Intro

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.

Toxic Breastmilk?

"'Cocktail of chemicals' found in UK mothers' breast milk due to home furnishings" 

The Telegraph

Household chemicals blamed as UK mothers have highest levels of toxins in breast milk

Daily Express

And yet again I wondered who really funds these clickbait headlines.


The paper that provoked such a media response is an environmental audit called "Toxic Chemicals in Everyday Life".  It explores the toxic contamination of our environment, the impact to wildlife, the food chain and society as a whole - with a particular focus on the aftermath of the Grenfell Tower fire. It discusses the levels of toxin exposure we face and how these can affect our health.

They note that toxins from fire-retardant sprays for home furnishing are at significant and worrying levels in everything they tested - from newborn cord blood to the urine of adults.

What's truly bizarre is that the media ran with the breastmilk angle - which is only noted briefly in one of the subsections, and frankly is a drop in the ocean in terms of the level of the problem.

The relevant section reads:
"44. Flame retardants have been detected in air, soil, water, food, wildlife and humans. They are present in homes and offices via dust and on surfaces including windows, floors and carpets.151 Exposure occurs when additive flame retardants leach from goods into the air, dust and surfaces.
So in short, flame retardants (PBDEs) have contaminated everything from the air in your home, to the soil your food is grown in. Oh and the formula you have to use if you don't breastfeed.
"152 Breast Cancer UK suggests the US and UK have the highest levels of flame retardants in human body fluids."
I dug out the Breast Cancer UK briefing which states:
"In general, the USA and the UK have the highest recorded levels of flame retardants in human body fluids (36). The highest concentrations of legacy PBDEs in mothers’ milk have been detected in American women, and the second highest levels in those from the UK (37). Elevated levels of PBDEs have also been found in human blood serum in Californian children at 5 times the US average, and 10-100 times the European and Mexican average"
Oh, so hang on Daily Express - UK mothers don't have the highest levels, Americans do. 

Reference 36 is a 2008 study exploring the US population - it highlights that there are significant differences recorded depending on area and age.

Reference 37 is a 2009 review with particular focus on external exposure routes (e.g. dust, diet, and air) and the resulting internal exposure to PBDEs (e.g. breast milk and blood).

So let's pause a moment to consider that yesterday's headlines were in fact based on a TEN YEAR OLD study...

They note that fats contain higher levels of contaminants presenting an important exposure pathway for humans. This includes foods like fish, dairy products and breastmilk,

They state blood serum levels are 10 times higher in the US in their study than in Europe.  Yet they  couldn't find ten times the difference in the food chain.

But do you know where they did?

Dust
"The ingestion of dust conveys the highest intake of BDE-209 of all sources, possibly also of other PBDE congeners. The PBDE exposure through dust is significant for toddlers who ingest more dust than adults.
Indoor air and dust concentrations have been found to be approximately one order of magnitude higher in North America than in Europe, possibly a result of different fire safety standards."

To compare breastmilk, researchers searched for recorded data from different countries. We're not really comparing like for like, since not all data compared is from the same time period, nor using the same techniques or sample sizes. In the context of contaminants this is a significant flaw, because even within the same area, research highlights massive variations from sample to sample based on their immediate surroundings; some data pooled was samples from 10 people, some from 100, we have no idea what the ages of the sampled were (as the previous study highlights, the older we are - the higher our toxin level).

Everything tested recorded higher in the UK than other parts of Europe, in the one data sample we provided - blood serum, dust etc.

Peeing your pants about breastmilk, is like realising the entire second floor house is on fire, about to burn to the ground - and you make a public announcement your ashtray downstairs in the basement has just caught alight, distracting everyone from the actual imminent disaster.

What the media also fail to recognise - is that by scaremongering against breastmilk, not only will infants continue to be exposed (via the placenta, maternal blood flow, infant formula, the air they breathe and so on), but parents may wrongly believe it to be beneficial to their infant to not receive breastmilk.

In fact - this is like swapping the water you were pouring on the fire to cooking oil.

Exposure to environmental chemicals has been linked to dysregulation of the immune and reproductive system, diseases like cancer - and are known to alter the gut bacteria (microbiome).

Numerous studies have demonstrated that breastmilk is significant in terms of the developing microbiome, contains factors that assist regulation of the immune system and in short, assist the body in dealing with the effects of exposure (1-8).

It's time some media sources started sorting fact from fiction, before they write their headlines.


  1. Pannaraj PS, Li F, Cerini C, et al. Association Between Breast Milk Bacterial Communities and Establishment and Development of the Infant Gut Microbiome. JAMA Pediatr. 2017;171(7):647–654. doi:10.1001/jamapediatrics.2017.0378
  2. Van den Elsen LWJ, Garssen J, Burcelin R, Verhasselt V. Shaping the Gut Microbiota by Breastfeeding: The Gateway to Allergy Prevention?. Front Pediatr. 2019;7:47. Published 2019 Feb 27. doi:10.3389/fped.2019.00047
  3. Alba Boix-Amorós, Fernando Puente-Sánchez, Elloise du Toit, Kaisa M. Linderborg, Yumei Zhang, Baoru Yang, Seppo Salminen, Erika Isolauri, Javier Tamames, Alex Mira, Maria Carmen Collado. Mycobiome profiles in breast milk from healthy women depend on mode of delivery, geographic location and interaction with bacteria. Applied and Environmental Microbiology, 2019; DOI: 10.1128/AE
  4. Cacho NT, Lawrence RM. Innate Immunity and Breast Milk. Front Immunol. 2017;8:584. Published 2017 May 29. doi:10.3389/fimmu.2017.00584
  5. Hsu PS, Nanan R. Does Breast Milk Nurture T Lymphocytes in Their Cradle?. Front Pediatr. 2018;6:268. Published 2018 Sep 27. doi:10.3389/fped.2018.00268
  6. Laura M'Rabet, Arjen Paul Vos, Günther Boehm, Johan Garssen, Breast-Feeding and Its Role in Early Development of the Immune System in Infants: Consequences for Health Later in Life, The Journal of Nutrition, Volume 138, Issue 9, September 2008, Pages 1782S–1790S, https://doi.org/10.1093/jn/138.9.1782S
  7. Molès, J‐P, Tuaillon, E, Kankasa, C, et al. Breastmilk cell trafficking induces microchimerism‐mediated immune system maturation in the infant. Pediatr Allergy Immunol. 2018; 29: 133– 143. https://doi.org/10.1111/pai.12841
  8. Babak Baban, Aneeq Malik, Jatinder Bhatia, Jack C. Yu. Presence and Profile of Innate Lymphoid Cells in Human Breast Milk. JAMA Pediatrics, 2018; DOI: 10.1001/jamapediatrics.2018.0148




