Discussions between grandparents and new parents reveal just how much advice around what’s “best for baby” has changed in just one generation. From sleep positions to even clothing and nutrition, what’s recommended, or even considered safe, has shifted more than many realize.
In the first installment of a new series called “Now What? A Series On Parenting,” reporter Chris Schulz sits down with Dr. Adriana Diakiw, an assistant professor of pediatrics at West Virginia University (WVU), to discuss how things have changed and what doctors recommend today.
This interview has been edited for length and clarity.
Schulz: Best practices for taking care of newborns, for infants, has changed quite a lot in the last 30 years, and maybe even a shorter amount of time. Why has that change happened? Why has so much changed around best practices for infant care?
Diakiw: The answer is simply based on the evidence. Over the last 30 years, we have learned so much about the best way to take care of newborns. One of the things that here at WVU, and I think sort of more globally, that pediatricians like to practice is what we call evidence-based medicine. And the recommendations for newborn baby care are based on what we consider the best evidence, and that is constantly changing and evolving. And we have learned so much, not just in the last 30 years, but even in the last 10 years, about the best way to feed and care for babies.
Schulz: Let’s get into some specifics here. I’m a new parent myself, and when I speak to even my parents, so just, you know, one generation back, there are things that I tell them that we do now that they say, “Oh, well, we did the exact opposite when you were a kid, and you turned out fine.”
Let’s start with sleep. Why is the back the best position for an infant for sleep?
Diakiw: Being on the back is the only safe sleep position for an infant. It is true that throughout all the generations, our parents, perhaps our grandparents, everyone was taught to put their baby to sleep on their tummy. It is true that in general, babies are somewhat more comfortable on their tummy. They might even seem to sleep more comfortably on their tummy. And I think that’s why going back for generations our parents and grandparents were taught that.
However, around 30 years ago, we learned that babies who are put to sleep on their tummy have about a 50 percent increased risk of dying of Sudden Infant Death Syndrome, or SIDS. That evidence is so strong that the American Academy of Pediatrics issued a recommendation and a campaign called the “Back to Sleep” campaign that sought to educate parents that one of the most important things that they can do for their newborn baby’s health is to always put them to sleep on their back.
Schulz: Why did it take so long for this evidence to be collected?
Diakiw: I think that in medicine, just as in society, we do tend to get set in our ways. That is why as physicians, we are constantly reexamining and reevaluating. We’re asking ourselves, “Well, if we do a certain intervention, like if we lay a baby to sleep on their tummy, or on their back, why do we do that? And what’s the evidence for why we do that?”
Sudden Infant Death Syndrome has been, in pediatrics, one of the most challenging issues to deal with both for physicians and for parents, because simply by definition, a baby who passes away of SIDS, there is no cause that can be identified. That’s part of the definition. Looking back at the evidence in these cases, researchers were trying to tease out what factors could possibly have contributed to that infant’s unexpected death. The one variable that stood out amongst all the others was the position in which the baby was placed to sleep the last time. That emerged gradually in a retrospective way, which means looking back at previous cases, and the evidence was so clear, and so compelling, that the American Academy of Pediatrics pioneered almost a sea change in how we care for babies.
One of the most important things we do for babies is how we put them to sleep. If you ask any new parent, the baby’s cycle of sleep and nap and waking is one of the most important things in their life. And, as you might expect, it was very difficult, at first, to change public opinion and to change practice, particularly when it’s embedded in generations of family practice, of cultural practice, cultural tradition, and years of advice that had been given to parents and grandparents by their own doctors and pediatricians. It really was almost like a campaign to try to change practice.
Schulz: Feeding. If sleep is one of the most important, feeding is probably the most important, especially if you ask the infant themselves. Today, we are told that milk or formula is the only thing that you can give a child. No water, certainly no honey. Why is the focus on milk or formula only now?
Diakiw: When we refer to milk, of course, we’re speaking of human breast milk. So mom’s breast milk, which is the best way of feeding an infant. It’s based on the evidence, and mom’s breast milk has such a tremendous variety of health benefits, we couldn’t list them all during this talk. If we’re not going to be taking mom’s breast milk, then infant formula is the only safe way to feed your baby between birth and 12 months.
Schulz: Can you explain a little bit more about why an infant can’t have water or honey or cereal mixed into their milk to quote unquote, help them sleep through the night?
Diakiw: Starting with water, if a baby gets too much water mixed in with their milk or their formula, the way that a baby’s kidneys work, the baby can actually get sort of water overloaded. Even mixing a little bit of extra water into formula, for example, diluting the formula, parents do it for various reasons. One of them is sometimes because they want to extend, formula is very expensive, and so they think, “Well, if we just watered down the formula a little bit, it’ll go a little bit farther.” But that can have really negative health consequences for the baby, because the way that the baby’s kidneys work and their fluid balance works, they can’t just get rid of that extra water so easily. It can have some pretty negative health effects for the baby.
On the topic of why we shouldn’t have honey before 12 months of age, that one has to do actually with risk of botulism. Honey can have little spores in it that are perfectly safe for toddlers or older children. But in babies, because of the special way that a baby’s immune system works, sometimes the spores that are in that honey can cause a very serious illness in the baby. We avoid giving honey until we’re certain that the baby’s immune system is more than strong enough to handle it. That would be right at one year of age, that’s the age where we pretty much feel comfortable feeding any food to a baby.
