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?

Upper Lip Tie Treatment in Infants - Informed Choice, Risks & Efficacy

In all the noise about lip ties, is there risk of misdiagnosis?  And are parents really making an informed decision?

We acknowledge there are risks to most things - from getting out of bed, to taking a paracetamol or treating a tongue tie. We typically weigh up what the benefits may be, what risks are involved and we (hopefully) get the chance to make an informed choice. 

When it comes to treating tongue ties, we have (thanks to diligent practitioners and researchers) over 20 years of studies under our belts.  NICE have explored the research, discussed this with experts in the field and drafted guidelines.  These tell us (among other things) that frenulotomy (treatment for tongue tie), is a procedure of minimal risk for most healthy neonates.  

Risks & Benefits need examining both short and long-term.

Short-term risks of tongue tie treatment would include for example infection in the wound site, baby bleeding more heavily then expected following the procedure or perhaps later in the day after the event.  Long-term risk may include say keloid scarring at the wound site, if you're genetically predisposed.

In short - aside from discussing the potential benefits and effectiveness of tongue tie treatment, we've also established what the potential knock on associated effects may be, and we can examine rates to discuss risks.

Recently some seem to have made the leap of logic to assume it's also therefore safe and beneficial to release other oral frena babies have too - if it is considered "tied".  Tied means that the frenulum is shorter, thicker or placed abnormally compared to a typical frenulum.

So here are the things I think we need to know:

1)  What is a normal infant upper lip frenulum & what is its function?
2)  How do we diagnose an abnormal infant upper lip frenulum?
3)  What problems can an abnormal upper lip frenulum cause?
4)  When & how should we treat it?
5)  What are the benefits, risks and outcomes of treatment?

Language that features below:

Frenulum/Frenum/Frena/Frenula:  The "string" that attaches to the top lip or tongue (or bottom lip/ cheeks)
Maxillary/ labial fraenum: Upper lip frenulum
Diastema:  Gap in the front teeth

Babies should have an upper lip frenum that attaches to the gum or palate.  Seriously I want to drive round with a loudspeaker on the top of my car simply repeating this phrase.

These pictures below show you normal infant placement.  Infant upper lip frena are supposed to be "low sitting".

SOME EXAMPLES OF NORMAL UPPER LIPS.

These babies had no feeding problems, reflux, wind or any other issues.

The confusion as to why everyone at the moment thinks these are ties, is I believe is explained well here.  It's because they can see the low sitting frenum.  As I discuss in this piece 93.4% of babies do, as the frenum attaches to the gum or palate.

Why?

People are concerned their child has a gap in their teeth, and yet this is exactly as it should be.  

Here we can see a normal ADULT MOUTH:

image pocketdentistry.com

In contrast let's look at the ideal INFANT MOUTH:

Image Glenn Carty Orthodontics 

See how different it looks?  And note the low sitting frenulum. Glenn Carty Orthodontist tells us:

"Did you know that Adult front teeth are 2-3 mm wider than baby front teeth? Adult front teeth therefore occupy more space than baby front teeth. A young child's smile should appear very different to that of an adult's. The smile should resemble a picket fence. The baby front teeth should be spaced. While this might not look pretty, the extra space is needed for proper alignment of the adult front teeth"

The frenulum moves up the gum-line in the first 10 years of life, until it sits in the adult position. The gap closes as second teeth align - as per the photo below.

Same child: shows normal frenulum regression and appropriate dental development during childhood

This spacing also makes teeth easier to keep clean.

A 2011 paper states:

The superior labial frenum is triangular in shape and attaches the lip to the alveolar mucosa and/or gingiva. It extends over the alveolar process in infants and forms a raphe that reaches the palatal papilla. Through the growth of alveolar process as the teeth erupt, this attachment generally changes to assume the adult configuration. [1] Taylor has observed that a midline diastema is normal in about 98% children between six and seven years of age, but the incidence decreases to only 7% in persons 12-18 yrs old. [2] But in some instances, the infantile arrangement is retained.

So normally they regress but sometimes this doesn't happen and the frenulum remains lower on the gum. Sometimes a gap (or a diastema) can be seen.  A very famous example of this being of course, Madonna:

Diastema is heavily prevalent in some cultures - for example Nigeria has incredibly high rates.  In turn it's considered extremely attractive and surgery exists to create the gap.  In contrast it's very uncommon in other areas such as china.  

What criteria are we using to diagnose tied versus normal?  How was this established and is it reliable?

When it comes to tongues we look at what normal presentation and function is, and we establish (or we should) how far away from that each baby is.

