As you know, the brain has two lobes. The studies show that music engages both hemispheres of the brain — its creativity and emotion engage the right lobe, while rhythm and pitch engage the left. So people who receive musical exposure at a young age develop a bundle of nerves that connects those two halves*

*I should go on, but I must note that the only thing correct in the above quote is that music indeed engages both hemispheres of the brain.

Since then, the effect of Mozart on intelligence was discredited. In fact, a comprehensive meta-analysis (a statistical reviews of previous studies on the topic) concluded that listening to Mozart actually had no effect on intelligence.

Yet, something very positive came out of these studies. Soon after, a series of studies showed that Mozart improves performance in some people because of its calming effects. That is, listening to mozart reduces stress in many people, and for those who are anxious, such reduction in stress would lead to better performance (e.g., whether a test or a sporting event). Other studies also showed that playing Mozart to at risk infants (premature or those with severe medical complications) resulted in better medical outcomes, such as fewer hospitalization days and more rapid weight gain.  Yet, researchers have not been able to identify the actual mechanisms that explain why premature babies react this way to Mozart.

In the last issue of the journal Pediatrics, there was a very small yet fascinating study on the effects of Mozart on premature babies. A team in Tel Avid was interested in examining whether changes in metabolic efficiency could explain the better outcomes observed among premature babies exposed to Mozart. In the study, the authors examined 20 preterm infants with a mean gestational age at birth of 29 weeks (range 26-35) and who were otherwise medically stable. At the time of the study, the infants were at a chronological gestational age of 30 to 37 weeks.  The methodology involved a “randomized cross-over design”. This means all babies where tested in both conditions during 2 consecutive days at the same time of the day. Some babies listened to Mozart during day 1 and underwent the no music condition during day 2, while other babies experienced the no music condition during day 1 and listened to Mozart during day 2.

The results:

The authors found that within 10 minutes of the start of the music the infants experienced an average of a 10-13% reduction in their “Resting Energy Expenditure” (REE). REE is often considered a measure of the amount of calories required to function during a specific time period during resting conditions. How could this contribute to our understanding of the Mozart effect on premature babies? If a baby reduces his/her REE, the baby then requires LESS calories to function. Imagine for a second that you require 2000 calories to function during the day. If you eat a 2,000 calorie diet, you would theoretically maintain your weight. Now imagine that you reduce your REE so now you only require 1,500 calories to function, yet you continue to eat the 2,000 calories (I think we call this aging!). What would happen? A similar process may be at play with these infants. It is possible that exposing the infants to Mozart reduces their REE and this results in a higher ratio of ‘consumed calories’ to ‘calories used’, and thus more rapid weight gain and better medical outcomes.

Although this is a very compelling study, the authors warned that more research is necessary with larger samples. Yet, these findings, combined to previous findings showing improved medical outcomes among at-risk infants exposed to music, makes you wonder whether neonatal intensive care units should consider music exposure as standard practice for at risk infants.

The Reference:

Lubetzky, R., Mimouni, F., Dollberg, S., Reifen, R., Ashbel, G., & Mandel, D. (2009). Effect of Music by Mozart on Energy Expenditure in Growing Preterm Infants PEDIATRICS, 125 (1) DOI: 10.1542/peds.2009-0990

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Last night I had a chance to start reading again and an article published in Pediatrics caught my attention. The article reported the findings of a study examining the link between father’s depression and infant excess crying or colic.  The study appears to continue a line of research that explores the often neglected role of father’s mental health on the child’s development. For example, recently I commented on the effects of father-daughter bond on the quality of the daughters romantic relationships, and on a study examining the impact of fathers (not mothers) postpartum depression on the child’s language development.

In this new study, the researchers were interested in examining factors that may be associated with excess infant crying. Specifically, although mother depression (pre and postpartum) has been associated with colic, little is known about the effects of father depression. This is of major importance since recent studies suggest that fathers get depressed during and after pregnancy at rates that are comparable to mothers. The study was part of the Generation R Study, a large population-based longitudinal of child development. The study included 7,654 children born between 2002 and 2006. The researchers evaluated maternal and paternal depression at 20 weeks of pregnancy. Crying behaviors were assessed via parental questionnaire at 2 months after delivery.

