Why is there so much crappy medical research?

The latest example, complete with press release, was just published in the British Medical Journal (BMJ). It’s entitled Early death after discharge from emergency departments: analysis of national US insurance claims data.

The authors found:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It’s not clear that the death rate exceeds the background rate of death of Medicare patients.[/pullquote]

Among discharged patients, 0.12% (12 375/10 093 678, in the 20% sample over 2007-12) died within seven days, or 10 093 per year nationally. Mean age at death was 69. Leading causes of death on death certi cates were atherosclerotic heart disease (13.6%), myocardial infarction (10.3%), and chronic obstructive pulmonary disease …

Every year, a substantial number of Medicare beneficiaries die soon after discharge from emergency departments, despite no diagnosis of a life limiting illnesses recorded in their claims. Further research is needed to explore whether these deaths were preventable.

The press release is hardly judicious:

These early deaths were concentrated in hospitals that admitted few patients to the hospital from the ED, hospitals that are often viewed as models by policy makers because of their low costs. By contrast, deaths were far less frequent in large, university-affiliated EDs with higher admission rates and higher costs, even though the population served by these EDs was generally less healthy when they walked in the front door of the ED.

The lead author elaborates in The Boston Globe STAT section:

The study’s lead author said that while the data reflect a fraction of Medicare patient deaths, the finding raises questions about the adequacy of hospital resources in rural and underserved areas and whether the US government’s quest to cut costs — and reduce inpatient admissions from ERs — is also cutting out essential care.

“There’s no doubt there’s a lot of unnecessary hospital admissions, but this study suggests there’s also avoidable harm from sending people home that shouldn’t go home,” said Dr. Ziad Obermeyer, an emergency medicine physician and professor at Harvard Medical School.

The implication is that people are dying preventable deaths because they were discharged from the emergency room instead of being admitted to the hospital.

Is that what the data shows? There’s no way to be sure because the single most important piece of information necessary to reach that conclusion is MISSING from the paper. How many Medicare patients die in a typical week? Quite a few, it turns out.

That’s not surprising. Medicare patients are age 65 and older. They did because everyone dies. Does the rate of death after being discharged from the ER exceed the background rate of death? The authors don’t tell us; indeed they don’t appear to have bothered to check, an inexcusable omission in a paper of this type.

Approximately 4.5% of Medicare patients die each year, for a baseline death rate of 0.09%/week. The study patients represent a subset of Medicare patients [those aged ≥ 90, receiving palliative or hospice care, or with a diagnosis of a life limiting illnesses, either during emergency department visits (for example, myocardial infarction) or in the year before (for example, malignancy) were excluded]. Nonetheless, the baseline Medicare death rate in the group being studied represents a substantial proportion of the death rate reported in the week after discharge from the ER.

Therefore, the implication that 10,000 patients die preventable deaths each year as a result of being discharged from the emergency room is flat out false. The majority of those patients almost certainly would have died anyway.

The authors do tell us how the admitted patients fared, although they do so in a misleading manner.

This chart compares the death rates of patients admitted from the ER compared to those discharged from the ER, divided into quintiles based on the admission rate.

There’s a glaringly obvious problem. The scale from admitted patients is different from that of discharge patients, making it look as if the death rate in discharged patients is higher than admitted patients when it is actually far lower. The death rate for admitted patients was generally 20X higher than for discharged patients! The only exception is the lowest quintile that admitted the fewest patients from the emergency room; in that quintile, the death rate of admitted patients was only double that of discharged patients.

It’s hardly unexpected that getting admitted was associated with a massively increased risk of dying. These patients were sicker. But it also suggests that getting admitted did not necessarily prevent death. We’ve already seen that the majority of the purported 10,000 people who die in the week after ER discharge were going to die anyway. Now we can see that admitting them to the hospital would not necessarily have prevented their deaths, either.

The authors know, or should know this. Indeed, they admit in the abstract that they have no idea whether the deaths they observed were preventable at all, then proceed to imply the exact opposite.

What does this paper tell us? NOTHING!

It’s just another crappy paper that spins a fairy tale from an observation stripped of context. For all we know, every single one of those 10,000 people who died would have died regardless. The authors certainly haven’t demonstrated otherwise.

In an op-ed piece in today’s New York Times, a geology professor Robert S. Young decries the planned Scientists’ March on Washington in a display of shocking naïveté:

Among scientists, understandably, there is growing fear that fact-based decision making is losing its seat at the policy-making table. There’s also overwhelming frustration with the politicization of science by climate change skeptics and others who see it as threatening to their interests or beliefs.

But trying to recreate the pointedly political Women’s March will serve only to reinforce the narrative from skeptical conservatives that scientists are an interest group and politicize their data, research and findings for their own ends.

With all due respect, Prof. Young, you’ve completely missed the point! Science has become politicized by politicians and a Scientists’ March on Washington is a declaration that scientists intend to take it back.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Science has become politicized; a Scientists’ March on Washington is a declaration that scientists intend to take it back.[/pullquote]

Whether it’s creationism, climate change denial or anti-vaccine activism, those who fear science have attempted to silence scientists by falsely declaring that it is political and by moving to suppress it as if it were political speech.

Prof. Young’s central claim is nothing short of absurd.

A march by scientists, while well intentioned, will serve only to trivialize and politicize the science we care so much about, turn scientists into another group caught up in the culture wars and further drive the wedge between scientists and a certain segment of the American electorate.

Wrong again! Scientists did not put themselves in the midst of the culture wars; they were deliberately placed there. It’s not hard to understand why. When you can’t discredit the science — and the purveyors of creationism, climate denial and anti-vax nonsense can’t discredit the science — the next best thing is to discredit the scientists. How? By insisting that they are not searching for truth but rather for political or economic advantage.

