Thursday, December 10, 2009
dosing Prevention and Management of Vitamin D Deficiency in Children: Part I: Vitamin D Requirements: New Recommendations
Prevention and Management of Vitamin D Deficiency in Children: Part I: Vitamin D Requirements: New Recommendations
- Mechanism of Action
- Current Standards for Vitamin D Intake
- Vitamin D Status in Infants and Children
- New Recommendations
- Patients at Increased Risk
Information from IndustryLatest research in the treatment of ADHD
Explore the science behind this new ADHD medication.
An extensive review on vitamin D deficiency in children, with new recommendations for supplementation, was published in the August 2008 issue of Pediatrics by Misra and colleagues on behalf of the Drug and Therapeutics Committee of the Lawson Wilkins Pediatric Endocrine Society. This paper provides an excellent resource for pediatric health care providers on topics ranging from biomarkers of vitamin D deficiency to dietary sources and dosing of vitamin D products.
Based on a review of the literature, the group recommended that serum 25 (OH)D levels be maintained at least above 20 ng/mL and that daily supplementation with 400 International Units (10 mcg) of vitamin D be initiated within days of birth for all breastfed infants and in formula-fed infants and children who do not ingest at least 1 L of vitamin D-fortified milk each day. Premature infants, dark-skinned children, and children who live at higher latitudes may require larger doses of vitamin D, up to 800 International Units (20 mcg) per day. Supplementation for vitamin D insufficient or deficient children should be dosed according to the chart below:
Patient Age Dose (International Units/day) < 1 month 1,000 1–12 months 1,000 to 5,000 > 12 months > 5,000
In addition to their recommendations, the authors also highlighted the need for additional studies to determine if higher levels of 25 (OH)D (> 32 ng/mL) should be considered, as well as to determine the appropriate balance of the benefits and risks of sunlight exposure.
In November 2008, the American Academy of Pediatrics (AAP) released a guidance paper on the prevention of rickets and vitamin D deficiency in infants, children, and adolescents. This new report replaces their 2003 statement which recommended a daily intake of 200 International Units. As in the Lawson Wilkins Society article, the 2008 AAP statement recommends that the daily vitamin D intake for all pediatric patients be increased to 400 International Units (10 mcg), with a goal 25 (OH)D level of at least 20 ng/mL. The AAP statement also recommends that breastfed infants receive a vitamin D supplement at a dose of 400 International Units/day beginning shortly after birth and continuing until they are weaned and consuming at least 1 L of vitamin D-fortified formula or milk per day.
Daily supplementation is also recommended for older children and adolescents who do not consume at least 400 International Units of vitamin D with their usual diet. The AAP guidelines were based on studies documenting the safety of vitamin D at this higher dose as well as new evidence suggesting a possible role for vitamin D in preventing cancer, cardiovascular disease, and diabetes.
Ninth Annual Year in Ideas -Thirdhand Smoke dangers - NYTimes.com
Many parents who light up are aware of the dangers of secondhand smoke; they blow it out the window or smoke at home only when the kids are not there. But people rarely account for what is left behind after a cigarette has been extinguished. When smoke dissipates, it does not just disappear. Compounds are left over that settle on walls, furniture and clothes, or become part of house dust. Call it "thirdhand smoke," which is what a team of researchers trying to raise awareness of the dangers of smoking named it in January.
The study, published in the journal Pediatrics, surveyed 1,500 smokers and nonsmokers about the hazards of secondhand and thirdhand smoke and found that 84 percent of smokers believe secondhand smoke is dangerous to children, while only 43 percent think thirdhand smoke is harmful. But the compounds in thirdhand smoke can be ingested or absorbed through the skin, and some give off gases as they deteriorate, says Jonathan Winickoff, an associate professor of pediatrics at Massachusetts General Hospital, who led the research. Many are carcinogenic. "The more you smoke in these locations, the more microlayers of these toxins build up," Winickoff says.PHOTO ILLUSTRATION BY REINHARD HUNGER
SET DESIGN BY SARAH ILLENBERGER Enlarge
Winickoff is analyzing data on children who live in apartments and encounter thirdhand smoke only from other units in their buildings. He expects to publish his results early next year. LIA MILLER
The States of Marriage and Divorce - Pew Research Center
Correlations in Marriage Patterns
Some state-level patterns of marriage and divorce correlate3 with the overall socioeconomic characteristics and political behavior in those states. This does not mean that one pattern causes the other to happen, only that both tend to be true in the same place.
A state's education levels, for example, tend to be associated with the median age at marriage and the multiple-marriage patterns of its residents. In states with high shares of college-educated adults, men and women marry at older ages, a finding supported by other research indicating that highly educated individuals marry later in life. In states with low shares of college-educated adults, adults are more likely than average to marry three or more times. In states with low income levels, men are more likely than average to have been married three or more times.
For this analysis, correlation also was tested between a state's marriage or divorce statistics and the share of its 2008 presidential election vote that went Democratic. States with high shares of Democratic votes tended to have lower shares of currently married residents, lower shares of adults married at least three times and low rates of marriages within the previous year. Residents of states with high shares of Democratic votes tend to marry at older ages than residents of states with low shares of Democratic votes.
This analysis did not find a strong correlation between divorce statistics -- either a state's share of divorced adults or its rate of divorce within the previous year -- and socioeconomic indicators (income and education) or 2008 presidential election patterns. There was a strong correlation, however, between young age at first marriage for women and a high divorce rate for women within the previous 12 months.
Correlation also was tested to see whether a state's religiosity was associated with marriage and divorce patterns. Religiosity was expressed as the proportion of a state's residents who said in response to a survey that religion was "very important" in their life.4 However, this analysis did not find a strong association between a state's religiosity and its marriage or divorce patterns.
Explore marriage and divorce patterns and see how your state measures up using interactive maps at pewsocialtrends.org.
Wednesday, December 9, 2009
Primary Care and Accountable Care — Two Essential Elements of Delivery-System Reform | Health Care Reform 2009
Diane R. Rittenhouse, M.D., M.P.H., Stephen M. Shortell, Ph.D., M.P.H., M.B.A., and Elliott S. Fisher, M.D., M.P.H.
With discussions about U.S. health care reform focused heavily on insurance reforms, relatively little attention has been paid to the delivery-system reforms that will be required to improve the quality and coordination of health care and slow the growth of spending. The “patient-centered medical home” (PCMH) and the “accountable care organization” (ACO) are two widely discussed models for delivery-system reform that take complementary approaches to achieving these goals. The PCMH model emphasizes the creation of a strong primary care foundation for the health care system, and the ACO model emphasizes the alignment of incentives and accountability for providers across the continuum of care. With support from the Commonwealth Fund, we recently met with other leaders involved in the development of these models to clarify their key elements and identify ways of ensuring that such reforms are mutually reinforcing.
The PCMH model builds on substantial evidence demonstrating that greater emphasis on primary care can result in higher-quality care at lower cost. The model combines the core tenets of primary care (first-contact care that is continuous, comprehensive, and coordinated across the care continuum) with 21st-century practice innovations such as the use of electronic information systems, population-based management of chronic illness, and continuous quality improvement. One important cornerstone of this model is a focus on meeting the needs and preferences of patients; another is payment reform that improves reimbursement to primary care practices and rewards high performance. The model is widely endorsed by purchasers, payers, physicians, and patient-advocacy groups, and multipayer medical home demonstration projects are under way throughout the country.