Babies 'don't need tongue-tie surgery to feed' - Rapid Response

"Babies 'don't need tongue-tie surgery to feed" is today's BBC headline, which had reached my inbox before I opened my eyes this morning (thank you readers).

We know the media sensationalise studies, so you want to know what it really says right?

Course you do, let's go.

112 babies who had been referred for tongue tie treatment, were assessed by "Speech and language pathologists, who examined the infants' ability to breastfeed prior to a surgical consultation".

112?  That's really one step beyond "large classroom experiment".

My next thought was:

Wow, do Speech and Language Therapists (SALTs) have breastfeeding training in the US?

So I of course asked the man in the know, Dr Ghaheri. His reply:

"Er no".

Errrrrm ok then.

He continues:
"Their professional organization (ASHA) doesn’t recognize TT as being a problem in breastfeeding, solid foods or speech. They are not the practitioner of choice when it comes to breastfeeding pathology either."
I want to clarify this early on (then probably repeat it 10 times throughout this piece for those who will still miss it) - NOT ALL BABIES WITH A TONGUE TIE NEED A RELEASE TO BREASTFEED WELL. At least I'm assured this is the case - people rarely ring an IBLC to say their baby has a tie but hey, they're feeding great and don't need our support.  

This study is exploring infants who were diagnosed as tied and symptomatic with feeding problems, thus had been referred and recommended for release. This means anyone not experiencing a feeding problem from their tie, wouldn't be included in this study.

I pushed on. The SALTS then:  
"offered techniques for mothers to address any feeding difficulties prior to surgical intervention was developed. Infants either found success in feeding and weight gain through this program or underwent procedures."
Ok, that sounds fair enough right?  Try other techniques such as improving attachment, positioning and so on. Indeed these interventions are listed. 

Brace yourself.
"If sleep state regulation was determined to be the primary issue (with the baby falling asleep and transitioned to a nonnutritive sucking pattern causing maternal nipple pain/ injury/prolonged feeding), interventions included arousal actions such as applying a wet facecloth or tapping the infant’s foot."
I had to stop and take a moment here to suck air through my teeth.

News flash - babies fall asleep when the flow of milk isn't worth staying awake for because their attachment is shallow. Tapping a baby or applying a cold wet cloth, may temporarily wake the baby, who will take a few more sucks/swallows before nodding back off again.

Next:
"If volume or rate of breast-milk flow (tongue clicking, gulping, or pulling off the nipple) appeared to be the primary issue, modifications included the following strategies to slow the flow of milk: placing the mother in a supine position (gravity to slow flow), expressing milk prior to breastfeeding, and/or placing the mother and baby in a side lying position."
If a baby is in a shallow latch, they will often perceive the breastmilk supply to be too fast. We can see video examples of that here: with a tongue tie. However with a deep latch, the flow is easily tolerated as we can see here: post tongue tie release.
"If previously-diagnosed reflux appeared to be the primary issue (eg, arching, pulling off nipple), verbal reassurance to continue gastroesophageal reflux disease medication treatment was provided"
Woah woah woah. Wait a moment.

First - pulling on and off the nipple and arching can mean many things.  It can mean "hey the milk has stopped", "I have trapped wind/gas" (top or bottom end), "my mouth is sore" or "my neck is stiff in that position".  Since when did the assumption these symptoms mean reflux become a given?

Shallow latch and feeding technique can cause reflux (NICE) - indeed the baby in the clips above was symptomatic prior to release. It seems though we're just ignoring that in this study and carrying on with medications.

This is where my alarm bells really started ringing.

The authors opened this paper with the statement:
"Inpatient surgical release of lingual frenulums rose 10-fold between 1997 and 2012 despite insufficient evidence that frenotomy for ankyloglossia is associated with improvements in breastfeeding
This is a rather confusing claim, since there are really quite a lot of studies exploring tongue tie and breastfeeding (1-15), my list isn't exhaustive. They consistently demonstrate breastfeeding improvement, none evidence any risk of significant harm and they include is comments such as:
 "No complications were reported with frenotomy."(2)
and
"Ankyloglossia, which is a relatively common finding in the newborn population, adversely affects breastfeeding in selected infants."(4)
and
"This review of research literature analyses the evidence regarding tongue-tie to determine if appropriate intervention can reduce its impact on breastfeeding cessation, concluding that, for most infants, frenotomy offers the best chance of improved and continued breastfeeding. Furthermore, studies have demonstrated that the procedure does not lead to complications for the infant or mother." (6)
and
"Frenotomy is a safe, short procedure that improves breastfeeding outcomes, and is best performed at an early age" (7)
and
"After lingual frenotomy, changes were observed in the breastfeeding patterns of the the tongue-tied infants while the control group maintained the same patterns. Moreover, all symptoms reported by the mothers of the tongue-tied infants had improved after frenotomy."(8)
and
"Tongue-tie is not uncommon and is associated with breastfeeding difficulty in newborn infants." (10)
and
This should provide convincing evidence for those seeking a frenotomy for infants with significant ankyloglossia.(15)
Apparently not.