The results:

1. Excessive infant crying, defined as more than 3 hours per day on more than 3 days per week, was observed in 110 kids, or 2.5% of the sample
2. Maternal depression was not associated with infant crying; however
3. Parental depression was significant associated with infant crying. Specifically, infants who showed excess crying were significantly more likely to have depressed fathers when compared to their peers.
4. The effect of paternal depression was still noticeable even when controlling for maternal depression and other explanatory variables.

Previous research have been criticized because of  the practice of obtaining all information from the same source. For example, fathers are asked to report on their child’s behavior and also on their own behavior. This often results in “report bias” so that the father’s reports on the child’s behavior may not be accurate and instead may be affected by their own behavior. However, this particular study has some strengths that help reduced the potential for report bias. Specifically, the study was prospective. Thus, parents reported on their depression  during pregnancy and then reported on the child’s crying months later. This helps reduce the chance that the parents reports on the child’s crying was affected by their own emotional state at that time. In addition, the prospective nature of the study helps control for the effect of the child on the parent. That is, babies with significant colic are more likely to elicit stress on their parents possibly leading to depression. However, since this study showed that parental depression prior to the birth of the baby was associated with excessive crying, the child’s distress could not be the cause of the parental depression (at least the depression experienced before birth). All in all, this study provides further evidence that fathers mental health during birth and early childhood have a significant impact on the baby’s development.

The reference: van den Berg, M., van der Ende, J., Crijnen, A., Jaddoe, V., Moll, H., Mackenbach, J., Hofman, A., Hengeveld, M., Tiemeier, H., & Verhulst, F. (2009). Paternal Depressive Symptoms During Pregnancy Are Related to Excessive Infant Crying PEDIATRICS, 124 (1) DOI: 10.1542/peds.2008-3100

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Deficits in executive functioning has been examined as a possible source of impairment in premature children. However, executive functioning is a broad term that refers to a number of cognitive processes, such as working memory, cognitive control, planning and organizing, etc, and it is unknown which of these components of executive functioning is particularly affected in preterm children.

The Journal of Abnormal Child Psychology recently published a comprehensive study of executive functioning among children born very preterm (less than 30 weeks gestation). The study included 50 premature children (27 boys, 23 girls) born at a mean gestational age of 28 weeks (range 25 to 30). The study also included 50 comparison children born at a mean gestational age of 37.7 weeks.  All children were about 6 years of age at the time of the study. Both groups completed a comprehensive battery of executive functioning tests (the Go/NoGo test, the Shape School task, the day-night stroop task. a verbal fluency task, Digit span, and the Object Classification Task for children). The children also completed a full IQ test (the WPPSI-R)

The Results:

Before controlling for processing speed and IQ, the premature children had significantly lower performance on tasks examining: accuracy and efficiency of cognitive switching, accuracy and efficiency of inhibitory control, verbal fluency, working memory, and concept categorization.

After controlling for processing speed and IQ separately, most of the previously observed differences remained, indicating that these deficits are not due to speed of processing or overall IQ. The only exception was efficiency in cognitive shifting, which was not different between these kids after controlling for processing speed.

The data suggest that impairments in executive functioning may be one of the underlying mechanism that contribute to the type of challenges that these children experience throughout childhood. However, the authors also raised one very interesting point. It is possible that these results do not reflect a stable pattern of deficits, but instead reflect a developmental lag. That is, these very preterm babies may just be delayed in the development of executive functioning skills and may not show the same patterns of deficits later in life.

The Reference: Aarnoudse-Moens, C., Smidts, D., Oosterlaan, J., Duivenvoorden, H., & Weisglas-Kuperus, N. (2009). Executive Function in Very Preterm Children at Early School Age Journal of Abnormal Child Psychology DOI: 10.1007/s10802-009-9327-z

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This new study was conducted by a group of researchers at the University of Colorado at Denver.  The authors examined data from the Colorado Adolescent Maternity Program. This program was designed to provide care to 12 to 21-year-old mothers mostly from low income, under-served backgrounds.  The authors wanted to explore the prevalence and incidence of parental depression and the effectiveness of an electronic screening reminder system for clinicians. Specifically, during a well baby visit, an electronic cue appeared on the patient’s electronic record requesting the clinician to administer a postpartum depression screening instrument.