The challenges to implementation of the PCMH model include two issues that lie beyond the direct control of the primary care practice.1 First, although the model calls for primary care practices to take responsibility for providing, coordinating, and integrating care across the health care continuum, it provides no direct incentives to other providers to work collaboratively with primary care providers in achieving these goals and optimizing health outcomes. Second, although evidence suggests that increased investment in primary care can result in savings from several types of reductions — for example, inappropriate use of tests and procedures, emergency department utilization, and hospitalizations for conditions that could be treated in an outpatient setting — most primary care practices do not have financial arrangements that allow them to share in these savings. The effect on total costs of implementing the PCMH model alone could be limited, because primary care physicians have little direct leverage over other providers in the care continuum, and under the largely fee-for-service payment system it is unlikely that other providers will respond to reductions in the number of referrals or admissions by allowing their incomes to fall. These limitations could be addressed most readily if the model were implemented in the context of a larger entity such as an ACO.2
An ACO is a provider-led organization whose mission is to manage the full continuum of care and be accountable for the overall costs and quality of care for a defined population. Multiple forms of ACOs are possible, including large integrated delivery systems, physician–hospital organizations, multispecialty practice groups with or without hospital ownership, independent practice associations, and virtual interdependent networks of physician practices.3 ACOs could receive fee-for-service payment and share in any cost savings achieved relative to a risk-adjusted projected spending target for their patient population; alternatively, payment could be partially or fully capitated, with risks and gains both being shared by all providers. Performance measurement to evaluate the quality of care and to prevent potential overuse (in fee-for-service organizations) and underuse (in capitated ones) is a cornerstone of the model. Some evidence suggests that more fully integrated ACOs provide higher-quality, more efficient care than smaller, more loosely organized ones.4 Challenges to the implementation of the ACO model include the need for strong leadership to address the cultural, legal, and resource-related barriers to creating new provider organizations in many communities.5
Regardless of the organizational structure, an ACO will not succeed without a strong foundation of high-performance primary care. The current shortage of primary care capacity and the outdated infrastructure of most primary care practices could limit the successful implementation of ACOs; conversely, investment in the PCMH model could accelerate the development of high-performing ACOs. The fact that the ACO model does not explicitly require support for primary care has led to considerable concern that ACOs dominated by hospitals or specialists would not adequately invest in primary care — or that hospitals and specialists would garner a disproportionate share of any savings. Because it is widely recognized that increased investment in primary care is needed to slow the overall rate of growth in spending, finding a way to ensure adequate support for primary care will be critical to the design and implementation of ACOs.
As both models move through pilot programs toward implementation, we have identified several strategies for ensuring that they are mutually reinforcing. First, accreditation and certification processes should be aligned. The National Committee on Quality Assurance (NCQA) has a voluntary PCMH recognition program that has been used in many of the early medical home initiatives. There is ongoing debate about the best criteria for recognizing a practice as meeting the standards of a PCMH, and the NCQA is seeking input on this topic from stakeholders. No ACO accreditation or certification process has yet been developed, but when one is, it will be critical to include criteria that ensure sufficient primary care capacity for the patient population and to closely align the standards with those of PCMH recognition.
Second, because successful implementation and evaluation of both models will require measurement of performance, a common set of primary care performance measures should be developed; these should be consistent with the domains outlined in the Commonwealth Fund’s “2020 Vision of Patient-Centered Primary Care” (e.g., timely access to care, coordination of care, and engagement of patients) and endorsed by the National Quality Forum. Performance measurement for determining the amount of shared savings or other financial incentives for ACOs must weight primary care measures heavily rather than focus narrowly on metrics related to hospital care.
Third, the payment mechanisms used must align the incentives of the two models to increase accountability for total costs across the continuum of care while ensuring that a sufficient investment is made in primary care capacity. In Medicare and other demonstration projects, incentives should be aligned so that primary care practices could benefit financially from simultaneous participation in both PCMH and ACO pilots. Because transforming primary care in accordance with the medical home model requires considerable resources, incentives for both quality and savings should emphasize high levels of primary care performance to ensure that ACOs provide adequate support to their primary care providers to enable them to attain and sustain the essential capabilities of a PCMH.
These two approaches are synergistic models of delivery-system reform that, together, promise to redirect the U.S. delivery system toward reduced cost growth and improved quality. ACOs will require a strong primary care core to succeed and, in turn, can provide essential delivery-system infrastructure beyond the primary care practice to ensure the full realization of the PCMH model. Ongoing evaluation of both models, preferably in combination and in diverse settings, is essential. Demonstrations should be designed as pilot tests that can be continued if successful, modified as necessary, and (when successful) implemented broadly, with continued adaptation. Finally, one of the most important elements of federal health care reform will be expanding the capacity of federal agencies, including the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality, to implement, support, and evaluate these promising delivery-system reforms.
Drs. Shortell and Fisher report receiving consulting fees from Kaiser Permanente; Dr. Shortell also reports receiving advisory fees from Centene. No other potential conflict of interest relevant to this article was reported.
From the Department of Family and Community Medicine, University of California, San Francisco, San Francisco (D.R.R.); the School of Public Health, University of California, Berkeley (S.M.S.); and the Dartmouth Institute for Health Policy and Clinical Practice and Dartmouth Medical School, Lebanon, NH (E.S.F.). The authors participated in the meeting along with Melinda Abrams, M.S., Michael S. Barr, M.D., M.B.A., Robert Berenson, M.D., Karen Davis, Ph.D., Kevin Grumbach, M.D., David Meyers, M.D., Hoangmai Pham, M.D., M.P.H., Robert L. Phillips, Jr., M.D., M.S.P.H., and Dana Gelb Safran, Sc.D. The consensus that emerged from the discussion and that is summarized in this article should not be taken to be the perspective of any specific individual or organization.
This article (10.1056/NEJMp0909327) was published on October 28, 2009, at NEJM.org.
Rittenhouse DR, Shortell SM. The patient-centered medical home: will it stand the test of health reform? JAMA 2009;301:2038-2040. [Free Full Text] Fisher ES. Building a medical neighborhood for the medical home. N Engl J Med 2008;359:1202-1205. [Free Full Text] Shortell SM, Casalino LP. Health care reform requires accountable care systems. JAMA 2008;300:95-97. [Free Full Text] Tollen L. Physician organization in relation to quality and efficiency of care: a synthesis of recent literature. New York: The Commonwealth Fund, April 2008. McKethan A, McClellan M. Moving from volume-driven medicine toward accountable care. Health Affairs Blog. August 20, 2009. (Accessed October 26, 2009, at http://healthaffairs.org/blog/2009/08/20/moving-from-volume-driven-medicine-toward-accountable-care.)
Tagged as: Primary Care
Flu During Pregnancy May Increase Risk Of Schizophrenia In Certain Offspring; influenza type B seems to be more implicated.
Flu During Pregnancy May Increase Risk Of Schizophrenia In Certain Offspring
ScienceDaily (June 11, 2009) — When mothers become infected with influenza during their pregnancy, it may increase the risk for schizophrenia in their offspring. Influenza is a very common virus and so there has been substantial concern about this association. A new study in the June 15th issue of Biological Psychiatry suggests that the observed association depends upon a pre-existing vulnerability in the fetus.
Specifically, Dr. Lauren Ellman and colleagues determined that fetal exposure to influenza leads to cognitive problems at age 7 among children who later develop a psychotic disorder in adulthood, but fetal exposure to influenza does not lead to cognitive problems among children who do not later develop a psychotic disorder. It is important to note that these results were dependent upon the type of influenza, with this association present only after fetal exposure to influenza B as opposed to influenza A.
This research was conducted as part of the Collaborative Perinatal Project, which followed pregnant women and their offspring in the 1950’s and 60’s, collecting blood throughout pregnancies for later analyses. A series of cognitive assessments were conducted with the children of study participants and then psychotic diagnoses were determined in adulthood.
The findings from this study suggest that a genetic and/or an additional environmental factor associated with psychosis likely is necessary for the fetal brain to be vulnerable to the effects of influenza, given that decreases in cognitive performance were only observed in influenza-exposed children who developed a psychotic disorder in adulthood.
“The good news is that most fetuses exposed to influenza virus while in the womb will not go on to develop schizophrenia. The bad news is that the prior association between influenza infection and later development of psychotic disorders was supported,” comments John Krystal, M.D., the editor of Biological Psychiatry.