What we should perhaps also explore some other stats too.

Prescriptions of a a child-friendly liquid formulation of a popular reflux medication (PPI), saw a 16-fold increase in use between 1999-2004.  Between 2006 and 2016, prescriptions of specialist formula milks for infants with cow’s milk protein allergy (CMPA) increased by nearly 500%. (16)

If we want to talk about things lacking an evidence base - let's start here.

"There was no significant difference for both outcome measures while taking either omeprazole or placebo.  Compared with placebo, omeprazole significantly reduced esophageal acid exposure but not irritability." (17)
and
"PPIs are not effective in reducing GERD symptoms in infants. Placebo-controlled trials in older children are lacking. Although PPIs seem to be well tolerated during short-term use, evidence supporting the safety of PPIs is lacking." (18)
and
"As more extensively discussed below, the inappropriate use of acid suppressive drugs has been indeed associated with consistent modifications in the intestinal microbiota by inducing gastric hypochlorhydria, delaying gastric emptying and increasing gastric mucous viscosity [48]. In adults, chronic acid suppression has been linked to an increased risk of small intestine bacterial overgrowth (SIBO). Although not reaching statistical significance, a trend towards an increased risk of SIBO has also been recently observed in children under long-term PPIs therapy (6 months) [49]. Apart from SIBO, the chronic use of acid suppressive agents is a well-known risk factor for gastrointestinal (acute gastroenteritis, Clostidium difficile infection, candidemia and necrotizing enterocolitis) and extra-intestinal (lower respiratory tract infections, community acquired pneumonia) infections, particularly in infants." (19)
and
"Several micronutrients require an acidic environment for optimal absorption. Iron, vitamin C, and vitamin B12absorption are dependent on the intestine's acidic environment. Several studies and case reports describe associations of omeprazole with altered calcium, magnesium, and vitamin B12 absorption. To date, there have been no prospective trials evaluating the effect of proton pump inhibitors (PPIs) on iron absorption.
Conclusions:
Existing data support the conclusion that the acid-suppressing effect of omeprazole can have important clinical implications for vitamin and mineral therapy. Clinicians should be cognizant of this issue in practice. Further studies exploring the relationship of PPIs and iron deficiency are warranted, especially in high-risk populations such as the elderly." (20)
And presumably infants.

I won't bore you with however many more studies and turn this into a reflux post, if you're interested you can read more here. The point is, there are recognised and potentially significant risks associated with reflux medications. As a result, current recommendations are to minimise use whenever possible, giving as a last resort not a first line response; it makes no logical sense as a preferred treatment pathway compared to frenulotomy.

The question this study really asks is - can we breastfeed tongue tied infants ie, provoke weight gain and not suffer nipple trauma, even when the baby is tied.

We of course all know that a lot of the time - yes you can!   2/3rd of the time according to this study. We can employ multiple compensatory strategies. 

Many do constantly jostle their babies awake and feed them 20 times per day to provoke gain or because it's the only way baby settled.

They may give reflux medications, keep baby upright an hour after feeds, use a specialist milk or undertake a restricted diet, at times completely unnecessarily:
"Inappropriate elimination diets have been imposed on pregnant and lactating women and their infants to prevent allergies without scientific evidence proving their efficacy. Even when well indicated in infants and children diagnosed with an allergy, the type of dietary products to eliminate and the duration of such elimination are not always logical."(21)
They may accept their baby is "higher needs" and sleeps badly or has "wind" or is "fussy" as they won't be put down or settle for long.

They may use techniques such as expressing before a feed, reclined feeding or catching the first "letdown" in a muslin.

They may accept they won't take a bottle and feed hourly.

Any family being offered tongue tie division should always be offered the option of doing nothing -  to carry on managing the situation as they have been up until this point, with added tips and tricks for positioning, wind and colic management, expectations and so on.

The problem though is, especially in the patriarchal world of medicine - often the only things valued as markers of "successful breastfeeding" are weight gain and nipple pain. "Symptoms of reflux" are medicated rather than looking the resolve the problem and mothers are told to rub their baby with wet flannels to keep them awake.

These studies don't consider maternal satisfaction levels and overall well-being - is this sustainable in terms of getting through a day?  Is this situation conducive to good mental health for family members?

As usual, social media comments sum things up best:




Join us and share your view here on our Facebook page.


