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.

Baby Landon - is Breastfeeding to Blame?

Many of us are familiar with the tragic case of baby Landon, for those that aren't you can get the lowdown that most commonly circulates here.

As LA makes all autopsy results public, a reader suggested I may be interesting in taking a look.  It can be easy for memory and recall to change over time and I wondered whether it was possible one bottle of formula could have saved him.  Whilst these cases are traumatic and difficult to discuss. It's vital we do so in order to minimise the risks of this happening to another child.

It's not exactly easy to pick this story apart, because errors appear to be present in the autopsy report:
  • Page 15 and the opening summary, states baby's birth weight was 7lb 7 ounces (3.36 kg).  It states in this same paragraph is records his discharge weight as 6lb 5 ounces (2.86 kg)
  • Page 17 also states his discharge weight was 6lb 5 ounces (2.86 kg)
  • Page 18 states that his discharge weight was  3.03 kg (6lb 11oz)
This is a significant discrepancy.  The first gives a loss of 15%, the second a loss of 9.8% at day 4.

But what happened before then?

"Fetal intolerance to labor"

Labour progressed typically until epidural meds were given, at which point baby's heartbeat decreased.  This didn't improve with maternal positioning and thus they ruptured mum's membranes to enable them to attach a monitor to baby.  This showed baby still had a slow heartbeat and thus they moved to cesarean section.

Once Landon was born:
  • Page 16, based on an interview with a doctor reviewing the case: 
He states baby was born dehydrated "but the explanation for that term was not provided in the documentation he reviewed".  It says baby was given fluids and transferred to NICU because of "a history of a poor transition". 
Note: Dehydration at birth isn't typical and is commonly associated with infant blood loss.
  • Page 17, based on maternal interview:
This states that parental understanding was baby's heart rate was slow to increase after birth (bradycardia) and oxygen was administered for 15-20 minutes plus a 35 ml bolus of fluid was given through a scalp vein.    Parents were advised baby was dehydrated and he was transferred to NICU.
  • Page 18, based on official medical records 
This states baby was born with Apgars of 8 and 9, but then experienced transient tachypnea (very fast or labored breathing) and thus was admitted to NICU.  It states baby was treated with CPAP (continuous positive airway pressure - presumably the inflation breaths given at birth) and given saline IV for hypovolemia.
Hypovolemia is a low level of fluid in the body (presumably the dehydration discussed). Lower levels of blood make it difficult to get nutrients and oxygen to the entire body. Hypovolemia will affect the entire body but certain organs are at higher risk of damage. Organs that are very active like the heart, kidney, brain, and liver may be affected the most.

Causes of Hypovolemia are:
  • Blood loss–from an injury or illness
  • Problems absorbing fluids in the digestive tract
  • Trouble feeding
  • Illness with vomiting or diarrhea
Clearly since he was just born - feeding and vomiting etc can't apply. 

All reports agree that just 2 hours later, Landon was discharged from the NICU to room in with his mother for the next four days.

They were taken to the maternity ward:
"She [mum] had concerns because he was fussy, she thought he would sleep and eat more".
"During the hospital stay, baby appeared to be nursing, but mum raised concerns she didn't have enough milk due to a history of PCOS".  The infant produced few wet diapers.

On day 4 baby was discharged at 3pm despite the fact baby had produced ZERO wet nappies that day and as we explored above, had a loss of either 10 or 15% at that point.

Once home Landon fed continuously.  Mum states she was advised that this was normal as baby was cluster "feeding".

The report becomes a tad contradictory:
  • Page 16 reads: the baby was home for 8-10 hours and was not feeding well.   The father states the child had poor skin turgor.  On the night in question they had called the hospital for advice and nobody suggested supplementation.  The child was not doing well and so they were going to take him hospital.
  • Page 18 reads: It was reported that the mother fell asleep breastfeeding the infant at 02:00 hours (no hospital visit).  She woke 30-40 minutes later to find him blue and not breathing.
  • In contrast posts online from mum recount how he slept in the car and then "they had fun playing with him that evening" yet awoke to find him unresponsive.
Rushed to hospital:
Baby was resuscitated, readmitted and rehydrated with IV fluids (noted by the pathologist to be visibly swollen due to the volume), at this point baby was 9.3% below birth-weight.