This finding has the potential to influence efforts to develop prevention, early intervention and treatment strategies, such as taking steps to maintain careful hygiene and, if clinically appropriate, administration of the influenza vaccination to reduce infection among women prior to pregnancy. Dr. Krystal notes, “It also raises an important unanswered question: How does influenza virus affect the vulnerable developing brain and how can we prevent or reverse the consequence of fetal influenza infection in vulnerable individuals before they develop schizophrenia?” More research is needed to elicit answers to these vital issues.
interesting paradigm of how viral diseases can affect gene expression and manifest in psychiatric disease 30 years later.
Exposure To Influenza During Pregnancy May Increase Risk Of Schizophrenia In Offspring
Exposure To Influenza During Pregnancy May Increase Risk Of Schizophrenia In Offspring
ScienceDaily (Aug. 3, 2004) — NEW YORK, NY (August 2, 2004)– A new study published today in the JAMA publication, Archives of General Psychiatry, indicates that prenatal exposure to influenza may increase the risk for development of schizophrenia years later. The study, which evaluated archived sera from pregnant women who participated in a large birth cohort called the Child Health and Development Study (CHDS) from 1959–1966, was conducted by researchers at the New York State Psychiatric Institute and the Mailman School of Public Health at Columbia University, in collaboration with the Kaiser Permanente Medical Care Plan, Northern California Region and the Public Health Institute, Berkeley, California.
Today's findings are part of a larger team study known as the Prenatal Determinants of Schizophrenia (PDS), which examines prenatal infection, nutrition, chemical exposure, paternal age, and a range of other prenatal factors that influence schizophrenia risk.
The study has shown for the first time that serologically documented prenatal exposure to influenza is associated with schizophrenia. The risk of schizophrenia was increased threefold when influenza occurred during the first half of pregnancy; however when influenza occurred during the second half of pregnancy, no increased risk was observed.
"It is an exciting time for research that combines serologic documentation of infectious diseases during pregnancy, long-term follow-up, and careful assessments for schizophrenia and other disease outcomes," said Alan Brown, MD, lead author and associate professor of clinical psychiatry and epidemiology at the New York State Psychiatric Institute and Mailman School of Public Health. "Because the individuals whom we are studying have only recently passed through the age of risk for schizophrenia, it has become possible only in the last few years to analyze archived prenatal serum specimens in order to address the question of whether schizophrenia is related to prenatal risk factors such as viruses, as well as nutritional factors and toxins, during pregnancy." The 40-year study of the CHDS was made possible by ongoing support from the National Institute of Child Health and Development.
"These findings represent the strongest evidence thus far that prenatal exposure to influenza plays a role in schizophrenia," said Ezra Susser, MD, DrPH, senior investigator of the PDS study, chair of the Department of Epidemiology at the Mailman School of Public Health and head of Epidemiology of Brain Disorders at the New York State Psychiatric Institute. "Although the findings may ultimately have implications for prevention, we strongly caution against making any public health policy recommendations until these links have been confirmed through further study."
The PDS, initiated by Dr. Susser together with Dr. Brown and Dr. Catherine Schaefer of Kaiser Permanente Division of Research, included a nested case-control study of the CHDS birth cohort, which was recruited from 1959-1967, and was followed up for psychiatric disorders 30-38 years later. During that time period, the CHDS, under the direction of Jacob Yerushalmy, University of California, Berkeley, recruited nearly every pregnant woman who received obstetric care from Kaiser Permanente in Alameda County, California. All of the children born were automatically enrolled in Kaiser Permanente. The PDS study cohort consisted of the sub-sample of 12,094 live births who were members of Kaiser Permanente from January 1, 1981 through December 31, 1997.
Dr. Brown and colleagues from the PDS team measured influenza antibody in archived serum samples derived from the blood of 64 pregnant women whose offspring later developed adult schizophrenia and from a comparison group of 125 pregnant women whose offspring did not develop schizophrenia. They found an association between the presence of elevated influenza antibody levels and schizophrenia in the adult offspring suggesting that prenatal exposure to influenza may increase the vulnerability for schizophrenia.
This study was funded by the National Institute of Mental Health, the National Alliance for Research on Schizophrenia and Depression, and the Lieber Center for Schizophrenia Research.
The PDS research is part of a number of "life course studies" being overseen by Dr. Susser at the Mailman School. In addition to the CHDS study, Dr. Susser and his team are looking at large birth cohorts from the U.S., Israel and Norway to observe the pathogenesis of chronic and acute diseases and their links to prenatal and postnatal exposure to environmental factors such as viruses and toxins.
The Long-Term Evidence for Vaccines | Print Article | Newsweek.com Prelude to backlash against backlash?
The Long-Term Evidence for VaccinesVaccination does more than protect against flu. Study after study shows that keeping children safe from viruses has long-lasting, positive health benefits.
By Laurie Garrett and Dana March | Newsweek Web Exclusive
Dec 7, 2009
With some reports saying that the worst of the H1N1 outbreak may have already come and gone this flu season in North America but not worldwide, parents who decided to sit out vaccinations for their children may feel validated. But not only is that strategy risky, it's uninformed, and ignores a larger truth about the benefit of vaccines. Throughout North America and Europe, an anti-vaccination movement has steadily grown over the past two decades, and was recently jet-propelled amid anxiety over immunizing pregnant women and children against the H1N1 "swine flu." The greatest fall-off in child vaccination, and the strongest proponents of various theoretical dangers associated with vaccines, are all rooted in wealthy, mostly Caucasian communities, located in the rich world. At a time when billions of people living in poorer countries are clamoring for equitable access to life-sparing drugs and vaccines for their families, the college-educated classes of the United States and other rich countries are saying "no thanks," even accusing their governments of "forcing" them to give "poison" to their children.
Will the children of these naysaying parents of the rich world turn to Mom and Dad 30 years from now and say, "Thanks for not getting me immunized. Thanks especially for saying no to the flu vaccine?"
If a woman is exposed to influenza while pregnant, or if an unvaccinated child gets the flu in his or her first year of life, the baby's developing brain may be severely damaged by the virus. Analysis of medical records of Americans who were born in the late '50s and early '60s shows that having the mother catch the flu while pregnant increased the chance her child would later develop schizophrenia. It's not a trivial difference: the children of moms who had flu midway during their pregnancies were as much as eight times more likely to become schizophrenic.
Overall, prenatal and infant exposure to influenza is strongly associated with cognitive failures. Babies are born with brains and immune systems that are still developing, and will not be hard-wired and strong until their second year of life. Scientists are increasingly discovering links between viral infections during those precious times, and psychiatric problems ranging from lifelong depression to acute learning deficits. In utero or infancy infection with chickenpox doubles the risk of cerebral palsy, according to Australian researchers. Having rubella during pregnancy increases by 80 percent the chances of severe birth defects in that mother's child, including small brains and hearts, blindness, deafness, and severe learning deficits.
Children who contract measles, chickenpox, or whooping cough can develop encephalitis or meningitis—infections of the central nervous system—which can cause epilepsy, brain damage, and death. Parents cannot protect their children's brains against everything, but the basic battery of vaccines can block the bulk of these viral insults. And the good news is that the still-developing immune system of babies and infants is ripe for the vaccine-induced programming that can confer decades—in some cases, lifelong—protection.
Other vaccine-preventable diseases—measles, rubella, mumps, chickenpox, and whooping cough—can damage the optic nerves and hearing of fetuses and newborns. The effect in these cases is immediate and obvious. In the pre-vaccine era in the United States, a thousand kids lost their hearing every year due to measles infection, five out of every 10,000 children who contracted mumps suffered permanent deafness, and 10 percent of child deafness was due to rubella (a.k.a. German measles).
And today, in countries with spotty child-immunization achievements—including the United Kingdom—viral infection in utero or in infancy accounts for 10 to 25 percent of child deafness.
Influenza in utero or in the first year of a child's life is a major cause of adult cardiovascular disease—heart attacks and strokes. People who suffered influenza during the Great Pandemic of 1918–19 were 20 percent more likely to develop heart disease as adults. To put that in perspective, having a "bad cholesterol count" of more than 240mg confers a 20 percent elevated risk of heart attacks, according to the American Heart Association.