When it comes to lips, there seems to be a lot of confusion and inaccurate information shared.

The advice many are given is to push the lip back and see if there is blanching, that if it pulls tight and there is a "notch" this will create a gap - and as such removing the frenulum prevents the risk of a diastema.  

But is this true?

It's not just as simple as the skin you can see...

Initially it was assumed the frenulum caused the gap, it seems obvious - we can see a thick meaty piece of skin between the teeth, thus it was assumed that the frenulum not regressing at the expected age, was the root cause of a persistent gap into adulthood.   Interestingly as researchers began exploring further, they discovered it wasn't quite so clear cut.

Some concluded that when the normal regression of the frenulum didn't happen, it wasn't the frenulum causing the gap, but the gap that resulted in the frenulum remaining low.   Another study found a cleft in the bone was associated with some gaps, and others found removing the frenulum did not alone, appear to make a difference to the gap compared to those that remained untreated;10 years later there was no identifiable differences between he two groups.   Some theorised certain types of frenulum could cause a gap, but researchers decided ultimately this wasn't so.  They noted gaps with frenula and frenula without gaps.  They also noted wide variance in the normal frenulum in terms of visual presentation - thickness and so on.

A 2012 review outlines the evidence concerning the cause of a persistent gap, and the possibility of closing it by removing the frenulum:

"At the beginning it was thought that the labial fraenum interfered with the closure of the midline diastema. This belief resulted in misdiagnosis and unnecessary surgical intervention of the fraenum 13,14.

They then outline all the papers and their findings - I've linked below if you want to look in more detail.

They continue:

"Since there is no evidence concerning the fact that the maxillary labial fraenum is the main causative factor for a midline diastema, some orthodontists propose the following therapeutic methodology 37,45: Initially, it is necessary for the dentist to make a diagnostic trial, in order to find out whether the fraenum is implicated in the pathogenecity of the diastema. 

1. Positive “blanch test” of the incisal papilla, when pulling the lips forward. By pulling the upper lip and exerting pressure on the fraenum, if there is a blanching, it is safe to predict that the fraenum will unfavourably influence the development of the anterior occlusion; 

 It is important to emphasize the fact that frenectomy has clinical validity only after the eruption of all 6 permanent teeth if it failed to close the diastema, and then only in conjunction with orthodontic treatment. So after the eruption of all 6 permanent teeth, 9,14,16,20,34,36,37 orthodontic appliances are used to close the diastema. A frenectomy is carried out, so as the scar tissue will hold the teeth together 16,20,27,33,37,39,48. During the primary dentition phase, surgical intervention of the labial fraenum is not recommended7."

This clarifies blanch tests etc are a tool that may be useful as a diagnostic tool once 6 permanent teeth are in.  They weren't designed for, nor tested in terms of accuracy or reliability, in babies and young infants who are expected to have a low sitting frenulum.

The above paper continues to explain the different opinions held by dentists and oral surgeons.

Surgeons tend to prefer removing the frenum and following immediately with orthodontics (so they have good, clear access to the tissue), some dentists agree; other dentists feel a better result is obtained by pushing the teeth together first with orthodontics, and then removing the frenulum, or only removing it if the teeth "drift" back apart again - so any resulting scar tissue holds the teeth together. The last group don't feel there are any benefits to frenectomy.

What all seem to agree on, is the risk of removing tissue from the gum when there are no teeth to push together, suggesting that this may at times result in scar tissue on the gum that makes it impossible to completely close the gap. They continue:

"In the orthodontic community there is unanimity on this issue 37. Orthodontists support that the fraenum should be maintained until the age of the eruption of all 6 permanent anterior teeth. After that, and only if the diastema remains the same, a frenectomy is indicated, with subsequent orthodontic closure of the diastema 9,16"

"Oral surgeons suggest that in case of a maxillary midline diastema, a small intervention of the fraenum is useful. In this way, the closure of the diastema is facilitated and the orthodontic treatment is not affected 9,2 "

So the "unanimous" view is that 6 permanent teeth should be in before the frenulum is removed - ie this is the optimal time for removal along with orthodontics.

What are the risks and benefits therefore to removing it earlier than this, or before the top teeth have even appeared?

I couldn't turn up any studies exploring this.

Here we can see the progression of teeth following lip tie removal in a child who should still have a low sitting frenum, as they do in the first picture:

We can see the child has typical spacing in the first picture, similar to that we saw above.  These pictures have been shared as evidence removing a tie removes a gap - and in this instance it seems clear that removal indeed rapidly resulted in adult dentition and lack of spacing between the teeth.

