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.

Why "Modest" & "Discreet" Shouldn't Be in Your Breastfeeding Vocab

I hear so often about how hard women try to breastfeed discreetly or modestly.  I mean it's not as as though the shift to caring for a small person 24/7 isn't quite enough to be dealing with; apparently they should also be mindful and take care to ensure not an inch of flesh is exposed.

Random ignorant members of the public who seemingly can't use their neck or eyes to filter their environment - trump the rights of either mum or baby.

Young babies who are feeding well tend to be still and focused due to the ongoing transfer of milk, particularly at the start of a feed; others however pop on and off, turn their head, kick their feet, giggle, cry, arch or any combination of the above.

A baby who has really trapped wind can wriggle and writhe, all limbs flailing.  One mum described it as akin to trying to feed the cartoon " Tasmanian Devil", another that surely it would be more practical for them to grow arms at a later stage when they needed them - they can't control the ones they have and they really just get in the way if baby gets into a tizzy.

We often end up laughing, however for some mums it's far from funny.  They may avoid feeding in public because in addition to the embarrassment felt that their baby's struggling to feed, the risk of exposing "their whole boob" can be unsettling.

I think all over the country there are mums who simply avoid putting themselves in that position and so stay at home - which in turn means we continue only to see the model standard of the "perfect feed" whilst others are stuck isolated

Why should anyone be panicking they're being judged when feeding their baby? - when many experience hiccups and bumps in the road.  Breasts are located smack bang on the front of a person, which makes hiding them really quite difficult.

Men get to remove their tops without the world ending, modesty is a female only thing.  In fact it did used to be just as taboo for men to expose their chests, until they protested and they're not even revealing their nipples to do something useful like keeping someone alive.

Let me be clear, I have absolutely no problem with mums who choose to cover up.  It's your body and if you want to wear a row of structured nursing covers to build yourself a tent - go right ahead.

What I take issue with is the suggestion this is discreet or modest breastfeeding.
  • Modest:
  1. (of a woman) dressing or behaving so as to avoid impropriety or indecency, especially to avoid attracting sexual attention.
  2. free from ostentation or showy extravagance: a modest house.
  3. having or showing regard for the decencies of behavior, speech,dress, etc.; decent:
Synonyms: pure,virtuous. demure. Modest implies abecoming shyness, sobriety, and proper behavior: a modest, self-respecting person
  • Discreet: 
  1. careful and prudent in one's speech or actions, especially in order to keep something confidential or to avoid embarrassment.
  2. modestly unobtrusive; unostentatious:
The further problem with language is when we label one way of feeding "discreet", anyone who chooses not to cover to the same degree or shows more flesh is potentially "indiscreet".
  • Indiscreet:
  1.  having, showing, or proceeding from too great a readiness to reveal things that should remain private or secret. 
  2. An act or remark that is indiscreet, especially one that is not morally acceptable.
  • Immodest
  1. not modest in conduct, utterance, etc.; bold, indecent; shameless.
  2. indecent, esp with regard to sexual propriety; improper
We need to think about the words we use and the impact they can have.  They're just breasts and as the Sparrow Folk highlight they're really not that scary.  Babies need to feed and we need to give new mums the support and confidence to feed their babies wherever they are.

A Gain is Not a Gain. Faltering Growth in Breast & Formula Fed Babies.

We've been running our weekly infant feeding clinic in Yorkshire for years now, and during that time it's been fascinating to note the changing trends when it comes to feeding babies. 

Book your infant feeding assessment with AA at Milk Matters Infant Feeding Solutions:

When we first started, a common problem was parents were advised their baby needed additional milk when they didn't.  This happened because their growth was plotted on charts based on the growth patterns of formula fed babies, resulting in the breastfed babies older than a few months, appearing not to grow adequately.  We spent so much time reassuring parents that their babies were growing perfectly well for a breastfed baby and didn't need coaxing to take additional milk.

Many believe formula fed babies gain weight more rapidly than their breastfed peers; however initially the reverse is actually true.   The  non-breastfed baby typically gains weight more slowly in the first four months, it's after this the shift occurs and they start to gain weight more rapidly compared to those who are breastfed.

Thus historically on the old charts, many breastfed babies appeared to have suboptimal gain and as a result the UK growth charts were updated to reflect the typical growth patterns of those exclusively breastfeeding.

In our clinic in the last couple of years, things have definitely shifted.  Now it's rare we see an over-supplemented baby, instead we've observed a steep increase in actual cases of "faltering growth" - that is babies who aren't a little underweight, but chronically so.

What's perhaps most surprising is both these babies above were under the care of and regularly seen by healthcare professionals.

In the case of the first baby, they were eventually referred to a paediatrician.  I completed a new growth chart for them to take, so weight trend was clearly visible.  Baby had a tongue tie and we can see when the supplement plan was initiated at 7 weeks.  Mum however was reluctant to give extra milk as her group online had warned her it would impact her supply (untrue, a baby not transferring milk will do that) and that anyone suggesting formula wasn't truly supportive of breastfeeding.  This meant additional milk was given (provoking gain), withdrawn (resulting in the same amount gained lost again) and re-introduced again - creating the static pattern at the end.

Note the growth trend - how far away from that bottom curve are the dots (the minimum typically expected weight) and we can see there's a consistent pattern of faltering growth resulting in a 38% deficit based on expected weight.

It was a cold winter's day when they attended their paediatric review and baby was dressed in a fleece snowsuit.  The paediatrician didn't feel it necessary to undress the baby, instead they unzipped the suit enough to listen to baby's chest with a stethoscope.  They asked if  he was peeing and pooping and said they weren't concerned about weight as we had plotted the chart wrong....

They said that although baby was 38 weeks when born and a typical weight of over 7lb, they felt a premature chart should be used (designed for babies born before 37 weeks and of a lower weight), and so adjusted the baby's chart in his red book notes to reflect this:

The bold dot and arrow indicate where the consultant felt the dot should be with this adjustment. Baby was a couple of days shy of 8 weeks at the last weigh in, (as you can see from the original dot now marked with the arrow), yet the new mark is plotted at 5 weeks.  This results in an almost 3 week adjustment...

I can still recall the exact words the mother said to me when I expressed surprise at the consultant's nonchalance and checked additional milk was going to be continued :  "You're the only one who is concerned about my baby's weight, everyone else thinks he's fine".  A relative expressed she felt I was causing the mum unnecessary concern and worry, when clearly "those in the know" were happy with his gain.

If parents find their baby is struggling to gain weight, they can soon find themselves on the receiving end of contradictory recommendations and conflicting advice.  They may be told by some just to "feed, feed, feed" or take baby to bed and "baby-moon" (both of which of course assume effective milk transfer when baby is feeding, rather than just burning yet more calories), whilst others are expressing concern and suggesting additional milk is needed alongside identifying the original issue that has led to growth faltering.

A further problem is  many don't really understand the charts, sometimes the graph isn't even completed by healthcare providers.  This means at a glance nobody can even see the growth pattern, let alone know if the baby is tracking an appropriate curve.

First we need to understand they're based on averages.  If we take a huge group of healthy, term, breastfeeding infants - we can identify the typical maximum and minimum rate of growth they undertake.  That's not to say every baby outside this range absolutely has an issue, only that its atypical enough (when compared to the masses) to warrant further investigation.

If we use this data of healthy babies to create a chart - the heaviest infants will of course sit around the top and the lightest infants will sit near the bottom.  We can also calculate the "average" - which would be the 50th percentile line (so half the babies will sit above this line and half below).  This range allows for genetics, stature, build and so on.

It isn't desirable to sit on a particular place on the charts - in fact that's really quite illogical.  We wouldn't take a group of adult females and identify their average weight is 7-13 stone, then tell everyone their optimal weight was 10 stone.  We'd expect the weight of someone who was 5ft and of petite stature, to be less than someone who was 6ft and of broader stature?