Medical professionals I've discussed this with have said if baby was discharged with a 9.8% loss, you'd typically expect a significant positive shift following IV fluids, particularly if baby looks oedematous.  As we know from what happened to Dr Christie del Castillo-Hegyi of "Fed is Best" - we start seeing these dangerous sequale unfold when we start hitting these very large losses.

Images show signs of excess weight/fluid loss visible on baby's hands.

Tragically Landon didn't survive:


The picture painted by the media and groups trying to use this story to promote a formula feeding agenda - is so far away from reality, it's at best misleading and at worst lies intended to manipulate.  Instead of a term, healthy baby apparently feeding well, with normal output and yet suddenly struck down (ie it could happen to anyone!), the reality is very different.

Baby Landon was dehydrated at birth with no explanation as to why since no excessive blood loss is noted.  Following his NICU stay and subsequent rooming in, there are persistent warning signs this was a compromised baby unable to transfer enough colostrum to sustain himself.  First mum states she thought baby was fussy and would have fed more - given this baby had just been discharged from NICU for dehydration, fussiness (which expends energy and suggests something is wrong) along with lack of feeding should surely have raised a red flag?

The report states during the hospital stay baby "appeared" to be feeding, yet mum was unsure if she was producing adequate milk and had concerns over PCOS and potential insufficient glandular tissue.  What this tells us is mum's instincts are baby wasn't feeding well, yet it seems no action was taken by doctors caring for Landon to ensure he now remained adequately hydrated and able to feed well during his stay.  

Babies can fail to latch effectively for a number of reasons but those most at risk of problems are babies in Landon's position.  In fact on day 4, after continuing to lose weight during his stay, a dehydrated baby without adequate urine output was discharged from hospital.  No feeding plan or safeguarding protocols were implemented and just hours late his mother fell asleep with him in arms.  

If the baby had been bottle fed and mum had kept handing back full bottles of unused formula, would staff have been OK with this too?  If not, it clearly demonstrates staff NEED the skills to identify when a baby is drinking well.  They need to check and double check infants who have left NICU following dehydration (of all things!), weighing baby to plot against nomograms if needed 

They NEED to listen to mothers who state their baby doesn't appear to be drinking well, is fussy, is never satisfied - these things are NOT normal!

Why Are Some Media Outlets So Reluctant To Use Qualified Infant Feeding Advisors?

There has been much discussion this week surrounding the "experts" presented in the media to proffer infant feeding support.

"This Morning" did a breastfeeding feature that resulted in a petition demanding those providing their infant feeding advice, hold a qualification in infant feeding.

It seems crazy to me we're even having this discussion, but as it stands those of us in practice have to squirm uncomfortably as mothers are advised to shake their breasts to change their nipple shape and express to check their supply, by "experts" who compare breastmilk to coca-cola.

This isn't the first time there has been social media uproar over the infant feeding advice given, so why are the media so keen to choose the "experts" they do?

They say a picture speaks a thousand words:

Midwives, International Board Certified Lactation Consultants, Breastfeeding Counsellors, Health Visitors are all bound to a code of practice which includes lack of commercial association along with working from an evidence base:
Midwives Code of Conduct
International Board Certified Lactation Consultant Code of Conduct
Evidence base is a tricky thing when it comes to infant feeding and the media.

We need to keep the majority of viewers happy, but statistics show us the majority of viewers aren't sustaining breastfeeding. Evidence based isn't the same as "audience pleasing".
This article is a great example of us liking "what we want to hear":
"The La Leche League, the NCT, the Association of Breastfeeding Mothers and the National Breastfeeding Helpline try hard these days not to sound too judgmental. They do not like being nicknamed ‘the Breastapo’, although some of the NCT’s bossier members can be terrifyingly dogmatic. 
‘We support all mothers, however they decide to feed their baby,’ they insist. But their websites also explain that if you choose formula rather than breast milk, your baby is more likely to suffer from gastroenteritis, diarrhoea, respiratory, urinary, gut and ear infections, asthma, pneumonia, diabetes, obesity, leukaemia and a low IQ. Anna Burbidge, a spokesperson for La Leche League, quoted a recent Unicef survey saying that a baby will be more likely to be hospitalised during its first year if not exclusively breast-fed for the first six months."
So supporting mothers means withholding the evidence base so as not to appear "terrifyingly dogmatic"?
The rest of the article makes it clear the author really would like to believe it doesn't matter how we feed our babies and feels this is what we should be telling parents...

