All content of this blog is my own opinion only. It does not represent the views of any organisation or association I may work for, or be associated with. Nothing within this blog should be considered as medical advice and you should always consult your Doctor.

Roll Up Roll Up, Come and Test Your Breastmilk...

Yes really.

This week I stumbled upon, or rather couldn't help but fall over - an advertisement for a test called "My Milk Count". The purpose? To check mum's breastmilk has adequate levels of DHA.

DHA or Docosahexaenoic acid, is one of the long chain polyunsaturated omega 3 fatty acids (LCPUFA) that people commonly refer to as "good fats".

It seems good old Bounty are advertising the test in their packs and via email, which is why the product (which actually launched in July last year) is suddenly in the spotlight.

Developed by Professor Gordon Bell and his team at Stirling University, mothers pay £99 and send off a milk sample, they then tell you whether it's "low, sub-optimal or optimal "in terms of DHA.

If levels are "sub-optimal", mothers are advised to improve their diets and take another £99 test a month later.

The website is a bit sketchy and thin on the ground as far as information goes, beyond telling you how important "optimal" levels are.   So I decided to contact Professor Bell, to ask some of the questions that you've all been asking this week.

I have to say he replied like lightening, he was out of office but Dr Tom Gilhooly, Clinical Director of Glasgow Health Solutions replied moments later.  He was extremely helpful and happy to answer my questions as you will see below.

Whilst waiting for a reply, I couldn't help but ponder what this all means for formula fed infants born pre 2000, who had absolutely no DHA in their early diet?  Perhaps we could identify those most severely affected by going through the readership of the Daily Mail (particularly those who feel compelled to add a comment)?

Before we even get on to the studies about DHA and whether supplementing is beneficial, let's start with the obvious:

1)  If you don't eat a 2-3 portions of oily fish per week, or take an appropriate supplement - and you haven't done for some time (ie your stores are reduced),  you're likely to find yourself in the suboptimal range.  And you don't need to pay me £99 :)  If this is the case either eat fish or spend some of the £99 you've just saved on a supplement. Simples. Well actually it's probably not give the polluted state of our oceans and the omega 6 rich diet of the fish farming industry, but hey ho - moving on.

2)  Milk composition changes constantly during periods as short as a breastfeed, and as long as the entire lactation period.  We know colostrum has more DHA than mature milk, and we also know the fat profile of breastmilk fluctuates in response to infant feeding; when the breast is fuller, milk has a lower fat content than immediately after a feed when the breast is emptier.

In addition to all that, a study recently found breastmilk expressed around 30 minutes after the end of a feed, was higher in fat than that expressed straight after a feed. This seemed to be related to the amount of milk removed, with larger volumes showing a more marked response. Read more here.

If amounts in breastmilk can be influenced by diet, what mum has eaten recently should be taken into account too?

So when it comes to expressing milk for "My Milk Count", how exactly does one pick an "optimal" time to check for so called "optimal levels"?  The same mum could surely have dramatically different results depending on which hour, day, week or month she expressed?

I decided to ask Dr Gilhooly, here is his reply:
"This is a very new test and we have not yet established when is the best time for expressing the sample. We are advising a sample in the morning prior to a feed."
The problem with this as discussed above, is that pre feed (when the breast is full) is likely to yield a low result, the first milk expressed ie before a feed would be more sugary first milk, unless an entire feed is sent off for sampling?  Even then a mother can typically only express around 50% of her milk without massage, compressions ie hands on techniques most aren't even told about.  Therefore the sample wouldn't be an accurate reflection of what a far more efficient baby would obtain in terms of fats?   Furthermore mothers are often most full in a morning if they've had a longer spell of sleep - which again would trigger a significantly different reading to say later in the day, half an hour after a feed.

3)  Breastmilk doesn't just contain DHA, it also contains precursors which the body can convert to DHA.  Whilst precursors alone don't increase the level in non breastfed babies like preformed DHA does, remember for breastfed infants this is in addition to the DHA already present in breastmilk, not instead of:
"Studies in modern humans and non-human primates show that modern infants consuming infant formulas that include only DHA precursors have lower DHA levels than for those with a source of preformed DHA." here
For any levels to exist in a formula fed infant only consuming precursors, it confirms conversion can and does take place to some degree.

This is confirmed by another study:
"Infants fed ALA-supplemented formula had significantly higher DHA levels than control infants." here
4)  How do we decide what "optimal" levels of DHA are for human infants?  We look at breastmilk right? The problem though is it's massively variable depending where mothers live - something one of the studies "My Milk Count" reference highlights.  Coastal regions who eat a lot of fish, unsurprisingly have higher levels than those inland who didn't.

