem cell therapies, go read it! This may not be as bizarre and ‘unnatural’ as it first sounds, though, as we may all be walking chimeras and carry cells from siblings, aunts and uncles.

Genome Sequencing for Foetuses (Wired Science)

Being able to test foetuses for genetic faults that increase the risk of a serious disease, such as Down’s syndrome and blood or nervous system disorders, is hugely important. This is currently done mostly by invasive techniques such as taking samples of the placental tissue or amniotic fluid. This study, however, showed that it’s possible to work out the foetus’ genetic make-up by piecing together tiny fragments of DNA floating around in the mother’s blood. The ease of such a test would, of course, raise ethical issues about what is appropriate to screen for and what counselling parents would need, as well as requiring a firm and clear communication of risk.

DNA-swap technology almost ready for fertility clinic (Nature News)

Mitochondria are little energy powerhouses within most of our cells and they contain a small amount of their own DNA that is inherited wholly from the mother. A range of devastating diseases, that can affect the brain, liver, muscle and many other organs, are caused by defects in this mitochondrial DNA. A group of US researchers showed it was able to swap the mitochondria in a mother’s egg with one from a healthy donor to produce a normal looking embryo free from the mitochondrial genetic faults (restrictions on this technology would not allow a live birth). You can read about how the scientists actually did this in David Cyranoski’s article. And I would add that, contrary to some scare stories, these would not be ’3 parent babies’ – mitochondrial DNA contains only 37 genes (involved in protein synthesis and biochemical reactions that make up respiration) compared with the many thousands of genes coded for by the DNA in the nuclei of our cells.

Babies are born dirty, with a gutful of bacteria (New Scientist)

Earlier this year I blogged about the “The microworld that lives inside you” and how the microorganisms that outnumber our own cells 10:1 are first transmitted from mum as a baby is born. A study by Spanish scientists, suggested that this isn’t the whole story. By studying the “meconium” – the baby’s first poo that is made up of materials ingested during the time in the womb – they detected two types of well developed bacteria. We don’t know for sure, but these were probably passed from the mother through the placenta. Our so-called “microbiome” is really important, because it influences our digestion, immune system, risk of disease, and maybe even our personalities.

Childhood stimulation key to brain development, study finds (The Guardian)

A US study provided more evidence that a sensitive period of learning and development exists early in childhood. They surveyed children from when they were four years old, recording details such as the number of books and the types of toys they had, to measure the amount of mental stimulation to which they were exposed. They also scanned the brains of the same children when they were between 17 and 19. As Alok Jha explains: “…the more mental stimulation a child gets around the age of four, the more developed the parts of their brains dedicated to language and cognition will be in the decades ahead.” Of course, this was an observational study and so limits the strength of the conclusions about whether the types of toys really caused brain developments, but the way the researchers tracked the same children over many years and the factors they took into account (parental nurturance had little effect, for example), was particularly impressive. Another cautionary note: the results were presented at a scientific conference and, as far as I know, have not appeared in a scientific journal, which means it won’t have yet been properly quality assessed by experts.

Golden ratio discovered in uterus (The Guardian)

At the risk of straying into mysticism, this was a nevertheless alluring report of a Belgian gynaecologist’s claim that the uterus represents an aesthetically pleasing “golden ratio”. This ratio is derived from something called the “Fibonacci sequence”, which is a sequence of numbers starting 0,1,… where every subsequent number is the sum of the previous two (so: 0, 1, 1, 2 , 3, 5, 8, 13, 21,…). The ratio between pairs of number in the sequence (divide one by the other) ends up being 1.618, which is the “golden ratio”. As Alex Bellos explains, its devotees believe it expresses aesthetic perfection and is found wherever there is beauty. According to Dr Verguts, when women are between the ages of 16 and 20 and at their most fertile, the ratio of uterine length to width is 1.6, spookily close to the “golden ratio”.