Prof. Young insists:

Rather than marching on Washington and in other locations around the country, I suggest that my fellow scientists march into local civic groups, churches, schools, county fairs and, privately, into the offices of elected officials. Make contact with that part of America that doesn’t know any scientists. Put a face on the debate. Help them understand what we do, and how we do it. Give them your email, or better yet, your phone number.

Why should it be one or the other? It shouldn’t. We can simultaneously seek to help lay people understand science while making a strong stand that science exists outside of politics and therefore scientists should never be censured by politicians.

Scientists marching in opposition to a newly elected Republican president will only cement the divide.

It is impossible to increase the divide between a newly elected Republican president who seeks to suppress scientists for political advantage and scientist who venerate truth regardless of which politicians seek to use and abuse them to score political points.

Young declares:

Believe me, I understand the desire to impart to everyone how important science is to every sector of our economy, the health of our planet and the future of our families.

That reflects a fundamental misunderstanding of of a Scientists’ March. It’s not to convince everyone that science is important to our economy or to anything else. It is to take a stand against a president who is already subverting science by censoring scientists.

The goal is to speak truth to power in the most basic sense of the phrase — to speak scientific truth to Trump, an ignorant bully drunk on power.

There’s an appalling amount of bad research out there and more is added with the publication of new papers every month.

How can we tell good research from bad?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Are the authors reporting the primary finding or have they replaced it with a secondary finding?[/pullquote]

One way is to look at whether the results hold up to statistical analysis: Are the findings statistically significant? Is the study large enough to have sufficient statistical power? What happens when you correct for confounding variables?

Those analyses require grounding in statistics. But there’s an even simpler way to tell good research from bad. Are the authors reporting the primary finding or have they replaced it with a secondary finding? In other words, have they engaged in “spin”?

A paper in this months edition of Obstetrics and Gynecology, entitled It’s All How You Spin It: Interpretive Bias in Research Findings in the Obstetrics and Gynecology Literature, explains:

Spin is a classic concept in fields such as marketing, journalism, and politics, where it is defined as a form of propaganda to influence public opinion. The concept of spin in the medical literature has been described as the manipulation of language to convince the reader of the likely truth of the result.

This is particular problem when the authors have undertaken a long, complicated investigation and arrived at results that are not statistically significant. There’s tremendous pressure to get some sort of publication out of the work.

One way to do that is to ignore the primary finding and look for a secondary finding that is statistically significant and present that instead. In fact, many such papers imply in the abstract that the secondary finding was what the authors were looking for.

What’s wrong with spinning research in this way?

Because many readers decide from the abstract whether to obtain further information from the full-text article, the authors evaluated the abstract for the following: 1) Was the primary outcome stated? 2) Was the effect size reported (ie, the sample size to discern the magnitude of the treatment effect)? 3) Was a precision estimate included (ie, confidence interval or P value)?

By promoting the secondary outcome in the abstract, the authors fail to acknowledge that there was no difference in the primary finding and thereby mislead readers as to the findicts. That’s spin.

There are many ways to spin research findings so that negative findings are presented as positive findings.

Three major types of spin strategies were identified that highlighted that the experimental treatment was beneficial despite a statistically nonsignificant difference for the primary outcome: 1) emphasizing statistically significant secondary results despite a nonsignificant primary outcome (such as within-group comparisons, secondary outcomes, or subgroup analysis); 2) interpreting statistically nonsignificant primary results as showing treatment equivalence or comparable effectiveness when the study was not designed to assess equivalence or noninferiority (such trials require specific design and larger sample size than superiority trials); and 3) emphasizing the beneficial effect of the treatment despite statistically nonsignificant results (eg, trending results).

Spin is disappointingly common:

the literature from other medical specialties such as oncology, anesthesiology, intensive care medicine, surgery, and psychiatry has noted rates of spin ranging from 59% to 66%.

It occurs less in the OB-GYN literature, but is still a big problem:

I reviewed a decade (January 2006 through December 2015) of the tables of contents of the journals Obstetrics & Gynecology and the American Journal of Obstetrics & Gynecology to identify RCTs. In this time period, there were 503 RCTs, of which, half (50%, n=251) noted a nonsignificant primary outcome (P≥.05).

Spin was employed in fully HALF of all OB-GYN RCTs. A substantial proportion of the spin occurred in the abstracts. Simply put, the abstracts misrepresented the findings of the study. That’s why reading the abstract is never enough and why journalists should never use the press release to report on findings of a study, but MUST read the entire paper.

It seems to me that spin is a particular problem in breastfeeding research. That’s why the bulk of breastfeeding research is weak and conflicting. It doesn’t reflect what the authors were attempting to prove, but rather an incidental finding that the authors choose to highlight while attempting to minimize the fact that they found the opposite of what they wanted.

For example, the authors might undertake to determine if breastfeeding increases IQ as determined by specialized testing. The results show that breastfeeding does not increase IQ. Like most negative findings, that’s unlikely to get published, so the authors search the subtest, find one with a statistically significant difference and declare that breastfeeding increases (for example) gross motor ability.

How does the average reader or journalist protect herself from research spin?

There’s are two threshold question that must always be asked: What were the authors attempting to find? And did they find it? If they didn’t find it, that what the headline should reflect. The fact that they were able to slice and dice their data to come up with a secondary finding that is statistically significant is ofree meaningless and should be reported as such.

I’m honored to be entrusted with publishing this incredibly powerful post from a mother who wishes to remain anonymous.

It took me just under three years to go from bright-eyed and expectant to waking up in a mental hospital in severe withdrawal from benzos (aka anti-anxiety medication). It’s not the whole story – what ever is, really? – but a big part of it centers around the current cult of attachment parenting that, at least in my circle, reigns supreme.