I had this discussion recently with another practitioner in the field of infant feeding.  The reality is, some parents may not want the evidence on which to base an informed choice, particularly if this causes cognitive dissonance (ie, when the information contradicts what someone already believes to be true).   We can encourage informed choice - but we can't force it and nor should we.

By the time mums get breastfeeding support, some (understandably) have had enough.  Sometimes we want "permission to stop" - for someone to say, maybe you're just not built for this?

Alongside this, marketers have worked hard to create a "militant" edge to anyone who works in the field of infant feeding.  Breastapo, Breastfeeding Nazis, dogmatic, judgmental, will push you to breastfeed at any cost.

In reality lactation consultants and breastfeeding counsellors are all trained in precisely the opposite, a non-judgmental approach to facilitate the parents to make choices.   But those who profit from the majority of parents purchasing formula, don't want mothers seeking help in their droves, that would never do in terms of profit margin. 

Creating a divide so parents are poised to perceive information as judgment is a crucial part of the picture in terms of restricting what parents share and who they reach out to.

Being seen to be supportive of breastfeeding, whilst also people pleasing can be a delicate line to tread - perhaps this is why so many media outlets are so keen to stick to what they know?  The Bruce Forsyth of breastfeeding.

Leah from Leeds, Dying to be Perfect

"When women are reduced to their physical appearances, all the things that make them beautiful on the inside, like kindness and intelligence, come to seem less importantThey waste time and energy perfecting their appearances that could be spent developing their careers, bonding with their loved ones, and making the world a better place."
Last week I heard the devastating news a local mum had tragically died undergoing Brazilian Butt Lift (BBL) surgery in Turkey.  Leah Cambridge felt body-conscious after having three smalls and the foreign clinic seemingly offered an attractive alternative to the the UK. 

The BBL procedure takes fat from elsewhere (such as your stomach, via liposuction), before it is re-injected into your butt.  Whilst the procedure seems to be marketed as safer than implants or fillers, there's still a risk of the injected product ending up somewhere it shouldn't - for example your heart or lungs:
“If somebody injects fat into the wrong place and goes deep into the muscle, then the chances of the patient getting muscle necrosis – muscle death – and fat going into the vascular system (which you can die from) are increased."
The Plastic Surgery Group in London reports that, during the second half of 2016, they saw a staggering 500 PER CENT increase in consultations for the BBL. 

The cosmetic surgery and procedure market size was valued at over $26.3 US billion in 2016 and is expected to reach $43.9 US billion by 2025, according to a new report by Grand View Research, Inc.

The photographs and clips published of Leah, show a young (29), vibrant, beautiful, engaging mother with an already model-like figure and a contagious laugh.  We learn about her long-term relationship with a man she planned to marry, how they were building a business and a future as a family.  In the blink of an eye her family are now planning a funeral and three children are left without a mother.

The news coverage highlighted how other young, glamorous  celebrities have also used the clinic - leaving many asking why.

Why are so many young women who seemingly have it all, tempted to risk going under the knife for the perfect butt, boobs or nose?
"The substantial increase in the volume of cosmetic procedures can be attributed to the popularity of digital photography, rising demand by consumers to boost self-esteem, introduction of self-monitoring apps, and increasing affordability of cosmetic surgeries in developing countries."
Dr Jack Duckett Senior Consumer Lifestyles Analyst at Mintel studies surgery trends in the UK:
“Our research shows that women are much more likely to be unhappy with areas of their appearance than men, reflecting the high level of pressure many women feel to look a certain way” says Jack.
“Much of this pressure comes from the advertising industry, with the continued emphasis on photoshopped models promoting unachievable aesthetic goals. But there can be no doubt that social media is also playing an important role in exacerbating many women’s self-image doubts.”
A recurrent theme reading around the topic is pressure to look a certain way, objectification (treating a person as an object or thing) and sexualisation (when a person's value comes only from her or his sexual appeal or behaviour, to the exclusion of other characteristics, and when a person is portrayed purely as a sex object) result in low self-esteem.  

Advertising, "Photoshopping" and now social media - whether you have a girl, boy, nieces, cousins, sisters - we all need to be aware of what's happening around us.

Reports show a trend for these pressures to now start at a disturbingly young age.