  1. Ghaheri BA, Cole M, Fausel SC, Chuop M, Mace JC. Breastfeeding improvement following tongue-tie and lip-tie release: A prospective cohort study. Laryngoscope. 2017;127(5):1217–1223. doi:10.1002/lary.26306
  2. Srinivasan, A., Al Khoury, A., Puzhko, S., Dobrich, C., Stern, M., Mitnick, H., & Goldfarb, L. (2018). Frenotomy in Infants with Tongue-Tie and Breastfeeding Problems. Journal of Human Lactation. https://doi.org/10.1177/0890334418816973
  3. Emond A, Ingram J, Johnson D, et al. Randomised controlled trial of early frenotomy in breastfed infants with mild–moderate tongue-tie Archives of Disease in Childhood - Fetal and Neonatal Edition 2014;99:F189-F195.
  4. Messner AH, Lalakea ML, Aby J, Macmahon J, Bair E. Ankyloglossia: Incidence and Associated Feeding Difficulties. Arch Otolaryngol Head Neck Surg. 2000;126(1):36–39. doi:10.1001/archotol.126.1.36
  5. Elvira Ferrés-Amat, Tomasa Pastor-Vera, Paula Rodríguez-Alessi, Eduard Ferrés-Amat, Javier Mareque-Bueno, and Eduard Ferrés-Padró, “Management of Ankyloglossia and Breastfeeding Difficulties in the Newborn: Breastfeeding Sessions, Myofunctional Therapy, and Frenotomy,” Case Reports in Pediatrics, vol. 2016, Article ID 3010594, 5 pages, 2016. https://doi.org/10.1155/2016/3010594.
  6. Edmunds, Janet & Miles, Sandra & Fulbrook, Paul. (2011). Tongue-tie and breastfeeding: a review of the literature. Breastfeeding review : professional publication of the Nursing Mothers' Association of Australia. 19. 19-26.
  7. Sharma, S., & Jayaraj, S. (2015). Tongue-tie division to treat breastfeeding difficulties: Our experience. The Journal of Laryngology & Otology,129(10), 986-989. doi:10.1017/S002221511500225X
  8. MARTINELLI, Roberta Lopes de Castro, MARCHESAN, Irene Queiroz, GUSMÃO, Reinaldo Jordão, HONÓRIO, Heitor Marques, & BERRETIN-FELIX, Giédre. (2015). The effects of frenotomy on breastfeeding. Journal of Applied Oral Science, 23(2), 153-157. https://dx.doi.org/10.1590/1678-775720140339
  9. BAXTER, R., HUGHES, L.. Speech and Feeding Improvements in Children After Posterior Tongue-Tie Release: A Case Series. International Journal of Clinical Pediatrics, North America, 7, jun. 2018. Available at:<https://www.theijcp.org/index.php/ijcp/article/view/295/254>
  10. Sopapan Ngerncham, Mongkol Laohapensang, Thidaratana Wongvisutdhi, Yupin Ritjaroen, Nipa Painpichan, Pussara Hakularb, Panidaporn Gunnaleka & Penpaween Chaturapitphothong (2013) Lingual frenulum and effect on breastfeeding in Thai newborn infants, Paediatrics and International Child Health,33:2, 86-90, DOI: 10.1179/2046905512Y.0000000023
  11. Hogan, M. , Westcott, C. and Griffiths, M. (2005), Randomized, controlled trial of division of tongue‐tie in infants with feeding problems. Journal of Paediatrics and Child Health, 41: 246-250. doi:10.1111/j.1440-1754.2005.00604.x
  12. Ankyloglossia: Assessment, Incidence, and Effect of Frenuloplasty on the Breastfeeding Dyad
  13. Jeanne L. Ballard, Christine E. Auer, Jane C. Khoury
    Pediatrics Nov 2002, 110 (5) e63; DOI: 10.1542/peds.110.5.e63
  14. Shaul Dollberg, Eyal Botzer, Esther Grunis, Francis B. Mimouni,Immediate nipple pain relief after frenotomy in breast-fed infants with ankyloglossia: a randomized, prospective study,Journal of Pediatric Surgery,Volume 41, Issue 9,2006,Pages 1598-1600,ISSN 0022-3468,https://doi.org/10.1016/j.jpedsurg.2006.05.024.
  15. A Double-Blind, Randomized, Controlled Trial of Tongue-Tie Division and Its Immediate Effect on Breastfeeding. Janet Berry, Mervyn Griffiths, and Carolyn WestcottBreastfeeding Medicine 2012 7:3, 189-193
  16. Efficacy of Neonatal Release of Ankyloglossia: A Randomized Trial Melissa Buryk, David Bloom, Timothy Shope Pediatrics Aug 2011, 128 (2) 280-288; DOI: 10.1542/peds.2011-0077
  17. Van Tulleken Chris. Overdiagnosis and industry influence: how cow’s milk protein allergy is extending the reach of infant formula manufacturers BMJ 2018; 363 :k5056
  18. Double-blind placebo-controlled trial of omeprazole in irritable infants with gastroesophageal reflux. Moore, David John et al. The Journal of Pediatrics, Volume 143, Issue 2, 219 - 223
  19. Efficacy of Proton-Pump Inhibitors in Children With Gastroesophageal Reflux Disease: A Systematic Review. Rachel J. van der Pol, Marije J. Smits, Michiel P. van Wijk, Taher I. Omari, Merit M.Tabbers, Marc A. Benninga. Pediatrics May 2011, 127 (5) 925-935; DOI: 10.1542/peds.2010-2719
  20. Rybak A, Pesce M, Thapar N, Borrelli O. Gastro-Esophageal Reflux in Children. Int J Mol Sci. 2017;18(8):1671. Published 2017 Aug 1. doi:10.3390/ijms18081671
  21. Humphrey, M. L., Barkhordari, N., & Kaakeh, Y. (2012). Effects of Omeprazole on Vitamin and Mineral Absorption and Metabolism. Journal of Pharmacy Technology, 28(6), 243–248. https://doi.org/10.1177/875512251202800604
  22. Lifschitz, C. & Szajewska, H. Eur J Pediatr (2015) 174: 141. https://doi.org/10.1007/s00431-014-2422-3

Boots UK Force Breastfeeders to Receive Baby Bottles?

This week saw the launch of what can only be described as an utterly random marketing move from Boots UK.  A move to include an obligatory "free gift" of a baby bottle when you purchase baby wipes. 



I'm not sure whether they got their team from the 1950s, but in 2019 we're drowning in plastic.  Not to mention the elephant in the room of course, from an environmental perspective - we really should be supporting those who want to breastfeed to do so.

Instead, not only is the bottle offered when someone is purchasing wipes, but there is no option to decline the free gift and remove it from the basket.

Image Emma Pickett @makesmilk Twitter
Some Tweeters agreed:

Twitter

I can't feel but this spectacularly misses the point. Why should someone who is trying to establish breastfeeding, have to find someone who needs a bottle to get rid of it - thus undertaking the bottle manufacturers' marketing for them? (it's still reaching a consumer in the hope they will purchase more of the same brand). 