I wanted to be a wonderful mother. I live in on the East Coast – a very progressive little state where attachment parenting is heralded as something akin to the next coming of Christ. Of course you must breastfeed. You must have a doula. A birthing plan. Birthing music. Co-sleeping. Lots of eye contact. The idea is, if you don’t, you don’t care.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]I checked myself into the hospital… Seven days later, I was released. I went home and tried to make sense of what had happened in our lives.[/pullquote]

I cared so much. So, I set about doing it all. My plans started to go afoul when my son was frank breech. He wouldn’t budge and we were coming down to the wire. My mother, a pushy and progressive obstetrics nurse in Boston, begged me to get a risky inversion (which could have put the baby in danger). She also implored me to attempt to deliver feet first vaginally (also very risky). Having worked on a labor floor before (thanks to nepotism), I knew I didn’t want risk when it comes to my child. I decided to go ahead with the Cesarian.

So, I started my son’s life with guilt. Lots of it. I remember dining out with friends who’d also had a baby around the same time and also had a c-section. Theirs had been entirely unplanned and the friend talked to me about her grief around the c-section. I couldn’t relate and that felt funny. I mean, it hurt like hell after but I was just so happy everyone was safe. What more could I ask? But…grief? What was there to grieve? We had ushered a new life into the world. That being said, I started to think something was wrong with me for not experiencing c-section grief and not being able to understand it…I mean, didn’t I care?

Next, we breastfed. Here’s the thing: my son cried around 20 hours out of every 24 hours a day while we breastfed. I was absolutely desperate to breastfeed. What sane person doesn’t breastfeed? I eliminated everything from my diet and went down to just eating white rice (i’ve since lost two teeth as a result). My mother was ruthless about it – I felt that if I even suggested formula she’d call the police on me! My mother-in-law was quite different (and not necessarily in a good way). She’d bring us cases of formula and suggest we try it. Well, we did and that didn’t stop the crying. Finally, one night at 3 am after a particularly hard stretch of our son crying for basically 40 hours, my husband suggested SOY formula. I agreed, he bought it and then magic happened: within 20 minutes, my son’s crying stopped. That was it. 8 weeks of round the clock crying and it was over. Just like that. Wow.

So, we went to the pediatrician and told her. She responded with great skepticism and told me she had a room I could go into to “latch-feed” asap before my milk dried up. I had enough confidence in myself to decline her offer – but I went home upset. Was I monstrous? Was I selfish because I couldn’t deal with the constant crying anymore? My motherly instinct told me my son shouldn’t have to cry like he had been but my pediatrician was acting like it was a medical emergency. I felt ashamed. I felt lazy. I felt like I wasn’t strong enough (in retrospect though, who is strong enough to endure 8 weeks of round the clock crying?).

I took on my mothering duties with a vengeance. The original plan had been that I would go back to work, but attachment parenting or not, that didn’t feel right for our situation. I restructured everything so I could stay at home. I found small writing jobs (for everything from beauty salons to software companies) that paid peanuts so that we could have enough money to make ends meet. I woke up every day at 4am to make the proverbial bacon.

During the days, I took my son out. We went to playgroups and gyms until he grew more and ended up getting so focused on things like a single set of car keys that he couldn’t no longer be in group environments like that. I remember packing up our things to leave, time and time again, and staring out at the sea of babies who didn’t need to leave. Where had I gone wrong? Was it because I hadn’t always eaten organic? Was it the traumatic c-section (although nothing had gone wrong)? Had I not made enough eye contact? Was I too stressed?

At around 8 months, my son went through a major sleep regression. He just… stopped… sleeping. It was like the colic days without the crying. Co-sleeping, which I had enjoyed as had he, became a total no-go. Instead of soothing him, it made him even more wired. Still, I kept at it. There he and I would be, night after night. He’d be bouncing in his crib (he couldn’t be right next to me because of safety due to his level of energy) and I would be on the floor next to him – awake and unrested. Finally, sick and bone tired, I looked into crying it out. I felt like an actual monster.

Crying it out wasn’t as easy as the books say it is. Not for us. It took a month of our son screaming day and night while I rocked him in his stroller. Back and forth. I would catch fifteen minutes of sleep at a time when he slept. It was unbelievably hard and it must sound like an exaggeration to the reader who doesn’t know me.

Finally, it worked. He started sleeping like clockwork. I could breathe again. I could think again. I started trying to teach him Spanish and French in addition to English ( I wanted to be super mom). He was learning it, too. It was a beautiful but short-lived time.

At around 14 months, he started to walk. He also stopped talking. He hadn’t been a prolific talker, but he had talked. Slowly, this went away. Eventually, it completely disappeared.

I would go into my pediatrician with my concerns about this. She would suggest I read to him more. I did. I followed our son around the house with book after book. He paid me absolutely no attention and I felt silly, but still I persevered.

I’d like to say that my perseverance paid off – but it didn’t. He didn’t talk. In fact, he started making less and less eye contact.

I beat myself up at every turn. If attachment babies were more engaged and happier, what did that say about what I had done? How had I failed so miserably and so fast? Hadn’t I tried? Clearly, it seemed to me, everyone else had tried much harder. Maybe, I thought in my darker moments, I didn’t even know the meaning of trying.

It was a bleak time. Eventually, our pediatrician referred us to early intervention. The words had a terrible register – were they intervening with my terrible parenting? The nice ladies came every week and suggested our son had anxiety. Again, I felt horrible. Anxiety? In a two year old? Oh, dear.

It was around that time that I met a new friend: Benzodiazepines. Well, we don’t speak anymore so maybe I should call them an enemy. At the time, though, they felt more friendly. My fears and self-doubt started to go away. I could hang in there. I could be present.

At around 2 and a half years old, we got referred to a neurologist to start evaluating our son for autism. It was at that time that my benzo abuse really ramped up. I remember the doctor pulling our son’s pants down and our son hobbling around the room because he didn’t know to pull them up. I went out to the car after and popped an extra pill. I was in so much pain.