In 2010 the Home Secretary commissioned an independent report:
“How have sex, sexiness and sexualisation gained such favour in recent years as to be the measure by which women’s and girls’ worth is judged?
While it is not a new phenomenon by any means, there is something different about the way it occurs today and how it impacts on younger and younger girls.”
The evidence collected in this report suggests these developments are having a profound impact, particularly on girls and young women.
As children grow older, exposure to this imagery leads to body surveillance, or the constant monitoring of personal appearance. This monitoring can result in body dissatisfaction, a recognised risk factor for poor self-esteem, depression and eating disorders.6 
Indeed, there is a significant amount of evidence that attests to the negative effects of sexualisation on young people in terms of mental and physical health, attitudes and beliefs.7"

If you haven't seen it - this presentation from a high school student is a good introduction to sexualisation many may not even be aware of.

The early sexualisation of girls has become such a concern, in 2014 a task force from the American Psychological Association (ASA) was established to examine its effects:
"Sexualisation can lead to a lack of confidence with their bodies as well as depression and eating disorders.".

At the United Nations CSW58 in 2014, Dr. Shari Miles- Cohen from the American Psychological Association (APA) explained:
"the inappropriate portrayal of women and girls in the media is not only negatively affecting women, but is also contributing to the misperception many men have about the female gender."
Outside of TV, music videos and advertising - even in toddlerhood clothes for girls are cut smaller and shorter.  By the time they reach tweenhood, getting a pair of shorts that covers their butt seems a challenge in itself, particularly if they're above average height.  If you succeed with that, finding a top that isn't cropped, cold shoulder or so tight it makes anything active uncomfortable becomes your next challenge.  My daughter frequently bought jeans and shorts designed for boys, because they were so much comfier and designed for movement.  And, they had pockets! 

Last year Clarks shoes sparked a sexism row after naming a girls' shoe range "Dolly Babe" while the boys’ equivalent was called "Leader".  The tough, robust boys' shoes made for action!  The girls' range often can't withstand even a puddle due to the low cut fronts and flimsy soles.

"Let Clothes be Clothes" highlights the problem
Merchandise for boys tells them to be adventurous, a muck magnet, brave, a leader, think big.

Hit the girls' aisle and the pink will knock you over.  Flowers, sparkles and sprinkles with little call to think big.  Leader becomes "bossy" and terms focussing on appearance - beautiful, perfect, pretty etc are in abundance.  Even if these slogans are not emblazoned on the front - the fabric, cut, colour and style fill in the gaps. 

"Princess Pamper Parties" for girls as young as three can now be booked for birthdays - an age where there is SO much more fun to be had than what your face looks like.
Old Snow White
Snow White 2018

Disney market "princess" fake eyelashes and alongside the fact most princesses are saved by their beauty, they've consistently made their princesses thinner and more provocative.

Worryingly "A study published in 2012 by psychologists in America found that girls as young as six were beginning to think of themselves in sexual terms. They were offered two paper dolls, one dressed in sexy, revealing gear, one in trendy, loose-fitting clothes. Asked which one they wanted to look like or thought would be popular, overwhelmingly they chose the “sexy” doll."

The same messages are echoed via toys - as the campaign "Let toys be toys" highlights.  Science, mechanical, engineering, space are all typically marketed at boys.  

Historically toys (and often clothes) were suitable for anyone, as this advert from the 1970 shows:

Modern Lego advert
Just like rinse and repeat doubled the sale of shampoo, gender specific doubles the same of clothes and toys in many households.

Disney Princess "Eyelashes"
I decided to search toys for boys and toys for girls on Amazon via Google.

Here are the search results (in order displayed)

Toys for girls:
  • Toy Electronic Washer
  • Learning Resources Pretend & Play School Set
  • John Adams Chocolate Lolly Maker
  • Toy Ironing Set
  • Learning Resources Time Tracker 2.0
  • Wooden Kitchen Accessory Set
  • Secret Safe Diary
  • Pretend & Play Doctors Set - Multi-Coloured
  • Standing Art Easel - Dry-Erase Board, Chalkboard, Paper Roller
  • Pink Vintage Play Kitchen. Wooden vintage style kids play kitchen.
Toys for boys:
  • Face and Body Paint Mini Starter Kit
  • Black/Yellow Twin Pack Walkie Talkie With Upto 3 km Range
  • Swingball Pro All Surface
  • Pizza Party Wooden Play Food Set With 54 Toppings - Multicolour, 266141
  • Tool Carrycase
  • Snakes and Ladders Ludo Game Set
  • Balance Bike - Red
  • Articulate for Kids
  • 3-D Planets in a Tube Glow-in-the-Dark
  • Bosch Tool Belt
Crafts, learning resources and lots of "homewares" dominate the girls' list, in contrast fun and adventure, games and "tools" dominate the boys'.  