Why can't they decline the "gift"?

Would Dr Cairns be equally as dismissive if mums were receiving free breastpads?  I can only imagine the uproar, the outpourings from mothers who didn't want them and the claims of pressure to breastfeed.

Other Tweeters noted this too:
Twitter


And of course the obligatory comments about how some people have to use bottles! (since 88% of babies are bottlefed by 4 months, I think the world is aware the MAJORITY of people are using bottles). 

However this does not justify the insidious, forced marketing to parents and carers who DO NOT WANT THEM.

Let's not even pretend this is all about breastfeeding.

Many who bottle-feed have a brand they use, or don't need or want more bottles either!

Manufacturers know this - so they've clearly done a deal to force their product into your home, like it or not. Maybe if you try one, you'll love it and buy more!  If not, it's used - then what?

Perhaps the most ridiculous argument I read around the subject, was that anyone using these wipes (a single use product that is only 20% recyclable), can't possibly complain getting a free multiple use plastic item.

Using that argument anyone who drives a car, gets on a plane or buys non-organic clothes, can't complain about anything ever.

What if someone doesn't always have reliable access to facilities to wash reusable-wipes, nor safely prepare formula, thus they're trying desperately to establish breastfeeding to free up government tokens for fruit and veg instead? What if more than 50% of children were being raised in poverty - oh no wait, that's right they are


So let's flip this around.


Why can't they decline the "gift"?

Anyone claiming they don't have a problem with this incentive is free to answer (on a postcard, or perhaps more effectively - in the comments below):
Why should parents have to receive an item that they do not want or need?

What Channel 4 Dispatches Didn't Expose About the Infant Formula Industry

Many watched with interest last night as Channel 4 Dispatches exposed infant formula manufacturers and the insidious marketing tactics used.  Top quotes from the programme included this, this, this, this and this.

What Dispatches didn't cover though, is the further problem of retailers, consistently repeatedly flouting the law with seemingly little consequence. Week after week after week offences are repeatedly highlighted and reported on social media - despite retailers claiming their systems won't even allow illegal discounting on first milks...

I scanned Baby Milk Action's Twitter feed.  Here are a sample of the breaches reported in the last month - it is by no means all as several report numerous violations:

Waitrose:


Amazon:

Sainsburys:


 Asda:
 Boots:
Tesco:


Booths:

Co-op:

Wilkos


The law came into force over TWENTY years ago so retailers can hardly claim ignorance. When questioned all claim they adequately train staff, yet day after day new violations come to light.  

Clearly the law is not rigorously enforced, to the point retailers clearly don't give a stuff about adhering to it.


Speaking to MailOnline, Mike Brady from Baby Milk Action, said: 
'The law prohibits the promotion of baby formula milk. But we have seen Tesco do this time and time again, year after year.
'They claim it was a mistake and that it won't happen again, but then it does. They are treating the law as a joke.
'We have been saying Tesco should be prosecuted for repeatedly breaking the law.
'Trading Standards Officers will sometimes visit stores but their numbers have been cut back drastically, so there are just a couple of officers trying to hold these massive companies to account which means no prosecutions are being brought.
'Tesco do seem to be the worst offenders when it comes to this.'  
What this means is that virtually all safe-guards to protect the consumer (in this case babies) are being blatantly ignored.  Companies are marketing to healthcare professionals, regulating themselves, providing the research and "evidence" and then ignoring laws regarding how it's sold.

How many documentaries and news reports do we need before something changes?

New Initiative - Colour Coded Hats on Newborns - No Thanks!

I felt a bit like I'd stepped back in time this morning, when I read the following Tweet from King's in London:



I really thought we were well and truly over the idea of "hatting up" term newborn babies? It seems not:



To be honest I'm even more confused, and the plan sounds more than a little flawed...

Why do term, typical, healthy newborns need a cap?  Could hats actually HINDER important newborn behaviours?

Historically hats were used as way back in the 70s as they were thought to prevent a dip in newborn body temperature. Then we learnt about skin to skin.

"Skin Contact is a powerful vagal stimulant, through sensory stimuli such as touch, warmth, and odor, which among other effects releases maternal oxytocin (Uvnas-Moberg 1998; Winberg 2005). Oxytocin causes the skin temperature of the mother’s breast to rise, providing warmth to the infant (Uvnas-Moberg 1996). In a study of infrared thermography of the whole body during the first hour post birth, Christidis 2003 found that SSC was as effective as radiant warmers in preventing heat loss in healthy full-term infants."


Another 2018 paper "The effect of mother and newborn early skin-to-skin contact on initiation of breastfeeding, newborn temperature and duration of third stage of labor" - found separation hindered all areas and those kept close breastfed sooner, were warmer and their mothers had a more rapid third stage.

Focus shifted to "the undisturbed hour" after which babies don't need a hat. Even back in 2003 and the birth of my first, the midwives took the dinky hat I'd taken and placed it neatly back in my bag. Instead they tucked baby down my nightie and said after that, the ward was quite warm enough.

This seems logical right?  If newborns needed a hat to survive those first few hours, surely they would pop out with their own built in hoodie?  


But alas no - I made a few calls and it seems hats are indeed back in fashion; in fact mums are expected to have early skin to
skin WITH a hat, and the colour coded initiative may be rolled out on a wider scale.



As a mum and an IBCLC, I have to say this is horrifying to me.


The claim is the coloured hat enables them to identifying babies at risk of hypoglycemia (low blood sugars). All term babies apparently wear a hat for the first few hours to help maintain their temperature, including during skin to skin. This intervention it is proposed, reduces risks of separation of the dyad.

The reality is somewhat different.