I rejected autism one thousand percent. It wasn’t autism, it was me: it was my countless failures as a mother. It was the c-section, I hadn’t done enough skin-to-skin, it was the breastfeeding, it was the formula, it was the co-sleeping, it was the crying it out, it was my stress. I cried and popped pills for the next few days. It was a low moment and not one that I am proud of but do feel it is important to share.

Four days later, I checked myself into the hospital. I spent the next two days in a state of delirium and sweat. Seven days later, I was released. I went home and tried to make sense of what had happened in our lives. A few weeks later, our beautiful boy was diagnosed with autism.

Since then (our son just turned five), it still hasn’t been easy. I still have a whole lot of self-blame. Should I have not vaccinated? Should I have used formula from the beginning (had the crying somehow damaged our son)? Should I have been wealthier so that I wouldn’t have had to work at all? I struggle. I go to therapy every week and talk about all of it. I stay far away from pills and anything addictive (other than crime drama television shows).

My husband begs me to see that autism is likely genetic. We both come from multi-generations of engineers and math nerds. Quiet people who preferred computers to parties. I am trying. But, on social media, I see friends share scary posts about breastfeeding being best or vaccines causing autism, and I momentarily crumble.

When I look back at my attempts at attachment parenting and my results (or lack thereof), I see that my son most likely was born different. I also see that there is an incredibly unhealthy social pressure put on mothers to “know better and do better” and to do the “best”. The montessori school I had once dreamed of for my son has been replaced by his IEP. I blame myself – but thanks to people like The Skeptical OB and their message that there is no perfect in parenting, I am starting to blame myself less and less. I am starting to be able to breathe, and to fall asleep more easily. I am starting to enjoy all of the wonderful quirks that come along with raising a child with autism. I am starting to tune out the endless sea of opinions that come with that and trust myself. He doesn’t talk yet but his smile – and his smile never went away – says so much. It says everything.

I oppose censorship.

I guess that’s not surprising since a rival blogger tried to force my blog off the internet because she disagreed with what I wrote. She was initially so successful that I had no choice but to sue her in Federal Court in 2013. The case, Tuteur v. Crosley-Corcoran, was ultimately settled confidentially, but you will notice that my blog is still here.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Gay’s move is a terrible philosophical mistake, and an utterly bone-headed move on a practical level.[/pullquote]

In is inevitable then that I cannot join in the general Leftist glee that feminist scholar Roxane Gay has withdrawn her work from publisher Simon & Shuster to protest their publication of a forthcoming book by Milo Yiannopoulos. Don’t get me wrong; I have the utmost contempt for Yiannopoulos and his lazy fascism. I intend to fight back against Yiannopoulos and his ilk with my heart and soul. But I think it is absolutely critical that the Left should not betray its own values in an effort to stymie the Right.

According to The Week:

Bestselling author Roxane Gay will no longer publish her forthcoming book with Simon & Schuster after the publishing house’s decision to reportedly buy alt-right personality Milo Yiannopoulos’ book in a $250,000 deal last month, BuzzFeed News reports. Gay’s book, How to Be Heard, was scheduled to be published by the Simon & Schuster imprint TED Books in March 2018.

“I can’t in good conscience let them publish it while they also publish Milo,” Gay said Wednesday. “So I told my agent over the weekend to pull the project.”

Don’t get me wrong. Gay is well within her rights to do this, but I think she is making a terrible mistake, both philosophically and practically.

It is philosophically wrong to use financial leverage to attempt to censor another author’s work, and that’s just what Gaye is trying to do. Gaye wants to send a signal that publishing houses will feel financial pain if they publish works by hard right/fascist authors. Perhaps it has escaped her notice but some of the most profitable published works are from conservative authors. How would we feel if Ann Coulter threatened to pull her work any company willing to publish Gay? I hope we would be outraged. It’s no less an outrage when Gay attempts to do the same thing to Yiannopoulos.

Free speech and the free exchange of ideas is at the heart of democracy. I may disagree with you profoundly but I will defend to the death your right to express yourself. That principle appears to face its greatest threat ever in the person of Donald Trump. It is at this critical moment that we must stand forcefully and unambiguously for that right and not invoke special privileges for ourselves that we would not see extended to our political opponents.

Gay’s move is a terrible philosophical mistake, but it is also an utterly bone-headed move on a practical level.

Yiannopoulos got a $250,000 advance of his book. That’s not much more than I got for my book. In other words, Simon and Shuster are not expecting a chart busting bestseller. He would not be able to afford a massive publicity campaign, but now Gay has handed him a million dollars worth of free publicity. This is the BEST THING that could have happened to his book and there is no doubt that he will exploit it to the last penny.

He also could offer a better demonstration of Left Wing hypocrisy than a this. And at this moment in time, when the Left Wing is caught on it’s back foot, that’s likely to be terribly damaging. It feeds into every stereotype relentlessly promoted by Yiannopoulos and his cronies. Why give them this gift?

I understand the righteous rage. It’s hard to be more angered than I am by the new Trump despotism. But free peoples have always understood that freedom to say, write and think things that offend others is a precious freedom. We should not betray that freedom by carving out special exceptions for censorship for ourselves, for we are the ones who will almost certainly suffer most from such hypocrisy.

 

Edited to correct Dr. Gay’s profession; she is a feminist scholar.

In the on going effort to demonize cesareans, the natural childbirth community seized on a tiny study and spun it into the claim that C-sections change the infant microbiome. A new, far larger study, shows that it does not.

As the Houston Chronicle explains:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The infant gut microbiome is probably determined in utero.[/pullquote]

In a new study of 160 pregnant mothers and their babies published Monday, Aagaard and a team of Baylor researchers found that any differences in the microbiome of babies born via C-section are not the result of the birthing process …

“We do not see a lasting association between cesarean delivery and a distinct microbiome community or its function in infants beyond the neonatal period,” Aagaard said…

Where did the erroneous claim come from. It started with a 2010 paper by Dominguez-Bello that involved only 9 mothers (10 babies) that looked at swabs of the baby’s skin, mouth and nose and meconium within the first 24 hours after birth. You don’t have to be a scientist to understand that an observational study involving 10 babies for only 24 hours cannot be extrapolated to the population at large.