What happens to women denied abortions? This is the first scientific study to find out (io9)

Another set of results presented at a scientific conference, rather than in a scientific journal, but that is worth noting nonetheless. Annalee Newitz cites a Facebook post written by the lead researchers of a study that followed up women who had sought abortions at different abortion clinics in the US: “We have found that there are no mental health consequences of abortion compared to carrying an unwanted pregnancy to term. There are other interesting findings: even later abortion is safer than childbirth and women who carried an unwanted pregnancy to term are three times more likely than women who receive an abortion to be below the poverty level two years later.” Newitz further emphasises the preliminary results: “When a woman is denied the abortion she wants, she is statistically more likely to wind up unemployed, on public assistance, and below the poverty line.” If these findings turn out to be valid when further quality checks are carried out, they could help shape the debate on abortion policies and the state support a women seeking an abortion receives.

Boys and girls may be entering puberty younger (New York Times and The Guardian)

A study on the timing of puberty in boys by the American Academy of Pediatrics complements an earlier study on girls, which both hinted that puberty is, on average, starting gradually earlier in both sexes. Current estimates, at least for US children, are that the average age of puberty onset is around 9 years in black boys and girls and around 10 years in white boys and girls (although full sexual maturity may happen later than this). No one, as yet, knows why, but speculations include diet, changes in physical activity, improvements in healthcare, and chemicals present in the environment that affect our hormones.

Fathers bequeath more mutations as they age (Nature News)

A Swedish study concluded that a father passes on more genetic mistakes to their children than do mothers, and the older the man, the more mutations he is likely to pass on. This is most probably explained by the fact that sperm are generated from dividing ‘precursor’ cells throughout a man’s life and this cell division becomes less precise with age. Most inherited mutations won’t lead to any problems for the child, but the occasional one may increase the risk of a genetic disease like autism or schizophrenia. Taken together with rising average age of fatherhood, does this help explain, at least in some part, why autism rates are rising? (It could, but awareness and diagnostic changes are also likely to be at play). It’s not definitive and it shouldn’t scare older would-be fathers, but it may help in better informed decision-making.

An HPV Vaccine Myth Debunked (New York Times)

One of the arguments opposing vaccinating children against the Human Papilloma Virus (HPV), which can cause warts and cancer, is that in the minds of the young girls it frees them up to be sexually more promiscuous. Studying long-term medical data from girls in Atlanta, USA, however, showed no difference between vaccinated and non-vaccinated girls in pregnancies, sexually transmitted diseases, testing for sexually transmitted diseases, or contraceptive counselling. The article finishes by saying: “As one expert said, parents should think of the vaccine as they would a bicycle helmet; it is protection, not an invitation to risky behavior.”

Hungry mothers give birth to more daughters (Nature News)

Another eye-catching story was the report that during the Chinese Great Leap Forward famine, the proportion of boys being born dropped (from 109 boys for every 100 girls to 104 boys for every 100 girls). This sets up the tantalising possibility that sex ratios are adjusted in response to environmental conditions such as nourishment, a situation already known in deer where undernourished males tend to have fewer offspring than undernourished females (although in humans other factors like psychological and physical stress could be at play).

A final story that caught my eye was the latest results from the Avon Longitudinal Study of Parents and Children (ALSPAC), also known as the Children of the 90s, which probably warrants a blog post in itself. Nature News covered it and The Guardian’s sublime Science Weekly podcast featured it too (after 26:10). My favourite bit was how they collected the children’s milk teeth: “We had to negotiate for those. They are worth money to children, after all. In the end, we only got the milk teeth when we presented each boy and girl with an official Alspac form, signed by the tooth fairy.”

How sweet!

Giving birth after a caesarian delivery

We are due our second child in February next year (a 20-month gap between no.1 and no.2 – yes, I’m weary just thinking about it). I shall spare you the warts-and-all birth story, but our first baby was born by caesarian section after a worrying dip in his heart rate.

There are two options for women in this situation. The first is to choose to have a caesarian delivery again, which is known as “elective repeat caesarian delivery”, or ERCD for short. The second is to have a “vaginal birth after caesarian”, often abbreviated to VBAC. The actual process of attempting a VBAC is called “trial of labour after caesarian”, or TOLAC.