The same is true for babies.

Once on the chart, we can similarly expect different levels of gain from those at the top and bottom too - and we know that typical healthy young babies gain roughly 5-8 ounces per week (140-225g), after the first few days and doing so will result in them returning to birthweight by around day 10 and tracking a curve on the chart.

Babies may sometimes plot slightly above or below a line, it doesn't have to be an exact track of a centile but should be thereabouts.

Below we can see the growth chart of a twin baby girl born at 38 weeks, weighing 5lb (2.27kg) and with a tongue tie. Baby was readmitted at a week old with significant weight loss and you can see on the chart where the hospital implemented a "top up" plan.  The next jump up the charts is when the tie was released:

If babies don't gain the expected amount as outlined above, instead if following a curve we see a flatter line appearing as they slide down the charts.  Crossing two centiles triggers referral to a paediatrician to rule out underlying and potentially significant causes.  Thus the saying "a gain is a gain" is ridiculous; I've heard this said when babies have gained 30g per week, the amount expected per day - that somehow as they haven't lost all is well.  Considering nobody seems to check intake before this referral - it also seems a costly exercise too.

When babies are underweight not only can they lack the energy to take a full feed, but they become disorganised and less effective - creating a catch 22 situation.  If this continues week after week, the energy and weight deficit often simply continues to get bigger, rather like you trying to run a marathon when you've just spent a month with Bear Grylls on a desert island.

What evidence are people working from that they feel a very underweight baby is better than one who is supplemented?

The first choice of course would always be mum's own breastmilk, however if baby feeds very frequently due to not transferring enough per feed, finding time to express may be difficult.  If baby has been taking less than they needed for weeks, mum's body similarly may have reduced production and supply may need additional stimulation.

Donated milk may be an option depending on accessibility and more mums are using and sharing donor milk, both informally and via their local milk bank; but for many it will mean considering infant formula.  The concern is that formula disturbs the microbiome, which is of course true - but we surely have to ask whether we believe there are no risks to inadequate food at a time of rapid growth when energy demands are high. 

Not enough calories also means potentially not enough vitamins and minerals either.  This could be a whole new discussion in itself, but let's pick one we know is important for the immune system, zinc:
"Infants and toddlers are vulnerable to zinc deficiency due to their rapid growth rate and high demand for tissue synthesis, neurological development; immune function and tissue growth (Aggett 2000; Friel 1994; Krebs 2014). Cells with rapid turnover demand the highest concentrations of zinc, notably skin, gastrointestinal, immunological, neurological, and, in the developing infant, skeletal cells.
"Mild to moderate zinc deficiency is characterised by stunted growth, deficits in immune function, and altered integrity and function of the gastrointestinal tract (Krebs 2014). Zinc deficiency may be associated with deficits in attention, and motor and cognitive development in children (Black 1998" here
We International Board Certified Lactation Consultants, often the only ones trained in infant feeding - can frequently find ourselves undermined by a whole range of people.

The twin baby above as an example was on a feeding plan - as she had a tie, combined with the fact mum hadn't received adequate advice on protecting her milk supply prior to our visit, this meant at the point we saw them baby couldn't physically transfer enough and the increased demand now exceeded supply.

Despite this a consultant in a different unrelated field (who works with multiples), saw fit to advise the parents to drop all the supplements and just feed her babies.  Thankfully the mother contacted us confirming this wasn't correct, but I do wish people would consider the implications of their lack of specialist knowledge and how parents feel when they receive this conflicting advice, from someone absolutely not in a position to be giving it.

We hear sometimes of underweight babies who seem  happy and settled - they sleep long periods, yet surely if they were hungry they'd wake and cry?  The reality is that hungry babies cry, very hungry babies who've experienced consistently reduced intake don't have the energy to expend crying.  On the contrary, they often sleep longer spells to conserve calories and don't signal too much (which again burns energy) if the feed intake is less than they'd like.   Some will feed very frequently yet never really seem "milk drunk" or full and that's without considering that persistent weight gain concerns can be a huge cause of maternal anxiety.

It's really difficult for parents who are with babies to accurately gauge gain in their newborns based on visual appearance.  Babies change a lot in the early weeks and when with someone a lot it's harder to notice subtle or gradual changes - which is precisely why we weigh newborns.  It's what we do with this information that counts, the earlier a problem is spotted - the more rapidly it can be resolved. Reassuring people things are ok when they're not, in the longterm doesn't help anyone.

Book your infant feeding assessment with AA at Milk Matters Infant Feeding Solutions:

Daily Mirror Claims Baby Nearly Starved After Milk Dried Up Overnight!

The British Media are at it again today, with the Daily Mirror running a spectacularly inaccurate, scaremongering piece claiming breastmilk suddenly dried up overnight, leaving a baby starving because his mum didn't realise.

It's a rather bizarre piece they claim is an "exclusive interview" with a mother in America and whilst articles that appear to try and scare parents into formula feeding aren't new,  they are increasing in frequency.  This is because as an "opinion piece" there's little restriction in what can and can't be said legally, with no need to provide accurate or evidence based information.  Thus we should all be extremely suspicious before we even start reading.

Of course the Mirror could choose to accurately convey the story of what supposedly happened, as ethically this piece is questionable at best.  But then there'd be no click bait headline, reduced readership and that doesn't make money does it?

Au contraire it's so dramatic, it's hard at times not to laugh - except the fact mothers may read this and panic, means it's actually far from funny funny.
"Before being allowed home with their son, Andrea was taught how to breastfeed, but admits in hindsight that this was the start of her problems."
Being taught how to breastfeed was the start of her problems? Yet as we'll discover, after the first few days breastfeeding was comfortable and according to mum and health records going well for the first FOUR months.

Kara O'Neill either seems a bit confused about what she's actually reporting, or is just particularly bad at explaining:
"It was only when he reached four months old and his weight dropped and Jogie began to look thinner that Andrea switched to formula milk and realised she had been starving her baby for eight weeks."
This infers that he reached 4 months old and was underweight, giving formula mum realised she'd been "starving" her baby for 8 weeks (ie since 2 months of age); yet as we read further into the piece this isn't what happened.

In fact at 4 months Jogie was thriving, perhaps those breastfeeding lessons helped after all ;)

"Doctors said her child was growing well, and he was gaining weight appropriately for his age. At four-months-old he weighed 14lbs 6oz."
If we plot Jogie's birth-weight on the growth charts, we can see he was born just under the 50th centile.  When he was weighed at 4 months, he again plots on the 50th and has doubled his birthweight - suggesting optimal growth, you couldn't get a more typical growth pattern.

The next bit is super important:
"But it was at this point that things started to take a turn for the worse.
Andrea said: "Jogie had a lot of trouble sleeping at night. I googled what the possible cause could be, and I saw many posts about the four-month-old sleep regression. So I sleep trained him, and after a couple of weeks, he was back to waking up only once or twice in the middle of the night."
"Sleep trained him" - another, perhaps nicer way of saying "so I withheld feeds he was signalling for".

Baby woke frequently and instead of exploring why - his cues were ignored as "undesirable behaviour", no doubt the words "self-soothe" also appeared in there.

Whereas previously he'd been getting calories at night, now he was limited to twice - and for whatever reason that clearly wasn't enough for this baby.

Thus it would seem to me that "sleep training" was in fact the start of her problems.  In fact a more accurate headline would be:

"Mum 'can't forgive herself' for not realising sleep training could cause breastfeeding problems".

The next section is a mish-mash of parent-misleading advice - whereas her breasts had previously felt full and engorged, now they didn't.  Whereas she could at first pump 4 ounces now she couldn't; she googled this was normal and so didn't worry.