The results:

1. The system provided 413 reminders and clinicians appropriately administered the depression screening 99% of the time.
2. 20% of the mothers screened positive of depression and were referred for further evaluation
3. The prevalence of positive screens was between 10 to 19% during a 2-week, 2-month, 4-month, and 6-month visit. Specifically, the prevalence was: for 2 week= 17%; 2-month= 16.5%; 4-month= 10%; and 6-month = 18.5%; Prevalence refers to the total number of current positive cases.  For example, at the 2-month visit, 16.5% of the mothers screened positive. However, at the 4-month visit only 10% of the mothers screened positive. There was no time-related trend in the prevalence of depression.
4. The incidence however varied significantly with time. The incidence was about 17% during the 2-week and 2-month visit and then only 2.9% and 1.9% during the 4- and 6- month visit, respectively.  Incidence refers to the rate of new cases. Thus the risk of testing positive for postpartum depression for the first time during the 4-month and 6-month visit was very low. In fact, the authors reported that only 2 cases of depression would have been missed if the screening had taken place only during the 2-month visit.

Two thoughts:  Other studies have shown a 20% prevalence rate of postpartum depression, so these numbers are relatively in line with previous research. But I was actually surprised that the prevalence wasn’t higher.  Remember these are adolescent mothers mostly with low SES and likely limited resources. I was expecting that these mothers were more ‘at-risk’ not only because of their background, but also because depression rates increase dramatically in adolescence.  In fact, a previous investigation of postpartum depression among adolescent mothers found the prevalence rate much closer to 30% (see Birkeland et al., 2005 Adolescent Motherhood and Postpartum Depression. DOI 10.1207/s15374424jccp3402_8). So it is possible that these low rates reflect the effectiveness of the Colorado Adolescent Maternity Program. This is promising as it suggests that social programs that provide health care access to adolescent mothers may reduce the risk of developing postpartum depression in this at-risk population.

My second thought was… what about the fathers? In my previous postpartum depression post I discussed the often neglected finding that fathers also experience postpartum depression at the same rate as mothers, and that it seems that father’s depression may have an even greater impact on the baby’s development.   I’m not blaming the researchers.  The absence of fathers from the study reflected the fact that only in a small number of cases the mother was not the person who brought the baby for the check up. So this reflects our social tendency of fathers to be absent from these aspects of the parenting process. The problem goes beyond the implications for equality and gender roles.  The absence of fathers during the well baby visits also means that these fathers are not being screened for depression, greatly limiting our ability to identify and address this potential public health problem.

The Reference: Sheeder, J., Kabir, K., & Stafford, B. (2009). Screening for Postpartum Depression at Well-Child Visits: Is Once Enough During the First 6 Months of Life? PEDIATRICS, 123 (6) DOI: 10.1542/peds.2008-1160

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Most of the original research reports on infant movements have been focused on motor problems. It makes sense that motor movements would reflect the development of motor regions of the brain. However, some researchers have suggested that infant movements also reflect the integrity of regions of the brain near the motor cortex that are in charge of cognitive and emotional control. Thus, it is sensible to predict that anomalies in infant motor movements may also predict cognitive and social functioning later in life.

In an upcoming issue of the Journal of Child Psychology and Psychiatry, Dr. Phillipa R. Butcher and a team from the University of Groningen report findings from a large longitudinal study of preterm infants. The authors used video tapes made at 11 to 16 weeks post-term in 65 infants born at or before 33 weeks of gestation. These infants were the followed for many years and completed a battery of neurocognitive tests when they were 7 to 11 years of age.

The authors were primarily interested in three types of movements:

1. Fidgeting Movements: These are small, circular movements of varying speed that appear around 6 weeks post-term.

2. Concurrent Movements. At this age, normative concurrent movements included kicking, manipulating clothing, and playing with fingers.

3. Concurrent Postural Patterns. These include for example the ability to hold the head in the midline and manipulating fingers so that the fingers are independent of one another (as opposed to always having the fists closed or open).

The results:

1. While controlling for maternal IQ and attention problems, an index of motor quality score was a significant predictor of total IQ, Verbal IQ, and Performance IQ when the child was between 7 and 11 years of age.
2. This association was driven exclusively by the presence and absence of normal and atypical postural patterns. That is, fidgeting movements and concurrent movements did not predict IQ, but it was postural patterns that was the strong predictor of IQ.
3. There was no association between infant movements and behavior or emotional problems during middle childhood (internalizing and externalizing behavior problems).