If we were living forty years ago, there wouldn’t be much debate – we would have been booked in for a C-section. This started to change in the 1980s as more women and couples pushed to have a more ‘natural’* vaginal birth, which led to an increasing number of VBACs. This was backed by improving caesarian surgery, such as a change from making the incision ‘up’ the belly (‘longitudinal’) to making it ‘across’ the belly (‘transverse’) to achieve more effective repair, as well as advice from leading health organisations to reduce caesarian rates.

It seems that in the UK, however, as in many other countries, caesarian deliveries after previous caesarians are back on the increase. One reason is the real fear that the uterus, weakened by the surgery, even by a transverse section, might rupture if a vaginal birth is attempted. A ruptured uterus can lead to complications for the mother and child (more on the specifics in a minute).

There are currently no randomised trials to compare the risks associated with two approaches and most studies have looked retrospectively at what happens in ERCDs or VBACs. This means that it’s hard to inform women before they give birth what the different risks might be.

An article in the scientific journal PLOS Medicine earlier this year – ‘To VBAC or Not to VBAC‘ by Catherine Spong - summarised two research papers that were published at the same time. They both capture information on what the mother intended to do, as well as what actually happened. This gives some relevant insight into whether preferences were successfully carried out, and what the true risks are for women planning either an ERCD or VBAC.

And good news, there’s no paywall so access is free!

The headline message for the woman is:

…risks such as uterine rupture are higher for women attempting a trial of labor following a previous cesarean delivery than those having an elective repeat cesarean delivery; however, the overall risks are low in both groups.

So how does it break down?

The mother

One study was based in the UK and the other in Australia, and both calculated that the uterus ruptures in approximately 2 in 1,000 planned VBAC cases and 1 in 1,000 planned ERCD cases. These figures are lower than those previously reported and communicated to patients, which range from 4-12 ruptures in every 1,000 women planning VBACs. The authors of the Australian study put this down to the hospitals following standardised treatment plans that were designed using the latest evidence. Either way, the results are encouraging.

The British study also found that the risk of rupture is higher for women who have had two or more previous caesarean deliveries, less than 12 months since their last caesarean section, or whose labour was induced (up to roughly 6 in every 1,000 cases, if I’ve calculated correctly, so still relatively low).

As for how the intended modes of delivery played out, nearly 98% of women who planned an ERCD succeeded, but only 57% of those who planned a VBAC did. Almost 25% of women originally planning a VBAC ended up choosing a caesarian delivery, which suggests they either changed their minds or doctors advised that a caesarian should be carried out instead.

The baby

The Australian study also assessed the outcomes for the babies. The researchers recorded fewer serious problems for the babies in the ERCD group when compared with the babies in the VBAC group – approximately 1 in a 100 ERCD births had difficulties, whereas over 2 in a 100 VBAC births had problems for the baby. Serious problems that needed treatment included physical birth injuries, infection and low oxygen in the umbilical cord.

There were two stillbirths in the VBAC group, but as Catherine Spong explains in the summary piece, there’s an important caveat to note. Elective caesarians, by their nature of being chosen, happen at a set time – in the Australian study the C-sections were performed, on average, after 38.8 weeks of term. Laboured vaginal births, by their nature of being involuntary, cannot be booked in, and the average time that these took place was at 40 weeks of term. As a result, it is uncertain whether these stillbirths were associated with the type of delivery or the extra time in the womb (or, even, that they happened by chance – 2 is a very low number from which to draw conclusions).

The state of play

Uterine rupture can increase the risk of stillbirth. According to statistics cited in Spong’s article from the National Institutes of Health in the US, infant death occurs in 6% of cases of a ruptured uterus – given the rates of rupture reported by these two studies, it puts the estimated risk somewhere in the region of 3 deaths every 50,000 ERCDs and 6 deaths every 50,000 VBACs.

Uterine rupture can also increase the risk of brain damage to the baby due to a lack of oxygen (‘hypoxic-ischaemic encephalopathy’, or HIE). Another review estimated this risk to be one in every 1,250 VBACs against practically zero risk in ERCDs.