First, the scent of her baby's head is extremely important to mum during skin to skin and continuing into the early days for early bondingI'm going to bet anyone who has sniffed their newly born baby's head knows exactly what I'm talking about - mothers often describe the scent as "addictive", which in turn encourages her to plant lots of kisses, colonising her with any microbes on her baby, enabling the tailor made production of antibodies, which are passed back via colostrum.


The scent also prompts mum to release oxytocin (often called the bonding hormone), which in turn causes uterine contractions, forcing an instant constriction of the blood vessels that were running to the placenta. (Odent, 2013). Oxytocin is also important when it comes to breastfeeding, and as outlined above it generates heat for the baby - and so it all neatly comes full circle. 



What's more, Dr Kajsa Brimdyr, researcher and expert in the field, covered at the UNICEF Baby Friendly Conference 2018, how hats can impede baby's "breast-crawling" reflexes after birth.

So, you'd think that if we're going to implement an intervention that has the potential to impact on all the above, plus hello, can you imagine skin to skin, half chewing on a pom pom instead of inhaling that delicious newborn scent? There must be some stonking evidence it helps.  A lot.  Right?


Nup, not at all.


There's a paucity of studies on hat wearing at all, there's differences in terms of which hats are used (plastic, stockinette etc) and almost none in conjunction with skin to skin.

However a super amazing midwife, IBCLC friend of mine (thanks Marilyn!) sent me a 2018 study, exploring the preterm baby and knits - in a rural setting where low cost interventions can be hugely beneficial:

"Thermal Effect of a Woolen Cap in Low Birth Weight Infants During Kangaroo Care."
"The use of a woolen cap was safe but provided no advantages in maintaining LBWI in the normal thermal range while being in a KMC ward."
Again these babies are low birthweight and so far more challenged in terms of maintaining their own body temperature - even for them, there was no advantage to a hat.

Going back to the cochrane review above, we can see what did make a difference to hypoglycemia?  Yep, skin to skin.

  • "Blood glucose mg/ dL at 75 to 180 minutes post birth Thresholds for low glucose vary from 40 mgto 50 mg/ dL 
  • The control group mean blood glucose at 75 to 180 minutes post birth was 49.8 mg/ dL
  • The mean blood glucose mg/ dL at 75 to 180 minutes post birth in the intervention group was 10.49 mg/ dL more (8.39 more to 12.59 more) 
  • The mean difference (MD) of 10.49 mg/ dL is clinically significant"
When not in use the hat is kept "near the cot".

Now I love the NHS, I think midwives do a sterling job in the face of ridiculous demands - with most having developed the bladder capacity of a Shire horse. But seriously, now they have to ensure colour coded hats, that are likely to be rarely atop a head, stay with the right baby too?  


Even under normal circumstances the hats wouldn't be needed, but anyone who has spent any time in summer in a typical NHS ward, knows colour coded fans may have been more appropriate. The air-con sucks, the windows barely open and the thought of a chunky knit hat becomes preposterous.


It's important to understand, I'm not questioning the the need to identify at risk infants - I'm questioning the implementation.


Surely a large acrylic colour coded magnetic disk that sticks to the side of the cot would be a far more reliable and environmentally friendly indicator, one that doesn't interfere with mums and babies?


9000 babies are born in King's hospitals each year - imagine if all hospitals roll this out, acrylic yarn isn't sustainable nor is the production of hats via volunteers.


The hat may in fact never even be worn - each baby gets a new hat for infection control reasons, (which must be a minefield in itself, w
ere all knitters healthy and in clean environments? and so on). It also surely raises the question from vegans (or anyone else who chooses to avoid animals based products) of - is that hat real wool or acrylic?  (I asked and they think mainly synthetic, but they're donated so don't really know). 


An alternative option which I think is at least worthy of consideration, is colour coded kangaroo care carriers.  

These are carriers designed to protect baby's airways during skin to skin (if mum falls asleep) and hold baby close when mum wants to be mobile.  


This facilitates best practice and could provide a mobile visual indicator. 


The other benefit of carriers is they could further protect against newborn falls.


Paediatrics 2019 published "
In-hospital Neonatal Falls: An Unintended Consequence of Efforts to Improve Breastfeeding".  The study claimed that in an effort to improve breastfeeding rates, rooming in rather than newborns in a nursery was putting babies at risk of falls.  

Therefore surely the appropriate response is to identify and minimise risks?

When newborn nurseries were introduced, the problem of increased infection risk, mixing up babies or them being stolen, would all be higher than when babies weren't separated from their caregivers. As a result, tags and improved security systems followed. Hospitals have evaluated and adapted to visible risks based on separating babies from their primary caregivers.   

Of course they didn't know then that separation was a bad idea for mothers and babies.

A 2011 paper however highlighed:

"The profound impact of maternal separation on the infant. We knew that this was stressful, but the current study suggests that this is major physiologic stressor for the infant."
They didn't know then that separating mother and infants who need intensive care support and were sent to different units, forcing increased separation - resulted in increased mortality.

They didn't know then that Mother-Child Separation Causes Neurobiological Vulnerability Into Adulthood or that 
scores and incidence of SAD were increased among children who were cared in the NICU and both were correlated with the duration of stay in the NICU.


These risks, whilst not as visible as dropping an infant, are far more common and wider reaching.
Now hospitals know more - they need to re-evaluate and react according. Dr Nils Bergman (a prominent expert and kangaroo care proponont) has long-said mothers shouldn't be left alone. 

The Paediatrics study noted:
All events were associated with mothers falling asleep while feeding their infant, and all occurred between midnight and 6 am
A UK hospital explored their fall rate even further. There they noticed:
"similarities in many of the circumstances in which the falls occurred. These were that the mother had:
  • Had a Caesarean section;
  • A low haemoglobin level [anaemic];
  • Restricted mobility, such as epidural or spinal anaesthesia.