The graphic below present a very clear picture of the findings. Note for example that the proportion on children with IQ in the 100 to 115 rage increased linearly as a function of the presence of normal postural patterns during infancy. Among those with less than 2 patterns, none of the children scored in the 100 to 114 rage, while among those with more than 2 postural patterns more than 50% of the children scored in that 100-114 range.

IQ scores as a function of infant postural patterns

The authors then commented on one additional important finding. The association between postural patterns and IQ was not explained by the presence of neurological problems. That is, even among the kids without clear neurological problems (such as Cerebral Palsy), infant movements still predicted IQ scores. These findings have important implications of preventive interventions. For example, the careful examination of infant motor patterns may help us determine which children may be at higher risk for cognitive deficits and could benefit from  intensive early intervention programs.
The Reference: Butcher, P., van Braeckel, K., Bouma, A., Einspieler, C., Stremmelaar, E., & Bos, A. (2009). The quality of preterm infants’ spontaneous movements: an early indicator of intelligence and behaviour at school age Journal of Child Psychology and Psychiatry DOI: 10.1111/j.1469-7610.2009.02066.x

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Routines are good. Routines are effective. Routines are adaptive. As a rule of thumb, most parents should use structured routines with their children.

I could end this post right here. The research about routines is so strong  that I feel comfortable breaking this blog’s policy of not providing clinical advice when saying that unless you have specific clinical reasons, most parents of infants and toddlers should use bedtime, mealtime, and other daily routines. But in the science-based spirit of this blog, let me talk briefly about one more study showing the benefits and effectiveness of bedtime routines, and then I will explain how to implement a bedtime routine.

This study was conducted by Dr. Jodi Mindell and her colleagues at Children’s Hospital in Philadelphia. The study included 405 mothers with 207 infants and 199 toddlers. The mothers were randomly assigned to a bedtime routine or a control group. After only 3 weeks, the children experiencing the bedtime routines had:

1. Faster sleep onset
2. Less night wakening episodes
3. improved maternal mood!!

Bedtime routines are safe, effective, and usually the standard treatment intervention for toddlers and infants with sleep problems. Routines are so effective, that bedtime sleep problems are one of the most treatable behavioral disorders in early childhood. And as an additional bonus, bedtime routines are associated with positive outcomes in the parents too, including improved marital satisfaction (see for example Reducing Bedtime Tantrums: Comparison Between Positive Routines and Graduated Extinction in Pediatrics Vol. 84 No. 5 ).

Often parents say “there is no way my kid will follow a routine”, or “fighting his bed time is a losing battle, he always wins”, or “I have tried routines and they don’t work”. This sense that routines won’t work is often stronger among parents who don’t have a bedtime for their kids and feel that it is now too late to implement a bedtime or a routine.  It is true that routines will not work for every single case. But for the majority of kids, routines will significantly improve sleep problems. The key issue here is knowing how to properly implement a routine.  Thus, let me briefly describe one method that has been found effective, specially with difficult children with no bedtimes (or very late bed times).

For kids with no bedtimes, it is very difficult to implement a bedtime routine with a new sleep time if this is done abruptly. For example, if your toddler is used to running around the house until 10 or 11pm, it is very unlikely that you will be able to get him to sleep at 8pm the day, or even week, you decide to implement a bedtime routine. In this case, one approach is to use a gradual positive bedtime routine procedure. The procedure works like this:

1. First, identify the time your child usually falls asleep on her own. 9? 10? 11?
2. Now, build a bedtime routine of 4 to 5 activities that last no more than 30 minutes with the last 15-20 minutes  in bed. For example you can start the routine 30 minutes before the desire sleep time by having the kid brush her teeth, wash her face, put on pajamas, followed by a bedtime story, etc. Make sure that a) this routine is the same every night (same order), b) avoid activities that make your child excited (playing active games, watching TV, etc), c) don’t extend the routine or make exceptions (“ just 5 more minutes pleeease“).
3. Start the routine 30 minutes before the kid’s current ’sleep time’. At the end of the routine, simply tell the child “it’s time to sleep”. (see below for what to do if the child refuses)
4. Use this routine at exactly the same time for at least a week. Then start the routine 10 minutes earlier and maintain that time for at least another week. You can continue to change the time every 1-2 weeks until you get the child to sleep at the time you consider best for your kid.

A few additional considerations:

• If the child refuses to sleep at the end of the routine and tries to get out of bed etc, you would need to use an extinction method. Put the child gently back in bed, give her a kiss, and firmly but softly tell her “it’s time to sleep” (avoid saying anything else). Don’t fall in the trap of starting negotiations with your kid at this time. It is time to sleep, nothing else. If you have to use the extinction method, please know that initially it will take many many tries until your child finally falls as sleep. It may be a very tough battle, but you will eventually prevail, and remember that you are doing all of this for the benefit of your child.
• Give your kid a “heads up” that the routine is about to start 30 minutes before the start of the routine (that’s 1 full hour before sleep time).  Then give her a 20, 10, and 5 minute notices. This will give her time to self regulate and prepare for the change. It is easier for the child to transition into the routine after being provided with such notices, than if abruptly interrupted in the middle of an activity.

Routines are relatively easy to implement and research supports that such routines are effective in reducing sleep problems.  Tell us about your experiences implementing bedtime routines.

The reference: Jodi A. Mindell, Lorena S. Telofski, Benjamin Wiegand, & Ellen S. Kurtz (2009). A Nightly Bedtime Routine: Impact on Sleep in Young Children and Maternal Mood Sleep, 32 (5), 599-606

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Dr. Kimford Meador at Emory University in Atlanta recently published a study in the New England Journal of Medicine exploring the effects of several antiepileptic medications taken during pregnancy on the cognitive performance of the children when they were 3 years of age. The study included 309 children whose mothers were taking one of four medications during pregnancy, namely: carbamazepine, lamotrignine, phenytoin, or valproate.

The results:

Children of mothers who were taking valproate had significantly lower IQ at age 3 when compared to all other children in the study.

The IQ of the children taking the different medications were:

• Carbamazepine = 98
• Lamtrigine = 101
• Phenytoin = 99
• Valproate = 92

Antiepileptic drugs and cognitive functioning

Two additional findings are worth noting:

• The effect of valproate was dose dependent. That is, the higher the dose taken during pregnancy, the lower the IQ of the child during early childhood.
• Maternal IQ was associated with child’s IQ (a very standard/common finding). Surprisingly however, this was not the case for mothers taking valproate. In this case, maternal IQ was not related to child IQ, suggesting that the use of the medication ‘overrode’ the natural intergenerational transmission of IQ scores.

The authors noted a number of limitations. Specifically, parents were not randomized to the medications, which means that the findings may be related to other characteristics that led to medication use. For example, mothers taking valproate were more likely than other mothers to have idiopathic generalized epilepsy. Therefore, it is possible that the relatively lower IQ levels observed in the children of these mothers were not at all associated with Valproate but instead were related to with having mothers with idiopathic generalized epilepsy.

One last related thought. Next week I will be in San Francisco at the annual meeting of the Association for Psychological Science (APS). One of the keynote speakers for the meeting is Dr. Richard E. Nisbett, a world-renown expert on education and intelligence. His talk will address the commonly held, but incorrect, belief that IQ is inflexible and entirely genetically determined. For clinicians conducting neuropsychological assessments this is a fact of our day-to-day work, and it applies most strongly to IQ scores during early childhood. That is, the IQ score obtained before the age of 7 is not stable (not highly associated with future IQ), and this variability is dependent upon environmental influences.

Considering this, the findings of valproate exposure during pregnancy have clinical implications in that early interventions may help these children improve their cognitive abilities and mitigate the possible effects of early valproate exposure.

The reference:  Meador, K., Baker, G., Browning, N., Clayton-Smith, J., Combs-Cantrell, D., Cohen, M., Kalayjian, L., Kanner, A., Liporace, J., Pennell, P., Privitera, M., Loring, D., & , . (2009). Cognitive Function at 3 Years of Age after Fetal Exposure to Antiepileptic Drugs New England Journal of Medicine, 360 (16), 1597-1605 DOI: 10.1056/NEJMoa0803531

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I get this question ALL the time. In fact I just gave a talk to a group of preschool teachers and this question came up: Can teaching sign language to my baby delay his talking? Let’s look at what the research tells us about using signs with babies. In an article published in the American Journal of Speech Language Pathology Elizabeth Crais, et al. provided an overview of the research on gestural communication and its effect in language development. For years, actually since I began practicing, I have used gesture development in early intervention. However, only recently has this practice been actively researched. This is in part due to the expanding research on Autism. Yet, most parents when told that the use of gestures helps verbal development fear that gestures will replace words. It seems that the research does not support that fear.