But Dominguez-Bello did just that anyway. Instead of undertaking a larger study to replicate her findings, she moved on the studying vaginal “seeding,” wiping C-section babies with their mother’s vaginal secretions. That study involved 18 mothers, 11 of whom delivered by C-section; only 4 babies were swabbed. The authors collected 6 sets of samples (oral, anal, skin) over 30 days. The authors claimed to find “partial restoration” of the infant microbiome.

In contrast, the new study by Aagaard et al. is far more robust. This study differed from the original studies in critical ways:

• More participants: At 81 participants, this study is 9X larger than the original study.

• More sample sites: Skin, mouth, nose and stool.

• Longer follow up: The sampling was continued to 6 weeks of age.

What did they find?

1. The infant microbiome is not homogenous. As with the adult microbiome, it differs substantially depending on where in or on the body you take samples.

We found that the neonatal microbiota and its associated functional pathways were relatively homogeneous across all body sites at delivery, with the notable exception of the neonatal meconium. However, by 6 weeks after delivery, the infant microbiota structure and function had substantially expanded and diversified, with the body site serving as the primary determinant of the composition of the bacterial community and its functional capacity.

2. Although there were some differences in microbiota between cesarean and vaginally born infants immediately after birth, these differences were restricted to the mouth, nose and skin. Gut bacteria did not differ based on mode of delivery.

Although minor variations in the neonatal (immediately at birth) microbiota community structure were associated with the cesarean mode of delivery in some body sites (oral gingiva, nares and skin; R2 = 0.038), this was not true for neonatal stool (meconium; Mann–Whitney P > 0.05), and there was no observable difference in community function regardless of delivery mode.

3. The infant microbiome changes rapidly in the first 6 weeks. By 6 weeks of age there was no detectable difference between babies born by C-section and those born vaginally.

For infants at 6 weeks of age, the microbiota structure and function had expanded and diversified with demonstrable body site specificity (P < 0.001, R2 = 0.189) but without discernable differences in community structure or function between infants delivered vaginally or by cesarean surgery (P = 0.057, R2 = 0.007).

4. The environment in the uterus is probably not sterile as previously thought. Thus the composition of the infant microbiome may be determined in utero, not at the time of birth.

unlike the skin, oral cavity or nares microbiota, the neonatal gut microbiota at the time of delivery did not significantly vary by mode of delivery. The content of the first meconium is hypothesized to reflect the in utero environment (in which the infant is swallowing amniotic fluid continuously from mid to late gestation), and thus we speculate that these microbes were similarly transmitted from the mother to the fetus during gestation, suggesting that seeding of the early microbiota may occur earlier than was previously thought.

The authors conclude:

In summary, we undertook the largest study to date … to analyze both the composition and function of the neonatal and infant microbiota with paired maternal–infant subjects across multiple body sites. We observed that by 6 weeks of age, the microbial community structure and function had significantly expanded and diversified. We further demonstrated that there was no discernable effect of the cesarean mode of delivery on the early microbiota beyond the immediate neonatal period (and never inclusive of that in the meconium or stool) …

In other words, C-sections do not change the infant gut microbiome.

Remember the joke about the drunk man searching unsuccessfully for his keys under the streetlight?

After a few minutes the policeman asks if he is sure he lost them here, and the drunk replies, no, and that he lost them in the park. The policeman asks why he is searching here, and the drunk replies, “this is where the light is.”

We see this behavior all to often in science. Researchers interrogate the data that they have to answer a specific question when the answer is nowhere to be found in that data. Yesterday’s piece in the NYTimes, Does Breast Milk Have a Gender Bias?, illustrates both the “drunkard’s search” as well as the shoddy nature of most breastfeeding research.

[perfectpullquote align=”right” cite=”” link=”” color=”” class=”” size=””]This is a “drunkard’s search.” The authors used the data they had instead of the data that is required.[/perfectpullquote]

According to Nancy Segal and Satoshi Kanazawa:

In 1973, the biologist Robert Trivers and the computer scientist Dan Willard made a striking prediction about parents and their offspring. According to the principles of evolutionary theory, they argued, the male-to-female ratio of offspring should not be 50-50 (as chance would dictate), but rather should vary as a function of how good (or bad) the conditions are in which the parents find themselves…

In short: If things are good, you have more boys, and give them more stuff. If things are bad, you have more girls, and give more of your stuff to them.

Is this hypothesis correct? In new research of ours, to be published in the April issue of The Journal of Experimental Child Psychology, we suggest that in the case of breast-feeding, at least, it appears to be.

The first red flag is the journal. What is a paper on breastmilk composition doing in The Journal of Experimental Child Psychology when the issue under investigation has nothing to do with child psychology? Almost certainly because the authors couldn’t get it into one of the relevant journals.

The second, glaring red flag is the nature of the study itself. The authors were trying to discern if breastmilk produced for male babies has a different composition or amount than breastmilk produced for female babies. Obviously, the only way to determine that is to compare the composition and volume of the two types of breastmilk.

That’s where the principle of the drunkard’s search comes in. The authors are psychologists, not chemists and they can’t investigate the actual composition of breastmilk. They do have a giant data base of information on adolescents, so they decide to look there.

They offer a Rube Goldberg version of reasoning to explain what they did.

The aim of our research was to figure out how to study the divergent effects of breast milk on sons and daughters on a much larger scale. Our solution: to look at twins.

In light of the emerging evidence of sex-specific variation in breast milk quality, the Trivers-Willard hypothesis implies that breast-feeding may be less beneficial for opposite-sex twins than for same-sex twins. Same-sex twins, after all, can benefit from their mother’s sex-tailored breast milk just as non-twins can. However, the breast milk of mothers of opposite-sex twins cannot be tailored for either sex. Perhaps it is selectively tailored for the wrong sex part of the time, or for neither sex all of the time.