Is it coincidence then that girls outperform boys on all 17 learning indicators in the early years? Yet by teenagehood, maths and sciences are male dominated to the extent 80% of physics A Level students are male.

 “Boys are naturally adapted to be better at maths and space stuff, whereas girls are better at language and communication,” says one. “Which means – logically, according to science – boys should have a natural ability to understand physics a bit better.”
Yet the reality in fact is that a 2015 study found when girls do study choose to study maths and science, they outperform boys all over the world.

The 2010 report noted this too:
"Although the original intention of the review was to focus on how sexualisation is affecting girls, it quickly became evident that we could not talk about girls without acknowledging the concomitant impact on boys and the hyper-masculinised images and messages that surround them. "

In 2014 a project collected all images of both genders featured in The Sun, and stuck them side by side to compare how men and women are represented in the paper:
"The men are nearly all active, doing things. Not posed. The women are passive. It's all about how they look. When I look at the men's side, I see real life. But when I look at the women's side it doesn't seem real. It's all manufactured
"This is a newspaper renowned for sport. And there's not a single picture of a woman doing sport... not one. The only older women on there are a woman on a mobility scooter, The Queen and Mrs Brown. There's a range of emotions on the men's side. The women are mainly smiling or pouting."
When women sportspeople are interviewed, they're often faced with questions about their appearance or personal life.  I'm sure many of us can remember the interview with Serena Williams, when she was asked why she wasn't smiling when she had won!  Commenters noted that in previous interviews male winners weren't smiling and yet were asked about their achievement not their face.  Yet this isn't an isolated example.
"Serena Williams has often been called an “ape” and “gorilla” across the dark caverns of social media; her body has been described in language not unlike the kind you’d find in old timey slave auction advertisements or Old English freak show exhibits. 
In 2014, a high-ranking Russian tennis official snarkily referred to Serena and her sister Venus as “the Williams brothers”. 
In 2012, Williams’ fellow competitor Caroline Wozniacki stuffed her top and skirt, doing her best Serena imitation by mocking her shapeliness. 
As far back as 2009, a sports columnist wrote a scathing editorial about Williams’ body, likening her derriere to food and complaining that she wasn’t attractive enough to him because of her size. 
Her latest Wimbledon win was no different." here
And it's not just Serena, as these Olympic gymnasts can testify.

We're asked if we're "bikini ready", our bodies are constantly
judged and shamed - too fat, too thin, boobs too big, boobs too small, boobs too saggy, makeup too much, not enough makeup, making too much effort, not making an effort.  Clothes too tight, too revealing, not revealing enough.

Women are so conditioned to only think skin deep, they're often just as critical and cutting about how others look.  Body shapes go in and out of fashion like hemlines and women are told to cheer up and smile by random strangers!

Society consistently and persistently delivers the message that our worth is measured by our appearance. It reinforces the message you aren't enough if your boobs are too small or your leggings show off your "love handles".

Being caring, thoughtful, generous, kind or being an amazing mother - aren't revered by the media in the way your hair, makeup, shape or "on trend" outfit is; yet Leah's children wont remember how taut or toned their mother was - they'll long for her warm embrace, her love, laughter and as they grow her wisdom.
The one sexist clothing range, heavily gendered toy or debate about "wolf-whistling" alone may seem an insignificant "snowflake" moan.  The problem though is that when enough snow falls at once, you can quickly find yourself facing a blizzard and stuck in a drift.

Breastfeeding, Dispatches & Society - Can We Provoke Change?

As a flurry of breastfeeding related news hits the headlines in anticipation of the upcoming Dispatches documentary, "discussions" reach boiling point in some quarters and I have to wonder where do we even begin to provoke the paradigm shift needed?

In the documentary preview, we can see the a clearly distressed mum needs help breastfeeding, yet her nearest support group is now two hours away.  Budget cuts mean her local one was closed.

As I highlighted in 2015, parents are being failed on a spectacular scale. 

Not just because of the lack of funding for support in recent years, because let's not pretend that we had good breastfeeding rates before.  It's an area that's long been problematic; some groups headed up by appropriately trained staff and providing a first class service, others whilst well-intentioned but manned by those working beyond remit and with inadequate supervision.

Parents deserve appropriately qualified, timely, effective, appropriately funded support - but the problem is much wider reaching.  Celebrities, the media, medicine, scientists and society as a whole fails mothers.