A review of: Crais, E., Watson, L., & Baranek, G. (2009). Use of Gesture Development in Profiling Children’s Prelinguistic Communication Skills American Journal of Speech-Language Pathology, 18 (1), 95-108 DOI: 10.1044/1058-0360(2008/07-0041)

The authors first provided a summary of gestures and their developmental course. There are two types of gestures: deictic and representational. Deictic gestures are either contact or distal and they are used by the child to refer, call attention to, or indicate and object or event. Contact gestures require contact between the child and adult (pushing away an adults hand for “no”) but distal gestures do not require contact (pointing or reaching). Representational gestures are semantic in nature. They can be object-related or culturally defined gestures that refer to a cultural or social action or concept (for example shushing). Deictic gestures emerge first around 7-12 months and representational gestures emerge closer to 12 months.

The authors discussed research showing that the use gestures by infants is a good indicator of later language development. Gestures can differentiate between typically developing children and those with language delays at the age of 9-12 months. And later, they can differentiate between children with different developmental delays such as Down’s Syndrome and Autism. Children with good prelinguistic gestural communication at 14 months usually have better comprehension at 24 and 42 months than those who do not. Thus, assessment of gestures can help differentiate a “late-talker” from a true language delay. Furthermore, symbolic play (which requires gestures) is not only associated with cognitive skills, but it has also been shown to predict later language skills. Gestures play a large role in symbolic play from pretending to drink to indicating night-night by closing eyes and putting hands against the head.

The authors then discussed the developmental trajectory of gestures and the number of behaviors within the use of gestures that are important. Typically 12-month-olds use one gesture per minute, 18-month-olds use two, and 24-month-olds use five gestures per minute. The type of gesture also changes with development. Twelve month-olds use mostly vocalizations or gestures, 18-month-olds begin to ad words, and 24-month-olds use mostly words. There are also specific gestures that are important markers or predictors of normative development. For example, pointing has been linked to better language development, especially receptive vocabulary. The extent to which a gesture has communicative function plays a role as well, so that the more “intent” is embedded in the gesture, the better the outcome for language development. Another important landmark in communication is when gestures are paired with eye gaze and vocalizations. In fact, in normative development we expect a child to move from eye gaze and vocalization to gestures and vocalization, and then to gestures and words. As you can see, just as language follows a developmental path, so do these prelinguistic sounds and motor movements.

So how do speech therapists assess gestures? Currently there are two assessment tools with specific focus on gestures; the Communication and Symbolic Behavior Scales Development Profile (CSBS-DP; Wetherby and Prizant, 2002) and the MacArthur-Bates Communicative Development Inventories, Words and Gesture Form (CDI; Fenson et al., 2002). The Rossetti Infant-Toddler Language Scale also has a strong focus on gestures but does not have normative data. Essentially though, gestures are assessed informally and are an integral part of an assessment and goal development.

Ok, so we know that the use of gestures by children is associated with better outcomes. But does this also mean that teaching gestures is associated with good outcomes? Most of the research says yes. For example, the teaching of gestures has been found to promote language development in children with autism (see for example Communication Intervention for Children with Autism: A Review of Treatment Efficacy). In addition, teaching gestures to infants has been associated with better language development in a number of studies (see for example Impact of Symbolic Gesturing on Early Language Development). And although there is still some controversy about this issue (a meta-analysis conducted by Johnston et al -DOI 10.1177/0142723705050340- concluded that the evidence for the benefits of teaching signing was inconclusive), to my knowledge there is no empirical evidence suggesting that teaching your child to sign will delay his speech.