Dr. Marietta Vázquez studied 350 mothers and infants from birth to 12 months of age who were hospitalized at Yale-New Haven Hospital over nine flu seasons (2000–2009). The babies of flu-vaccinated moms were larger, healthier, and, 85 percent of the time, fully protected against influenza. Similar findings have recently been reported out of Bangladesh, where the babies of vaccinated moms averaged a half pound larger than their unprotected peers and were less likely to be born prematurely.
The good news is that five decades of global child-vaccination programs have dramatically reduced infant and child mortality rates, and improved life expectancies in most of the world. In September, UNICEF reported that for the first time since WWII the number of children dying in the world annually fell below 10 million in 2008, largely due to child immunization. Vaccines, UNICEF says, are saving 2.5 million kids from dying every single year.
But outbreaks of vaccine-preventable diseases are surfacing wherever clusters of people either decline immunization, or are denied it by virtue of population poverty. The unimmunized few are a threat to all, as they may harbor viruses and pass them onto others whose vaccine-induced immunity is waning due to HIV, cancer, or simply the passing of time. Conversely, failing to be immunized in childhood renders young adults vulnerable to infectious diseases that they may not encounter until they go off to college or travel outside of their home regions.
A cursory search of outbreak reports over the last 13 months demonstrates that measles, mumps, diphtheria, whooping cough, polio, and typhoid fever are surfacing now in all sorts of settings, from jet planes to college dormitories, from Dutch religious sects to villages of Caribbean islands. Some of these outbreaks are tiny, involving no more than a cluster of individuals. But over the last year, several outbreaks have reached epidemic levels.
The United Kingdom has more such outbreaks than any other wealthy country, and that comes as no surprise as Dr. Andrew Wakefield—a key proponent of the theory that additives in vaccines cause autism—started his anti-immunization career in the U.K., in 1998 publishing now thoroughly refuted "evidence" of an autism link. Wakefield is now the subject of a hearing conducted by the U.K.'s General Medical Council for alleged medical misconduct. The discovery that he was secretly funded by personal-injury lawyers that sued vaccine makers has further fueled inquiries. Still, Wakefield's ideas continue to resonate in the UK, to the dismay of the country's pediatricians. Today, 20 percent of U.K. children enter primary school without having completed their full schedule of basic vaccinations— 40 percent, in some parts of the country—according to the Department of Health.
For those fighting disease on the global stage, the H1N1 pandemic has brought into stark relief a puzzling, difficult dichotomy. In the wealthy world, where individuals have the luxury of demanding 100 percent safety, the balance between individual and population rights has shifted so far toward individualism that it is nearly impossible for public-health authorities to persuade people to accept even one in 1 billion risks on behalf of society as a whole. (The exception is the U.S. armed forces, where duty to country includes an obligation to accept full vaccination.) But the very tools of protection that many individuals in the rich world are rejecting—especially the H1N1 vaccine—are completely unavailable to more than half the population of the world. Some 24 million children last year had no access to basic vaccines, says UNICEF, and at least 4 billion people cannot get flu vaccines right now.
For the poor and emerging-market countries, this inequity in access to life-sparing public-health tools is viewed as not only grossly unfair, but as a sign of the arrogant hypocrisy of the wealthy world. The rich countries demand that the planet's poor make sacrifices to slow down epidemics—such as slaying their chickens to stop bird flu, or losing tourist dollars by publicly acknowledging outbreaks within their borders—but offer little in return, including access to precious vaccines.
Yes, the proper adjective is "precious": miracles of science that, combined with smallpox immunization, saved more lives during the 20th century than were lost in all the wars, all the genocides, and all the epidemics of that hundred years. When a baby in an African village dies of measles, or a schoolchild in China succumbs to typhoid fever, none can question how precious that lost life was, or how vital a difference a vaccine could have made.
GARRETT is a Pulitzer Prizewinning writer and senior fellow for global health at the Council on Foreign Relations. MARCH is a doctoral candidate at the Mailman School of Public Health at Columbia University, specializing in life course, social, and psychiatric epidemiology.
Find this article at http://www.newsweek.com/id/226097
People in flight – Photography by Denisa Tarzaka | Amusing Planet
Cool to be suspended
Thursday, November 19, 2009
tough love, and urban legends zjoy
Most people think it's improper to spank children, so I have tried other methods to control my kids when they have one of 'those moments.'
One that I found effective is for me to just take the child for a car ride and talk.
Some say it's the vibration from the car, others say it's the time away from any distractions such as TV, Video Games, Computer, IPod , etc.
Either way, my kids usually calm down and stop misbehaving after our car ride together. Eye to eye contact helps a lot too.
I've included a photo below of one of my sessions with my son, in case you would like to use the technique.
This works with grandchildren,
nieces, and nephews as well.
John C Kim MD
Monday, July 6, 2009
Wednesday, July 1, 2009
Tuesday, June 30, 2009
A brief history of American Parenting as an enterprise in the US in New Yorker Magazine; Is there a demand for experts or by virtue of rite of passage of birthing or adopting enough to make us good parents, or at least good enough parents.
The fuss about parenthood.
by Jill LeporeJUNE 29, 2009
Middle-class parents are an insecure, easily gulled consumer group.
Am a Failure as a Mother,” a talk given on NBC radio in 1932 by Clara Savage Littledale, mother of two, has a lot to answer for, including a couple of new memoirs by grownups determined to profess their parental ineptitude: “Home Game: An Accidental Guide to Fatherhood” (Norton; $23.95), by Michael Lewis, father of three; and “Bad Mother: A Chronicle of Maternal Crimes, Minor Calamities, and Occasional Moments of Grace” (Doubleday; $24.95), by Ayelet Waldman, mother of four. Littledale was the founding editor of Parents’ Magazine; in the nineteen-thirties, her radio program—a column broadcast over the wireless—filled Emily Post’s noontime slot on Wednesdays, Miss Manners’s day off. Lewis and Waldman are columnists, too. “Home Game” started as a series on Slate, episodes in which Lewis, tenderhearted and befuddled, tries to figure out the unwritten rules of the “new fatherhood”; “Bad Mother” revisits essays first written for Salon, in which Waldman uses stories about her family to argue that there’s no such thing as a good mother. If you’ve ever read a parenting blog, and I don’t say you ought to, you have a good idea what lies at the heart of these books: ersatz confession. Lewis finds newborns hard to love; Waldman hires a maid to clean up after her maid. Lewis tells all—all!—about his vasectomy; Waldman provides her sexual history. Waldman insists that how any woman rears her kids is nobody’s never-you-mind. “Let’s all commit ourselves to the basic civility of minding our own business,” she writes. This puts a reader in a tight spot: can I or can I not skip the chapter in “Bad Mother” wherein our author confides her regret over her breasts’ lost buoyancy?
Lots of people find this kind of thing winsome, I guess, and I did like it when Lewis admitted to sneaking out during his wife’s ten-hour labor to score Ring Dings from a hospital vending machine. But as long as we’re trafficking in unsought revelation, reading these books made me think of nothing so much as traipsing to the playground with a twelve-month-old who merrily toddles off to the sandbox while I, despite hiding behind a newspaper and attempting to appear exactly as approachable as Napoleon Bonaparte, find myself cornered by a stranger: “You have a baby? I have a baby! Doesn’t parenthood beat all?” I’ve been that stranger, too (I confess! I confess!), which must be why I’m such an easy mark; the sandbox, my Waterloo. I used to like that conversation. Lately, though, it’s been getting old: all the mothers want forgiveness; all the fathers want applause. A few years back, in “Confessions of a Slacker Mom,” Muffy Mead-Ferro admitted that during her pregnancy she did not actually buy a gizmo that was supposed to pipe Mozart into her belly; in “Dinner with Dad,” Cameron Stracher offered an account of his valiant year of getting home in time for supper. Frankly, I’d just as soon stipulate that most baby gear is worthless, stupid junk and that eating dinner with your kids is really important. Then I’d like to get back to reading the paper. But, hey, sure, amnesty, ovation, whatever gets you through the long, sleepless night.
