Response:Guardian Letter to a Lactation Consultant

On Saturday The Guardian printed an anonymous “parent piece” from a mother who has a bad experience with a “lactation consultant” and her tongue tied baby.

Many aren’t aware that “Lactation consultant” is neither a recognised nor protected title. Your sister’s, friend Margaret who breastfed for half a day can call herself one.

Similarly, there isn’t an NHS job titled “lactation consultant” either (unlike I believe in the US) - so who this person was or what their qualifications are is incredibly unclear.

International Board Certified Lactation Consultant (IBCLC) is a certified title (although not registered and so ultimately poorly protected) , yet 90% of the time when someone says “lactation consultant”, the person doesn’t hold this certified title.

Unlike in the US, many hospitals in the UK don’t employ a certified IBCLC, even under a different title - although some do.Parents therefore often refer to anyone who helps them breastfeed as the lactation consultant.

As an IBCLC I cringed at the claims of what someone supposedly said, or perhaps implied.

So this certified lactation consultant is going to add another perspective:

1. No mum should be spending 12 hours a day feeding their baby. If someone feels overwhelmed, it’s important that the wants and needs of the parents are central to any “plan” established. I have seen plans set by some hospital staff with little breastfeeding experience, that have no gap for sleeping or eating. Instead two hourly feeding and pumping around the clock may be suggested, which is of course completely unsustainable.
2. Some mums want to use a hospital grade pump, other don’t. Some want to try a nipple shield, some don’t.
3. I’m unsure why a lactation consultant would ask a mum if she’s “fixed the tongue tie”, since this isn’t something a parent can do at home? If baby had a tongue tie diagnosed, when and by whom? Why is this "lactation consultant" not aware of if/when this is happening? It's all very confusing.
4. Frenugreek is a herb typically taken for low milk supply, which can follow a shallow latch associated with tongue tie. I’m not a huge fan personally, but some swear by it.
5. I’m not sure what poor garlic did wrong - a large study found that when breastfeeding mothers consumed garlic, their infants stayed at the breast and breastfed longer (1). And since an increase in breastfeeding can lead to an increase in the breast milk supply, this may be one of the reasons garlic can help breastfeeding mums make more breast milk.Which any certified IBCLC would likely know...

So what appears to have happened here is mum has been discharged attempting to breastfeed a tongue tied baby, with the first mention of support being after a problem has arisen.

The shallow latch meant baby couldn’t pull a full feed, despite feeding at the breast and so was still hungry afterwards. To try and provide more milk for the still hungry baby, mum has expressed - yet many are not given appropriate guidance on how to drain their breasts effectively with a pump. This means mums can invest significant chunks of time, for little milk removal. Some mums struggle to express well even if they have oodles of milk - triggering the milk ejection reflex is a learnt art and even then, some mums don’t respond to a pump the way they do a baby.

As a result of the reduced milk removal though, mum’s supply may reduce further despite her dedication - rather like pushing a boulder up a hill. This can quickly become understandably overwhelming.

The next section again leads me to question whether this was a certified IBCLC:

“more lactation cookies, more mother’s milk tea, more essential oils, more water, more calories, more nutritious calories, more hand expression, more, more, more.”

Lactation cookies and tea aren’t on the whole evidence based, and certainly not routinely recommended in the UK (much more popular in the US) - they tend to have more popularity on parent to parent social media pages.

Essential oils aren’t within the remit of an IBCLC and so would never be suggested in the UK (unless presumably the practitioner is also a certified and insured aromatherapist). Any parent needs to drink normal amounts of water and consume normal calories - drinking and eating excessive amounts doesn’t link to milk supply, so again this is a rather bizarre statement from someone who has supposedly undertaken rigorous training.

There are good and bad in any profession, I saw an appalling GP for an emergency appointment for a relative recently - not that I’m sure the Guardian would be interested in that though.

What’s worse here, is we internationally certified lactation consultants get the flack for anyone and everyone who ever helps with breastfeeding! In the absence of knowing the title of the person that actually helped, lactation consultant is used.

I’m not sure whether this article originated in the UK as the guardian doesn’t specify - but I’m sure many parents can relate to unskilled support lacking appropriate counselling skills they often find themselves left with.

I won’t hold my breath for a guardian article that follows from a mother with a polar opposite experience, I suspect I’d be quickly turning blue.

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
Jeanne L. Ballard, Christine E. Auer, Jane C. Khoury
Pediatrics Nov 2002, 110 (5) e63; DOI: 10.1542/peds.110.5.e63
13. 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.
14. 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
15. 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
16. 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
17. 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
18. 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
19. 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
20. 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
21. Lifschitz, C. & Szajewska, H. Eur J Pediatr (2015) 174: 141. https://doi.org/10.1007/s00431-014-2422-3
    

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.

This has been exposed by the media and Tesco highlighted as particularly problematic here. 

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?

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.

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.

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?

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 before?  Why 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.