However we know already this is what happens in the majority of people with time, so what benefits and risks of hastening this process?  How will this impact on adult teeth spacing long-term?  

Interestingly we can note the top lip still looks thin and pinched.  There also appears to be slight yellowing between the teeth on the last photo, although I'm not sure whether that is just this particular photo and the light.

One mum has expressed concern her child's top teeth have come in crossed following his upper tie removal (he had no teeth at the time of the procedure):

Will this self correct as other teeth align and a correctly functioning tongue exerts appropriate pressure? Is this linked with premature removal of the frenulum and something parents need to factor their decision making process?

Without studies we're working from anecdote, which is non-transparent and unreliable.

Mr Sheehan (ENT) Manchester, proposes that as part of the role of the upper lip frenum is to stabilise the top lip, removal of the upper lip tie may also allow over extension when smiling in some people, perhaps those with naturally longer gums.

Helen Marshall (IBCLC) shares similar concerns:

"I had my upper tie removed at around 10 or 11 years old because of a gap in my teeth.  My lip pulls higher up and exposes more of the gum when smiling, and which started post-revision. You can see where it attached to my lip and gum, and my smile would not be the same if it hadn't been cut - --my lips wouldn't be able to ride up and uncover my gums"

Assessing an infant for lip tie.

Even if we were to establish the blanch test above may accurately determine the lip is tight, does that mean we can assume the cause is the length of the frenulum?  We talk about assessing function not appearance, but even this isn't straightforward.

Tongue ties can cause tension through the lips that makes them tight:

The above baby had incredible tension pulled through his mouth by his tongue tie. When we "flipped his lip", it didn't flip at all - instead it blanched and felt incredibly tight.   His parents commented they didn't know where he got his mouth shape as they both had full, plump lips. After the tongue was released and baby turned to his parents, the first thing they both noted was the phenomenal difference in his lips and mouth shape.

The little girl below didn't just have her lips bound down by her tongue tie, her whole chin and jaw was pulled back too.  We saw her chin move forward when feeding immediately post revision, and function was completely changed.

Something as simple as being hungry can cause a baby to tighten their lips. When we assess hungry infants post feed and note tightness, this often presents different when baby is full and relaxed.

Therefore in order to accurately hope to assess function, don't we need to release the tongue first?

What people also often don't understand is that if baby is in a shallow latch on the breast or bottle, the top lip can sometimes curl under when feeding, appearing as though it can't do anything but - to try and compensate.  

Image Milk Matters - tongue tied baby compensation

This is extremely common in tongue tied babies as this post demonstrates. However as anyone who fully understands the mechanics of milk transfer and has observed thousands of dyads will know - it is not desirable for the top lip to flange outwards when feeding either -  it should be neutral as the post above highlights (and the image below shows), flange suggests anything from slightly shallower to very shallow latch.

Below is the same breastfed baby as above with the curled under top lip, immediately after tongue tie release:

Image Milk Matters 

If we just treat the lip, do we sometimes just allow for more or better compensation?

"The added ability to fully flange the top lip will allow a baby to compensate for continued poor positioning or tongue function issues. But of course this is treating a symptom and not the underlying cause. Improving positioning, tongue –tie division, tongue exercises and suck training to promote effective tongue mobility would be more appropriate. "(Oakley 2016)"

And of course, again without studies - what about possible negative consequences? 

One mum on Facebook explained how her journey developed.

Her son had a tongue tie, he had learnt to feed gripping extra hard with his top lip - just like the babies above.  However they were unable to find anyone who would release the tongue and so only the lip was treated.

Following this, he was no longer able to adequately grip with the excess force he had been doing to compensate, and was no longer able to breastfeed.

This proved an extremely traumatic time for all involved and mum feels more studies are needed.

Lack of Guidance

We have no NICE guidance pertaining to lip tie, nor recommendations from any other recognised authority.

Nobody has (in any official capacity), questioned whether the procedure is beneficial to infant feeding, or for the prevention of diastema; whether it has the desired outcome or when the best time for treatment is. Whether the area needs numbing and if pain relief afterwards is required.  Whether both tongue and lip should be released together, given not only the change in presentation post tongue tie release, but because of the difficult or discomfort baby may have feeding with two sore areas in the mouth.

At the moment different practitioners use different lasers (some use heat to cauterise the area, others use intense water jets to vapourise tissue).  This paper discusses that scarring can occur, and describes a surgical technique combining the frenectomy with a "laterally positioned pedicle graft", to give the best aesthetically pleasing response- are infant frenectomies different?  Which method is safest, most effective?