The most common scenario was that the mother had restricted mobility, due to having had a Caesarean section, felt sleepy, and fell asleep with the baby in her arms. The baby then fell from her arms and onto the floor.
  • Simple interventions like open curtains and using bedside cots can reduce baby falls"
These strategies brought about a marked reduction of baby falls and are now being established across all the maternity units across the trust.

Bedside cots were so in demand they had to source more!


Kangaroo Carriers could reduce falls, protect airways and provided the additional colour coding re hypoglycemia.  Either way - ditch the wooly pom poms and let mothers smell their babies.

Edited to add: A midwife friend raised an interesting theory this morning, that newborns (she felt) were at risk of becoming colder with a hat, particularly the babies with hair. Although wiped, their heads are still damp and a hat on a damp head can reduce temperature.  Another interesting theory to throw into the mix!

Infant Feeding - Massive Straw Men with Ambivalence & Gaslights

"A straw man is a common form of argument and is an informal fallacy based on giving the impression of refuting an opponent's argument, while actually refuting an argument that was not presented by that opponent. One who engages in this fallacy is said to be "attacking a straw man."
When it comes to discussing infant feeding, we cover bodily autonomy a lot; mothers and their families have the right to decide how to feed their babies. Nobody should be pressurised into breastfeeding and similarly no mother should be pressurised into not breastfeeding.  It sounds pretty simple and yet it's not.

Infant feeding and discussion of, is fuelled by sleep-deprivation, hormones and significant cognitive dissonance - tangled up with complex emotions and a healthcare system that has now lost valuable skills.

Ultimately we know that many fail to receive adequate support when it comes to feeding their baby, leaving a wake of mothers failed by the system, society or both.

The perhaps most vocal response to this recently, is to claim that it doesn't really matter how we feed our babies anyway.

You can see how this happens - a mum wanted to breastfeed, couldn't and thus relays her story of the difficulties she's faced.  Human nature to many when it comes to hearing pain/distress in others, is to attempt to "fix" it.  To provide a solution which will relieve, however temporarily, the discomfort another is feeling.

To hear, acknowledge, to agree that not everyone can or wants to breastfeed or to help her unpick what happened may not feel enough - particularly when so many lack the skills to enable the latter.

So follows the response is that she shouldn't worry - as it doesn't really matter anyway...

The mum's words often read as though it mattered to her. Whether expressed as anger, guilt, sadness or in any other form, the one emotion that doesn't provoke a heated response is ambivalence.  Thus we can safely say mum is feeling something. To dismiss her desires or needs as unimportant seems the ultimate act of anti-feminism.

If a mum is telling you she wants to breastfeed, trying to convince her she's wrong and that it doesn't matter, or that she probably can't do it, that she's selfish and just doing it for herself, would really not be OK in any other discussion than how we feed our babies.

This is also when we typically see the Straw Man rear his head.

When it comes to infant feeding, the biggest clue is that the writer will often use made up terms to address imaginary groups of people - for example "lactivists".

Strangely enough this term doesn't appear in the recognised dictionaries, but we can turn to the urban dictionary for this definition:
"A lactivist is a lactation activist: someone who considers him/herself an advocate for breastfeeding, whether or not s/he's nursed. Lactivism comes in many forms: choosing to breastfeed, choosing to breastfeed for an extended period of time, choosing to breastfeed in public, choosing to smile at a breastfeeding woman, encouraging other women to breastfeed, educating the public on the benefits of breastfeeding, lobbying for pro-breastfeeding legislation, etc. Maybe you're already a lactivist, and didn't know it."
That would seem to cover rather a large demographic - anyone who considers
himself an advocate, anyone who has breastfed, anyone who smiles at someone breastfeeding?

One article someone screenshot recently stated that "lactivists promote inadequate weight gain in babies by saying it's acceptable".

This is the classic straw-man, a technique to derail discussion by refuting an argument that has never been made.  

There is no statement from the "world leader of lactivists", representing all lactivists worldwide making any such statement - they didn't ask me, did they ask you?  Who exactly are the "lactivists" referenced?

If  specific people are making the claim babies don't need food, addressing them directly would seem more effective than an open letter to a fictional collective.

"Lactation consultants" are another group readily attacked in a similar way. 

Recently I read suggestion that "lactation consultants claim a single bottle of formula can destroy supply."

I'm an International Board Certified Lactation Consultant (IBCLC) and I don't claim this, so is my colleague Debs and neither does she.  My friend Helen in Canada is also an IBCLC and similarly makes no such claims, neither does Jo in the US.  Our regulatory body didn't make this statement - so perhaps what is actually meant is one person, somewhere, calling themselves a lactation consultant, said it?

We often see similar tactics employed by far-right groups, but they're often much more easily identified than when it comes to infant feeding.

Instead this anti-breastfeeding agenda is promoted as merely a reasonable middle ground - a place where no infant feeding method is considered superior to another, because this is really what many want to hear right?  Pat pat women on the head, don't fret dear...

Imagine this in any other area of health - does what adults eat matter or will my GP be promoting beige ready meals and chips next?  If so at what age does it shift from not mattering to being the cornerstone of health?
What about an active lifestyle, is there really enough consistently convincing evidence we need to move?

The next time someone tells you how a mother feeds her baby doesn't matter, blow out the gaslight and listen to the mothers telling you it does.

All Tongue Tie Providers Now Need to Register with the CQC - Outcome & Implications for Parents

Many people still don't truly understand the whole hoo-ha with the CQC.  The confusion I think is the result of a number of factors; the embellishment of whispers, passed along morphing into a "ban" and resulting in a rather bizarrely worded petition to "reinstate providers" - so I've tried to form an analogy that might help give a better understanding.