However, these ever-so-slightly higher risks of complications in VBACs need to balanced against other potential problems associated with caesarian deliveries. Serious infant respiratory problems are more common in elective caesarians (observed to be 3-6 in 400) compared with vaginal deliveries (observed to be 1 in 400). Newborns are also more likely to be admitted to the neonatal intensive care unit (NICU) due to the need for ventilation therapy and more likely to spend longer than seven days in hospital. Other caesarian-specific risks to the mother, such as dislodged blood clots, need for a blood transfusion, extended wound healing, a longer stay in hospital and future pregnancy complications, are also present.

The extent of some of these risks is greatest in the cases of caesarian sections following failed VBACs, which means understanding which women are most likely to have a successful VBAC is hugely important. A group of US clinicians highlighted various factors that increase the likelihood of a successful VBAC: women with one previous caesarian delivery with a low transverse incision, women who at some point have had a prior successful vaginal delivery, and women who had their caesarian because the baby presented breech or some other form of malpresentation rather than for other reasons. Vaginal births in general are more successful when women have access to high level of healthcare, something we should always seek to protect and improve wherever necessary.

Other factors decrease the likelihood of a successful VBAC: failure of the labour to progress or baby to descend during a previous TOLAC, a higher age and weight of the mother, and preexisting medical conditions such as hypertension or diabetes.

And, so…?

What does all this population data mean for the individual woman? The risks for TOLAC seem reasonable in the context of the inherently uncertain process of labour, but women should be properly prepared and counselled to understand the benefits and risks. This should ideally be done with full reference to real numbers and so that the discussion takes the individual’s status into account. That way, the chances of a satisfactory outcome for mother, child and doctor can be at its greatest.

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*I hesitate to use natural to describe vaginal births: ‘natural’ has so many connotations about medical interventions and vaginal births vary from case to case, which renders ‘natural’ a bit of a messy description.

What not to do during pregnancy and childbirth

Ben Goldacre – author of Bad Science, scourge of secretive Pharma companies, and champion of evidence-based healthcare – highlighted a great resource on his secondary blog. It is a collection of ‘do not do’ recommendations from the National Institute for Health and Clinical Excellence (pleasingly abbreviated to NICE), which publishes guidelines on best healthcare practices within the UK’s National Health Service.

The ‘do not do’ database holds information on a range of clinical practices that NICE recommend should be stopped or not used routinely, all of which is based on the best available evidence. There is a section on ‘Gynaecology, Pregnancy and Birth’, which contains 174 recommendations. Many are for specific interventions that may be more of interest to health professionals, such as “A serum ferritin test should not routinely be carried out on women with heavy menstrual bleeding (HMB)”. But there are a few nuggets that mothers- and fathers-to-be may like to hear.

There is a range of advice on alternative and complementary therapies, for instance: “Healthcare professionals should inform women that the available evidence does not support herbal supplements, acupuncture, homeopathy, castor oil, for induction of labour”. There is no evidence for hot baths, enemas or sexual intercourse either. For labour pain, transcutaneous electrical nerve stimulation (TENS) should not be offered to women in established labour”, which our midwife obviously had not read (or just ignored!).

As for acupuncture, acupressure and hypnosis, they “should not be provided, but women who wish to use these techniques should not be prevented from doing so”, which seems sensible, although potential side effects should be forgotten. Generally for alt med, it advises that: “Pregnant women should be informed that few complementary therapies have been established as being safe and effective during pregnancy. Women should not assume that such therapies are safe and they should be used as little as possible during pregnancy.” Sound  advice.

There is a mention of supplements during pregnancy – iron supplements shouldn’t be taken routinely (unless a deficiency is identified) – but I would love to see that section expanded to cover other areas of nutrition. More specifically, there is no good evidence that magnesiumfolic acidantioxidants (vitamins C and E), garlicfish oils or algal oils can help prevent disorders related to high blood pressure, such as pre-eclampsia.