Best practice should surely be based on best for baby, not "we've travelled a long way so may as well just do both..."

Perhaps most importantly,  nobody seems to have explored whether there could be any unintended risks associated with the procedure.  Some argue those who treat would have observed problems should that be the case - however long-term risks can be very difficult to identify in practice rather than research, especially if we're approaching with a bias, and we're not clarifying what "normal" is.

Abnormal lip frena of course exist, and whilst those promoting removal of the ULT claim we in the UK are "behind" and "ignorant" when it comes to diagnosis and treatment, I'm not entirely convinced.

I've found when there is truly abnormal presentation (such as a excessively wide, tight frena that have bound down the lip) the NHS have treated.

Interestingly they tend to release the tissue up where it is attached to the lip, not touching tissue on the gum margin.  In the private sector I have seen both methods used, suggesting we also need assessment and standardisation of this area too. 

However, when presented with normal low sitting frena being called a tie, the NHS (as evidence supports), recommend reassessing again age 8-10 and treating if appropriate.

This is why controlled studies are key.

We need to start asking questions, so that we continue to push for studies and evidence to support guidance for practice.  Simply accepting the word of those performing the procedure is not enough.

Some charge as much as £500 for a consult and release lasting around 15 minutes, enabling them to see 4 per hour.  A 7 hour day that's potentially £14,000, or £70k per week, 280k per month, and so on. Further charges may be applied for feeding support, which many parents report is often needed. 

That's of course not to say there aren't situations where removal may be beneficial - lack of evidence isn't lack of efficacy, but we need to know more!

Parents need facts on which to base a decision, as do those supporting infant feeding.

MUST READ LIP TIE LITERATURE:
The Maxillary Labial Fraenum -A Controversy of Oral Surgeons vs. Orthodontists

The midline diastema: a reviewof its etiology and treatment 

Upper Lip Tie – 4 Facts About Breastfeeding And Upper Lip Ties

Is the Perfect Prep Formula Machine Really Perfect? & Cheaper Cheat Alternative...

It sounds like a dream for formula feeders everywhere; previously torn between risking making bottles in advance or trying to prep them as per the guidelines at 2am - now the perfect prep machine promises to help.

At first glance it looks like the baby equivalent of a Tassimo.

I get the appeal.

Making up formula properly (as any honest mum will tell you) is a complete pain in the arse.  It's not easy or convenient to wash, sterilise and prepare each and every bottle to a 14 step plan; particularly when you consider newborns can feed 12 times per day if fed responsively/on demand.

The perfect prep promises to deliver a ready made bottle in under 2 minutes, at just the touch of a button.

Too good to be true?

If you're expecting something like a coffee machine, whereby you press a button and get a ready to go bottle of formula, you're probably going to be quite disappointed.

You still have to measure and add the powder, add to the machine which first adds a "hot shot" to kill any bacteria in the powder.  You then shake the bottle before cold water is dispensed, resulting (when all works well) in a body temperature bottle.

You also can't make up bottles any smaller than 4 ounces, which is a vast amount for a newborn or young baby and may result in lots of waste or encouraging overfeeding.  This is in my opinion a big downside to the product, as surely it's mums of newborns who wake and feed lots who would potentially benefit most from such a gadget?

So how hot is the hot shot?

Establishing this isn't as easy as you might think, a Google threw up different results and so two mums with perfect prep machines kindly dispensed a shot and measured the temperature.

One reported a reading of 99 degrees and the other 92.  Of course this doesn't mean much as it's hardly controlled, one might have a less accurate thermometer or suchlike - but suffice to say these two are well above the recommended 70 degrees.

Does this matter?

As many will know there has been changes in formula preparation guidelines over the past 10 years or so. We've gone from people using any temperature cooled boiled water, storing bottles for long periods etc to quite a strict protocol.

This has come about not because the UK Government wants to make life difficult for formula users, but because the more we have learnt about the bacteria linked with conditions like gastroenteritis and what their main vessels of transfer are, we can make things safer.  For example we now know 50 degrees is a lovely temperature for bacteria to breed, whereas 70 kills things like E-Coli.

Initially the formula companies were (in my opinion and for quite obvious reasons) quite resistant to these changes. Making the product more difficult and time consuming to prepare is not a manufacturers dream. Even now tins say things like "3 Level scoops; Cooled, freshly boiled water", with no measure of an appropriate temperature (taken from SMA first milk for sale @ Ocado).

The infant nutrition council (the association for the infant formula industry in Australia and New Zealand) quite quickly expressed concerns about people using water too hot stating:

"Nutrients most destructible by heat are the vitamins; thiamin, folate,pantothenic acid and vitamin C. For example, thiamin is destroyed at 100°C."