Thus, the Trivers-Willard hypothesis led us to surmise that opposite-sex twins would be disadvantaged for health and growth. This would be reflected in their being shorter and weighing less than same-sex twins.

What??!!

There are so many unwarranted assumptions here that it’s hard to keep track.

Unwarranted assumption #1:Assuming gender specific breastmilk confers benefits. This is a version of the white hat bias that plagues all breastfeeding research: if it’s in breastmilk it must provide a benefit. But that doesn’t have to be true. If breastmilk plays a role in regulating gender composition of a population isn’t doesn’t necessarily have to provide gender specific benefits. It’s only necessary to provide benefits to one gender.

Unwarranted assumption #2: Assuming that looking at adolescent height and weight should tell us whether breastmilk is gender specific. This assumption is just bizarre. If the point of gender specific variations in breastmilk is to regulate the gender composition of the population, we would expect to see the differences in infancy and childhood, not adolescence.

Unwarranted assumption #3: Assuming that the benefits of gender specific breastmilk would be expressed in physical characteristics? Why? The point is supposed to be a survival advantage for one gender over another. What would make height and weight the relevant variables to look at. Wouldn’t survival rates be far more important?

Unwarranted assumption #4: Assuming that it makes any sense at all to look at anything besides the chemical composition and volume of breastmilk to determine whether there are gender specific differences in breastmilk. The authors undertook a drunkard’s search of the data in their possession instead of searching for the answer in the only place it can possibly be: in the composition and volume of breastmilk itself.

And if all that isn’t bad enough, the authors looked at only one twin in each pair, breastfeeding history depended on maternal recall more than a decade after the fact, and zygosity of same sex twins was determined by the mother’s impression instead of genetic testing.

What did they find?

The Wave I sample included 779 twins for whom the sex of their co-twin could be determined; of these, 546 respondents (277 females and 269 males) had same-sex twins and 233 respondents (120 females and 113 males) had opposite-sex twins…

The results showed that, among the ever-breastfed twins, same-sex twins were marginally significantly taller, F(1, 176) = 3.784, p = .053, significantly heavier, F(1, 170) = 5.400, p = .021, and significantly larger (either taller or heavier), F(1, 165) = 5.900, p = .016, than opposite-sex twins. In sharp contrast, among never-breastfed twins, same-sex/opposite-sex twin status was not significantly associated with height, F(1, 275) = 0.228, p = .633, weight, F(1, 266) = 0.417, p = .519, or body size, F(1, 259) = 0.798, p = .373.

The authors’ reasoning is extremely tortured:

The analysis of the Add Health data showed that breastfed same-sex twins were consistently taller and heavier than their opposite-sex counterparts throughout adolescence and early adulthood (from Age 16 to 29). In contrast, never-breastfed same-sex twins were no taller or heavier, and might even have tended to be shorter and lighter, than their opposite-sex counterparts. Our results are consistent with the recent findings that human breast milk may be tailored for each sex to facilitate its health and growth most efficiently. Same-sex twins can benefit from such sex-tailored breast milk, just as singletons can, but opposite-sex twins cannot do so and, therefore, may be at a disadvantage.

That reasoning would only apply if all four of their unwarranted assumptions were true and there’s no evidence that any of them are.

This is shoddy research, not surprising when you consider that it is a drunkard’s search. The authors used the data they had instead of the data that is required. The authors presume to draw conclusions about gender specificity of breastmilk without looking at breastmilk and without looking at infant and child outcomes. There is simply no reason for believing that adolescent height and weight tell us anything about breastmilk and it is irresponsible for the authors to imoly that there is.

Let’s try a thought experiment.

Imagine I told you a story about a 16 year old girl who committed suicide because she was bullied for being overweight. She felt herself to be surrounded by messages that women who aren’t thin are worthless. She was surrounded by peers who claimed she was ugly and worthless. Everyone in her life, including her parents and her doctor, told her that she could be thin if she only tried harder. She drowned herself because she could no longer bear the pain.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]I have yet to see a single lactivist acknowledge that pressure to breastfeed was a significant factor in Leung’s tragic death.[/pullquote]

Would your first response be to insist that she needed more support in dieting? Or would you conclude that she needed more support in recognizing that her weight was not a marker of her worth?

I’d conclude the second: that the societal pressure to be thin was toxic and that young women should be taught to love themselves regardless of weight.

The first response is a form of gaslighting. It’s denying the lived reality of the young woman who died. It’s denying the pernicious effect of the pressure to be thin. It’s refusing to take a hard look at a society that relentlessly undermines the self-worth of young women by judging them on their appearance first and foremost.

I’ve conjured this example in the wake of the lactivist response to the suicide of Florence Leung, a young mother whose lived reality was unbearable pressure to breastfeed when she could not do so exclusively. I have yet to see a single lactivist acknowledge that pressure to breastfeed was a significant factor in Leung’s tragic death.

All I’ve seen is gaslighting.

It wasn’t pressure to exclusively breastfeed in the face of her inability to do so that led to her suicide;

…if she had only received more lactation support she could have breastfed exclusively.

…if only she had received more mental health support she would have persisted and ultimately breastfed exclusively.

…there must be more to the story. Pressure to breastfeed was not the reason she took her own life.

Or even more egregious:

Facts are facts; if she wasn’t breastfeeding exclusively she wasn’t giving her baby the best.

I had difficulty breastfeeding; I persevered a was ultimately successful.

Or my personal favorite, the repulsive humble brag posted on the Leung’s memorial Facebook page:

Breastfeeding 18 months and still going. I feel for the mothers who are unable to nurse their babies, no need to make them feel bad about it.

Lactivists seem to be unable to come to grips with scientific reality: the benefits of breastfeeding in first world countries are trivial.