In your local area is a private road that connects a housing estate to a busy working area. Nobody really knows who the road belongs to, only that some have permission to use the road and some don't need permission. There's a list of prohibited activities that can't be undertaken on the road - for example dancing and shouting, but walking isn't mentioned.

The police don't do anything about people walking on the road, since it isn't causing anybody any problems. The risks to the public of people walking down the road are minimal, because only people who work at the end of the road are carefully walking down it, and in 20 years, there's been no problem; all "walkers" are trained in road safety and their regulatory body ensures they follow standards, to use roads in a safe and responsible manner. A local group check on two occasions if they can use the road and the police reply that they can.

One day, a member of aforementioned local group contacts the police call centre independently to ask if he needs permission to use the road. The call handler (who has no idea about the road in question as they haven't heard of it before), gives the standard response which is to have a look at the local maps, ownership deeds and decide for themselves.

The person takes this back to the local group - concerned they now don't have permission to use the road. The local group contacts the police again, asking for confirmation they legally have express permission to use the road. The call handlers again say it's up to them to decide - there isn't a blanket rule as when it comes to roads, some need permission and some don't..

The group hires a barrister to ask the police for a definite yes or no answer - can we walk down this road without permission?  Who owns this road? Is it technically illegal to trespass? If so can you give us permission to trespass until we've planned an alternate route?  If we are acting illegally, will you, the police take action to stop any of us?

The police state that the road is privately owned, which can be in no doubt if we look at the deeds. The law states most need permission to walk down it - and no they can't give permission without application, because they don't own the road and can't break the law themselves.

They state if someone is acting illegally, of course they may take action to stop them, however if those who have always walked that way, choose to continue walking that way until they find an alternate route, they can consider each person passing on their own merits. For example, if they're from the area and are in the process of applying for permission to pass, are governed by the road safety regulatory body, following the rules and are insured to be in the area - the police can choose not to take any further action.

Frenulotomy has been undertaken by midwives and nurses in the UK for 20 years. Ironically the only fatality reported is at a CQC regulated hospital.  There seems to be confusion that registering with the CQC makes practices safer - and there are some areas of healthcare where this is true.  However tongue tie has historically always been performed by sole registered, insured, healthcare professionals, with an absence of significant adverse effects. If you have a complaint, you contact the healthcare provider's regulatory body (NMC, GMC etc) - this is still the case when CQC registered.

The CQC is designed to regulate hospitals, GPs, Care homes and suchlike - "to monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety".  The OFSTED of healthcare, they are body bound to act in the interest of the public.

Hospitals, clinics etc employ a lot of staff, not all are HCP, they need to know places are following safety protocols and have ways of monitoring satisfaction in the setting.  If we look at their fundamental standards - how many even apply to a self-employed midwife treating 3 tongue ties per week in someone's home? 

When it's one or two people working alone as registered healthcare professionals, their own training and insurance ensures fundamental standards of quality and safety are met -they're not bloody Bupa!

As soon as the ATP started pinning down the CQC, some members (including the chair herself) started completing their CQC applications. - knowing they would have little choice but to deem tongue tie a surgical procedure. By virtue of the law and their own guidance, when backed into a corner, they had little choice but to require registration.

The question is, what happens next?

The costs of preparing and maintaining CQC registration are huge (the application form alone takes weeks to complete, in part again because it's really designed for larger organisations with "staff policies", not a "one-man band").  No doubt some who just did a few here and there will decide not to continue in practice - and for those who do register, these costs will likely be passed on to parents.  Many who ceased practicing before Christmas as advised by the ATP, may have already had such an impact to their business and earnings from which it could be difficult for them to recover.

This is likely to make tongue treatment less attainable to those least able to afford it, leading the way for larger clinics and hospital treatments over the personal one to one service many have valued for so long.
------------------------------------
I spoke with the CQC 18.2.19 and clarified the following (posted initially on the Infant UK tongue tie group)

1) Since pressed legally, the CQC now really have little choice but to regulate frenulotomy. They recognise that it's low risk, has been practiced for years and so on, and as such wasn't an area of interest to them; however, legally it's impossible for them to argue that scissors, a frenulum and blood isn't surgical. Therefore, when asked to define the legal position - they've had to concede pin holding HCPs need to register. The CQC don't write the laws (parliament do), they interpret and enforce them.
.2) The only exemptions in terms of "practicing privileges" apply to doctors with GMC registration (as outlined in numerous pieces of legislation). Petitioning parliament would be the only way to potentially extend this exemption to other HCPs. Similarly if people wanted to propose frenulotomy should be on the list of exempt procedures (like toenails for example), they'd need to do the same.
3) They didn't/don't automatically expect midwives/nurses who are certified/insured and co-operating with the CQC, to stop practicing privately whilst applications are completed/processed. Under the law they cannot give permission for a "grace period", however they do decide who they do/don't prosecute and any action has to be in the public interest. Note - THERE IS NOT A BAN as some have claimed.
4) The CQC ONLY regulate registered healthcare professionals. In this RA osteopaths will require registration, however they do not regulate lay healthcare professionals eg IBCLCs, thus they will not be required to register.
5) If contacting the CQC, please remember those that answer are call handlers. Please ask to speak to the registration team for detailed information.
6) ETA: For the avoidance of doubt, frenulotomy does not fall under the regulated activity ‘maternity and midwifery services’, even where it is carried out by a midwife. Tongue-tie is a condition that is usually picked up in infancy, as a difficulty to breast feed and attach to the breast. Older children or adults may require the treatment related to speech difficulties and, where this is the case, the condition is treated by other healthcare professionals. Treating it is not part of midwifery care. It is post-natal care (see NICE interventional procedures https://www.nice.org.uk/guidance/IPG149).
Click here for Letter ATP received from the CQC and sent to ATP members