I blame, as I say, Clara Savage Littledale, whose job it was to help invent American parenthood. Stages of life are artifacts. Adolescence is a useful contrivance, midlife is a moving target, senior citizens are an interest group, and tweenhood is just plain made up. Parenthood seems, at first, different. There have always been parents, and parents have always been besotted with their children, awestruck by their impossible beauty, dopey high jinks, and strange little minds. But “parenthood,” the word, dates only to the middle of the nineteenth century, and the notion that parenthood is a distinct stage of life, shared by men and women, is historically in its infancy. An ordinary life used to look something like this: born into a growing family, you help rear your siblings, have the first of your own half-dozen or even dozen children soon after you’re grown, and die before your youngest has left home. In the early eighteen-hundreds, the fertility rate among American women was between seven and eight children; adults couldn’t expect to live past sixty. To be an adult was to be a parent—nearly everyone lived in households with children—except that people didn’t usually think of themselves as “parents”; they were mothers or fathers, and everyone knew that there was a world of difference between the two.
In Littledale’s day, all that had begun to change. People were living longer, having fewer children, and starting families later in life. Littledale, who was born in 1891, didn’t have a baby until she was thirty-one. By 1920, women bore, on average, just over three children. Child rearing no longer circumscribed every woman’s life; motherhood and fatherhood, though not the same, had more in common than they used to. The slice of the population that consisted of adults who did not have children at home—people who would never have children, hadn’t had them yet, or had already had them and now had an empty nest—was sizable, and growing. In 1880, seventy per cent of American adults lived in households with children under the age of fifteen; by 1920, that number had fallen to fifty-five per cent. All these changes, aggregated, made parenthood into something different, something big, something planned.
By 1922, when Littledale became a mother, parenting had also begun to look especially mystifying to the increasing numbers of people, generally wealthier people, who had not grown up caring for their siblings, neighbors, cousins, and nieces and nephews, and who, it turned out, had no idea how to bathe or dress or soothe a baby. Looking after babies and little kids is skilled labor, but, as the number of children dwindled, so did the number of adults who had any real skill. The growing uprootedness of American life meant that many first-time parents couldn’t count on grandparents, or, really, on anyone. In stepped experts, who argued that taking care of children was not just a skill; it was a science. In the eighteen-nineties, the psychologist G. Stanley Hall established an American foothold for the academic discipline of child study (imported from Europe, along with kindergarten), just as pediatrics was becoming a specialty. The U.S. Children’s Bureau was established in 1912. As Littledale explained in 1930, the year the American Academy of Pediatrics was founded:
Once it was believed that the very physical fact of parenthood brought with it an instinctive wisdom that enabled one to rear children wisely and well. Parents knew best. Today fathers and mothers are unwilling to struggle under such a load of self-imposed omniscience. Even if they were, the facts would be against them. For in this country various studies made in the last ten years present incontrovertible data to prove that devoted but unenlightened parenthood is a dangerous factor in the lives of children.
This almost passes for a definition: parenthood is being so inept that you’re a danger to your own children. That, at least, was the premise of Littledale’s magazine, and its price.
Littledale was the editor, but Parents’ Magazine was the brainchild of a philanthropist and publisher named George Joseph Hecht. Hecht, who was born in New York in 1895, had served in the government’s office of public information during the First World War, where he helped found the Bureau of Cartoons. In 1919, he published an amazing collection, “The War in Cartoons”—a history of the war in a hundred cartoons—and, the following year, began publishing Better Times, “the Smallest Newspaper in the World.” (It measured less than four by five inches.) For a while, Hecht wrote the entire paper, which was a weekly, and pretty good. Hecht liked to tell this story: In the early nineteen-twenties, while sailing back from a trip to Europe, he met a well-heeled woman who confided to him, “I have failed where every woman wants to succeed—as a mother.” Moved, and curious, Hecht began reading child-rearing manuals. “They were all great big thick books,” he noticed. He liked little books; he liked pictures. He began raising money for a magazine that would teach a de-skilled middle class how to be parents. (Hecht did not, at this point, have children.) For the editor, he wanted a woman, and required “that she be a college graduate, that she should have had an editorial position preferably with a woman’s magazine, that she should be able to write if dire necessity ever required it of her, that she be married and that she should be a mother.” In 1926, he hired Clara Savage Littledale.
Littledale, talented and driven, had written features for the New York Timeswhile still a student at Smith; after graduating, she became only the second woman reporter to be hired by the Evening Post. But at the Post, as elsewhere, women were almost never allowed into the newsroom; she was named editor of the paper’s woman’s page. (Joseph Pulitzer had started a woman’s page in 1886, in the New York World. Woman’s pages lasted for about a century. In 1969, the Washington Post renamed its “For and About Women” page the Style section; other newspapers followed suit. Parenting blogs like the Times’ Motherlode are basically a throwback.) In 1914, Savage left the Post to become press chairperson of the National American Woman Suffrage Association; and the next year she took a job as associate editor at Good Housekeeping, though she mainly reported on policy matters, from Washington. In 1918, she went to Europe, to cover the war. When peace came, Savage quit Good Housekeeping, stayed in Europe, and, in 1920, married a journalist named Harold Littledale; two years later, she gave birth to a daughter. In 1924, Littledale wrote a short, bitter piece for The New Republic about sharing a maternity room with a woman whose baby had been stillborn. We never learn the woman’s name; Littledale calls her 41A. Weirdly, the story, much of which is conversation overheard during a visit from 41A’s husband, has a lot in common with “Hills Like White Elephants,” which Hemingway published in 1927, in “Men Without Women.” The couple never mention the dead baby, but everything they say is about the dead baby:
“Is my aunt cookin’ your meals?” she asked.
“Yep, and, say, we had a pie.”
“What kind of a pie?” the girl demanded fiercely.
“Did she use up those apples I was savin’?” The face of 41A was white and set.
ith Littledale at the helm, the first issue of Children, The Magazine for Parents appeared in 1926 (a year after Harold Ross started The New Yorker). It was full of expert advice, offered by leading psychologists, doctors, educators, and scholars. There had been advice literature before, of course—not only great, thick books but also magazines, including Babyhood (1884-92) andAmerican Motherhood (1903-19)—but Hecht and Littledale came up with a formula for explaining the new science of parenting. “The staff sits up nights throwing scientific words out of the articles submitted by college professors,” Littledale wrote. She also domesticated her experts. If the magazine “publishes an article by a Ph.D.,” she wrote, “it hastens to explain that said Ph.D. has a baby or if the Ph.D. is a man that he is the uncle of a dear little tot.” More important, Littledale solicited contributions from people who had no academic expertise—“Mammas and papas are encouraged to contribute articles and they do”—chiefly to point out what rank amateurs they were. In 1927, the year Littledale worked through her second pregnancy, she ran articles like “Can a Tired Business Man Be a Good Father?,” an argument for what later came to be called “quality time” (“An hour can be made more significant than a day”) and “Confessions of an Amateur Mother,” the lament of a wealthy, well-educated woman who hasn’t the slightest idea how to care for her newborn: “Why is it that for the women of my type—professional women—motherhood, as a rule, comes so hard?” (She complains, too, that she isn’t eligible for social services; there are “motherhood clinics and baby stations aplenty in the districts of the ‘poor’ women: why not for me?”)
