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?

AA Answers The Daily Mail Question - How To Keep A Hungry Baby Happy

Health: How to keep a hungry baby happy - Daily Mail

I didn't like Sarah Stacey's answer in the Daily Mail on the link above to the question below. So I decided to reply myself.

Q: I am a first-time mum and don’t produce enough milk for my hungry six-week-old baby boy at night, which makes us both stressed. I want to avoid using formula if possible so the health visitor advised expressing milk with a pump in the mornings – when I have plenty – but I find a manual pump very difficult to use.

A.  What makes you think you don't produce enough milk at night? During the evening it's very normal for babies of this age to cluster feed, which is when they take multiple feeds with shorter spacings in between, sometimes back to back.

In the early days, hunger is driven partly by a hormone called CCK - the same hormone that induces relaxation and sleep. After a feed baby has a high level of CCK, which tells him he’s full, but it drops after another 10 or 20 minutes, so he thinks he’s hungry again. He may go through this loop several times, in what’s known as cluster feeding, before dropping into a solid, longer sleep. This is thought to allow baby to fill their whole digestive system, so excess hunger doesn't occur during a longer sleep spell.


The other thing to consider is that babies often have something called a "growth spurt" at 5-6 weeks ish (sometimes termed "fussy spell"), which can last anywhere from a couple of days to a week or so. This is when a previously settled baby has a sudden increase in appetite and wants to feed feed feed, sometimes appearing insatiable and generally fussy.  It's a normal developmental step seen in both breast and bottle fed infants and they may have a few days sleeping lots after the spurt, which is when some suggest the growing (physically or mentally) occurs.

Therefore the first thing to ascertain is whether you really are not producing enough, or whether you actually have a perfectly normal supply and your baby is just doing what  babies do (but which many "experts" fail to tell parents about).

You mention you have plenty in the mornings, enough to express - which wouldn't suggest a shortage of milk?  It is though totally normal for milk volume to be greatest in the morning and fall gradually as the day progresses, which can leave mums concerned there isn't enough.  But it's also worth knowing that if we measure the fat content of feeds this increases during the day as volume decreases - magic!

Really you need to look at the big picture.  Does baby pee, poop and gain weight as expected, was he previously settled after feeds and you felt things were going well prior to this point?  Is feeding pain free?  If you answer yes to the above, following your baby's lead and feeding on cue is the quickest way through a fussy spell without using formula (which you mention you would like to avoid using). 

If not and your baby remains unsettled or you're experiencing any pain or discomfort,  there is specialist help out there.  From Lactation Consultants to Breastfeeding Counsellors there are lots of options if you know where to look.  Ask your Midwife or Health Visitor for details of local groups and breastfeeding counsellors, find out who is your local Infant Feeding Advisor or call one of the helplines.  If you prefer there are also private Lactation Consultants who charge for their one to one services.  Keep hunting for effective support, with which the vast majority of mums can make enough milk to satisfy even the hungriest of babies.

Big Thumbs Down For Dr Ellie

Dr Ellie off the Telly decided to add her two penneth to the whole "feeding older babies" debate this weekend.  For those who haven't had the pleasure, Dr Ellie is a bit like a female version of Dr Christian Jessen; her website confirms she:

"Works in a busy inner city NHS practice as well as a private practice. She has a very family-orientated practice, specialising in children health from newborns to teenagers."

It's never promising when the publisher is the "Daily Mail", but as Dr Ellie specialises in infants and children - she will surely have her facts straight right?

Errrrrrrrrrrrrrrr hmmmmmmmmm

"Women who breastfeed their older children argue they are doing nothing wrong, and that each mother should be free to do what is right for their child, whether not to breastfeed at all or continue indefinitely.
But as a doctor, I must advise there is little benefit and possibly harm to be done by the latter."

Yikes, right!

Best read on!

Dr Ellie acknowledges the WHO recommendation to breastfeed for two years before adding:

"But there is little evidence of any health benefits beyond the age of one. ."