We tell them to cover up, put it in a bottle, feed in a toilet and make babies independent ASAP (ideally in their own room, sleeping 12 hours per night and "self soothing").  We promote detachment, creating a non-breastfeeding culture and then blame those who are a product of the world they live in.

We can then throw in the "Mummy Wars", a concept created and marketed to mothers by formula companies.  This campaign also successfully resulted in a direct reduction of feeding related information shared across social media networks, the risk of provoking "guilt" - reducing support and overall information even further.

Nowadays someone ALWAYS brings guilt to the table and I tweeted my thoughts this week:

We also have formula companies pushing the "breast is best" message, a recognised marketing technique to induce sales.  As a result academics, highly respected scientists and doctors - talk about the "benefits" of a mammal consuming same species milk. 

They conduct studies that hold those not breastfed as the norm against which they compare the outcomes of those who are - creating the illusion of "benefit".

If we hold breastfeeding as the norm against which we compare the outcome of alternatives, we would find ourselves exploring risks.  Far more beneficial to medicine and science as a whole, but far less desirable when it comes to formula sales.

We have major supermarkets repeatedly breaking laws regarding the promotion of infant of formula milk - a collection of this weeks Tweets include Boots, Tesco, Sainsburys and Asda:

We have campaigns like "Fed is Best" - where retired doctors from completely unrelated fields (and some I suspect suffering their own trauma), wave their HCP status like a banner - right before gas-lighting mothers that how they feed their babies doesn't really matter anyway.

Yet mothers, grandmothers, sisters, aunts tell us it does.  Long before science extolled the "benefits", many mothers had a primal, instinctive drive to feed their young.  The emotion provoked as they unpack their breastfeeding grief, is proof alone that we need to support mothers whatever journey unfolds.

We have Baby Milk Action reporting as doctors like Ellie Cannon joined the Nestle payroll.  Turning next to the Daily Mail this week to tell people breast isn't best so "stop bashing" bottle feeders.

Cannon writes:
"Studies do show that five per cent of breast-cancer rates are attributable to not breastfeeding. So there is an effect – but it’s small and I don’t believe it poses enough of a risk to be a worry for my patients who do not breastfeed."
There are so many problems with this comment.

First, where is this statistic even pulled from?  There isn't a citation.

A 2017 review states:
"From the 13 [studies] that evaluated the effect of length of breast-feeding, the report finds that for every 5 months of breast-feeding duration, there is a 2 percent lower risk of breast cancer.
A rather different statistic to ponder as the WHO recommendation of at least two years would result in a reduction of almost 10%, double that quoted by Cannon.

Second whether that risk was significant for your patient would also surely depend on their other factors such as a family history and other health concerns?  Can we make sweeping generalisations about the health of individuals?

Third, shouldn't patients get to decide whether they feel it's enough of a risk to "be a worry"?  Don't they deserve unbiased advice?

After briefly mentioning asthma and obesity (two conditions from hundreds), we learn that a "study from Brussels" found as long as we add prebiotics, "the health benefits for infants could be almost identical to that provided by human breast milk".   There's no citation and try as I may I can't turn up any such study.

The Daily Mail also tells us in a separate article that "2/3rds of people think breastmilk and formula are "no different" anyway.  Despite science telling us otherwise, the general public aren't convinced!  Well I can't think why, can you Dr Cannon?

Perhaps we shouldn't be surprised given this week, UC Davis professor and researcher Dr Bruce German told us:
"There’s a simple reason we have missed the critical importance of breast milk for lifelong health. It’s because science has been completely focused on the diseases of rich, middle-aged white men. Heart disease, high cholesterol, high blood pressure – these are the ailments that science has been focused on treating since the 1950s.”
We have the volunteer breastfeeding organisations manned by unpaid staff, propping up the entire system - one in which highly paid healthcare professionals refer mums to volunteers donating their time for only minimal expenses.

Breastfeeding is competing with a multi-billion pound industry and it's a battle we're clearly not winning.

We can't pretend how we feed our babies doesn't matter, yet the alternative - to recognise it does and yet leave people with completely inadequate support is just as bad. Even with support, without society on board- we can only get so far.  Yet a huge chunk of society including many health professionals have themselves been failed and cognitive dissonance is the biggest barrier of all.

We need our government to step up and take the lead with funding, but we need to think much bigger and better to hope for it to be more than a drop in the ocean.

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.