In the face of lactivist insistence that breastfeeding is lifesaving, I’ve challenged them to point to the term babies whose lives have been saved. No one can do it.

In the fact of lactivist insistence that “breast is best,” I’ve pointed out that dehydration and starving from insufficient breastmilk is unhealthy for babies and guilt is unhealthy for mothers. No one has a response.

In the face of lactivist insistence that breastfeeding pressure led to Leung’s suicide, I’ve pointed out that they are gaslighting, denying the lived reality of a suffering women. No one appears to care.

It’s remarkable when you think about it. Lactivists, the same people who insist that failure to breastfeed is caused by lack of support, the same people who have rearranged the world to blare support for breastfeeding in the face of every mother and every healthcare provider, the same people who have banned formula gifts in hospitals because the mere sight of formula could undermine a woman’s will to breastfeed are suddenly denying that breastfeeding pressure could impact a mother’s mental health.

How ironic that the same people who are relentlessly “normalizing” breastfeeding so that some mothers feel supported could claim that is impossible that those efforts could make other mothers who can’t or don’t wish to breastfeed feel unsupported, worthless and suicidal.

It makes sense, though, when you realize that breastfeeding is not about what’s good for babies and mothers. It’s about what’s good for lactivists, their profits and their self-image.

We’ve come to realize the pernicious effect that idealizing thinness has on they psyches of young women. It’s long past time to recognize the pernicious effect of idealizing breastfeeding has on the psyches of mothers. How many more babies and mothers have to be harmed before lactivists acknowledge that breastfeeding “support” can be toxic and even deadly?

Homebirth kills babies; pressure to exclusively breastfeed injures and kills babies and mothers; anti-vaccine advocacy kills children of all ages. All three are part of the larger societal trend of killing kids with quackery.

Of course no parent intends to maim or kill her child by embracing quackery; in general “natural” parents are busily preening before their peers and may even believe (based on the nonsense they’ve absorbed) that they are making healthy choices. However, as the piece Gluten-free baby: When parents ignore science in Macleans makes clear, children are being harmed by their parents “natural” choices.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Quackery kills kids with fad diets, foolish joint manipulations and ridiculous “natural remedies.”[/pullquote]

Consider:

Nova had plans to her raise her son Zion on a vegan diet—and she had thousands of Instagram followers giving her plenty of love throughout her journey. But trouble struck when Zion’s teeth started to come in. One tooth, she recalls, had started to crumble apart by his first birthday. “It happened so fast,” Nova says. “His teeth are just really weak.”

But crumbling teeth are the least of it.

In Mississauga, Ont., in 2011, two-year-old Matinah Hosannah died of complications from asthma and severe malnutrition stemming from a vegan diet lacking in vitamin D and B12.

And:

A similar tragic outcome occurred in 2012 with 19-month old Ezekiel Stephan of Cardston County, Alta. His parents diagnosed their toddler’s meningitis as croup and treated it with natural remedies … After Ezekiel arrived at the Alberta Children’s Hospital in Calgary with abnormal breathing, he was quickly put on life support, but died within two days.

As a nutritionist at Sick Kids Hospital explains, she has seen children in her clinic:

… with everything from cognitive delays to rickets, a softening of the bones due to lack of vitamin D or calcium. One family, she remembers, had a diet that encompassed basically fruit, nuts, seeds and homemade almond milk—and the child came in with vitamin D deficiency, vitamin B12 deficiency, and, well, “the list was endless.”

What’s going on here?

…[T]here is the trend toward vilifying or fetishizing components of food, be it sugar, fat, gluten, salt or protein. Consider the gluten-free boom: Despite the fact that only an estimated one per cent of Americans lives with celiac disease, an autoimmune disorder that would require a gluten-free diet, a 2015 survey found about one of every five Americans actively choose to eat gluten-free foods. Meanwhile the spike in protein consumption is so far-reaching that General Mills created a “Cheerios Protein.”

There is undoubtedly no “Cheerios Protein” in the wild and that reflects the conceit that natural parenting has anything to do with parenting in nature. It doesn’t.

If anyone wants to see what living on natural medicine looks like, [pediatrician] Michael Rieder suggests, they should go to Afghanistan. “Afghanistan is about as natural as you’re going to get in …” For every 10 children born in Afghanistan today, odds are one of them won’t see their fifth birthday. “Most of them die before they turn one and most of them die from infection,” Rieder says. “That’s what happens when you don’t have vaccination or antibiotics.”

Anyone with least bit of scientific knowledge would realize that but many “natural” parents are pretty limited when it comes to science.

We’re slipping into this ‘all knowledge is relative’ dark age,” says Caulfield [a professor of law and public health]. “You don’t see this in other areas of science. We don’t have alternative physics or people who believe there’s a natural healing force that can be utilized to build bridges. But in health, we have this huge tolerance for this alternative, non-scientific perspective.”

But all knowledge is not relative. There’s actual knowledge and pseudo-knowledge, the fake news equivalent of knowledge. Much of what passes for “knowledge” in the world of food fetishism, child chiropractic and naturopathy is is fake, entirely made up to boost the economic fortunes of quacks.

Sadly, a certain kind of parent is particularly gullible when it comes to this kind of fake knowledge. Not only do they fail to understand science; they fail to understand that parenting is not an opportunity to burnish your self-image vis a vis other parents. Those who eagerly purchase quackery imagine themselves to be smarter than other parents when the reality is that they are as dumb as rocks, at least when it comes to child health.

The truth is that children have never been healthier. Rather than dying in droves from infection, starvation and nutritional deficiencies, they have begun to suffer from diseases of excess like obesity and type 2 diabetes. The solution, of course, it to cut back on excess. It is not to embrace unrestrained infectious disease by refusing to vaccinate, nutritional deficiencies caused by food fetishism; or quackery like chiropractic and naturopathy.