I had the link for this saved, but interestingly whilst other references to it remain online, I can't locate it any more anywhere on the internet: http://infantnutritioncouncil.com/wp-content/uploads/2009/03/preparation-of-infant-formula-and-safety-around-70-degrees.pdf

Their general guidance as to safe preparation of formula has also been removed.

There was no reference for this statement at the time and nobody seems very sure whether it's actually true.
Several members of a parenting forum therefore contacted formula companies directly to ask.  These posts still currently stand including comments like:

"Originally Posted by mamas_melon I actually emailed sma about this and this is what they said:
Thank you for your enquiry.
We would expect boiling water to adversely affect the nutritional value of Vitamin C, followed by Vitamin B1 and B6. We would not expect any of the other nutrients to be adversely affected, but we don't have any data to support this position."

Others have been told it's because of the probiotics or to avoid scalding the powder.

I found this "Letter to the Editor" in the Journal of Pediatric Gastroenterology & Nutrition 2010

"On the other hand, the use of hot water implies acceptance of some untoward consequences, such as the formation of curds and the loss of some nutrients, mainly vitamins" (14) 

In conclusion, before definitive changes in the recommendations on home handling of powdered milk are made, additional studies may be needed to clarify the cost/benefit ratio of the 2 possible options: water heated to 50°C or to ≥70°C. 

According to the European Society of Pediatric Gastroenterology, Hepatology, and Nutrition, water heated to ≥70°C is not required and may be potentially harmful to the nutritional quality of formulas.

Unfortunately I was also unable to track down the paper for reference 14: "Buchanan R. 2003. Resistance-Thermal and Other. Presentation to the US FDA Advisory Committee, 18–19 March 2003.http://www.fds.gov/ohrms/dockets/ac/03/slides/3939sl_Buchanan_file/frame.htm."

A midwife I asked said some parents she has worked with, have commented some breastmilk substitutes become really lumpy if the water is too hot.  A quick scan through Amazon reviews suggests others have had experienced similar:

"Great invention but the bottles end up too full of air and lumpy."

Other reviewers suggest people check the temperature as they felt the resulting formula was much too cold.

Overall the good reviews do outweigh the bad - a lot of the negative reviews are about reliability and technical problems experienced with the machine, rather than dissatisfaction when it was working well.

So I wondered: is there a cheaper alternative to faster, safer formula?

If you want instant boiling/near boiling water instead of waiting for a kettle?  I can't see any reason you couldn't use something like the Breville hot cup currently selling for £25 if you can wait for it to return to stock (you will see under other sellers on the right there is Amazon at the cheaper rate).

There's your instant "hot shot" - simply top up with cooled boiled water as per the amounts listed on the tin, and tada - fast formula. 

I decided to try a quick experiment for those who want to make up milk with 70 degree water - using either a kettle or an instant hot water machine:

I boiled my kettle and discovered it clicks off at 82 degrees (checked by two thermometers). 

I poured 60ml into an empty bottle and added 10 mls of cooled boiled water.  This (when checked) created water of 72 degrees.

Add this to the infant powder, shake and if making a 4oz bottle (which for the brand I looked at calls for a total of 120ml) adding a further 50ml of the cooled boiled water resulted in a bottle at a suitable for drinking.

You would need a cheap thermometer to test yourself at home what ratios worked for you (because everyone's kettle will be slightly different, as will fridge temp of the cooled boiled water) - then all one needs is to keep cooled boiled water in the fridge, and you can make a bottle quickly in the time it takes to boil the kettle.

Another option to a flask is a water container - you could add the cooled boiled water to something this so it's even quicker when needed, and can still be used long after the days of making formula are gone.

If you wanted a really rapid 2am setup with 70 degree water - you could even pour the initial small amount needed with the hot shot into sterilised, sealed bottles in the fridge all ready to go.  When needed just add the hot shot, powder and top up cold water..  

If you really wanted you could even get the "top up water" amounts ready in advance too - so you grab one bottle with the small amount, add a "hot shot" or water from kettle and then top up with the second bottle of water.

Out & About?
OK so neither the perfect prep or a hot water dispenser can go in your pocket, so I get asked a lot about safe formula preparation outside the home.

Something like this fold up liquid thermometer can be really handy to test liquids on the go, and can also be used to check the milk is cool enough to drink.

If you want a product that can serve more than one purpose, and doesn't need wiping/washing like something that touches milk would, we have this one below.