However the study didn't examine whether these higher levels conferred any benefits  They just noted that eating more fatty acids increased the amount in breastmilk, ie it could be influenced by maternal diet.

They also noted:
"There is evidence that poorly nourished mothers conserve PUFAs and LCPUFAs in their breast milk at the expense of saturates. Breast-milk FA concentrations, therefore, vary with the lifestyle of the population of lactating mothers under study; thus, FA concentrations vary by region." here
I posed this question to Dr Gilhooly, here is his reply:
"The optimal levels are drawn from a paper on worldwide variation on breast milk levels of DHA. The optimal level we aim for is the Japanese level which we also do in the much better established Omega Blood Count test. The study is"
Japan is second only to the Canadian Arctic in terms of average DHA levels.  They're are extremely high compared to other countries, Click here to see the table.

Since we're not Japanese, and our diet isn't comparable to theirs - how do we arrive at the conclusion, (particularly if we consider epigenetics) that this is the level the UK mum should strive to achieve?  I've asked Dr Gilhooly and will update when he replies.

5)  We can't extrapolate data from formula fed infants and apply it to breastfed babies.  How well someone can make DHA from precursors partly depends not only on the other types of fat consumed, but also vitamin and mineral intake.  Breastmilk needs to be viewed as a whole product, not as individual constituents.

Absorption from synthetic sources rather than human, may also influence outcome and formula fed infants have a different gut profile because they receive a different source of nutrition - therefore any data needs to pertain to exclusively breastfed infants.

6)  They're not even sure it's lack of DHA that links to poorer neurocognitive outcome in non breastfed infants.  A 2013 review states:
"Over the years, many prospective observational studies have indicated that breastfed infants have a significant neurocognitive advantage over their formula fed counterparts. It has been theorized that this is due to the higher presence of DHA in breast milk, relative to formula milks.
They also note studies are confounded by the massively variable composition of breast milk (both within and between lactating individuals) as well as environmental factors such as maternal/infant bonding, or the act itself which may assist development (Morley et al., 1988). " here

In short DHA appears to have some impact but it's really not that simple.
"The proposal that DHA enhances neurocognitive functioning in term infants is controversial. Theoretical evidence, laboratory research and human epidemiological studies have convincingly demonstrated that DHA deficiency can negatively impact neurocognitive development. However, the results from randomized controlled trials (RCTs) of DHA supplementation in human term-born infants have been inconsistent." (1) here
They go on to say that in order to establish whether fatty acid intake is linked to outcome, several trials based on formula fed infants have taken place.  These typically compare DHA enhanced formula with placebo (un-supplemented formula).
"The majority of trials in healthy term infants have shown little or no consistent, beneficial effects on neurocognitive outcomes as a result of dietary LC-PUFA supplementation. However, infant LC-PUFA supplementation has resulted in no negative effects on growth, development or morbidity. There is, therefore, currently no compelling argument either for or against LC-PUFA supplementation in term infants with respect to neurocognitive outcomes. This conclusion has been re-iterated in three consecutive versions of the Cochrane review that have evaluated 9, 14, and 15 relevant RCTs, respectively"here
So even for infants who are receiving zero DHA as they're drinking unsupplemented formula, benefit in terms of outcome have not been established.

In contrast:
"Both DHA and AA have been found in all breast milks examined to date via appropriate methods." (here
 7.  Fats aren't a solo, they're a choir.  Ask any nutritionist and they will tell you that health is really not as easy as picking one fatty acid such as DHA and deciding that's the important one.  A balance of different fats is important, and the best way to deliver that is simply by eating a healthy balanced diet - however you feed your baby.

Prof Bell himself says:
"An excess of omega 6 may hinder children's brain development. This is because omega 6 and omega 3 compete with each other to be absorbed by the body, so excessively high levels of omega 6 can effectively block omega 3 from entering your system." here
So presumably the test looks at omega 6 too, and tells you to cut that down if it's high?  It doesn't appear so looking at the sample report, and omega 6 doesn't appear to get a mention on their website.  I asked Dr Gilhooly
"The test will look at omega 6 levels which are actually quite important for brain development at this stage. We are planning to only report DHA levels as this is where most research is."
Make what you will of that...

I have asked for clarification as to whether this means they are testing the levels but not reporting them back to mum, and also whether data collected will be used for research purposes.