Indeed this IS normal - mum shouldn't feel uncomfortably full at 4/5/6 months, mums who don't regularly express wouldn't expect to pull 4 ounces unexpectedly at this age (breasts regulate to provide what baby needs) - but I can now imagine mums all over the country worrying their totally normal supply is in fact dwindling because of comments such as this.   It feels really insidious...

Mum noted she felt "empty" and perhaps more importantly that:
"Jogie's nursing sessions reduced in time dramatically. When he was born, Jogie would be latched to her breast for 10 minutes each time he was fed."But his time feeding continued to get shorter and shorter, falling from eight minutes down to six, and eventually just three minutes in total.Then, in early July,  Jogie refused to feed from Andrea's breast completely"
The timeline is a little confusing as if he was born December, his 6 month check would have been due in June.  However Andrea says they didn't see a doctor at this time as they didn't have insurance (remember no NHS there) - thus July would make him 7 months and it can't have been only 8 weeks since last weigh in as the Mirror report.

Andrea recalled: "The doctor didn't seem too concerned, but she also did not know how much he weighed before, so she didn't want to make any judgements. Her children were also very small and light, so she didn't want to say anything"

Switching doctors usually means transferring of notes so why did this doctor not have a prior weight recording? In the UK this doesn't happen as the baby has their "red book" which parents hold and is taken to different healthcare professionals.

If mum noted the baby looked thin at this time, why didn't the doctor?  I'm also not entirely sure what is meant by "she didn't want to say anything", is the mum implying the doctor was medically negligent based on her own personal situation?  If so this surely needs investigating?

Did the mum tell the doctor her baby had reduced his feeds down to only a minute or two?  Clearly not enough time for a baby of that age and size to take a full feed?

Something else confusing is Americans don't see a "GP" for baby checks, they see a paediatrician, so it's confusing why the Mirror chose to use this terminology.
"On July 4, after Jogie had refused to feed entirely, Andrea made a decision that would ultimately save his life and decided to switch to formula milk."
In the timeline of the piece it reads as though Jogie saw the doctor for his 6 (now 7) month check PRIOR to the switch to formula - because according to mum from the first feed it clicked he had become underweight because he'd been hungry and his gain soared to 50g per day as she immediately abandoned breastfeeding in favour of the bottle.

The switch to formula was the 4th July and the 1st and 2nd were a Saturday and a Sunday -  which only leaves July 3rd as the day he must have seen the doctor, ONE DAY before this "lifesaving" decision.

Are we seriously to believe his life was at risk?  The moment he refused the breast entirely, his mum gave another milk - he wasn't at death's door.

But yey for formula milk, the saviour for mothers worldwide who receive sub-optimal, substandard, crappy internet advice!  No mention that mum could have taken steps to increase her supply, that she could have continued to breastfeed alongside formula whilst someone helped to establish why - that wouldn't fit the narrative at all would it?

I begin the lose the will to live at this point:
"My message to other mothers is that their milk supply can dry out suddenly and without any explanation. Breastfeeding was great for the first four months of Jogie's life. Everything went well.
"He was happy. Then things took a turn for the worse, and I kept blaming it on something else because my internet searches kept reassuring me that the baby can get the milk he needs from you via supply and demand."
 My message to Andrea would be no, milk supply can't and didn't in this case dry up "suddenly and without explanation".

Breastfeeding was going "great" until his night-feeds were restricted, perhaps at a time he was feeding more frequently to naturally increase supply to meet his growing needs.  As you say it's all about supply and demand, yet when he "demanded", he was sleep trained.  As supply fell in response, his feeds became shorter yet having being trained his cues are ignored, there was little point expending energy to rouse more frequently.

As feed duration reduced (IE demand reduces), supply would fall further in response - compounding the problem.  Indeed his feeds gradually became shorter - highlighting it was as the opposite of "suddenly and without explanation".

My first rule is always to feed the baby, and I do get so sick of internet groups, where clearly starving, drastically underweight babies are told repeatedly everything is fine.  Yet again this mum was failed by the system, failed by those around her and left blaming herself.  Now THAT is what we should all be up in arms about.

New Study PROVES Breastfeeding Causes Cavities!

News headlines to cover this study include:
"The Breastfeeding Health Risk No One Talks About"
"Breastfeeding May Be Causing Your Baby To Suffer From This Common Issue Later In Life"
"Prolonged breastfeeding linked to higher risk of severe cavities"

"Toddlers who are breastfed have a higher number of fillings and decayed or missing teeth - because mothers are not brushing their teeth afterwards"

<Insert dramatic sound effect of your choosing here> continue with:
"Women who breastfeed may putting their babies at risk for something that's rarely on a newborn mother's radar: cavities. 
According to a recent study published in Pediatrics, despite the fact that breastmilk is nutritional AF (and 100 percent free of charge!), moms should be wary one of the common downsides, particuarly for those who nurse their babies well beyond their first 6 months. 
For the study, researchers analyzed breastfeeding behaviors and sugar consumption of 1,129 children. What they found was that kids who were breastfed for two years or longer were 2.4 times more likely to experience severe cavities than those breastfed for less than a year. 
The study's author, Dr. Karen Peres told CNN, “There are some reasons to explain such an association. First, children who are exposed to breastfeeding beyond 24 months are usually those breastfed on demand and at night. Second, higher frequency of breastfeeding and nocturnal breastfeeding on demand makes it very difficult to clean teeth in this specific period."
Perhaps Dr. Karen Peres isn't aware studies have found that whilst soaking a clean tooth in lactose (the sugar in breastmilk) results in caries, breastmilk as a complete substance doesn't.  And it seems barely anyone is aware of all the studies prior to this that found the opposite, including conclusions such as
  • "Human breast milk is not cariogenic [cavity causing]" Ericsson 1999
  • "No correlation found between caries and breastfeeding among children who were breastfed up to 34 month" Alaluusua 1990
  • "There is not a constant relationship between breastfeeding and the development of dental caries. Mothers should be encouraged to breastfeed as long as they wish."  Valaitis 2000
  • "Prolonged demand breastfeeding does not lead to higher caries prevalence" Weerheijm 1998
  • "Breastfeeding may act preventively and inhibit the development of nursing caries in children" Oulis 1999
Otherwise they'd have realised Dr Peres' explanation made zero sense.  But hey now, let's not let evidence stand in the way of a hefty dose of sensationalism.

Of course I had to get my hands on the original.

Within a few seconds I'd established an association a whole lot more plausible than that proffered by Peres.

The short answer?

Many Brazilian children don't brush their teeth properly and/or see a dentist regularly.
At age 5 years, 37.0% of the children had visited a dentist, and 45.7% still received assistance when toothbrushing. 17
Brushing should be assisted until children are 7.  Whilst many may be enthusiastic, dexterity to ensure all surfaces are adequately cleaned is required.  The NHS also recommend:

Take your child to the dentist when their first milk teeth appear. This is so they become familiar with the environment and get to know the dentist. The dentist can help prevent decay and identify any oral health problems at an early stage. Just opening up the child's mouth for the dentist to take a look at is useful practise for the future.
Remember the researchers  above concluded dropping a clean tooth into breastmilk didn't cause decay? They conversely found:
"HBM is not cariogenic in an in vitro model, unless another carbohydrate source is available for bacterial fermentation"
Carbs on the teeth + breastmilk causes decay.

This perfectly ties in with the presentations by Dr Brian Palmer who noted:
"There are 4,640 species of mammals, all of whom breastfeed their young. Lactose is present in most of the breastmilk of these species, yet humans are the only species with any significant decay in deciduous teeth. Modern Homo sapiens have been around for 30,000 to 35,000 years, but dental decay, however, did not become a significant problem until about 8,000 to 10,000 years ago. Anthropologists believe the increase in decay was primarily due to the advent of the cultivated crops."
Now let's explore the typical Brazilian diet:
"Rice and beans is a staple of the Brazilian diet. They are usually eaten with a protein (meat or eggs), salads, farofa (a toasted flour of manioc or corn). The afternoon snack (merenda or lanchinho) is a small meal between lunch and dinner, and it could consist of coffee, tea or chimarrão, which is a traditional infusion of the South, accompanied by cookies, typical cakes or bread. Dinner consists of a light meal of soups, salads and vegetables, and pasta and rice-and-beans are the most common dishes."
Carb city.

