Evidence Based Mothering

Some people just have a way with words - this one is for Ayesha - who has beautifully trained words dripping from every orifice!

EBM = evidence based medicine. So a potted summary for the 'lay-person' to make the rest of this post intelligible. 

The theory is, we, as doctors, should move from the hocus-pocus of dogma and towards medical practice defined by scientific method. The gold standard being randomised controlled trials preferably performed blinded with large populations. Where it is impractical or unethical to perform interventional trials; epidemiological observational studies are performed to identify 'best treatments' and risk-factors. 

In an interventional trial one treatment is compared with another e.g. two different kinds of chemotherapy for a defined cancer and outcome measures are assessed e.g. overall or disease-free survival.

There are two common ways to perform an observational study. 

1. Try to find the difference in outcome between two groups who are very similar except for a difference in behaviour/exposure (prospective). For example, comparing the cancer rates between a group of people exposed to a nuclear test with a matched group who were not exposed.

2. Compare the difference between two groups with different outcomes and assess whether there were any significant differences in exposure/behaviour that might have led to the different outcomes. For example, comparing lung cancer patients with matched people without lung cancer identified the risks of smoking.

Observational studies can only discover correlation. Causation is suggested if it is scientifically plausible BUT confounds (other factors that may also influence the outcome that are linked to the behaviour/risk factor) may actually be the causative agent.

So, to evidence based mothering and a controversial subject on birth-boards currently - sleep-training (an awful term)

1. Does sleep-training at six months result in better sleep patterns in later childhood?

2. Does sleep-training at six months result in psychological effects in later childhood?

3. Does sleep-training at six months result in differences in attachment in later childhood?

4. Is sleep-training at six-months effective in breaking negative sleep associations?

5. How long does sleep-training take to be effective?

Difficulties !!

-- An interventional trial can't be performed as the pro-sleep-training parents and anti-sleep-training parents won't be randomised or matched resulting in selection bias. And forcing parents to raise their children in a certain fashion is draconian and won't work!

-- how to perform an observational trial ? 

1. so many confounds as the parents will differ in so many other ways
2. children with 'bad-sleep' may be more likely to be sleep trained and may have differences in psychology, sleep patterns, attachment inherent to them as individuals
3. how to measure outcomes? what is normal sleep? what is abnormal sleep? what is normal/abnormal attachment?
4. how many children would be needed to attempt to get any sort of statistical power?
5. what sleep-training method to choose? 
6. how to teach/observe/enforce/ensure consistency of practice?

Research is defined by the questions asked but can not be performed ethically without a reasonable expectation of useful data. I can't imagine a study design that would lead to meaningful results. So the trial will never or rather should never be performed.

An illustration of why mothers will be relying on anecdote and word-of-mouth advice for many years yet!