8.  Milk banks don't test for adequate DHA,  yet numerous studies show better outcome for infants who are giving human donor milk compared to infant formula.
"We test for protein, carbohydrates and total solids. These are the important things, and we have found that all our samples are nutritionally sufficient, even for vulnerable premature babies"' spokesperson for Human Milk Bank at the Countess of Chester Hospital NHS Foundation Trust.
9.  You can have too much of a good thing.  In late 2013 a review suggested that "omega-3 fatty acids taken in excess could have unintended health consequences in certain situations, and that dietary standards based on the best available evidence need to be established."
“What looked like a slam dunk a few years ago may not be as clear cut as we thought,” said Norman Hord, associate professor in OSU’s College of Public Health and Human Sciences and a coauthor on the paper. 
“We are seeing the potential for negative effects at really high levels of omega-3 fatty acid consumption. Because we lack valid biomarkers for exposure and knowledge of who might be at risk if consuming excessive amounts, it isn’t possible to determine an upper limit at this time.”
Previous research led by Michigan State University’s Jenifer Fenton and her collaborators found that feeding mice large amounts of dietary omega-3 fatty acids led to increased risk of colitis and immune alteration. Those results were published in Cancer Research in 2010". Read more here
10.  Is it closing the door after the horse has bolted?  DHA demands rapidly increase during the last trimester of pregnancy, and the amounts in umblical cord plasma have been positively associated with higher cognitive scores for both mental and psychomotor performance at 11 months. Furthermore most studies have recognized a positive association between maternal intake of good fatty acids during pregnancy and neurocognitive development of offspring.  Here

So shouldn't we actually be testing pregnant mothers and ensuring their intake is "optimal" long before lactation if at all?

In fact given evidence suggest pre-conception diet can permanently influence DNA, perhaps those planning to conceive should be the target market?  And puberty, and childhood - remind me again exactly how much omega 3 can be found in the typical British school dinner?

11.  Because there's far better things to spend £99 on!.

Note:  I asked Dr whether the test was funded by the university, or whether outside funding was sought:
The development of the test has been jointly between Glasgow Health Solutions Ltd and the University .We have had a some assistance from Scottish Enterprise to help with marketing of it and two major pharmaceutical companies are also interested.
Many thanks to Michael @yournutritionmatters for the all the fatty acid discussion of late!

Review: Marsden Medical Grade Baby Scales

For anyone looking for paediatric scales, I can highly recommend you check out Marsden.

Earlier in the year I began hunting for a suitable set, the last straw being a baby nearly 2 months old and not back at birthweight, who hadn't been weighed for 2 weeks prior to our visit.

I asked around for recommendations, but I particularly wanted some manufactured in the UK and these seemed harder to track down.

A search turned up Marsden, a company who have been manufacturing a wide variety of weighing equipment for 90 years.  There's something reassuringly solid about a longstanding British company, so I dropped them an email and they recommended I check out the M-300.

A couple more (rapidly answered) emails later and a set were winging their way to me.

Something probably a lot more important to me than a clinic based practitioner was portability.  The scales weigh 3kg, so they're easy as pie to transport - particularly in the backpack style carry bag.  However they still feel sturdy compared to others I've used in the past (which have felt a bit like they might move if an older baby had a good wiggle), and the non slip feet also mean they're going nowhere.  There is also a rather nifty built in spirit level at one side, and each foot can be twisted to raise or lower marginally; this means when using a range of surfaces you can always ensure the scale is level.

The other obviously important factor is accuracy.  The M-300 weighs in graduations of 2g up to 6kg and then 5g increments thereafter.  A lot I looked at were only accurate to 10 or even 20g, which can make a big difference to a very small baby.

They're super simple to use with two basic functions.

This is the one I think so many health professionals need to get to grips with.   How often do we see a newborn baby stripped and placed on a piece of tissue on a cold scale flat on their back?  The baby rather like a stranded beetle often fusses, wiggles and it's generally not a pleasant experience all round.

Put a blanket, muslin, disposable changing mat or whatever you choose on top and press tare.  The scale will then zero so you still get an accurate baby weight.  Always consider weighing newborn babies prone 

I'm sure we've all been there with a wriggly baby, as the scale jumps up and down with each movement trying to wait for the split second baby is still enough to get an accurate reading.  Using the hold function means you can lay baby on the scale, it will start weighing and beep when it has established a reading - you can then remove baby and the weight remains displayed on the screen.

Lastly the one piece design makes them easy to clean,  a very important feature when babies are involved - so there's no nooks and crannies for things to seep into.

If I could add one more feature, it would be a conversion to pounds and ounces button.  Lots of parents still work in "old money" and want to know what their baby weighs in imperial.  Red books have a space for both and indeed there is a conversion chart in the back - however I see so many mistakes where someone has looked at the wrong line, so it would be handy if the scales took away this margin for error.  I should add that medical grade scales legally have to measure in kg.

This is the only change I would make, which for me is great (I often mentally redesign half of the stuff I buy!)

There is a full look at the scales in the clip below: