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.

Do Babies Who Eat Solids Before 6 Months Sleep "Better"?

Better for whom?

The media had fun this week with a study that told us:
"The early introduction of solids resulted in small but significant improvements in infant sleep characteristics."
Not "changes" to infant sleep, but "improvements".  A "making better" of. 

Or in this case, a change reported as an improvement because of author bias that longer = better.

Human infants rouse and signal frequently when close to their caregivers.  As I cover in my book, there's a whole host of reasons they do this,  yet things can interfere with or even stop this normal communication entirely.  As an example (and as this study confirms) the further away from their parents babies are, the less they signal.  This is precisely why "baby tamers" are always keen to get baby in their own room despite safety guidelines. 

These behaviours are assumed to be desirable by the study authors, because it results in a longer sleep stretch for caregivers and result in them feeling their baby is more "normal".

Attempting to manipulate and shift infant sleep patterns to be more like those of an adult and thus more convenient for parents isn't new, in fact it sells very well. 

Whether it's comfort blankets (although nowadays we prefer to call them "transitional objects") to "condition" a baby to accept cloth over a caregiver, or cry it out so the baby realises signalling is futile - it's considered entirely normal in Western society.  As such we like to pretend there are no consequences or cost to the infant of doing so.

In biological terms if we explore animals generally, the more mammals "signal" - the healthier they and their relationship with their caregivers is considered to be.  As with anything, when we intervene to shift away from the biological norm- we have the potential for both risks and benefits.

If we examine the risk and rates of SIDS, studies show us that not hitting deep sleep levels and retaining the the ability to rouse and signal is the best protection infants under 6 months have.   We know for example some studies find non-breastfed infants are less rousable, whilst others also link not breastfeeding an increased risk of SIDS, when compared to those who are mix-fed or exclusively breastfed. 

What impact does introducing solids and reducing arousal ability further, have on SIDS?  

It would seem prudent to ask given the authors note:
"Following the early introduction of solids, infants in the EIG slept significantly longer and woke significantly less frequently than infants in the SIG."
Although this effect was only visible in babies around 5/6 months (despite some having food from 3), what impact does introducing solids before readiness have on rates of infection, longer term microbiome and overall health? 

They didn't explore that either.

The "significant" change referenced is an average of 15 minutes total sleep in these older babies - which let's be honest, in knackered parent land is but a snifter. 

As was highlighted on Twitter, it would take longer than this to give the food and deal with the solid poop that comes with it.  Yet authors noted 10% fewer arousals, which is huge in terms of a shift from the biological norm.

What also isn't clear from reading the media coverage is the data is from "parental questionnaires". 

Here tired new parent who barely has time to shower and eat some days, pick the baby sick from your hair and accurately recall your baby's sleep for the last week please.  Make sure you're entirely honest about how much breast and formula you're giving too (rather than putting what you think we want to hear or what you'd rather be doing); after all your answers are going to influence the nation!

Seriously?  Researchers have already established that this isn't a reliable method of data collection.

Although the study authors don't acknowledge this, they do comment:
"The commonly held belief that introducing solids early will help infants sleep better could have produced a reporting bias. Mothers, anticipating improved infant sleep, could have reported better outcomes."
Ya think?

Given we have numerous studies highlighting babies can and do reach for food and start eating when ready and that there are risks before this time, why are researchers even going there with sleep?

A quick glance and no conflict of interest is disclosed.  So I dug a little deeper:

First - you'll recognise the names from the EAT study:

Professor Gideon Lack states on his bio that he receives "Personal remuneration: Lectures (SHS Nutricia, Nestle, SHS International)"

Dr Michael Perkin says he receives "Personal remuneration: Lecture (SHS Nutricia)"

Next I checked out the author associations:
"The Population Health Research Institute, St George's, University of London, London, England."

I dug out their financial statement which outlines that they've received grants from a number of people including the "Wellcome Trust".  A quick click later and we can see the Wellcome Trust's financial statement shows they own profitable shares in Nestle...

A cynic might propose parents may not be the only ones with a bias, but when has that ever stood in the way of a good headline?

Aptamil Formula Changes - Comparison Vitamins/Minerals

Since the changes to Aptamil first milk recently, I've received lots of enquiries as to whether I know what the nutritional changes are.

I snapped the back of a can and checked with online stores and have compiled a chart comparing old and new standard first milk, plus the pro furtura.

First up - they've adjusted the Whey/Casein balance.  Previously it was 60/40 to mimic breastmilk, now it has shifted to 50/50.  This may be why some babies are finding it harder to digest.

They've shifted some of the levels around, but the other big difference seems to be the addition of neucleotides.

A 2010 randomised control trial concluded:
"Nucleotides could be conditionally essential for optimal infant growth in some formula-fed populations. Additional research is needed to test the hypothesis that the benefits of nucleotide supplementation for early head growth, a critical period for brain growth, have advantages for long-term cognitive development."
So let's cut to the chase - if indeed nucleotides are indeed important, aren't we actually saying "oops, we're realised we were missing something needed for optimal development, and without which babies may be at a cognitive disadvantage"?

So what about all the babies given formula prior to the addition of nucleotides?  And that's the nub of the problem with infant formula manufacturers.  We pretend it's close to breastmilk, until we discover the next new "essential" ingredient at which point we admit otherwise?

Click here for the PDF

Image: Ocado Website

Clickbait Headlines as the Media Fails Mothers (again)

It's been a clickbait fest over the last 48 since the Royal College of Midwives (RCM) launched this press release, sending the tabloids into a bullshit frenzy.

First prize (you may need to sit down in shock) goes to the Daily Fail (who I'm not even sure bothered to even read the whole press release) with:
"End of the breastfeeding shaming: Midwives ordered not to judge new mothers who choose to bottle feed."
I've found myself becoming increasingly angry as all I've heard bandied about is that women must have a choice and we must respect that choice.

Well shut the front door!  Grown adults should make a choice and it should be respected - whatever next?  The right to vote?  Letting women work outside the home? I can see why that made the headlines in 2018. 

Except of course it's all absolute nonsense, because for the most part as I discuss in my book, mothers don't really get to make a choice at all; they have but the illusion of choice, which unsurprisingly leaves mothers pretty damn angry.

RCM Chief executive Gill Walton said:
If, after being given appropriate information, advice and support on breastfeeding, a woman chooses not to do so, or to give formula as well as breastfeeding, her choice must be respected.”
First, there's no obligation for the mother to accept "appropriate information and advice" to earn the right to have her choice respected.  We can promote informed choice, but we absolutely have the right to make an uninformed choice if we wish, or to seek education from "inappropriate" sources and still have that choice respected.

Second, it has to actually be a viable choice for any decision to affect outcome.  For example I can make a choice to amputate my leg, but if I can't find a surgeon to agree to lop it off - I have no choice but to keep the leg and my "decision" becomes a moot point.  I can make a choice to live off dried African tree bark, but if I can't find a stockist to send it to me - my decision is irrelevant.

Women can make a choice to breastfeed, but if they can't find anyone to help them do in a way that's sustainable (ie without pain, without feeding 19 out of 24 hours because the baby can't ever be put down, with appropriate weight gain etc) - she may find herself left with no choice as something has to give.

A survey I ran found EIGHTY FIVE percent of over 1000 mothers surveyed said they DID NOT receive the help they needed to succeed.  Yet the choice about feeding according to the RCM is a woman's right!  So why then prey tell have funding cuts left mothers with even less support than ever beforeWhy are tens of thousands of women even unable to get hold of a midwife?

Aren't we trying to use pretty wallpaper to cover up the crumbling walls?

The Daily Mail touch on this with:
"Those who want to breastfeed, but are unable to, are up to two and-a-half times more at risk of post-natal depression." 
Random idea - perhaps if we helped those women to succeed, we wouldn't have to worry about trying to assuage their guilt at a later date? 

Yet suddenly we only seem to care if the choice of a mother who chooses NOT to breastfeed is respected?  There's a right to bottle feed but no right to breastfeed.

Who will deliver all the "appropriate information" on which mothers will base their informed choice?   It would have to be a pretty long chat given most parents have virtually zero knowledge prior to pregnancy. 

What format will this take?  Because the problem is it's incredibly difficult for midwives to both give evidence based feeding material AND yet not simultaneously be perceived as applying pressure as this post explores.  If a midwife tells a mother the risks of not breastfeeding her baby - given mothers typically want the best for their child, this information in itself could easily be perceived as pressure or a "guilt trip" if they didn't plan or want to do so.

I've learnt over the years in practice, that mothers will blame themselves and feel guilty for almost anything relating to their baby.  Even if it's something that you'd have needed a degree in medical science or  the gift of second sight to know - mothers will still utter the words "I should have known" or "I should have done...". 

This happens so much, I've now taken to asking dad (or her significant other) - do you feel guilty or to blame?  It's fascinating it if only for the momentary look of confusion.   I've yet to meet one who does - why would you feel guilty about something you didn't know or couldn't change?  Yet mothers do. 

Gill Walton continues:
"We would focus on the risks and benefits of both breastfeeding and formula feeding – and help them do that – rather than say “Oh, this mother’s decided to formula feed, we’re not going to help her”.
A dire quote if verbatim but regardless, listing the risks and benefits of breastfeeding is notoriously problematic for a healthcare system - since there are no health benefits to not breastfeeding, no area in which formula confers an improved outcome.  This means we're realistically going to give a heap of information to a mother which tells her lack of breastfeeding can impact negatively in the long-term.  Surely it's an unrealistic expectation that they won't then feel something if they can't or choose not to do so. 

The reality as social media repeatedly highlights, is far many more mothers are told by their healthcare providers (including doctors and other senior medical professionals) to introduce formula, give a bottle or restrict breastfeeding - often because their lack of training and ignorance means they simply don't understand lactation.  But I guess that's not a convenient narrative.

Yet the media seems to forget women can read and think - instead others must be making these mothers feel guilty (their magic guilt inducing powers must be useless on dads since they don't get a media mention when it comes to feeding their offspring).  But given I recently saw a mum express guilt in the face of a research study, it would seem these recommendations are about as doable as rotating your hands and feet in different directions at the same time (it's really tricky, try it ;))

The media is selective in what is "problematic pressure" for women.   Lose the baby weight, "get your life back" (but not too much), work (but not too much), stay at home (but not too much), mother enough (but not helicopter parenting), cook nutritious food, have just the right number of after school activities.  Be yummy but not too slummy and on and on and on.

I'm still undecided whether we as mothers are conditioned via society to put up with this constant dialogue of drivel trickling into our daily lives.  That men aren't subject to this constant appraisal is spectacularly highlighted by the "Man who has it all" Twitter account.  If men were breastfeeding would we pat them patronisingly on the head and tell them not to feel guilty that resources had been cut so much there was no help and as such they were failed in feeding their child how they wanted?

I very much doubt it.

The Probiotic, Prebiotic Pacifier (Dummy)

Probiotic, Prebiotic Pacifiers or PPP as we like to call them, are finally here.  We asked parents what they wanted from a paci, we added extras they didn't even know they wanted and *BOOM* PPP was born.

With all the hype about your infant's microbiome (the crew of bacteria hanging out in your baby's body), imagine a pacifier that delivers both pre and probiotics with each and every suck?   Imagine no longer, PPP™ is here!
  • Unique, patented "never drop" function*
  • Now Cleaning Dummies is Not Advised (ncDNA) thanks to our Bioclens flora technology™, making sterilising a thing of the past.     The pacifier doesn't even need soap!  A rinse is all that's needed to keep the PPP™ at its best.
  • 9 out of 10 mothers said their baby preferred PPP ™, even if they refused all other dummies on the market.
  • Suitable from birth through to weaning for both breast and bottle fed infants.
*Never drop function means the PPP™ will never drop away from the owner's body. No throwing it out of the pram, crawling under the cot trying to find it at 2 am

And if that wasn't enough.  THERE'S MORE!!!

The PPP is CLINICALLY PROVEN to assist in the development of your baby's jaw and teeth!  Reduce risks of malocclusion (misalignment of the two dental arches when they approach each other as the jaws close), teeth crowding and decay.

Why does my baby need bacteria from their binky anyway?

According to researchers:
"Beginning at birth, the microbes in the gut perform essential duties related to the digestion and metabolism of food, the development and activation of the immune system, and the production of neurotransmitters that affect behavior and cognitive function."
What that actually means is the bacteria perform an essential job when it comes to digesting and absorbing food, how the immune system develops and how well it responds.

These bacteria can even affect how you act and how you think, act and feel, a "Collective unconscious" - your bacteria communicate directly with your brain.

Studies also warn we may be short changing our baby's biome increasing risks of asthma and allergies.

PPP™ brings not only the big guns of good bacteria to the party (probiotics), it brings their favourite snacks (prebiotics).  Helping your baby's biome to thrive like a newly seeded garden in spring.

Many probiotics you buy have a few strains, some have ten or eleven.  The PPP™ responds to your baby's environment and has been found to deliver up to SEVEN HUNDRED different bacterial species.

However you feed your baby, PPP™ is suitable.  Offer after a breastfeed to help your baby nod off, or whilst preparing a bottle to calm your baby - a godsend at 3am!

Look down and you'll find your complimentary pair.

The Omeprazole (Prilosec/Losec) Epidemic & Infant Reflux - Risks & Benefits

Many infant feeding practitioners have observed an exponential increase in the number of babies diagnosed with reflux and given hypoallergenic formula/and or reflux medication.  It's something I've blogged about before.

We have a situation whereby some babies are suffering with severe digestive issues, yet mums feel their concerns are not taken seriously (and I say mums intentionally, as many comment their concerns are taken more seriously should they take baby's dad with them or if he takes them).  In contrast others simply presented at A&E with an infant crying, were diagnosed immediately with "reflux" and given a host of medications and milks.

Today thought I'd specifically like to explore Omeprazole. 

I've heard parents feel confident Omeprazole makes a huge difference to their babies, whilst others feel there is little to no change at all; or maybe some improvement but still symptomatic enough to be seeking further help.

It isn't without risk of side effects, therefore it's surely key to ensure that the medication is needed, effective and ultimately providing more benefit than risk - this decision will be unique to each baby and situation.

Omeprazole belongs to a class of drugs called "proton pump inhibitors" or PPI's.  Unlike say ranitidine which aims to neutralise the acid, omeprazole actively works to reduce it being produced in the first place.

The National Institute for Health and Care Excellence (NICE) & PPIs:
1.3 Pharmacological treatment of GORD
Consider a 4-week trial of a PPI or H2RA for those who are unable to tell you about their symptoms (for example, infants and young children, and those with a neurodisability associated with expressive communication difficulties) who have overt regurgitation with 1 or more of the following:
  • unexplained feeding difficulties (for example, refusing feeds, gagging or choking)
  • distressed behaviour
  • faltering growth.
1.3.4 Assess the response to the 4-week trial of the PPI or H2RA, and consider referral to a specialist for possible endoscopy if the symptoms: 
  • do not resolve or
  • recur after stopping the treatment. 
I decided to give NICE a tweet to ask for the studies that formed this guidance, and in the meantime scoured journals for studies.  I'll list them in date order, oldest first:

Next we have a teeny tiny study from 1993 of just 15 children ranging from 8 months - 17 years:
"Mildly elevated transaminase values in 7 patients and elevated fasting gastrin levels in 11 patients were present; in 6 of the 11, gastrin levels were 3 to 5.5 times the upper limit of normal."
"We found omeprazole to be highly effective in this group of patients with severe esophagitis [insert: irritation or inflammation of the oesophagus].  Omeprazole appears to be safe for short-term use, but further studies are needed to assess long-term safety because the significance of chronically elevated gastrin levels in children is unknown."
So in short, it worked to soothe an irritated or inflamed oesophagus, however it resulted in high gastrin levels, the impact of which is unknown and as such needs further investigation.  Gastrin is a hormone that is produced by ‘G’ cells in the lining of the stomach and upper small intestine; dring a meal, gastrin stimulates the stomach to release gastric acid. It also however acts as a disinfectant and kills most of the bacteria that enter the stomach with food.

I then decided to directly search for safety studies. The first thing I pulled up was a site called Choosing Wisely is an initiative of the ABIM Foundation, which was created by the American Board of Internal Medicine (ABIM) in 1989 with a mission "to advance the core values of medical professionalism as a force to improve the quality of health care."

Their goal via Choosing Wisely,  is "advancing a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures".  They provide evidence based information and are supported by over 70 partners including the American Academy of Paediatrics and The American Academy of Family Physicians

One of their publications is entitled:

Five Things Physicians and Patients Should Question

This was released in 2013, still stating a lack of effectiveness and lack of exploration of potential adverse effects.

NICE then kindly tweeted back telling me I could find the supporting evidence here. So off I went:
Under A.3.3 Analysis it says: " The literature search found no trials evaluate the effectiveness of PPIs in children and therefore there is not sufficient evidence to include these treatments in an economic model." 
A.3.4 Resource use and costs: "No studies were identified that looked at the comparative cost effectiveness of medical therapy for GORD in children, either comparing different drug regimens or comparing medical management with surgical management. The comparative evidence of efficacy is poor.
A.3.5 Conclusion: " Therefore, no comparison of the cost effectiveness of medical management and surgical management was possible for this guideline".
I then ran through the studies listed under "I.8 Effectiveness of medical management (H2RAs, PPIs and prokinetics) in GOR or GORD", picking out those that examined omeprazole and infants.

The first I found on the list was the study quoted in the purple box above, concluding irritability was not improved.

The second study they list is the study quoted in the pink box above, concluding safety had yet to be addressed.

I then got excited when I found a new study I hadn't yet found.
Efficacy and Safety of Once-Daily Esomeprazole for the Treatment of Gastroesophageal Reflux Disease in Neonatal Patients, AAP 2013
The similarities between omeprazole and esomeprazole outweigh the dissimilarities.  Some claim esomeprazole is even more effective, although this doesn't appear to be supported by evidence.


The second paragraph is particularly interesting "the signs and symptoms traditionally attributed to acidic reflux were not significantly improved by esomperazole"

And does well tolerated mean no potential long-term adverse effects?

I scanned the rest of the papers and couldn't find any others relating to omeprazole and infants under 12 months.

So we have it seems, very little evidence demonstrating omeprazole is effectively resolving the symptoms parents seek help for, even if acid levels are reduced in a lab.

What about undesirable side effects?

If we look at the bigger picture than just babies, a paper entitled "Outcomes of a medicationoptimisation review inpatients taking proton pumpinhibitors" for the QUIPP (Quality, Innovation, Productivity and Prevention) agenda reads:
"Proton pump inhibitors (PPIs) are one of the most commonly prescribed groups of drugs.1–4 Although PPIs are generally well tolerated, long-term use has been associated with adverse effects such as increased risk of bone fracture, 5–8 nutrient deficiency,9–11 Clostridium difficile infection, 12–15 and pneumonia.16–18 Because of these risks, the lowest effective dose of PPI should be used.19-21"
"Proton pump inhibitors may trigger the very symptoms that they are designed to treat because of compensatory mechanisms.23,24 Studies have shown that patients can suffer from rebound gastric acid hypersecretion following PPI withdrawal,25–27 which may make it difficult to maintain step down/off.28 In our experience, many healthcare professionals (HCPs) and patients are unaware of the risk of rebound symptoms and how best to manage them"
In particular problems observed include magnesium deficiency and B12 deficiency.  Furthermore these studies are of adults, with increased risks to the elderly - what about babies?

In 2013 a study linked PPIs to constriction of blood vessels. 
"We found that PPIs interfere with the ability of blood vessels to relax," said Ghebremariam, a Houston Methodist molecular biologist. "PPIs have this adverse effect by reducing the ability of human blood vessels to generate nitric oxide. Nitric oxide generated by the lining of the vessel is known to relax, and to protect, arteries and veins."
There is concern ""If taken regularly, PPIs could lead to a variety of cardiovascular problems over time, including hypertension and a weakened heart.  In the paper, the scientists call for a broad, large-scale study to determine whether PPIs are dangerous." 

I asked Dr. Flanders, a paediatrician in Canada for his thoughts about young infants:

He also suggested we check out an article from Canadian Family Physician 2013:

So what does all this mean?

It seems clear that PPIs should not be widely prescribed for most babies.

Omeprazole appears well tolerated in the short term, but guidance suggests this is reviewed and reduced/removed ASAP to minimise potential side effects. If tests demonstrate babies are at risk from acid damage or have an inflamed oesophagus, omeprazole appears in the short term to be effective.

It means we also have a huge overlap of symptoms and so we need to be extremely thorough in assessments - because it's also clear from studies that many babies we think have "acid reflux", don't improve with medication that tests show is effectively working.

For example the NCT state:
"If your baby shows discomfort when feeding, such as arching away, refusing to feed and crying, it can be a sign of reflux. She may also frequently vomit or spit up (more than normal posseting, which is only about a teaspoon) and cough a lot, including at night, with no other sign of a cold.
Other symptoms include:
  • Waking often at night
  • Comfort feeding to help alleviate pain
  • Weight loss or poor weight gain
  • Excessive crying or irritability during or after feeding
  • Regurgitation"
Yet a baby with a feeding problem such as difficulty latching or using a teat well will arch, refuse to feed and cry.  They will often vomit if they gulp down air and can develop symptoms of reflux as a result.

 They may feed little and often appearing to "comfort feed" as a result and may struggle with poor weight gain too.  Babies generally not transferring enough milk also wake often at night.

A shallow latch can also cause aspiration (Catherine Genna Watson, Sucking Skills) and thus a persistent cough and so none of the symptoms are exclusive to reflux.

Tesco baby club have an almost identical list, as do Babycentre - it's hardly surprising parents are visiting doctors in their droves.

The problem is, we risk losing the babies suffering GORD, those who are most at risk of significant complications from their reflux, in all the noise of misdiagnosis. 

The babies who can suffer "An apparent life-threatening event" (ALTE), breathing difficulties, or experience damage to their oesophagus, experience recurrent aspiration pneumonias, persistent coughs and have a constant hoarse voice and acidic breath. 

NICE guidance clearly states infants should have their feeding fully assessed before any medications are prescribed, yet we know this isn't happening.  Parents please push to see if someone can identify why your baby is refluxing, or why it's to such a degree they need medicating - rather than just symptom shooting.

When The Breastfeeding Baby Keeps Falling Asleep Before They're Full

AKA "The Power nap"

We all know it's totally normal for breastfeeding babies to fall asleep when they've finished their dinner.  We know that in the first few days after birth it's also not unusual for baby to "forget" what they're were doing and take a quick snooze mid-feed, particularly if they're a little jaundiced or have had a more tiring delivery.

But what about when baby is consistently falling asleep before they're full?

It tends to go like this - baby drinks the first milk ejection or letdown, a nice suck/swallow ratio can be seen and this tends to be the part of the feed everyone watches.

As this naturally slows down, instead of pausing and then starting to drink with a regular swallow pattern again - baby adds more and more sucks for each swallow, becoming slower and slower until they're asleep. 

Except they're not. 

If you try and move them they will suddenly spring back into action.  Eyes open, hand comes back to mouth - rooting ensues.  Baby was taking a power-nap whilst waiting for more milk, they were not ready to leave the restaurant thank you very much.

I hear lots of solutions to resolve this.  Strip the baby down, blow on them, use a cold wet cloth to rouse them (yikes!), change a nappy.  Much doesn't tend to work for long though and so it goes like this:

mum blows on baby
baby takes three sucks
baby goes back to sleep
mum blows on baby
baby sucks a few more times
baby goes back to sleep
mum blows on baby
baby ignores blowing
mum blows AND tickles hands
baby suck a few more times
baby falls back asleep
mum undoes baby grow a bit, blows and tickles hands
and so on and so forth

It's probably easier to ask the question - why is the typical term, healthy baby persistently falling asleep before they're full?

A big reason babies fall asleep at the breast or bottle, is when the flow (for whatever reason) becomes too slow to be worth staying awake for.  Lots of sucking without swallowing lots of milk, isn't a sensible idea for a small human with limited energy supplies - they want bang for their buck.

We know this as if we take a "power-napper" and increase milk flow, baby's eyes spring open!  Oh we're back in action?  Nice one, I'll wake up then...

WATCH THIS CLIP - when additional milk is given, we can see the shutters ping open.

