Last week, a pediatrician sent me an email with a link to a paper she just published with several co-authors. “I thought you might like this!” The paper discusses baby formula, and the pediatrician figured I would find it interesting—which I did—because I’m an economist who writes about child care. As many new parents may (or may not) know, official guidelines suggest that parents boil water before mixing in powdered formula, then cool it before giving it to the baby. As the authors note, the rules call for a lengthy process with 12 distinct steps: “Twelve steps to be performed by sleep-deprived parents, often with other children to care for, up to 8 times per day.”
The 12 steps are meant to forestall bacterial contamination. The authors argue, however, that the risk of contamination in the United States is minimal—smaller than the risk that exhausted parents will seriously scald themselves or a child with hot water. They note that there are four to six cases of this particular bacterial infection reported to the Centers for Disease Control per year, whereas some 300 children are brought to the emergency room each day in the U.S. for burns from hot water (obviously these are mostly not a result of formula preparation). “Currently,” the authors conclude, “our recommendations may be doing more harm than good.”
Walking to work, I told my husband (also an economist) about the formula controversy. “Yeah,” he said. “Just another unfunded parenting mandate.”
“Unfunded mandate” refers to situations where the federal government requires states to do something, but doesn’t provide them with the money. Unfunded mandates create complications; money to pay for the mandated programs must come from somewhere, usually from other programs. This term from the world of governance is a good lens through which to understand modern parenting, which comes with a lot of rules (a lot of mandates) but not a lot of help (funding).
In pregnancy: Don’t eat this list of foods, drink this list of beverages. Sleep on your side. Don’t go skiing or engage in contact sports. Gain exactly 25 to 35 pounds. And then the baby arrives: Breastfeed exclusively until six months, continue to a year. Give them allergens as soon as you can. And, yes, if you have to use formula, mix it with boiling water.
But resources are finite. There are only 24 hours in a day. If you spend an extra hour boiling water to mix formula, that hour isn’t spent doing something else. It might be impossible to do everything that the medical and child-care establishments (Big Baby?) tell you to do as a new parent. And yet by framing each recommendation as an imperative, Big Baby provides little guidance for how to choose among them when you are constrained.
In the U.S., for example, official safe-sleep guidelines decree that parents not sleep in the same bed with their babies (commonly called co-sleeping), out of concern about higher rates of sudden infant death syndrome and suffocation. The policy message against co-sleeping is very clear, and very dire; when my daughter was born there was a brief controversy around a set of anti-co-sleeping advertisements, which equated bed sharing with allowing your infant to sleep next to a kitchen knife.
When I wrote my recent book, Cribsheet, I spent a lot of time with the data on co-sleeping. And I ultimately came to agree with the official guideline, in the sense that I believe the evidence shows a higher risk of infant mortality when parents share their bed with their infant. But the story’s not as simple as Big Baby would have you believe.
Co-sleeping is especially dangerous when accompanied by parental smoking, heavy drinking, or pillows and fluffy covers on the bed. In a safe sleep environment there is still a risk, but it is fairly small compared with other risks people take regularly (such as driving their children in a car). Seeing these risks for what they are, some parents might decide that co-sleeping (as safely as possible) is what works for their family.
The typical argument against framing risk in this way goes like so: Assuming there is a risk, even a very small one, we should tell people to avoid it. By informing parents that the risk is small, we normalize this behavior, making it seem okay. The same argument applies to the formula-mixing example at the start of this piece: Sure, the risk of bacteria is small, but it’s not zero, so why not tell parents to just boil the water?
But some infants simply will not sleep on their own. Despite parental best efforts at swaddling, white noise, rocking, tiptoeing out of the room, etc., some three-week-old babies will always wake up within a few minutes of being put down alone. In this situation, what’s a parent to do? Remember that Big Baby also tells parents that sleep is incredibly important for the developing brain (which it is). And consider that if baby’s not sleeping, Mom and Dad aren’t sleeping, and if Mom and Dad aren’t sleeping, they’re probably stressed—and perhaps clumsy with that boiling water.
It is easy to say, “Do the safest thing, it’s only a few months, it ends,” but where do people get the resources to survive these few months? When parents set out to do everything by the book, too often they ultimately muddle through, making choices at random. They co-sleep by accident: They try to stay awake and end up snoozing with the baby on a sofa (much more dangerous). Or parents try to split the night between them and then both drive to work the next day exhausted.
If parents understood that the risks of co-sleeping (in a safe sleep environment) are small, more of them might do it—just like if they understood that the risks of using room-temperature water for formula are small, they might do it. The simple fact that resources are limited means the alternative might be worse.
The upside of mandates—either in parenting or in policy—is that they are clear. Telling parents that you “must not” co-sleep and you “must” breastfeed could produce slightly better outcomes overall if everyone were able to follow instructions to a T. But in a world of constraints, parents might not be able to do everything they are told. If they lack accurate information on the actual benefits and risks of each behavior, they also lack the ability to make optimal choices under those constraints.
Here’s an example from pregnancy. Women are told not to drink too much coffee, and not to smoke cigarettes. Many might conclude that the risks are similar; some might feel that they can really only give up one, and choose to break the coffee habit. (You have to find the money for that unfunded program somewhere … ) But the risks of copious coffee drinking are extremely small relative to the risks of smoking during pregnancy. Knowing this information might lead to a different choice. Similarly, if parents disregard mandates derived from small risks (such as the imperative to boil water for formula) and find that nothing harmful happens, they might feel emboldened to disregard mandates derived from large risks—such as the imperative to vaccinate children.
Communicating risks accurately is a challenge. But it is one that advice-givers such as the American Academy of Pediatrics need to meet. Let’s end unfunded parenting mandates and replace them with evidence-based advice about risks. We can start by saving a few parents from scalding themselves.
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