So when a parent or teacher asks me if teaching gestures and signs in conjunction with verbal development is a good idea I say yes. One caveat though. Sign language is a language just like Spanish or English. If a parent takes teaching signs to an extreme and incorporates syntax and use the signs in lieu of speech the child may use more signs than speech. Just like when a child learns more than one language in a home. And remember, there is a time of silence before both languages emerge.
Here is a very cute video of a 12-months-old using signs:

[youtube=http://www.youtube.com/watch?v=7gSZfW4gVhI]

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In the wake of the recent controversy created by Hanna Rosin’s article “The case Against Breastfeeding,” I decided to discuss a brief but powerful study that was just published in the Journal of the American Academy of Pediatrics. A German team of researchers examined the association between breastfeeding and the risk for sudden infant death syndrome (SIDS).

SIDS is a major public health problem, as it is the leading cause of death for infants in the developed world. Several countries have initiated campaigns to try to raise awareness about factors that have been associated with an increased risk for SIDS. These factors include smoking during
pregnancy, sleeping in the prone position (face down), and bed sharing with an adult. In addition, many studies conducted in the 1990s showed that breastfeeding also lowered the risk for SIDS significantly, which led some countries to add breastfeeding to educational campaigns designed to lower the risks of SIDS. However, these older studies had a number of methodological problems, mainly their tendency to compare “never breastfed” against “any breastfeeding.” That is, most previous studies divided the infants’ feeding history into two discrete categories: those who were never breastfed and those who were breastfed at least some times. This creates a number of problems. For example, it is unknown if the potential “protective” features of breastfeeding is limited to “exclusive breastfeeding” or whether “some” breastfeeding is sufficient to lower the risk of SIDS.

In the current study, the authors examined data from the German Study of Sudden Infant Death Syndrome. The study included 333 infants who died from SIDS in Germany between 1998 and 2001, as well as 988 age-matched controls. The authors examined the history of breastfeeding before the babies’ death and compared them to the history of breastfeeding of the healthy control peers up to the same age.

The results:

By two weeks of age only 50% of the SIDS cases were breastfeed. In contrast, by this age, 83% of the healthy babies were breastfed.

By one month of age, only 40% of the SIDS cases were exclusively breastfed compared to 72% of the healthy babies. In addition, 50% of the SIDS cases were not breastfed at all compared to only 17% of the healthy peers. The percentage of both groups that were partially breastfed was the same at around 10%.

Most importantly, during the month before their death, 78% of SIDS babies had not been breastfed, compared to 39% of the healthy babies at the equivalent age. Only 9% of the SIDS babies were exclusively breastfed during this month compared to 34% of the healthy peers. Moreover, during this time, 13% of the SIDS cases were partially breastfed, compared to 28% of the healthy peers.

The authors then controlled for a number of possible confounding (explanatory) variables to determine whether breastfeeding was associated with a reduction in the risk of SIDS. These variables included smoking during pregnancy, maternal age at delivery, socio-economic status, family status, number of other births, birth weight, bed sharing, whether there were pillows in the baby’s bed, sleeping position, and use of pacifiers.

The authors found that breastfeeding (any and exclusively) was associated with a 58% reduction in the risk of SIDS (OR .42 95%CI = .36-.48) when not controlling for the confounds, and a reduction of 31% (aOR .69 95%CI = .57-.84) when controlling for the possible confounding variables. Being exclusively breastfed was associated with a risk reduction of 48% (OR .52 95%CI = .46-.60) unadjusted, and 18% after adjusting for the possible explanatory variables (aOR .82 95%CI = .68-.98).

It is worth noting that while there was no difference between the groups in “partial breastfeeding” at 1 month of age, during the month prior to their death, SIDS cases were significantly less likely to be partially breastfed than the healthy comparison group. In addition, being exclusively breastfed did not seem to provide significantly added benefit from being partially breastfed. It thus appears that it is the absence of any breastfeeding that poses the biggest risk. The authors concluded:

This large study conducted after the major reduction in SIDS mortality adds to the body of evidence showing that breastfeeding reduces the risk of SIDS, and that this protection continues as long as the infant is breastfed. In our study, 73% of the infants died before 6 months of age. The implication of our findings is that breastfeeding should be continued until the infant is 6 months of age and the risk of SIDS is low.

But why is breastfeeding associated with a reduction in the risk of SIDS?