It has one mode to take the temperature of people or animals, and a second for liquids or other objects.  I've compared this with a mercury thermometer and was surprised at how accurate it was.  It comes in a drawstring bag for travel too.


Have you got a perfect prep?  Has it revolutionised formula making for you?  Let me know in the comments below :)

Perfect Parents, Breastfeeding Bullies & The Mummy Wars - video entry!

So I thought I would spice things up a bit with some Armadillo TV!  Or at least a YouTube Channel :)

Here is the first entry looking at breastfeeding in the UK today and sharing results of the poll I ran in the last entry.   Hope you enjoy it and I look forward to your feedback.

Is Dr Ellie Off The Telly Really That Silly?

As I read this today - my thoughts were not unlike those of the author, Lorraine Candy. Except it wasn't the "vitriolic war" between mums I was hoping to escape, but articles like this one.  The ones that say "go on, give a bottle" - yet forget to mention that could carry negative health implications *oops*.

I discovered the risks post "just one bottle" and I can't lie, I was pretty peed. But hey it's an "opinion piece", so you can say whatever you fancy right?

Lorraine I can forgive, after all why would we expect a DM journo who writes primarily about non-topics like eating custard creams for breakfast, to have a clue? She probably has the best intentions, alongside the fact she might have considered that adding a bit of drama could be good for readership. She's probably right.

I don't however understand people like Dr Ellie, supposedly educated, intelligent health professionals, who seem to do an amazing job of failing to see the wood for the trees when it comes to infant feeding.

There are some formula users who are just as vicious as some breastfeeders.  You see some people are mean, that's how it is - and those mean people are going to fall either side of the "debate".

That doesn't mean it's representative of the vast number of "pro-breastfeeders".  Instead it's rather like claiming all Muslims are Islamic extremists and nicknaming them the Musapo.  Would UK Doctors casually throw that around?

Dr Ellie likes black and white.  Yes breastfeeding is best, if you can't do it don't feel bad, and don't let anyone else make you feel bad.  Yes I know we medical professionals usually spend our time telling you about the "benefits of breastfeeding", and that this time next week you will be reading (in this same newspaper) an article extolling the virtues of human milk; but hey if you can't do it - y'know we'll backtrack and say actually it's not important.  

PS don't feel bad if you can't eat a healthy diet or exercise either - I know we say they're key to being healthy too, but hey working mothers run out of hours, pressure to "provide the best" and guilt over ready meals or not increasing one's heart rate is uncalled for.  My sister was so stressed trying I told her, that undoes any benefits!  And she's the picture of health, despite never exercising and living off convenience food.

Oh no sorry, there are only certain health messages Doctors feel can be scrapped at their convenience.  I don't suppose we should tar all of them with the same brush, I'm sure a fair amount cringe when they see Dr Ellie heading up a column. 

I agree with her mothers are often the ones left feeling bad - so Ellie's pat on the back of "there, there it doesn't really matter", might provide some short term feel good factor.  Until next week's article that is.  The other problem is that given there's only a very small percentage of mothers still  breastfeeding after the first few months - that's an awful lot of people you need to reach and give your feel good message to.

I guess that's where the media comes in, which works well as Dr Ellie can appear the reasonable, caring, "middle ground" - compared to those "extreme lactivists", with the added bonus of a nice boost for book sales.  There was this in March, which just happens to tie in perfectly with this.

But before you shoot out and buy it, perhaps we need to ask - if Dr Ellie is such an advocate of mothers, and by her own admission those she sees distraught have tried really hard to feed.  Perhaps, random idea - it might be more helpful to effectively support these mothers and try and enable them to do so?  

By effective I don't mean a GP who has nothing but the bare minimum of infant feeding training - I mean someone appropriately qualified.  That can't be a difficult concept for a GP to grasp surely?  Ear problems get referred to an ENT, Alzheimer's symptoms referred to a neurologist - if there's one thing GP's aren't a stranger to it's signposting.

So, we get a mother with a lactation problem we refer to?

Nobody.  We tell her not to feel bad because formula is good enough.  

How many GP's even know what a lactation consultant (IBCLC) is?  Despite the fact many areas have an odd one or two employed.  Last week during a discussion with a paediatrician, I mentioned the IBCLC's (there are two) in his hospital.  He had never heard of them, nor their qualifications and didn't regularly work with them to support babies having feeding problems.  Right you are then.

Some areas don't have them at all, perhaps Dr Ellie's is one of them?  Bizarre isn't it, that the NHS promotes feeding intensively on the one hand, yet doesn't provide enough infant feeding supporters to help everyone?