 So in short, brush your teeth, see your dentist, encourage your toddler to snack on cheese instead of carbs (traditionally aged cheddar would be perfect) and breastfeed as long as you blooming well want.

Related Reading
Ask The Armadillo - Does Breastfeeding Cause Tooth Decay?

Dove & Their Fauxpology

Dove have been in the spotlight this week due to their new Baby Dove adverts.

Another gem reads:

"36% are for feeding him when he cries, 64% are passionately against it. What's your way?"

Their website adds:

"So whether you're among the 66% who think that breastfeeding in public is fine, or the 34% who think otherwise, whatever choice you make, we are with you every step of the way."

Unsurprisingly parents weren't impressed and have taken to social media to express their outrage.

In response Dove, well Unilever replied:
"We believe there are many ways to be a great mum or dad.
"Our campaign simply aims to celebrate the different approaches and opinions around parenting, including whether or not mums choose to breastfeed in public, recognising that it's ultimately what works for you and your baby that matters the most."
However that's certainly not what their first quote implies.

The terms "say it's fine" and "put them away" clearly implies external judgment of others and that 25% don't feel people should breastfeeding in public.  If indeed they intended to suggest they support all parents, they really need to sack their marketing team.

A far more aptly worded slogan, if they really need to refer to infant feeding at all would be:
"75% feel comfortable breastfeeding in public, 25% prefer not to.  What's your way?"
Is it just incredibly bad marketing of a good intention?  The bizarre wording of the second quote leaves us even more perplexed:
"36% are for feeding him when he cries, 64% are passionately against it. What's your way?"
What does this even mean?

If he cries 10 mins after he's finished an 8 ounce bottle, or if he's crying due to hunger because someone missed an earlier hunger cue like lip smacking and head turning?  Even if someone chooses to feed their baby to a schedule, are we seriously meant to believe 64% are "passionately against" others responding to their babies cues and are passionately for leaving them hungry?

Statements like this are incredibly divisive; mothers are fighting back against the "judgement" manipulation they've watched play out promoting formula, trying to play parents off against each other.

A cynic might suspect Unilever were trying a similar stunt - clearly many won't stand for it again...

Related Links: 
Baby Dove adverts criticised over breastfeeding stance

Infants, Vitamin D & The Truth About Diet

ALL infants need vitamin D supplement in the UK, anyone in the Northern hemisphere is deficient! As rickets reappear, so do generalised guidelines - and parents are often told that diet can't provide much vitamin D, instead it's all about sunshine and supplements.

Official Guidance

The NHS say:
"Vitamin D only occurs naturally in a few foods, such as oily fish and eggs. It is also added to some foods, such as fat spreads and breakfast cereals. The best source of vitamin D is summer sunlight on our skin. 
It's important that young children still receive vitamin drops, even if they get out in the sun.  All babies and young children aged six months to five years should take a daily supplement containing vitamin D, in the form of vitamin drops. This helps them to meet the requirement set for this age group of 7-8.5 micrograms (mcg) of vitamin D per day.  Babies who are fed infant formula don't need vitamin drops if they are having 500ml (about a pint) of formula or more a day. This is because formula is already fortified with the vitamins they need.  If you are breastfeeding your baby and didn't take vitamin D supplements during your pregnancy, your health visitor may advise you to give your baby vitamin drops containing vitamin D from the age of one month."
So I thought it might be interesting to explore just how much D lurks in food and what contribution this could realistically make to intake.

First we need to talk briefly about the different types of vitamin D.  There are 6, but D2 and D3 are the types sold as supplements.  D3 is generally considered superior to D2 but again it gets more complicated because not all studies nor experts agree.

It's also not easy to tease things apart, as many studies use synthetic supplements, whilst in nature other compounds that work in synergy (if you want to get techy read more here) are also found. 

Some studies that make the case against D2, highlight more is needed to generate the same circulating levels and it has a much shorter life after a single ingestion when studied over the next 28 days, however when it comes to infants they concede:
"Despite early evidence of differences in potency between the 2 vitamin D forms on a per weight basis, it must be highlighted that the widely practiced addition of vitamin D2 to milk in the United States and Europe in the 1930s served to successfully eradicate rickets as a significant health problem.  Additionally, fortification of milk with either vitamin D2 or vitamin D3 to this day has proven effective in the elimination of infantile rickets in North America. 
To prevent infantile rickets, a minimal intake of 2.5 μg (100 IU) vitamin D/d in infants with little sun exposure was shown to be efficacious (10). Thus, despite potential differences in the dose equivalence of vitamin D2 and D3, it is likely that vitamin D2 is currently provided at a high enough dose per kg infant body weight to maintain adequate bone mineral metabolism." here
In short, in "real life" either appears to protect against rickets, in a lab D3 sometimes looks better on paper - particularly when discussing supplements..

They're often quotes as offering a little, but not much D.  But what if that depends on the egg?

An independent study showed that UK eggs today have 70% more vitamin D3 than in the 1980's.  Birds also need sunlight or food sources of D and the reduction in caged hens and increase in free range and organic who see daylight,  plus improvements to their diet mean things have changed.

How much?
Well one medium sized egg can now contain as much as two-thirds (66%) of the RDA for an adult according to EU labelling regs.

At the time several, including the director of the "British egg information service" (made me chuckle) called for this significant egg finding to drive industry use (Pinchen H., Roe M., Finglas P. M., Buttriss J., Grey J., Cryer A.2012)

So, the EU lists adult RDA of 5µg and the NHS states that 1-5 year olds have a requirement of 7-8.5µg.  If one egg provides 66% of adult RDA, each egg provides roughly 3.3µg.  I wouldn't call nearly 50% an insignificant contribution would you?  

Fish can be a good source of D3.  This study though found farmed salmon contained 75% less than vitamin D than wild did.  As farmed fish is now the supermarket standard, you can see why some conclude it's not always easy to obtain D from food.

Furthermore cooking method impacts; baking salmon retains almost all the vitamin D, whilst frying in vegetable oil reduced the content by half.

What this paper also highlighted was that type of fish, diet, environment all impacted on vitamin D levels. You can see a list of the vitamin D value of fish here - although researchers concluded that the lists were out of date and new tests were needed.

Mushrooms are a huge vitamin D secret mainly because they can be hacked (by exposing them to bright sunlight), to have a higher D level either during after picking, Maitake for example, when grown in the sun can boast as much as 28.1µg per 100g, with 1 cup serving providing 20µg of D.

This has been dismissed by some as it's D2, however along with what we learnt about about D2, a 2011 study specifically explored mushrooms.

They found "the bioavailability of vitamin D2 from vitamin D2-enhanced button mushrooms via UV-B irradiation was effective in improving vitamin D status and not different to a vitamin D(2) supplement"

And a 2013 study again exploring vitamin D and mushroom consumption/bioavailability noted several things. 

First that the D2 in mushrooms was as bioavailable as that in a supplement. Furthermore the D2 in mushrooms was as effective at raising and maintaining blood levels of D as a supplement of either D2 or D3.

Second that D4 had been found in mushrooms as early as 1937. Therefore they decided to test a range including oyster, portabella & shiitake and found all contained varying levels. Another study continued their research exploring the D4 and again found this linked to light exposure.

Further examination revealed some also provided D3 whilst "Shiitake mushrooms not only produce vitamin D2 but also produce vitamin D3 and vitamin D4"

Leading them to conclude:
"The observation that some mushrooms when exposed to UVB radiation also produce vitamin D3 and vitamin D4 can also provide the consumer with at least two additional vitamin Ds"

Hack my shrooms

Some mushrooms like button, grow in the dark and so naturally have lower levels of vitamin D. However this study found a short short exposure to sunlight increased the vitamin D levels from 5µg to 374µg per 100 grams.

And the more exposure, the more vitamin D.  Putting Shiitake mushrooms with 40 IU of vitamin D into the sunlight for eight hours with the gills upward (ie sun-drying) resulted in 46,000 IU of vitamin D2. Another six hours (14 hours in total) of sunlight exposure boosted levels to an astonishing 267,000 IU of vitamin D per 100 grams."

In addition, researchers found that one year later, the sun-dried mushrooms retained a large amount of vitamin D; therefore sun-dried mushrooms could be stored and used in winter months.

Some feel more data is needed about mushrooms however because of one particular study in which researchers gave "sun-treated" or untreated mushrooms to a group of adults.  They found vitamin D2 supplementation via mushrooms didn't help overall, as the participant's vitamin D3 levels reduced to compensate - thus giving no-overall effect.  The massive flaw in this study as I see it is that these were healthy adults who started with totally normal serum levels, and maintained totally normal levels.  Yet it appears well accepted when giving a D supplement that the blood level does not keep increasing even with ongoing supplementation. It rises into the ideal range and then it stabilises. Vitamin D is consumed by the body, it is utilised and then inactivated (Dr David Grimes, Consultant physician and gastroenterologist)

You can see a table here of the different values recorded in meats in different studies.  As you can see beef offal packs a huge punch.

Our shift in what meats we choose to eat has also likely reduced our vitamin D intake:

This review finds numerous studies linking fat and vitamin D and says it was:
"significantly associated with the fat content of whole cuts, and in the cuts 8 to 10 times more vitamin D-3 and 2 to 3 times more 25(OH)-D-3 was found in lard and intramuscular fat than in the lean parts."
Fatty whole joints slow cooked used to be pretty standard as they were cheap (now often called "traditional cuts").  Many locally recall their parents home rendering lard and "dripping" which was even eaten on bread for lunch.

Then came the fat phobic/convenience era and lean steaks with the fat removed that could be cooked in minutes increased in popularity.  Use a Griddle so you make sure you strain as much of the evil arterty clogger away.   Liver was left behind, the overcooked dried offerings presented as school dinners etched on our brains, mingled with a fear of overdosing on vitamin A.  Lard and tallow were replaced with vegetable and sunflower oils and without realising we also waved goodbye to fat soluble vitamin D.

The problem with the convenience era, is that animals don't grow 33 leg chops and chickens don't have 20 breasts.  We therefore need many more animals to meet demand than when "nose to tail eating", that is consuming as much of the animal as possible rather than selecting choice cuts.

The trouble is if nobody wants a huge chunk of the animal, the parts we do want become more in demand - this drives down price and producers need to find cheaper and more economical ways of raising animals. 

Hello factory farming; feeding animals low grade foods, keeping them in low grade conditions provides cheap meat and fish. But at what cost?

Turns out raising animals in substandard conditions leads to substandard meat.  What the animal is fed impacts on what nutrients it provides, to quite a large degree.  It also turns out that animals, like humans need sunlight themselves to produce adequate quantities of vitamin D, or they need their feed supplementing too.

PART 2: Shame on the British Media! What Really Happened?

After posting this blog, I was made aware that the devastating story of Landon's life, portrayed by the media - may not be entirely accurate.

These posts sent to me, were from a PUBLIC forum:

Some points that may be relevant:

1)  Baby had experienced a difficult delivery,  with concerns for oxygen levels and heart rate following compression of the umbilical cord - resulting in 14 medical staff and an emergency section.

2) Being " a bit dehydrated" after birth, typically occurs when there has been excessive blood loss such as placental abruption, which isn't noted above.  I suspect what actually happened is they tested baby's blood sugars, which due to the difficult delivery were low enough to warrant immediate IV intervention whilst still in recovery.  
"Treatment depends on how severe the low blood sugar is in your baby and on your baby’s feeding skills. In some cases, frequent feeding is enough to correct the problem. In other cases, the doctor or advanced practitioner caring for your baby may provide extra sugar in a mixture that is given through a tube placed in the baby’s nose or mouth. In severe cases, sugar (called glucose) is fed right into the baby’s bloodstream through a needle placed in the infant’s vein. This is called an intravenous line or IV. The baby may need an IV for several days, but he or she can usually still feed from the mother’s breast or bottle during this time."
3.  The next few days in hospital don't give detail as to what happened with regard to doctors monitoring baby following this.  Normal protocols following this type of delivery and early IV required, would be that blood sugars and hydration levels would be checked constantly during this period; ensuring baby had stabilised.   This means either baby was hydrated with good blood sugar levels during his stay (and he was feeding well and crying for another reason, perhaps linked to delivery), or that inadequate checks were made during this period.

4.  There is no mention of distress when they returned home - in fact far from the media reports of constant crying, or sleeping as one would expect in a dehydrated infant, parents report they enjoyed "playing" with their baby.

5.  Only a few hours later at 2.15am did mum discover the tragedy - there isn't enough time here for a baby to have become severely dehydrated since their discharge at tea-time.

6.  Doctors immediately discussed seizures and SIDS.  And with good reason.  If we look at
"What causes neonatal seizures", we can see the most common causes listed here, the first being:
  • lack of oxygen before or during birth because of problems such as placental abruption (premature detachment of the placenta from the uterus), a difficult or prolonged labour, or compression of the umbilical cord.
In fact as this paper from the Department of Clinical Neurophysiology, Great Ormond Street Hospital, London outlines, 30-53% of seizures are as a result of such labour complications - compared to 0.1-5% as a result of low blood sugars.  As low sugars are also linked to complicated deliveries like the above, this makes things more complex.

"Seizures in the neonatal period are also the most common neurological emergency and are associated with high mortality and morbidity 1,2."
6.  Baby Landon survived several weeks in hospital, following his re-admittance - where he received expressed breastmilk.

6.  There is no mention of any link associated with feeding and the initial episode until 2015, when Christie del Castillo-Hegyi, founder of the "fed is best" movement, and recipient of questionable healthcare pertaining to her own infant, contacted this family.

It appears a not entirely unbiased mother (an A&E doctor, not a pathologist), went through the autopsy results of another, and concluded it was lack of breastmilk that caused the seizure that resulted in Landon's death.


Do you think the media representation accurately depicted the mother's words?

    Shame on the British Media! The Starving Breastfed Baby - Fact V Fiction

    1. I've watched in horror as the British media including the Sun, Mirror and Metro have covered the tragic story of a newborn who died from dehydration, in the inaccurate, irresponsible, scare-mongering style only they can.

    Headlines have included:
    "If I Had Given Him Just 1 Bottle, He'd Still Be Alive"
    Which the cynic in me struggles to believe isn't a play on one of breastfeeding's most hard hitting papers "Just One Bottle Won’t Hurt” -- or Will It?".
    "Cluster Feeding Led to Newborn's Death"
    This one irks me as "cluster feeding" is a totally normal, typical part of feeding - yet parents everywhere will now be terrified, but perhaps that was the plan?  This baby wasn't "cluster feeding" - when a term, healthy baby feeding well and typically several weeks old, takes a number of feeds back to back over two or three hours, in order to fill up their tummy and support a longer sleep stretch of 5 or 6 hours.  

    This baby wasn't "clustering", he was starving.  He was trying constantly to get food - he didn't die from cluster feeding, no "feeding" was taking place, he died from insufficient milk intake.

    The level of ignorance from doctors who have been quoted on the subject goes beyond cringe-worthy, to downright shocking - although it's no surprise the press have jumped to support the "fed is best" campaign, when it's all about readership not facts.

    Until I started reading studies and facts from other sources, I don't think I would have believed how much manipulation goes on to sell the desired angle to the audience - click bait headlines and half the facts, deliver a very different picture to the truth.

    So let's talk about the story this week.

    Indeed tragically a breastfed baby died due to insufficient milk intake.  This much is true.

    However a number of key details that parents should be aware of:

    1) This was the USA FIVE years ago!

    Practices and protocols surrounding infant feeding and hydration in the UK are completely different. The risk of hypertraenemic dehydration in some US hospitals is recorded as relatively high, particularly in comparison to the UK.

    A 2013 study analysing almost 1,000,000 births in the UK and Ireland found just 62 cases of severe neonatal hypernatraemia, equivalent to just seven in every 100,000 births and an individual risk of 0.007%. No baby died, had seizures or coma or was treated with dialysis or a central line. At discharge, babies had regained 11% of initial birth weight after a median admission of 5 (range 2-14) days and none had long-term damage. (3)

    2) This was medical ignorance; numerous warning signs were ignored by healthcare providers:

    In startling parallels with the story of  Dr Christie del Castillo, founder of the "Fed is Best movement", whose son also developed hypertranemic dehydration (and was inappropriately re-hydrated leading to life-long consequences) - numerous flags were raised here too.

    According to newspaper reports, the baby cried for abnormally long spells:
    "Mother whose baby cried all day didn’t realise he was starving to death"  (Mirror)
    And had lost a concerning amount of weight even prior to discharge:
    "Landon was discharged from hospital on the third day of his life, having lost 9.7 per cent of his body weight - considered 'routine' and 'unremarkable'."
    Considered "routine" and "unremarkable" by whom?

    The American Academy of Pediatrics states:
    “Weight loss in the infant of greater than 7% from birth weight indicates possible breastfeeding problems and requires more intensive evaluation of breastfeeding and possible intervention to correct problems and improve milk production and transfer.” 
    The International Lactation Consultant Association and the Registered Nurses' Association of Ontario specify that:
    A loss of more than 7% of birth weight, continued loss after day 3, or failure to regain birth weight within a minimum number of days (i.e., 10 days or 2–3 weeks, respectively) are signs of ineffective breastfeeding.
     The Academy of Breastfeeding Medicine advises:
    "Possible indications for supplementation in term, healthy infants [include] weight loss of 8% to 10% accompanied by delayed lactogenesis (day 5 or later).” (1)
    So we have a concerning situation - a baby with a bigger than typical weight loss, who is crying excessively, being discharged without any feeding plan to ensure adequate intake.  This was a huge gamble.

    If my child was in hospital showing every sign of kidney failure and a team of kidney specialists all failed to recognise this -you can bet I'd be looking for answers as to how on earth they were so incompetent they missed the blooming obvious.  I'd be campaigning not that we should all be given artificial kidneys, but that those paid and employed to care for those with kidney conditions, could a) identify when they were failing, b) know the safest course of action to take should this arise.

    The debate surrounding the number of women with "failed lactation" is thrown about - but in terms of saving lives, knowing a figure isn't key to outcome; even one baby suffering a preventable condition as a result of poor practice is too many.  As long as we have trained healthcare professionals who can then educate caregivers, we can save lives - it's not an invisible situation where baby goes from fine to desperately ill without warning.

    3) Neither the British media, nor fed is best have made parents aware that far more babies die as a direct result of infant formula e.g bacterial contamination and as a result of not being breastfed.

    Bacterial Contamination

    In April 2016, the CDC released a new report, warning of a bacteria called Cronobacter Sakazakii, one of the most lethal contaminants found in paediatric food and/or milk formula, with an estimated mortality rate as high as 80%.  This bacteria has been isolated from items in the home such as vacuum cleaner bags - and thus often contamination of the powder can also occur once the tin has been opened.  Using recommended protocols to reconstitute the powder significantly reduces risks - trace levels of bacteria are unlikely to cause harm, but multiplying in warm milk can significantly increase the load.

    This information isn't new. 

    In 2008 the CDC Morbidity and Mortality Weekly Report covers two cases and states:
    "Previous investigations have found Cronobacter spp. cultured from prepared formula, unopened Powdered infant formula (PIF) containers, and the environment where PIF was reconstituted, clearly implicating PIF as the source of outbreaks. "
    Infants throughout the world consume PIF, some exclusively. PIF preparers should be aware that PIF is not sterile and can contain pathogenic organisms (e.g., Cronobacter spp.). Preparers also should be aware that PIF can be contaminated extrinsically (although mechanisms for such contamination are not well defined) and that bacteria can multiply rapidly in reconstituted PIF. Consequently, WHO has developed guidelines for preparation of PIF, including reconstitution with water hot enough to inactivate Cronobacter organisms (3). Universal adoption of these guidelines can aid in implementation of safer PIF preparation, storage, and handling.
    Yet we don't know is what prompted the 2016 safety update...

    In June 2016, just two months later, 27 day old Axel Burnett tragically succumbed to the meningitis & sepsis caused by Cronobacter bacteria.

    On her Facebook page his mum Jamie says:
    "We are so mad and so upset that Enfamil Gentlease would not put a warning label on the label knowing this could happen! Our baby boy got tooken from contaminated formula, did we know this would happen? No, why? Because NO ONE WARNED US!"
    His mum tried to raise awareness of the issue online, founding a "Justice for Baby Axel" page, which has received over 11,000 likes.  Despite this still no major news station or parenting site has covered the story.
    "This bacterium is an emerging opportunistic pathogen that is associated with rare but life-threatening cases of meningitis, necrotizing enterocolitis, and sepsis in premature and full-term infants. Infants aged <28 days are considered to be most at risk. Feeding with powdered infant formula (PIF) has been epidemiologically implicated in several clinical cases."
    One study found:
    "The presence of Enterobacter sakazakii and other Enterobacteriaceae was surveyed in 82 powdered infant formula milk (IFM)

    Although Enterobacteriaceae were enumerated from one powdered IFM sample (Klebsiella ozaenae, 200 cfu/g), 7/82 had detectable Enterobacteriaceae after enrichment in EE broth."

    Do you know how many babies die per year of Cronobacter from infant formula?  No?  Neither does anyone else.  As the CDC explained in 2008in the United States; formal surveillance and reporting systems exist only in Minnesota. 

    Yet parents are still not aware how important safe formula preparation is, we only have to look at how popular products like the "Perfect Prep" machine are.  Despite concerns the small amount of water released in the "hot shot",  may rapidly fall below 70 when it hits the powder, not sustaining the temp for 2 minutes to effectively eradicate all bacteria present - nobody appears to have examined this further.

    Lack of breastmilk & formula use

    A review published in the journal Archives of Disease In Childhood titled, “Marketing breast milk substitutes: problems and perils throughout the world,” suggests:
    "Currently, suboptimal breastfeeding is associated with over a million deaths each year and 10% of the global disease burden in children"
    In her article with over 100 references - Dr Folden Palmer estimates over 9000 US infant lives are lost each year due to lack of breastfeeding.  She says:
    "The final relative risk for formula feeding comes out to 2—that’s double the risk of death for American infants who are fed with formula, compared with babies who are fed naturally.
    A multitude of studies demonstrate that when breastfeeding is accompanied by formula supplementation, illness and death rates are much closer to those of babies who are fully formula-fed. Studies also reveal conclusively that the longer breastfeeding lasts, the greater the measurable difference in illness and death rates."
    A 2010 a study published in Pediatrics quoted 1000 lives:
    "The United States incurs $13 billion in excess costs annually and suffers 911 preventable deaths per year because our breastfeeding rates fall far below medical recommendations," the report said.
     There's also a whole heap of interesting studies and reading on risks of not breastfeeding here.

    We need to realise this one sided approach from our media, is purely to appease their readership. The "Fed is Best" campaign is anti-feminist, paternalistic propaganda, to try and convince parents how they feed their baby doesn't really matter.  It does.

  • Enterobacter sakazakii: An Emerging Pathogen in Powdered Infant Formula 2006
  • Marketing breast milk substitutes: problems and perils throughout the world 2011


    This blog: 

    Upper Lip Tie Treatment in Infants - Informed Choice, Risks & Efficacy

    In all the noise about lip ties, is there risk of misdiagnosis?  And are parents really making an informed decision?

    We acknowledge there are risks to most things - from getting out of bed, to taking a paracetamol or treating a tongue tie. We typically weigh up what the benefits may be, what risks are involved and we (hopefully) get the chance to make an informed choice. 

    When it comes to treating tongue ties, we have (thanks to diligent practitioners and researchers) over 20 years of studies under our belts.  NICE have explored the research, discussed this with experts in the field and drafted guidelines.  These tell us (among other things) that frenulotomy (treatment for tongue tie), is a procedure of minimal risk for most healthy neonates.  

    Risks & Benefits need examining both short and long-term.

    Short-term risks of tongue tie treatment would include for example infection in the wound site, baby bleeding more heavily then expected following the procedure or perhaps later in the day after the event.  Long-term risk may include say keloid scarring at the wound site, if you're genetically predisposed.

    In short - aside from discussing the potential benefits and effectiveness of tongue tie treatment, we've also established what the potential knock on associated effects may be, and we can examine rates to discuss risks.

    Recently some seem to have made the leap of logic to assume it's also therefore safe and beneficial to release other oral frena babies have too - if it is considered "tied".  Tied means that the frenulum is shorter, thicker or placed abnormally compared to a typical frenulum.

    So here are the things I think we need to know:

    1)  What is a normal infant upper lip frenulum & what is its function?
    2)  How do we diagnose an abnormal infant upper lip frenulum?
    3)  What problems can an abnormal upper lip frenulum cause?
    4)  When & how should we treat it?
    5)  What are the benefits, risks and outcomes of treatment?

    Language that features below:

    Frenulum/Frenum/Frena/Frenula:  The "string" that attaches to the top lip or tongue (or bottom lip/ cheeks)

    Maxillary/ labial fraenumUpper lip frenulum
    Diastema:  Gap in the front teeth

    Babies should have an upper lip frenum that attaches to the gum or palate.  Seriously I want to drive round with a loudspeaker on the top of my car simply repeating this phrase.

    These pictures below show you normal infant placement.  Infant upper lip frena are supposed to be "low sitting".

    These babies had no feeding problems, reflux, wind or any other issues.

    The confusion as to why everyone at the moment thinks these are ties, is I believe is explained well here.  It's because they can see the low sitting frenum.  As I discuss in this piece 93.4% of babies do, as the frenum attaches to the gum or palate.


    People are concerned their child has a gap in their teeth, and yet this is exactly as it should be.  

    Here we can see a normal ADULT MOUTH:
    In contrast let's look at the ideal INFANT MOUTH:
    Image Glenn Carty Orthodontics 

    See how different it looks?  And note the low sitting frenulum. Glenn Carty Orthodontist tells us:
    "Did you know that Adult front teeth are 2-3 mm wider than baby front teeth? Adult front teeth therefore occupy more space than baby front teeth. A young child's smile should appear very different to that of an adult's. The smile should resemble a picket fence. The baby front teeth should be spaced. While this might not look pretty, the extra space is needed for proper alignment of the adult front teeth"
    The frenulum moves up the gum-line in the first 10 years of life, until it sits in the adult position. The gap closes as second teeth align - as per the photo below.

    Same child: shows normal frenulum regression and appropriate dental development during childhood
    This spacing also makes teeth easier to keep clean.

    A 2011 paper states:
    The superior labial frenum is triangular in shape and attaches the lip to the alveolar mucosa and/or gingiva. It extends over the alveolar process in infants and forms a raphe that reaches the palatal papilla. Through the growth of alveolar process as the teeth erupt, this attachment generally changes to assume the adult configuration. [1] Taylor has observed that a midline diastema is normal in about 98% children between six and seven years of age, but the incidence decreases to only 7% in persons 12-18 yrs old. [2] But in some instances, the infantile arrangement is retained.
    So normally they regress but sometimes this doesn't happen and the frenulum remains lower on the gum. Sometimes a gap (or a diastema) can be seen.  A very famous example of this being of course, Madonna:

    Diastema is heavily prevalent in some cultures - for example Nigeria has incredibly high rates.  In turn it's considered extremely attractive and surgery exists to create the gap.  In contrast it's very uncommon in other areas such as china.  

    What criteria are we using to diagnose tied versus normal?  How was this established and is it reliable?

    When it comes to tongues we look at what normal presentation and function is, and we establish (or we should) how far away from that each baby is.

    When it comes to lips, there seems to be a lot of confusion and inaccurate information shared.

    The advice many are given is to push the lip back and see if there is blanching, that if it pulls tight and there is a "notch" this will create a gap - and as such removing the frenulum prevents the risk of a diastema.  

    But is this true?

    It's not just as simple as the skin you can see...

    Initially it was assumed the frenulum caused the gap, it seems obvious - we can see a thick meaty piece of skin between the teeth, thus it was assumed that the frenulum not regressing at the expected age, was the root cause of a persistent gap into adulthood.   Interestingly as researchers began exploring further, they discovered it wasn't quite so clear cut.

    Some concluded that when the normal regression of the frenulum didn't happen, it wasn't the frenulum causing the gap, but the gap that resulted in the frenulum remaining low.   Another study found a cleft in the bone was associated with some gaps, and others found removing the frenulum did not alone, appear to make a difference to the gap compared to those that remained untreated;10 years later there was no identifiable differences between he two groups.   Some theorised certain types of frenulum could cause a gap, but researchers decided ultimately this wasn't so.  They noted gaps with frenula and frenula without gaps.  They also noted wide variance in the normal frenulum in terms of visual presentation - thickness and so on.

    A 2012 review outlines the evidence concerning the cause of a persistent gap, and the possibility of closing it by removing the frenulum:
    "At the beginning it was thought that the labial fraenum interfered with the closure of the midline diastema. This belief resulted in misdiagnosis and unnecessary surgical intervention of the fraenum 13,14.
    They then outline all the papers and their findings - I've linked below if you want to look in more detail.

    They continue:
    "Since there is no evidence concerning the fact that the maxillary labial fraenum is the main causative factor for a midline diastema, some orthodontists propose the following therapeutic methodology 37,45: Initially, it is necessary for the dentist to make a diagnostic trial, in order to find out whether the fraenum is implicated in the pathogenecity of the diastema. 
    1. Positive “blanch test” of the incisal papilla, when pulling the lips forward. By pulling the upper lip and exerting pressure on the fraenum, if there is a blanching, it is safe to predict that the fraenum will unfavourably influence the development of the anterior occlusion; 
     It is important to emphasize the fact that frenectomy has clinical validity only after the eruption of all 6 permanent teeth if it failed to close the diastema, and then only in conjunction with orthodontic treatment. So after the eruption of all 6 permanent teeth, 9,14,16,20,34,36,37 orthodontic appliances are used to close the diastema. A frenectomy is carried out, so as the scar tissue will hold the teeth together 16,20,27,33,37,39,48. During the primary dentition phase, surgical intervention of the labial fraenum is not recommended7."
    This clarifies blanch tests etc are a tool that may be useful as a diagnostic tool once 6 permanent teeth are in.  They weren't designed for, nor tested in terms of accuracy or reliability, in babies and young infants who are expected to have a low sitting frenulum.

    The above paper continues to explain the different opinions held by dentists and oral surgeons.