Of course, in a symptom solving society the answer seems obvious - increase milk flow, breast compress and switch feed.  Indeed short-term this can help, particularly for the sleepy newborn or baby who is a little early/small and simply running out of energy too soon.

A common reason for many "breast hangers" is a shallower than optimal latch, resulting in reduced milk transfer.  

I had an interesting discussion last week over on "Occupy Breastfeeding".  This was the stunning image posted.  Mum looks radiant but oh my days look at that teeny latch.

I love seeing breastfeeding in all sorts of positions and attachments, I'm not for a second suggesting we only show "optimal" images - this mum has clearly overcome a difficult time getting baby latched and feeding well and the resulting photo is glorious.  

I do though think we have to acknowledge when a latch is shallow - because we seem to have a nation of people who can't recognise the difference or who believe it doesn't matter and I don't think it's really helping anyone.  If we saw a heap of well attached babies, the odd shallow latch wouldn't need a mention - but we see so few breastfeeding images and we've lost so many skills around feeding...

Perhaps this baby had just fallen asleep at the end of a lovely feed and slipped shallow as mum moved to take the pic?  Who knows, it doesn't really matter as long as we can acknowledge that whilst it's a stunning picture, that latch as we see it won't work for many.

To some a shallow latch won't be a huge deal, particularly in the early days.  Some can compensate well,  especially when demands are small and milk supply is abundant.  Some mums are happy to feed half hourly day and night as baby gets older, or hold them upright or sling-wear to compensate for the colic, wind or reflux.  We're re-framing this as "normal", but for some mums, tapas style eating around the clock isn't always sustainable.  Some will experience mastitis from the regularly ineffective breast drainage, whilst for others the tiny mouth causes problems for baby if not for mum.  From reducing the transfer, to gulping air a myriad of symptoms can follow.  

I'll take it as a compliment to be accused of "being very big on latch" (I'm still not entirely sure whether the pun was intended, but I chuckled anyway).  I think we underestimate mothers to suggest they're going to stop breastfeeding en-mass because whilst they believed until now everything was completely fine, someone pointing out it doesn't quite look like a textbook may prompt them to abandon the breast and reach for the bottle.  If whatever your doing is working for you and your baby, run with it!   

I propose though,  mums are more likely to stop breastfeeding when despite telling everyone they have some concerns, they're pacified that it's just a (never ending) growth spurt, or their baby is fine with a teeny tiny mouth and perhaps she just has insufficient glandular tissue or baby has an allergy?

The Global Beastfeeding project has uploaded some great clips, including exploring why latch matters for many.  Here is a still from their clip showing a deep latch versus shallow latch or "nipple hanging".

In action this means we can't see the corners of baby's mouth:

The problem I think is the myth that refuses to die.  The pain myth.  How often do we hear the two key questions?  
  • Are you in pain?
  • Is your baby gaining weight? 
As though these are the only markers of effective feeding.

***Newsflash:  Babies can have an incredibly shallow latch and not cause pain.***

These babies will typically have slower gain, and/or feed super frequently or for long periods to compensate. Not all though, sometimes mum has so much milk, baby is full after drinking the milk that pours out with the first milk ejection (lactose rich milk) resulting in typical or above average gain.

In order to cause damage a baby has to to:
a) Have enough of something in their mouth to damage it
b) Be doing a compensatory action that causes damage.  Whether that's pushing the nipple up to the hard roof of their mouth, pinching and trapping it, rubbing their tongue against it or sucking extra hard like a vacuum cleaner.  

Sometimes a baby's suck is so disorganised they don't generate enough suction to cause pain to anything - it's weak and ineffective, like a sock in a washing machine.  These babies may also have initial early latching problems and trouble staying on the breast (lack of effective suction).  Sometimes mum is show positions to try and compensate for this which gets baby on, but not necessarily transferring milk as well as they could.

All of this also fails to recognise that the very mechanics of breastfeeding, mean that even if a baby doesn't latch "optimally", the act of suckling (creating a seal and rippling the tongue) - will assist in shifting them in to a deeper latch.

Normalising the weeny latch as "fine" doesn't really I suspect help many beyond the early weeks - we need to up our game in terms of breastfeeding education to help parents recognise when their baby is latched and drinking well, versus hanging out eating tapas style.