Within two years of Children’s first issue, Hecht and Littledale had changed the magazine’s name, a decision that made a lot of sense, since all this business about parenthood, then as now, has very little to do with kids. By 1931, Parents’Magazine boasted two hundred thousand subscribers. Middle-class mothers and fathers turned out to be a very well-defined consumer group, easily gulled into buying almost anything that might remedy their parental deficiencies. In 1938,Parents’ peddled a correspondence course: “Add Science to Love and Be a ‘Perfect Mother.’ ” The magazine’s success carried Littledale into broadcasting; she was heard on NBC radio beginning in 1932, where she administered advice by the anecdote. “A child needs two parents” was her answer to a letter from a listener who wished that he knew his children better. “I’m afraid I’m a failure as a mother,” a woman fretted, and Littledale wisely counselled her, “One way to be a failure as a mother is to overplay the role.” Littledale’s advice was usually perfectly sensible. She didn’t much like punishment; she thought kids needed to learn to do things for themselves. On more particular matters, such as how to handle a crying baby, Littledale’s advice, like her magazine, followed parenting fashion, which changes with the hemlines. Urgent social issues that affected the way many Americans reared their children—segregation and poverty, for instance—had no place on Littledale’s list of parenting problems. In 1946, the year Benjamin Spock published “Baby and Child Care,” Parents’ reached four hundred thousand subscribers; it came to be known as the Family Bible. Today, it claims fifteen million readers, nearly all of them women. The magazine lost its apostrophe somewhere along the way, as well as its purchase on American life, but confessions of amateur mothers—“Parents is for every woman who lives and parents in her own authentic way”—and a column called Fatherhood 101 can still be read at its Web site, parents.com, where you can also find out about a lot of worthless, stupid baby gear and learn that eating dinner with your kids is really important.
In the United States today, people raising children are, statistically, a minority. With the notable exception of the baby boom, the percentage of American adults living in households with children younger than fifteen has been falling for more than a century; by 1990, it was down to about a third. The fertility rate is now just slightly more than two. The average American can expect to live into his or her seventies; the population, as everyone knows, is aging, fast. Forty per cent of American babies born in 2006 were their mother’s first. We are more inexperienced and unskilled at caring for them than ever, something Anne Lamott wrote about in her wry and smart memoir, “Operating Instructions: A Journal of My Son’s First Year.” Small families make for few economies of scale; a father finally figures out how to swaddle his baby, and, damn it, the age of swaddling is over. A not uncommon experience is a mother who, upon first holding her newborn, realizes that it is the first baby she has ever held.
One of the stranger things about the success of a magazine whose premise was that parents are a danger to their own children is that, by the time Hecht began publishing Parents’, children were safer than ever. In 1850, more than one baby in every five died before its first year. By 1920, infant mortality in the United States had dropped to one in twenty. By the Second World War, accidents had replaced disease as the leading cause of childhood death. Today, infant mortality is at one in two hundred. Historians once assumed that when childhood mortality was high people must not have loved their children very much; it would have been too painful. Research has since proved that assumption wrong. Now that children are very likely to survive to adulthood, you might think parents wouldn’t worry so much. This is wrong, too. We love even when that spells grief, and we worry even when that means worrying about nothing. Or, at least, that’s the best explanation I’ve got for why I once bought one of those little mirrors you Velcro to the back seat of your car so that, when your baby has to ride facing backward, you can keep an eye on him. I could tell that story, I guess, but only two things about it are worth knowing: (1) those little mirrors, while in all other respects useless, make a pretty good ice-skating rink for Lego people and (2) it’s more important to mind the road.
Meanwhile, the changes of the past two centuries have created actual problems, structural problems that affect everyone, not just the demographic that reads Parents, problems that can be very hard to see when you’re driving while looking in a baby-view mirror. Most jobs are made for people who aren’t taking care of children. The sharper the division between parenthood and adulthood, the worse those jobs fit, and the less well people who aren’t rearing children understand the hardships of people who are. Employers are seldom asked to accommodate family life in any meaningful way; employees do all the accommodating, which mainly involves, especially for women, pretending that we don’t actually have families. Everyone has a story about how painful that is. It’s also crazy, and maddening, and unfair. We’ve all got stories to tell, but stories aren’t going to rewrite employment law.
Neither are cute books about parenthood as an exclusive club whose initiation rites include confessions of ineptitude, though it’s easy to see why people write them. The average age of a woman at the birth of her first child is now twenty-five, an all-time high, and the fastest-growing cohort of first-time mothers is women over thirty-five. Most Americans become parents only after having been fully grown for a goodish while, which means that we share an experience—a set piece in every parenting memoir—that can feel as if it binds us to one another and alienates us from everyone else, the experience of crossing a great divide between Life Before Children and Life, the Much Sloppier, Sweeter, and More Ridiculous 3-D Sequel. I love that sequel. I laugh! I cry! I also really like the part where I get to read the newspaper.
wasn’t prepared for how ill suited and poorly trained I was for the job of full-time mother,” Ayelet Waldman writes in “Bad Mother,” unintentionally echoing “Confessions of an Amateur Mother,” even though Waldman, a former public defender, is explicitly arguing against the idea that she, or any woman, needs Littledale-style parental education. As Waldman sees it, expert advice about how to be a “good mother” is the problem; a “bad mother” movement is her solution. (Hey, sure, absolution, three cheers, but I’m with Littledale here: don’t overplay the role.) If only more mothers were willing to be more honest about how far we fall short of an ill-conceived ideal—June Cleaver is Waldman’s straw woman—we’d all be better off. That’s why Waldman confesses, and confesses, and confesses: she’s taking a hit for the rest of us. Paid parental leave? Better day care? Nah. More memoir is what we need. Michael Lewis isn’t trying to start a movement; mostly, he’s trying to make fun of the new fatherhood. “This book is a snapshot of what I assume will one day be looked back upon as a kind of Dark Age of Fatherhood,” he writes, archly. “Obviously, we’re in the midst of some long unhappy transition between the model of fatherhood as practiced by my father and some ideal model, approved by all, to be practiced with ease by the perfect fathers of the future.”
The thing is, we are in the midst of a long transition. But it’s no happier for these books. You have a baby? I have a baby! Doesn’t parenthood beat all? Well, yes, it does. But I still miss adulthood. ♦
ILLUSTRATION: PHILIPPE PETIT-ROULET
Wednesday, June 24, 2009
For ankle injuries, cold is best.
The Claim: Heat Should Be Applied to a Sprained Ankle
Published: June 22, 2009
Health Guide: Ankle Pain | Sprains
Ankle sprains are one of the most common sports injuries; they send about a million Americans to clinics every year and cause chronic problems for many.
The problem is clear, but the first-aid treatment is not: heat or cold?
Many people swear by heat, saying it soothes the pain and promotes healing by stimulating blood flow. Others advocate ice, precisely because it does the reverse, slowing blood flow and minimizing inflammation.
According to research, ice wins every time.
In multiple studies, scientists have compared heat and ice by randomly assigning people who showed up at sports clinics with sprains to receive one treatment or the other, in combination with a pain reliever like ibuprofen. One prominent study found that immediate ice therapy “resulted in earlier return to activity, as defined by ability to walk, climb stairs, run and jump without pain.”
In people with the most severe injuries — including torn ligaments — treatment with ice resulted in a 13-day recovery, compared with 30 days for those treated with heat.
For the best results, experts recommend the Price method: protection, rest, ice, compression and elevation. They caution that ice should be applied only 20 minutes at a time.
THE BOTTOM LINE
Ice is far better than heat for ankle sprains.
Tuesday, June 23, 2009
Review of Kessler’s book on food and over eating, sounds like dummy proofing ourselves from an fat inducing environment is a crucial step toward freedom. But catch the last few paragraph, ah when the chips are down, and we are tired, the chips come up.
How the Food Makers Captured Our Brains
Published: June 22, 2009
As head of the Food and Drug Administration, Dr. David A. Kessler served two presidents and battled Congress and Big Tobacco. But the Harvard-educated pediatrician discovered he was helpless against the forces of a chocolate chip cookie.
In an experiment of one, Dr. Kessler tested his willpower by buying two gooey chocolate chip cookies that he didn’t plan to eat. At home, he found himself staring at the cookies, and even distracted by memories of the chocolate chunks and doughy peaks as he left the room. He left the house, and the cookies remained uneaten. Feeling triumphant, he stopped for coffee, saw cookies on the counter and gobbled one down.