But hang on,

"WHO is the directing and coordinating authority for health within the United Nations system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends."

So why would they recommend at least two years if actually only a year mattered?  Does Dr Ellie have evidence there aren't health benefits beyond a year?

I could re-write the reply to Clare-Byam Cooking in my last blog post - but as it was only yesterday, I will go for a copy and paste!

Dewey in 2001 found:

"Breast milk continues to provide substantial amounts of key nutrients well beyond the first year of life, especially protein, fat, and most vitamins.”

From Kellymom:

In the second year (12-23 months), 448 mL of breastmilk provides:
29% of energy requirements
43% of protein requirements
36% of calcium requirements
75% of vitamin A requirements
76% of folate requirements
94% of vitamin B12 requirements
60% of vitamin C requirements

Furthermore breastmilk isn't just about nutrition is it? Even if we take this out of the equation, what about immunological implications?

The American Academy of Family Physicians note:

"Children weaned before two years of age are at increased risk of illness (2008).

Again from Kellymom:

“Antibodies are abundant in human milk throughout lactation. In fact, some of the immune factors in breastmilk increase in concentration during the second year and also during the weaning process. (Lawrence & Lawrence 2011, Goldman 1983, Goldman & Goldblum 1983, Institute of Medicine 1991)."

If we think about what's in breastmilk, there is protein that cause cell suicide in over 40 types of cancer, stem cells that develop into many different cell types in the body, serving as an internal repair system. Lymphocytes that kill infected cells directly or mobilise other components of the immune system, enzymes, immunologlobulins and a whole lot more, that actively seek out and destroy harmful pathogens, sweeping them from the body and regulating immune response. Anti infective factors, hormones, growth factors, anti-inflammatories and more. Why on earth would we assume that this is of no benefit after 12 months when we know a child's immune system doesn't mature fully until much later? Where is the evidence supporting this frankly archaic statement?

We can go a step further and remove the nutritional and immunological reasons to breastfeed after a year, and there is still a whole plethora of reasons to continue! Kellymom again covers this in great detail with references here, so I see little point reinventing the wheel; but numerous implications are "dose related" - ie the longer it happens the bigger the "benefit" (or if you want to word things accurately, the earlier it ceases the more increased the risk).

Dr Ellie doesn't stop there though:

"But in my opinion, breastfeeding your child up until three or even later is unnecessary"

Right so is that Dr Ellie's professional or personal opinion?  At least there is clarification it's opinion and not fact.

Dr Ellie then moves on to Sears:

"Every cry from an infant is a cry for help and should never be ignored, he says. Dr Sears even claims that allowing a baby to cry for too long can cause them brain damage."

The "even" implies the comment outlandish, but what Dr Ellie fails to mention is this isn't some far fetched ideal Dr Sears has come up with.  It's one supported by evidence. A 2002 paper entitled "Infant Crying: Nature, Physiologic Consequences, and Select Interventions" states:

"Documented immediate and long-term sequelae of crying include increased heart rate and blood pressure, reduced oxygen level, elevated cerebral blood pressure, initiation of the stress response, depleted energy reserves and oxygen, interrupted mother-infant interaction, brain injury, and cardiac dysfunction. Caregivers are encouraged to answer infant cries swiftly, consistently, and comprehensively."

In fact I would suggest Dr Ellie takes a look at this article as a matter of urgency to bring herself up to date with the latest research surrounding infant crying given her "day job".   Darcia Narvaez, Ph.D. provides an excellent referenced run down on the topic.

Anyway, back to the article:

"The attachment parenting crowd argue this is the way parents have been doing things for thousands of years. I’m not an anthropologist, but I do know that we’re living in an era when these things are not the norm"

Well I think the "AP crowd" probably argue that because it makes anthropological sense?  I appreciate Dr Ellie acknowledges she isn't an anthropologist, so if you would like to hear from someone who is and read an educated opinion  - click here.  Nope it's not the norm, that doesn't therefore make it wrong though does it?

"And breastfeeding until a child goes to school is fulfilling a mother’s needs, not a child’s. It is self-indulgent and possibly narcissistic. Children are at the centre of our world but it doesn’t mean we need to be at the centre of theirs."

Woah backup the truck Dr Ellie, we're definitely into "personal opinion" territory now right?  I know Dr Ellie confessed to no training in anthropology, but surely she can recognise that "appropriate nursing duration" is based on social norms not biological?

Dr Ellie then states that many psychologists worry that "extreme breastfeeding" (perhaps whilst parachuting?) hinders normal child development and indulges the mother with attention and purpose.

I would suggest any such concerned psychologists explore the numerous cultures where children are often nursed until older such as Mongolia, are they a country full of narcissistic needy mothers caring for developmentally delayed children?

Or perhaps some existing research?

In 2010 a study set out specifically to evaluate whether breastfeeding duration predicted later psychosocial development.     Researchers found the opposite of the concerns Dr Ellie raises, and that breastfeeding duration was a positive predictor of future psychosocial development (using an index shown previously to predict school readiness) measured in late childhood, concluding:

""These findings add to growing evidence that breastfeeding could provide lasting economic and social benefits" (Am J Hum Biol. 2010 Nov-Dec;22(6):725-30.)

The American Academy of Paediatrics state:

“Increased duration of breastfeeding confers significant health and developmental benefits for the child and the mother… There is no upper limit to the duration of breastfeeding and no evidence of psychologic or developmental harm from breastfeeding into the third year of life or longer.”(AAP 2012)"

 The Academy of Breastfeeding Medicine state:

“The average age at weaning ranges anywhere from six months to five years… Claims that breastfeeding beyond infancy is harmful to mother or infant have absolutely no medical or scientific basis".

Just to throw a few in to start with...


Back to Dr Ellie:

"Children go to nursery aged three, so they need to be able to cope without their parents."

Um, children don't always go to nursery at three; some go much earlier and others not at all.  But I don't see the link between the "need to be able to cope without their parents" and breastfeeding?  Does Dr Ellie really think toddlers who are breastfed when at home with their mother, can't go to nursery and cope without?

That because they choose to still feed at the breast, this is comparable to feeding a newborn who cannot be left or that the toddler will choose to stay home just because the breast is there?  The mind boggles as to what Dr Ellie thinks feeding a toddler is like!

A bizarre comparison is then made to continuing breastfeeding and not allowing a child to move on from nappies or a pushchair.   As though continuing to provide a child with milk of their own species rather than swapping to that from a cow was directly comparable to these acts.  Perhaps I'm wrong but my radar detects "personal baggage" sneaking into the mix here...

The next comment is the one I find most disturbing:

Toddlers & Tiaras

"Children are sexually aware from a young age. They become interested in body parts and what they do. Breastfeeding a child old enough to walk over to his mother and open her shirt creates a confusing message about personal boundaries and our bodies."

Dr Ellie is attributing sexual traits to a toddler?  For real?  Yikes, I've no idea where Dr Ellie lives but I can assure you that my toddler was not sexually aware!  He still isn't at 6 although he self weaned several years ago, but he does understand breasts are there for the purpose of nourishing (regardless of what else he goes on to appreciate them for as he matures!).

Perhaps I'm the only one that finds it disturbing to hear a Doctor making such links?  For those interested in the culture of sexualising our toddlers, this may be of interest.  But my children could walk over to me and lift my shirt at 10 months and a year respectively, should I have weaned them then despite the evidence highlighting the risks of doing so?

So to conclude, a statement from the American Academy of Family Physicians about GPs and lactation:

"Family physicians should be knowledgeable regarding the ongoing benefits to the child of extended breastfeeding, including continued immune protection, better social adjustment, and having a sustainable food source in times of emergency. The longer women breastfeed, the greater the decrease in their risk of breast cancer.” (AAFP 2008)"

It seems some still have rather a long way to go...