The authors explained that many SIDS cases are believed to be related to dysregulated inflammatory reactions during infections. Many of these cases present respiratory infections prior to their death and inflammatory cytokines (a type of molecule produced by the infection) are associated with respiratory and cardiac dysfunction. So how does breastfeeding help? Breast milk contains immunoglobulin, an antibody that plays a critical role in the human immune system, and has been linked to improved immune functioning in infants (actually children and adults too). So it is likely that breastfeeding reduces the risk of SIDS by enhancing the baby’s immune system and thus reducing the risk of dangerous infection-induced inflammatory reactions.

Finally, a note of caution about this type of epidemiological study and a thought about using the term “risk reduction”. The statistical model used estimates the odds of an infant being in one group or another (the SIDS vs. the Controls) based on the variable(s) in question (in this case breastfeeding). Thus, when we say that there was a risk reduction of 48%, we are extrapolating from a model that is telling us that the chances of being “observed” in the SIDS group decreased by 48% simply by having been breastfed (any or exclusively). We interpret this result as a reflection of a reduction in risk, but technically we can’t tel
l with certainty if breastfeeding would directly lead to such reduction. This is therefore, very similar to a correlation, in that the findings do not imply causation. It is still possible that another factor that is associated with breastfeeding explains why the healthy babies were more likely to be breastfed than the babies who died of SIDS.

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In 2004, Dr. Nancy Jones and a team at Florida Atlantic University published a study on the brain electrical activity of infants of depressed mothers. They recruited 31 depressed and 47 non-depressed mothers and their infants. 27% of the depressed mothers were breastfeeding. This compared to 52% of the non-depressed mothers. The authors were interested in examining the association between breastfeeding and the EEG patterns of these infants, and in particular pre-frontal asymmetry.

There is a large body of research showing that relative right prefrontal asymmetry (greater right than left activation) is associated with withdrawal-related behaviors, including emotional responses to some (but not all) negative emotional stimuli (fear and sadness for example). In contrast, relative left prefrontal asymmetry is associated with approach-related behaviors and positive affect. With few exceptions, depressed people display decreased activity in the left prefrontal regions relative to the right. It is believed that this reflects both anomalies in the processing and experience of positive and negative emotions, as well as anomalies in the systems that control approach motivation (“I want to get of the house and enjoy the outside”) leading to anhedonia (lack of pleasure on pleasurable activities). Surprisingly however, many investigators have shown that infants of depressed mothers also display relative right prefrontal asymmetry, which suggests that this pattern is present before people become depressed.

Back to Jones’ study. The authors of the study measured EEG activation in these infants during a quiet activity (being held by their mothers or sitting on a high chair). The authors found that babies of depressed mothers who were bottle fed displayed significantly less left frontal activation than babies of depressed mothers who were breastfed. Surprisingly, babies of depressed mothers who were breastfed did not differ from the babies of non-depressed mothers in their brain activation.
It would be easy to just conclude that breastfeeding served as some sort of protective factor in these at-risk babies, making them ‘look’ more like their non-at-risk peers. However, the story is not that simple. The babies temperament also affected breastfeeding, in that more reactive babies seemed to elicit less breastfeeding than ‘easy’ babies. Temperament has also been associated with EEG patterns, with reactive babies showing more right frontal asymmetry. So it is possible that what we have here is a two way street. In one direction, easy babies (who have left-frontal asymmetry) elicit more breastfeeding, while more difficult babies (who have right frontal asymmetry) elicit less breastfeeding. However, this can not be the only way, since among the non-at-risk babies, breastfeeding did not appear to be related to EEG pattern. So although maternal breastfeeding behaviors are clearly affected by the babies temperament, it seems that breastfeeding also affects the babies temperament and EEG patterns.

The authors provide a nice conclusion:

Specifically, infants of depressed mothers who breastfed did not demonstrate the greater relative right frontal EEG asymmetry (nor the left frontal hypoactivity) compared to the bottle fed group. Moreover, increased positive affect was apparent in 3-month-old infants of breastfed compared to the bottle-feeding/depressed group suggesting that breastfeeding should be examined further as a potential intervention factor for depressed mother and their infants.

Jones, N. (2004). Patterns of brain electrical activity in infants of depressed mothers who breastfeed and bottle feed: the mediating role of infant temperament Biological Psychology, 67 (1-2), 103-124 DOI: 10.1016/j.biopsycho.2004.03.010

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