But surely during her appointments with upset mothers, at some point she has pondered the support services?  Where are her vocal calls for improvement? Then instead of trying to convince mothers that actually breastfeeding doesn't matter, they could have a fighting chance at achieving their breastfeeding goals?

We're not talking about trying to convince anyone to breastfeed who doesn't want to.  We're talking purely about helping those that want to do it.  Or does Dr Ellie actually think so many UK women are fundamentally broken, they're simply unable to successfully breastfeed in such large numbers?

You see the trouble is Dr Ellie, breastfeeding isn't just about nutrition.  So you tell a distraught mum, it's OK, formula provides perfectly adequate nutrition, and expect her to be placated.  But you've failed to consider the deep primal drive many mothers have to feed their young; how not doing so can hurt some mums so deeply that "adequate nutrition", doesn't begin to cut it.  If a mum has had a great breastfeeding relationship with one child, has experienced it working - to be deprived of that with subsequent babies can provoke a grief so deep, I've seen grandmothers crying as they recall it.

Those for whom it doesn't work from the start, may never know what they're missing - until they have more babies of course.

Because if Dr Ellie chose to delve beyond the immediate knee jerk reaction of trying to make mums feel better, asked the right questions and listened, truly listened to stories like that in the link above - she would surely see that supporting mothers, has to go much further than platitudes.  Throwing them a bone might work in the short term, but it doesn't last.

To suggest someone is a "bad parent" for not breastfeeding is ridiculous; I too see what some mothers go through trying to feed their babies and I see why some can't continue.  I also meet mothers with issues that could have be easily resolved if only she had received effective support after three days and not three months. 

You see the trouble is, the same health establishment Dr Ellie represents, telling you not to feel bad - are the ones letting mothers down.

Why on earth should a mother feel guilty that her healthcare providers failed to provide her with adequate support?

If  I got in a car without taking a single driving lesson, just a 5 minute crash course in how to operate the mechanics of the vehicle, and then set off down the M1 - would you be surprised if it ended in disaster?  I had a driving instructor, but they were understaffed, so didn't have time to sit and work through the detailed stuff with me.

When I crashed they told me not to feel bad and said not everyone could manage driving, if I wanted to quit public transport was a perfectly acceptable method of getting around - oh and never let the smug drivers make you feel bad either. 

When I said I wanted to try learning to drive a bit longer, and that I thought my car might be damaged - I was told whilst the ideal would be to see a mechanic, a qualified driving instructor and some moral support from Jim who managed to get down the M1 last year.  Problem was they had cut the hours of the mechanics and instructors, they didn't work there half the week - but Jim would call me daily.

When things didn't improve, they said I had tried hard enough, and being happy was more important than being able to drive.  Being unhappy would undo any benefits of driving anyway, and they really needed to tick the box to say that at least one method of transportation was going well...

Unlike not learning to drive, not getting help to breastfeed carries health risks.  It's a hundred times more emotive and linked to depression and feelings of guilt - and yet we're not only accepting this level of care as adequate, we're going to try and pretend after the event that none of it matters?  

Whilst Dr Ellie might like to portray those who are actually passionate about improving care for women, as nutters.  I have my own message for mothers:

1.  Whether you chose to formula feed from the start, or tried breastfeeding and it didn't work - never, ever apologise for how you feed your baby.  Not to a doctor, a mum at a group, a health visitor, a family member - anyone.  I hate hearing mums say "they failed" at breastfeeding, because the vast majority of time they "were failed". 

There are some mothers who can't breastfeed - but with support these mums can understand why, or even choose other methods of feeding at the breast if they wish via a supplemental system.

2.  Ask yourself whether you received the information and support you needed in a timely manner.

3.  If you didn't, pass the blame back:  "I wanted to breastfeed for longer, but didn't receive adequate support to do so."  

Perhaps if more mums started saying this instead of "I couldn't breastfeed", other mums might realise they too were let down,  that it's not their fault.  Perhaps if GP's like Dr Ellie, start hearing facts instead of misplaced guilt from mothers - they might start listening.

Starting Formula Doesn't Have To Mean Stopping Breastfeeding...

We hear lots of different reasons mums choose to introduce formula when breastfeeding; pain, a very unsettled, hungry (or perceived to be) baby, feeling overwhelmed at being the sole person responsible for nourishing their new bundle (who perhaps may be growing slower than health professionals are happy with), returning to work or fear over feeding in public are a few of the common ones.

Society has researched, surveyed and tried to explore these reasons, in the hope barriers to success can be broken down.  But something I don't see examined with such scrutiny, is why mums so often "switch to" formula.