Schulz: One of the ones that frustrates young parents the most, just because I think there’s an understanding that it is well intended, is temperature regulation. I’m talking about grandparents, parents, aunts, uncles, being very insistent that a baby must have a hat on at all times, even if you’re in an 80 degree room. Socks, mittens.
Talk to me a little bit about what the modern recommendations are towards ensuring that a baby is at a comfortable temperature.
Diakiw: This is a topic that I can relate to very well. Culturally, in my family, my parents both emigrated from Ukraine after World War II. They were absolutely convinced that not just cold air, but even a draft in the house, could cause serious illness like a cold or even pneumonia in a baby. My parents’ generation and grandparents were very insistent that the room be kept very warm for babies, and that not even a draft of cooler air could come into the room. They were also firmly convinced that if a child went outside, in even slightly cool air not thoroughly bundled in three layers of jackets and a hat and mittens and boots, that they might be more likely to get sick.
What the evidence shows, Chris, is that is absolutely untrue. In fact, the opposite is true. With newborn babies in particular, it’s very important to avoid overheating or over-bundling a newborn baby because overheating is one of the biggest risk factors for Sudden Infant Death Syndrome (SIDS), apart from being placed to sleep on your stomach. I can’t emphasize enough how important it is to avoid overheating a newborn or an infant.
Schulz: One of the things that has always stood out to me as I’ve learned more and more about infant care is the issue of colic. It is this very generalized term that seems to kind of brush away a very concerning set of symptoms for infants. A lot of discomfort for not only the infant, but obviously their parents and their caregivers have to deal with that, [and] can last for months at a time.
What can you tell me about how the pediatric field’s perception or understanding of colic is changing even as we speak?
Diakiw: Our perception of colic has changed dramatically over the past several years. So this is a field in which there’s a lot of active research. It’s one that I think we could talk about for quite some time. But in simple terms, parents typically think of colic as abdominal discomfort, or tummy troubles. A lot of parents will say they feel that colic is an excess of gas, or that the baby is having trouble digesting their formula, because the symptoms include crying, squirming. Sometimes babies will draw their legs up towards their abdomen, and they may grunt or push and they may seem to pass a lot of gas. Colic had for generations been understood as abdominal discomfort. There are cases in which a baby’s discomfort is absolutely due to excess gas, or perhaps a formula intolerance or perhaps acid reflux.
But there’s another definition of colic, which actually has nothing to do with tummy pain or with pain at all. That interpretation of colic, which we don’t quite have a separate word for yet, we now understand as more of a developmental process. We think of a baby when they’re born full-term as really having been born three months too early. This is the idea of the fourth trimester. Babies, when they’re first born, and in order to even be able to pass through the birth canal, a baby has to be born about three months earlier than their brain and nervous system is really ready to face the world. As a result, the baby’s parent or caregiver acts almost like an external nervous system for the baby during the first three months.
Human babies are unique in the animal kingdom really, in being utterly helpless when they are born. They depend on their parents for everything. And newborns have absolutely no ability to self-soothe. That’s because during that first three months, their brain and nervous system is so immature, and it’s growing and changing so rapidly, that a baby can easily become overstimulated with all of the sound and light and color, the music, the new faces, family members, pets, all of these things in a baby’s changing world, all of which are new, can sometimes almost overload the baby’s developing brain.
As a result, usually towards the evening, the baby will start to cry inconsolably. When we’ve looked at babies who have this unexplained crying, which we also call colic, we found that these colicky babies actually are not in pain. We can test for this actually, they’re not in pain at all. It’s more that their nervous system is so overstimulated that the only way that they can express that overstimulation is with this inconsolable crying. And it’s kind of a tough thing to wrap your mind around when you’ve always been taught that your baby’s unexplained crying is because they have excess gas or colic or tummy pain.
Schulz: My partner was quite insistent when I told her that I was coming to speak to you that I ask about infant probiotics. Is that something that you would recommend to a patient? Is that something that has even been studied? Because I know that probiotics for adults are questionable. So where do probiotics, and other supplementary products for infants, land for you?
Diakiw: Right now, I would not recommend giving probiotics to any infant, unless it was at the specific guidance of your own doctor or pediatrician. And most specifically, infants who are premature, their immune systems are not quite as strong. Because probiotics aren’t very well regulated, there have been instances where probiotics were given to premature babies or babies that didn’t have a well-developed immune system where they caused harm. Right now, until we have more evidence, more data, and perhaps better regulation of probiotics, sort of at the level of perhaps the FDA or government agencies, I would not recommend giving probiotics to an infant, except in cases where your doctor or a specialist recommends it.
Schulz: There’s so much research going on, with regards to infants, that I feel we could spend the rest of the day and then probably many days sitting here talking. Are there any other topics or any of the topics that we’ve already touched upon that I haven’t given you a chance to discuss, that you think is important for me to know?
Diakiw: So on the topic of temperature regulation for babies and as pediatricians we recommend that the baby’s environment and the room in which they sleep be kept at a pretty steady temperature, and we’ve come to a conclusion that somewhere between 68 degrees and 72 degrees is the perfect temperature for babies. When in doubt about whether to add another layer of clothing to your baby, or perhaps to leave it off, if you’re ever in doubt, the best advice is leave that extra layer off. Or another good way to think of how bundled your babies should be, is, however many layers of clothing you’re comfortable in. You can add one more thin layer of clothing for your baby, but no more.