“Why does that chocolate chip cookie have such power over me?” Dr. Kessler asked in an interview. “Is it the cookie, the representation of the cookie in my brain? I spent seven years trying to figure out the answer.”
The result of Dr. Kessler’s quest is a fascinating new book, “The End of Overeating: Taking Control of the Insatiable American Appetite” (Rodale).
During his time at the Food and Drug Administration, Dr. Kessler maintained a high profile, streamlining the agency, pushing for faster approval of drugs and overseeing the creation of the standardized nutrition label on food packaging. But Dr. Kessler is perhaps best known for his efforts to investigate and regulate the tobacco industry, and his accusation that cigarette makers intentionally manipulated nicotine content to make their products more addictive.
In “The End of Overeating,” Dr. Kessler finds some similarities in the food industry, which has combined and created foods in a way that taps into our brain circuitry and stimulates our desire for more.
When it comes to stimulating our brains, Dr. Kessler noted, individual ingredients aren’t particularly potent. But by combining fats, sugar and salt in innumerable ways, food makers have essentially tapped into the brain’s reward system, creating a feedback loop that stimulates our desire to eat and leaves us wanting more and more even when we’re full.
Dr. Kessler isn’t convinced that food makers fully understand the neuroscience of the forces they have unleashed, but food companies certainly understand human behavior, taste preferences and desire. In fact, he offers descriptions of how restaurants and food makers manipulate ingredients to reach the aptly named “bliss point.” Foods that contain too little or too much sugar, fat or salt are either bland or overwhelming. But food scientists work hard to reach the precise point at which we derive the greatest pleasure from fat, sugar and salt.
The result is that chain restaurants like Chili’s cook up “hyper-palatable food that requires little chewing and goes down easily,” he notes. And Dr. Kessler reports that the Snickers bar, for instance, is “extraordinarily well engineered.” As we chew it, the sugar dissolves, the fat melts and the caramel traps the peanuts so the entire combination of flavors is blissfully experienced in the mouth at the same time.
Foods rich in sugar and fat are relatively recent arrivals on the food landscape, Dr. Kessler noted. But today, foods are more than just a combination of ingredients. They are highly complex creations, loaded up with layer upon layer of stimulating tastes that result in a multisensory experience for the brain. Food companies “design food for irresistibility,” Dr. Kessler noted. “It’s been part of their business plans.”
But this book is less an exposé about the food industry and more an exploration of us. “My real goal is, How do you explain to people what’s going on with them?” Dr. Kessler said. “Nobody has ever explained to people how their brains have been captured.”
The book, a New York Times best seller, includes Dr. Kessler’s own candid admission that he struggles with overeating.
“I wouldn’t have been as interested in the question of why we can’t resist food if I didn’t have it myself,” he said. “I gained and lost my body weight several times over. I have suits in every size.”
This is not a diet book, but Dr. Kessler devotes a sizable section to “food rehab,” offering practical advice for using the science of overeating to our advantage, so that we begin to think differently about food and take back control of our eating habits.
One of his main messages is that overeating is not due to an absence of willpower, but a biological challenge made more difficult by the overstimulating food environment that surrounds us. “Conditioned hypereating” is a chronic problem that is made worse by dieting and needs to be managed rather than cured, he said. And while lapses are inevitable, Dr. Kessler outlines several strategies that address the behavioral, cognitive and nutritional factors that fuel overeating.
Planned and structured eating and understanding your personal food triggers are essential. In addition, educating yourself about food can help alter your perceptions about what types of food are desirable. Just as many of us now findcigarettes repulsive, Dr. Kessler argues that we can also undergo similar “perceptual shifts” about large portion sizes and processed foods. For instance, he notes that when people who once loved to eat steak become vegetarians, they typically begin to view animal protein as disgusting.
The advice is certainly not a quick fix or a guarantee, but Dr. Kessler said that educating himself in the course of writing the book had helped him gain control over his eating.
“For the first time in my life, I can keep my weight relatively stable,” he said. “Now, if you stress me and fatigue me and put me in an airport and the plane is seven hours late — I’m still going to grab those chocolate-covered pretzels. The old circuitry will still show its head.”
Mother’s guilt magnified and recycled. serious problem. Mom’s depression affects infant development, and may have longer lasting affects, insidious as some parents are not well aware of themselves, or just in plain denial.
Postpartum Depression Epidemic Affects More than Just Mom
A deep despair mars the first year of motherhood for as many as one in five women. Without treatment, postpartum depression can weaken critical bonds between a mother and her child
By Katja Gaschler
The psychologist smiles at Manuela, a new mother in her late thirties. “Please play with your baby for two minutes,” the therapist instructs her and then leaves the room. Two video cameras film Manuela (which is not her real name) and her three-month-old daughter. In the next room, a split-screen monitor shows the mother’s profile on the left and her infant in a baby chair on the right.
At first, Manuela appears to be at a loss for what to do. Then, her face noticeably stiff, she begins to talk softly to her baby. Her baby fidgets, briefly makes eye contact and then turns away. Manuela eventually stops talking and stares into the distance, unsure again how to act. She absentmindedly strokes her baby’s foot with one hand. The psychologist knocks on the door; the videotaping is over. The new mother is now on the verge of tears.
Manuela is undergoing therapy at the Clinic for General Psychiatry in Heidelberg, Germany, for postpartum depression, an ailment that has strained her relationship with her baby. Although the vast majority of mothers experience periods of crying and irritability along with concen tration lapses and exhaustion, these so-called baby blues disappear within a few hours or days of delivery. But 10 to 20 percent of women in the U.S. develop, in the first year after childbirth, the more disabling despair that afflicts Manuela. These mothers succumb to a deep sadness that, if untreated, may persist for months to years.
Manuela frequently feels exhausted and emotionally empty. When her baby cries, she sometimes wants to flee or hide. She is wracked with guilt because she cannot show love to her daughter. Mothers with symptoms of postpartum depression [see box on page 70] are often overwhelmed by the feeling that they might harm their babies. Although they rarely cause any outright harm, depressed mothers may have difficulty caring for their infants—and that fact can heighten their distress.
These emotional problems plague women worldwide. A 2006 review of 143 studies in 40 countries documents that postpartum depression is especially common in Brazil, Guyana, Costa Rica, Italy, Chile, South Africa, Taiwan and Korea, with prevalence rates as high as 60 percent in some countries.
The causes of the disorder are not fully known, but the dramatic hormonal fluctuations that occur after delivery may contribute to it in sus ceptible women. A bout of previous depression is a huge risk factor for the postpartum variety, new research shows. Whatever its cause, depression can weaken the nascent bond between a mother and her child, studies suggest, and thereby make a toddler more passive, insecure and socially inhibited—although a child’s intellectual development usually remains unimpaired.
Thus, in addition to treating the mother’s depression, psychologists and psychiatrists increasingly focus on strengthening the relationship between the mother and her child—for example, by using a video camera to record and analyze their interactions. “We need to change the unfavorable behavioral patterns that develop between mother and child during depression,” says University of Heidelberg psychologist Corinna Reck.
Women seem to be particularly vulnerable to depression during their reproductive years: rates of the disorder are highest in females between the ages of 25 and 45. New data indicate that the incidence of depression in females rises, albeit modestly, after giving birth. In the October 2007 American Journal of Psychiatry, epidemiologist Patricia Dietz of the U.S. Centers for Disease Control and Prevention and her colleagues reported that 10.4 percent of 4,398 mothers had been depressed in the nine months following childbirth, compared with 8.7 percent in the nine months before pregnancy and 6.9 percent during pregnancy. More than half of the women with postpartum depression had also been depressed during or before pregnancy, suggesting that a previous occurrence of depression may be the biggest risk factor for acquiring the illness postpartum.