What I mean is why does it have to be a straight swap from 100% of one to 100% of another?   Why does it have to be all or nothing? 

Of course if a mum has damaged/sore nipples wanting to rest them is natural, but if we consider all the other reasons mothers change to exclusive formula feeding, why is it so often assumed once formula is regularly used one might as well switch 100%?

If we think of the breast purely as food, it perhaps seems logical.  If baby is getting adequate nutrition from another source, why continue any feeds at the breast?

But it's not.

Breastfeeding is about so much more!  Hormones, antibodies, bonding and comfort, often a "go to sleep" switch for all involved, to name just a few from a long list.

The problem is how often does a new mum know all this?

Whilst mums often hear oodles of tales about cracked nipples and mastitis, how often does someone who has breastfed successfully for longer than a few months, sit at a baby group regaling others with tales of all the upsides?  Er no, that's the definition of smug, judgy breastfeeding mum is it not?

For women who have never breastfed, have no family or friends that can share their insight into what lays beyond the early days, the sad thing is most don't even know what they're missing.

Of course the norm should be that all mothers get fast, effective help to resolve their problems; that all should be supported to exclusively breastfeed for as long as they wish.  But at the moment this isn't the reality.   For those who haven't managed to resolve problems and are about to switch 100%, don't they deserve to know they have other options?

To be supported to even share one breastfeed per day?  To know they can put the baby to the breast before or after the bottle (a baby causing lots of nipple damage may be more patient in adjustments and suck less strongly when he's not as hungry) at every feed, at some feeds or even for just one if that's all mum feels she can manage.

Once nipples have healed, mum may then choose to increase this if desired.  If we remember babies who  (for whatever reason) are not able to transfer milk as effectively as they need, may consistently feed for very long stretches or very frequently, and that baby is most likely not transferring well because of shallow attachment - the combination of the two can quickly cause cracking or bruising to the nipple.  Once this has healed mum may find combination feeding doesn't permit frequent enough feeding for trauma to reoccur.

I think mums also deserve to know that even if baby's main source of nutrition is formula, that doesn't mean they must also switch to an artificial pacifier; mum can continue to use the inbuilt original aka her breast should she wish to do so.  I've known babies suckle at breasts with barely any milk supply, which surely only confirms that to them, it's definitely not always just about feeling full.

Using some formula doesn't mean mum has to also miss the special little moments; baby pulling from the breast smiling, milk running down his chin.  The instant soothing of a teething pain, learning to sit bump, or 3am fussies with a simple lift of her shirt?

Some mums who feel baby just wasn't getting enough at the breast might choose to supplement feeds during the day and breastfeed only overnight.  If we think calories over a 24 hour period, if low intake was the issue (and increasing supply isn't an option) the extra milk can be given during waking hours, giving the ease and convenience of being able to roll over and feed baby instantly without either party fully waking.

For mums returning to work with younger babies and not wanting to express, you can continue to breastfeed your baby when you're with them.  Yes supply may drop compared to exclusive feeding, but if the alternative is a complete swap, then any feeds are a bonus right?  If baby drains the breast well when you do feed, and this happens with any regularity, supply is unlikely to dwindle altogether.

Even if baby isn't drinking lots of milk when at the breast and supply does reduce, it is likely to happen more gradually; this reduces the chance of mum suffering blockages or mastitis.  As supply reduces the breast begins a process called "involution", and milk gradually reverts to a more colostrum like substance to give the weaning nursling a boost of antibodies.

We could go through lots of scenarios to show how breastfeeding can work in different situations, and it is worth noting there is the potential for a baby finding breastfeeding difficult to become increasingly fussy or refuse the breast once nutritional needs are met elsewhere.  But if the alternative is no breastmilk anyway, some may feel they want to give it a try.

Lastly, and perhaps a key reason to not jump feet first, is that it leaves a window open for a change of heart.  Mums often choose to stop breastfeeding when emotionally at their lowest; tiredness may be overwhelming and she's aching for the situation to stop, never wanting to breastfeed again!  But a few days down the line feelings can change, if partners go back to work the realisation of just how much of a faff formula is (not to mention the ongoing cost) can hit. If not, mix feeding may feel more doable, but if mum does want to stop entirely that option is still there.  At least then the decision has been made rationally and not because things are so unbearable mum feels she has no choice.

I think we have to recognise that whilst there are such gaping holes in the support mothers receive, and a culture still so pro alternatives, any continued breastfeeding should be celebrated as one small step for mothers.  Perhaps instead of focusing on what we can't or don't do, we need to look more closely at what we can.  Celebrating every single feed as one more than might have been; after all every day matters.