    Surgeons tend to prefer removing the frenum and following immediately with orthodontics (so they have good, clear access to the tissue), some dentists agree; other dentists feel a better result is obtained by pushing the teeth together first with orthodontics, and then removing the frenulum, or only removing it if the teeth "drift" back apart again - so any resulting scar tissue holds the teeth together. The last group don't feel there are any benefits to frenectomy.

    What all seem to agree on, is the risk of removing tissue from the gum when there are no teeth to push together, suggesting that this may at times result in scar tissue on the gum that makes it impossible to completely close the gap. They continue:
    "In the orthodontic community there is unanimity on this issue 37. Orthodontists support that the fraenum should be maintained until the age of the eruption of all 6 permanent anterior teeth. After that, and only if the diastema remains the same, a frenectomy is indicated, with subsequent orthodontic closure of the diastema 9,16"
    "Oral surgeons suggest that in case of a maxillary midline diastema, a small intervention of the fraenum is useful. In this way, the closure of the diastema is facilitated and the orthodontic treatment is not affected 9,2 "
    So the "unanimous" view is that 6 permanent teeth should be in before the frenulum is removed - ie this is the optimal time for removal along with orthodontics.

    What are the risks and benefits therefore to removing it earlier than this, or before the top teeth have even appeared?

    I couldn't turn up any studies exploring this.

    Here we can see the progression of teeth following lip tie removal in a child who should still have a low sitting frenum, as they do in the first picture:

    We can see the child has typical spacing in the first picture, similar to that we saw above.  These pictures have been shared as evidence removing a tie removes a gap - and in this instance it seems clear that removal indeed rapidly resulted in adult dentition and lack of spacing between the teeth.

    However we know already this is what happens in the majority of people with time, so what benefits and risks of hastening this process?  How will this impact on adult teeth spacing long-term?  

    Interestingly we can note the top lip still looks thin and pinched.  There also appears to be slight yellowing between the teeth on the last photo, although I'm not sure whether that is just this particular photo and the light.

    One mum has expressed concern her child's top teeth have come in crossed following his upper tie removal (he had no teeth at the time of the procedure):

    Will this self correct as other teeth align and a correctly functioning tongue exerts appropriate pressure? Is this linked with premature removal of the frenulum and something parents need to factor their decision making process?

    Without studies we're working from anecdote, which is non-transparent and unreliable.

    Mr Sheehan (ENT) Manchester, proposes that as part of the role of the upper lip frenum is to stabilise the top lip, removal of the upper lip tie may also allow over extension when smiling in some people, perhaps those with naturally longer gums.

    Helen Marshall (IBCLC) shares similar concerns:
    "I had my upper tie removed at around 10 or 11 years old because of a gap in my teeth.  My lip pulls higher up and exposes more of the gum when smiling, and which started post-revision. You can see where it attached to my lip and gum, and my smile would not be the same if it hadn't been cut - --my lips wouldn't be able to ride up and uncover my gums"

    Assessing an infant for lip tie.

    Even if we were to establish the blanch test above may accurately determine the lip is tight, does that mean we can assume the cause is the length of the frenulum?  We talk about assessing function not appearance, but even this isn't straightforward.

    Tongue ties can cause tension through the lips that makes them tight:

    The above baby had incredible tension pulled through his mouth by his tongue tie. When we "flipped his lip", it didn't flip at all - instead it blanched and felt incredibly tight.   His parents commented they didn't know where he got his mouth shape as they both had full, plump lips. After the tongue was released and baby turned to his parents, the first thing they both noted was the phenomenal difference in his lips and mouth shape.

    The little girl below didn't just have her lips bound down by her tongue tie, her whole chin and jaw was pulled back too.  We saw her chin move forward when feeding immediately post revision, and function was completely changed.

    Something as simple as being hungry can cause a baby to tighten their lips. When we assess hungry infants post feed and note tightness, this often presents different when baby is full and relaxed.

    Therefore in order to accurately hope to assess function, don't we need to release the tongue first?

    What people also often don't understand is that if baby is in a shallow latch on the breast or bottle, the top lip can sometimes curl under when feeding, appearing as though it can't do anything but - to try and compensate.  

    Image Milk Matters - tongue tied baby compensation
    This is extremely common in tongue tied babies as this post demonstrates. However as anyone who fully understands the mechanics of milk transfer and has observed thousands of dyads will know - it is not desirable for the top lip to flange outwards when feeding either -  it should be neutral as the post above highlights (and the image below shows), flange suggests anything from slightly shallower to very shallow latch.

    Below is the same breastfed baby as above with the curled under top lip, immediately after tongue tie release:

    Image Milk Matters 

    If we just treat the lip, do we sometimes just allow for more or better compensation?

    "The added ability to fully flange the top lip will allow a baby to compensate for continued poor positioning or tongue function issues. But of course this is treating a symptom and not the underlying cause. Improving positioning, tongue –tie division, tongue exercises and suck training to promote effective tongue mobility would be more appropriate. "(Oakley 2016)"
    And of course, again without studies - what about possible negative consequences? 

    One mum on Facebook explained how her journey developed.

    Her son had a tongue tie, he had learnt to feed gripping extra hard with his top lip - just like the babies above.  However they were unable to find anyone who would release the tongue and so only the lip was treated.

    Following this, he was no longer able to adequately grip with the excess force he had been doing to compensate, and was no longer able to breastfeed.

    This proved an extremely traumatic time for all involved and mum feels more studies are needed.

    Lack of Guidance

    We have no NICE guidance pertaining to lip tie, nor recommendations from any other recognised authority.

    Nobody has (in any official capacity), questioned whether the procedure is beneficial to infant feeding, or for the prevention of diastema; whether it has the desired outcome or when the best time for treatment is. Whether the area needs numbing and if pain relief afterwards is required.  Whether both tongue and lip should be released together, given not only the change in presentation post tongue tie release, but because of the difficult or discomfort baby may have feeding with two sore areas in the mouth.

    At the moment different practitioners use different lasers (some use heat to cauterise the area, others use intense water jets to vapourise tissue).  This paper discusses that scarring can occur, and describes a surgical technique combining the frenectomy with a "laterally positioned pedicle graft", to give the best aesthetically pleasing response- are infant frenectomies different?  Which method is safest, most effective?

    Best practice should surely be based on best for baby, not "we've travelled a long way so may as well just do both..."

    Perhaps most importantly,  nobody seems to have explored whether there could be any unintended risks associated with the procedure.  Some argue those who treat would have observed problems should that be the case - however long-term risks can be very difficult to identify in practice rather than research, especially if we're approaching with a bias, and we're not clarifying what "normal" is.

    Abnormal lip frena of course exist, and whilst those promoting removal of the ULT claim we in the UK are "behind" and "ignorant" when it comes to diagnosis and treatment, I'm not entirely convinced.

    I've found when there is truly abnormal presentation (such as a excessively wide, tight frena that have bound down the lip) the NHS have treated.

    Interestingly they tend to release the tissue up where it is attached to the lip, not touching tissue on the gum margin.  In the private sector I have seen both methods used, suggesting we also need assessment and standardisation of this area too. 

    However, when presented with normal low sitting frena being called a tie, the NHS (as evidence supports), recommend reassessing again age 8-10 and treating if appropriate.

    This is why controlled studies are key.

    We need to start asking questions, so that we continue to push for studies and evidence to support guidance for practice.  Simply accepting the word of those performing the procedure is not enough.

    Some charge as much as £500 for a consult and release lasting around 15 minutes, enabling them to see 4 per hour.  A 7 hour day that's potentially £14,000, or £70k per week, 280k per month, and so on. Further charges may be applied for feeding support, which many parents report is often needed. 

    That's of course not to say there aren't situations where removal may be beneficial - lack of evidence isn't lack of efficacy, but we need to know more!

    Parents need facts on which to base a decision, as do those supporting infant feeding.