But the hormonal changes that occur in a new mother’s body are also thought to contribute to postpartum depression in some cases. During pregnancy, a woman experiences a surge in blood levels of estrogen and progesterone. Then, in the first 48 hours after childbirth, the amount of these two hormones plummets almost 50-fold back to normal levels. This chemical seesaw could contribute to depression just as smaller hormonal changes before a woman’s menstrual period may affect her moods.
Of course, hormonal flux does not fully explain postpartum depression. After all, this biochemical oscillation occurs in all new mothers, and yet only a small proportion of them become depressed. In addition, studies have shown that pregnancy hormone levels in a woman do not predict her risk of depression.
Nevertheless, the rapid rise and fall of female sex hormones may buffet the emotions of a subset of women who are predisposed to depression and thus may be acutely sensitive to the hormones’ effects. In 2000 endocrinologist David R. Rubinow, then at the National Institute of Mental Health, and his colleagues reported that simulating the hormonal ebb and flow that occurs during pregnancy and childbirth in 16 women precipitated depressive symptoms in five of the eight women with a history of postpartum depression but not in subjects who had no such history.
The demands of motherhood very likely play a role as well. Many women feel exhausted from a baby’s broken sleep and become overwhelmed by new child care duties. Some may lament the loss of the life they led before having the baby or of their former figure. Women who must endure such stresses on top of marital problems, a complicated birth, job loss or lack of support from family and friends are more likely to succumb to depression.
The consequences of depression inevitably reach beyond the mother. In a fog of sadness, a mother often lacks the emotional energy to relate appropriately to her baby. Overwhelming grief prevents her from properly perceiving a child’s smiles, cries, gestures and other attempts to communicate with her. Getting no response from mom, the child quits trying to relate to her. Thus, three-month-old infants of depressed mothers look at their mothers less often and show fewer signs of positive emotion than do babies of mentally healthy moms.
In fact, infants of depressed mothers display something akin to learned helplessness, a phenomenon University of Pennsylvania psychologist Martin E. P. Seligman and his colleagues described in the 1960s. In Seligman’s experiments, an animal would conclude that a situation was hopeless after repeatedly failing to overcome it—and then remain passive even when it could effect change. A similar passivity characterizes depression. “Sometimes the infants mirror their mother’s depressive behavior,” Reck says.
Such reciprocal withdrawal can start to fray the critical emotional bond between mother and child, especially if the depression occurs early in the baby’s life. Other work has shown that infants develop essential social skills in months two through six, building relationships with their mothers as well as other people. In a 2006 study of 101 new mothers, psychiatrist Eva Moeh ler, Reck and their Heidelberg colleagues found that maternal depression strongly diminished the quality of a mother’s bond with her child at two weeks, six weeks and four months postpartum—but not at 14 months. Thus, depression during the first few months after birth may be particularly perilous for a child’s social development.
A child of a depressed mother may even become more introverted and face a greater risk for social phobia, an extreme fear of social situations, among other emotional difficulties. In 2007 Reck, Moehler and their colleagues reported that in the same 101 mother-infant pairs, postpartum depression at six weeks, four months and 14 months after birth tended to make a 14-month-old toddler more fearful and inhibited as compared with same-age toddlers of healthy moms. Other work suggests that postpartum depression may produce behavioral problems and negativity in children.
Postpartum gloom usually does not have a long-lasting impact on children’s cognitive development, however. In a 2001 study psychologists Sophie Kurstjens and Dieter Wolke of the University of Munich tested the intellectual skills of 1,329 children (92 of them born to mothers who had depression) at various ages from 20 months to eight years. The researchers generally found no cognitive deficits among the children of depressed mothers as compared with those of healthy mothers. They did find cognitive problems, however, in boys of low socioeconomic status who had chronically depressed mothers as compared with children whose mothers had less severe depression.
Despite the devastating fallout from postpartum depression, many mothers shy away from getting help—in some cases, out of shame for emotions they cannot justify. Manuela, for example, was initially afraid to talk about her feelings and fears. She felt no one would understand why she was sad after the birth of a healthy, beautiful baby. Eventually, however, at her breaking point, she sought treatment at the Heidelberg clinic.
Many new mothers require medication to take the sting out of their sadness. A doctor may prescribe an antidepressant such as Prozac and, in some cases, may recommend taking a hormone such as estrogen as well. In addition, a small 2007 study by Yale University psychiatrists Ariadna Forray and Robert B. Ostroff suggests that electroconvulsive therapy can ameliorate postpartum depression and its more severe cousin, postpartum psycho sis, in women who do not respond to drug therapy.
Psychotherapy for the mother’s depression may also be beneficial. One proven approach is cognitive-behavior therapy, in which a therapist tries to correct distorted and negative ways of thinking either by discussing them openly or by asking the patient to practice more adaptive behaviors.
But treating the mother in isolation is often not enough to prevent her illness from affecting her child. In a study published last year psychologist David Forman of Concordia University in Quebec and his colleagues compared 60 mothers who received psychotherapy for depression with a group of 60 untreated depressed mothers and 56 healthy mothers. Six months of therapy did lower parenting stress in depressed women as compared with untreated depressed women, but the treated women still viewed their infants more negatively than did mothers who had not been depressed. Perhaps as a result, after 18 months of therapy the affected mothers reported more behavior problems, a lower level of attachment security and a more negative temperament in their children as compared with moms who had not been depressed.
Now these and many other researchers believe that therapy for postpartum depression should also involve the child. Psychologist George Downing of Pitié-Salpêtrière Hospital in Paris developed video intervention therapy, for example, to improve mother-infant interaction. The technique helps mothers to correctly perceive their infants’ behavior by recording and analyzing it—and to feel better about their own actions as mothers. “The goal of therapy is to reactivate the intuitive maternal behavioral repertoire that was covered over by the depression,” explains Heidelberg clinic psychiatrist Thomas Fuchs.
Tabea, a mother in her early thirties whose depression was severe enough to warrant hospitalization for several weeks after she gave birth, is still having difficulty interacting with her four-month-old son. At the Heidelberg clinic, a psychologist asks Tabea (which is not her real name) to sit in front of a video camera with her baby. Tabea speaks loudly to him. She raises her eyebrows and laughs. Her infant makes eye contact, and a smile flits across his face. His mother feels reinforced. But then the infant turns his head away. And Tabea says, “Well, what’s the matter now? Sulking again, are we? Did mommy leave you by yourself too long?” Tabea feels guilty for having had to leave her baby to be treated for depression.
But it is normal for infants to turn away after a social interaction. That is how they regulate stimuli. It is not, as Tabea sees it, a personal affront or a sign that she is a bad mother. Nevertheless, Tabea’s misinterpretation of her baby’s actions can prompt a vicious cycle in which the child’s apparent rejection hurts Tabea, making her feel insecure and sad, which in turn has a negative effect on the baby.
The therapist’s job is to break that cycle, large ly by correcting a mother’s misimpressions and emphasizing what she has done well. Tabea’s wide-open eyes, for example, signaled that she was paying attention to her child. The psychologist points out that Tabea’s expressive face and melodious speech are similarly appropriate and helpful. Then she encourages Tabea to wait for her child to take the initiative, which will be her signal to respond.
Some hospitals have mother-infant treatment centers for postpartum depression so that the mother can remain with her infant during treatment. There hospital personnel help the mother feed, diaper and bathe her child while also providing behavior therapy. Fathers can play an important part, too. Assuming he is not depressed, a father can significantly ameliorate the effects of a mother’s depression by building a close relationship with his son or daughter.
Meanwhile a mother can take steps to ease her emotional burden by asking for help from family and friends, sleeping more, spending time with her spouse, getting out of the house and putting less pressure on herself. In the end, most mothers who receive adequate treatment—often a combination of psychotherapy, medication and self-help—usually recover completely within about two months of starting treatment, according to psychiatrist Ricardo J. Fernandez of Prince ton Family Care Associates in New Jersey. Some mothers even emerge from their cloud of sadness with a new sense of clarity. As one mother said of her depression, “It gave me the impetus to change my life.”