A random titbit that’s not really connected with other recommendations, says that if a women wants to breastfeed, then breast examination during pregnancy does not seem to help breastfeeding in the long run.

There are more pieces of intriguing guidance about midwife support during labour (“Team midwifery and active management of labour), psychosocial interventions to reduce the likelihood of developing a mental disorder, and approaches to fertility problems.

All of which can only be good for mums and dads in making informed decisions and for health professionals in providing the best care possible. Happy browsing!

Telly addicts: alarm over kids’ TV viewing habits

There was a flutter of activity across Twitter and blogs the other day, in response to some reports that suggested kids’ increasing TV viewing was having a detrimental effect on mental health. According to the reports, TV viewing should be limited for children even into their teens and banned altogether for under-threes. The issues highlighted here will be familiar to detractors of Bad Science and Bad Reporting, but I wanted to record some thoughts for posterity.

I first saw the story in The Guardian and it was also picked up by BBC News, The Independent, The Telegraph, Daily Mail, Metro and many other outlets. Whilst it’s an interesting and worthwhile area of study, the paper published in the journal Archives Of Disease In Childhood and the subsequent press statements, had a few problems that undermine the stark headlines.

The paper was not an original research paper, but an opinion piece that looked back at some previous research. The chief agitator in this is Aric Sigman, a psychologist whose method of ‘cherry-picking’ evidence Ben Goldacre has had much to say about in the past. ‘Cherry-picking’ is essentially picking the bits of evidence that support a particular claim, whilst ignoring other evidence that doesn’t. As Goldacre points out, a better way to analyse previous research is to perform a ‘systematic review‘. These reviews say exactly how the literature was searched and compiled, which means it is more free from bias and allows others to reproduce it.

As for this specific case, Pete Etchells at SciLogs does a good job at highlighting the problems with the selective nature of the analysis and why it’s important to understand the cause of something before issuing guidance on fixes. I worry that many developmental outcomes – such as empathy, attention, educational performance – are lumped in under the banner of ‘mental health’, but that is probably for someone more qualified to comment on. Professor Dorothy Bishop‘s remarks in the Guardian article are salient too – if Sigman’s concerns are to do with kids just sitting for long periods, you shouldn’t advocate reading books for too long.

My first thought on reading the reports was that the conclusions seem to be based entirely on correlative studies, so it’s hard to determine cause-and-effect. What if children who watch more TV are also more likely to have inattentive parents? You may still see an association between more TV watching and developmental problems if these are both caused in some way by inattentive parenting, but enforcing a reduction in TV time wouldn’t do anything – getting parents to interact more at other times would have the most effect. (For the record, this is just an example of ‘correlation does not imply causation’ and I’m not suggesting this is supported by the evidence!)

On a more general but related point, there is a real problem with defining ‘screen time’, because you’re essentially describing a medium and not an activity. The Mind Hacks blog (written by KCL psychologist Vaughan Bell and Sheffield University psychology lecturer Tom Stafford) has written about this in relation to internet use. Bell has also written about how there have been worries throughout modern history over new technology. Even ‘education’ was once considered a risk to mental health.

As for TV, there are clearly different types of programmes kids can watch – some are aimed at learning and education, some are musical and participatory, some are interactive, and so on. And there are also different contexts in which to watch TV – alone, with parents talking things through, in the background whilst doing other things, etc. Understanding whether different types of TV interaction have different effects or whether other factors in the child’s environment tend to lead to a particular sort of behaviour, are critical in getting to the root of the issue.

The evidence just isn’t strong or reliable enough to make the sort of alarmist claims Sigman has made. And this is why it is again so disappointing to see the same blanket coverage across much of the press, with little in the way of a proper critique (Prof Bishop’s comments aside). It was once again left to bloggers and commentators on social media to provide a more discerning look at the issues.

I want to emphasise that I’m not dismissing these issues, and there may well be problems caused by excessive use – however that’s defined – of certain types of ‘screen time’ (as Etchells notes too). But it’s important to know what you’re measuring and understand the nuances. It is also crucial to have proper evidence before issuing supposed evidence-based guidance.