Quackery kills kids and the only people who appear to be unaware of that are those parents torturing their children with fad diets, foolish joint manipulations and ridiculous “natural remedies.” They proudly imagine themselves to be educated but they are merely wallowing in their own ignorance while their children suffer.

The suicide of a young mother is an unspeakable tragedy:

Thirty-two-year-old Florence Leung went missing without an explanation in late October, causing New Westminster police to launch a massive search. It was revealed she was suffering from postpartum depression and her family was concerned about her well-being.

On Nov. 16, Leung’s body was found in the waters near Bowen Island. No foul play was suspected.

Her husband knows that breastfeeding pressure contributed to her suicidality:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]How many dead babies and dead mothers will it take before we repudiate the tactics of breastfeeding advocates?[/pullquote]

Do not EVER feel bad or guilty about not being able to “exclusively breastfeed”, even though you may feel the pressure to do so based on posters in maternity wards, brochures in prenatal classes, and teachings at breastfeeding classes. Apparently the hospitals are designated “baby-friendly” only if they promote exclusive-breastfeeding. I still remember reading a handout upon Flo’s discharge from hospital with the line “Breast Milk Should Be the Exclusive Food For the Baby for the First Six Months” , I also remember posters on the maternity unit “Breast is Best”. While agreeing to the benefits of breast milk, there NEED to be an understanding that it is OK to supplement with formula …

Postpartum depression, like all clinical depression, is a multifactorial problem. No one can say for certain what causes it. But we can say for certain that bullying makes it worse. And contemporary breastfeeding advocacy is BY DESIGN a form of bullying.

I finished my medical training before breastmilk became “the elixir of life” and before colostrum became “liquid gold.” What scientific evidence came to light in the last 35 years to elevate breastfeeding from one of two excellent forms of infant nutrition, the other being infant formula? No evidence. Indeed most of the scientific evidence around the purported benefits of breastfeeding is weak, conflicting and riddled with confounding variables. To the extent that there is definitive scientific evidence about the benefits of breastfeeding in first world countries, it appears to be limited to 8% fewer colds and 8% fewer episodes of diarrheal illness across the entire population of term infants in the first year. In other words, the vast majority of term infants will experience NO OBVIOUS BENEFIT from breastfeeding.

So if the scientific evidence hasn’t changed, what happened? Two things: the monetization of breastfeeding and the adoption of bullying as a deliberate marketing tactic.

Organized breastfeeding support originated with La Leche League, started by a group of seven traditionalist Catholic women whose goal was to keep mothers of young children out of the workforce. They reasoned that Mary, mother of Jesus, would not have worked because she was breastfeeding. Therefore all mothers should breastfeed so they wouldn’t be able to work either.

La Leche League was originally a volunteer organization that shared breastfeeding information and offered free support. It had to be a volunteer organization because the whole point was to prevent mothers of young children from working. But by the early 1980’s, mores had changed and the folks at LLL reasoned that they could charge for information that they had been giving away for free. They spun off the organization that created the lactation consultant credential and began campaigning vigorously for the employment of lactation consultants in hospitals, doctors’ offices and private practices.

Initially they met the existing demand for breastfeeding support. But like any industry, they wanted to grow and that meant expanding the market for their services beyond those women who wanted to breastfeed to those women who didn’t. They hit upon the perfect tactic: grossly exaggerating the benefits of breastfeeding, fabricating “risks” of infant formula, and, above all else, bullying new mothers.

Make no mistake, bullying is not an unfortunate side effect of contemporary breastfeeding advocacy. It is a deliberate tactic designed to increase market share. It is meant to create a sense of fear, obligation and guilt.

As I have written in the past, the foundational document of marketing breastfeeding through bullying is Diane Weissinger’s Watch Your Language.

All of us within the profession want breastfeeding to be our biological reference point. We want it to be the cultural norm; we want human milk to be made available to all human babies, regardless of other circumstances …(my emphasis)

In contrast, all of us within the medical profession want HEALTHY BABIES and HEALTHY MOTHERS to be the biological reference point. We are concerned with outcome; the breastfeeding industry is concerned with process, specifically the only process by which it can profit. And profit depends on bullying ever more women into breastfeeding.

The breastfeeding industry induces fear by lying about the benefits of breastfeeding and ignoring the risks (dehydration, starvation and death); it induces obligation with bullying catch phrases like “breast is best,” and “Baby Friendly Hospital Initiative,” and it induces guilt by insisting that “even one bottle of formula” is the mark of a mother who doesn’t truly love her baby.

The breastfeeding industry has perfected a particularly vicious forms of bullying, gaslighting. This is a specialized form of invalidation that involves denying reality. A mother says her baby is hungry? Tell her all babies scream like that. A mother worries that she is not producing enough breastmilk? Lie and say that all women produce enough milk. A mother needs medication incompatible with breastfeeding? Tell her she doesn’t really need it. A mother says that breastfeeding is harming her baby’s physical health and her mental health? Tell her that she is a failure at mothering before she’s really even started and imply that her baby deserves a better mother than her.

Is it any wonder then that some women will commit suicide as a result and a far greater number will experience significant postpartum depression?

We MUST put an end to the vicious bullying of new mothers by breastfeeding advocates.

• Take down the “breast is best” posters and acknowledge that fed is best.
• Stop lying about the benefits and risks of breastfeeding.
• End the Baby Friendly Hospital Initiative immediately.
• Stop pretending that “even one bottle” of formula harms breastfeeding or babies.

Breastfeeding advocates like to prattle about the theoretical “cost savings” from increasing breastfeeding rates. But what does it cost to hospitalize a mother for postpartum depression? What is the cost of the lost earnings of a mother who commits suicide? And what is the cost to a child of losing his or her mother? Incalculable.

How many dead babies and dead mothers will it take before we repudiate the bullying tactics of breastfeeding advocates?

Fed is Best!