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.

Infant Formula – What IS The Magic More?

Copied over from the Milk Matters blog for anyone who hasn't seen :)

My baby needed more than just breastmilk..

Breastmilk wasn’t filling him so we had to give formula.

Baby was big/hungry and not satisfied on breastmilk alone, big babies sometimes need more than exclusive breastfeeding.

My baby isn’t getting what she needs as she wants to feed frequently every evening.

Baby wasn’t gaining enough weight and needed something more.

These are phrases many of us are used to reading online, and I have long pondered – what is the magic “more”?

Firstly let’s think about it logically – human infants are born perfectly designed to consume human milk; just like calves are to drink cow’s milk and piglets are to drink sow’s milk.  For this to be “inadequate” for some infants would make no sense, because before the days you could buy a tin it was the only option.  Secondly the volume of breastmilk isn’t limited to x oz per feed, if baby is hungrier they can drink more and mum makes more!  As the vast majority can (with the right support)  make enough milk for twins, even the hungriest baby can have their fill.

Standard breastmilk substitutes contain around 20 cals per oz, breastmilk contains on average 22.  Fat levels in substitutes are at around 3.5 g per 100ml, compared to an average of 4.2 in breastmilk.  Protein levels in a standard formula are approximately the same as breastmilk, around 1.3g per 100ml.

Breastmilk is often compared to a “healthy salad”, because of how easily it is digested and how the baby feels after feeding; in contrast substitutes are often compared to a “roast dinner”, because baby may zonk out for a long period.  This is partly because it’s easy to inadvertently overfeed with a bottle, but also because milk of another species is much harder to digest – whilst both contain protein, one is human and one is bovine.   In terms of nutrients to grow, breastmilk is no “lighter lunch” than the typical alternative.

So if substitutes offer nothing “more” than breastmilk (and lack all the immunological propertes of breastmilk), why do some parents feel their baby needs them?

I suspect there are several or more answers to this question.  Firstly, formula frequently matches what many mums perceive as a more sated infant, based on cultural expectations.  Many mothers only know infants who are fed substitutes and so their behaviour is held as the norm.   Breastmilk is digested in 1 1/2 - 2 hours, whereas formula can take 3-4 hours; if baby wants feeding every couple of hours or more, mums are often concerned her baby is hungry or “not as settled as they should be”.  The truth is breastmilk is digested at a normal rate - it’s non breastfed infants who often take a longer than normal time to digest, resulting in longer than normal feed spacings.  Nothing to do with “being more content” and all to do with working hard to digest foreign milk!

Some infants struggle so much to digest it results in cconstipation or colic – resulting in less sleep all round – the opposite of the desired result; and for a small proportion of infants the supplement makes absolutely no difference at all to sleep, settling, or frequency of feeding - but a big difference to their gut.
If the sitution in society were reversed and the majority of mums were breastfeeding every couple of hours – a baby suddenly going a long time between feeds would be the cause for concern, not the reverse.  I wonder if the advice then would be to supplement with breastmilk?


It also comes down to ineffective breastfeeding support and education – most babies have fussy periods (previously called growth spurts) where they want to feed much more frequently for a few days, and many in the early weeks cluster feed (lots of feeds back to back early evening) but as a lot of mums are never even told about this, they understandably believe they aren’t making enough milk to satisfy baby, or that for some reason it wasn’t filling enough.  I for one fell into this group with my first and was quite gobsmacked when I read about it online that despite spending 9 months convincing me “breast was best”, nobody had bothered to let me know about that part!

It could also be down to less than great positioning and attachment - baby may not be actually drinking well and so in that case genuinely may need more milk; but that’s because the amount of milk being consumed is too small – not a quality issue.   With good support this can be quickly and easily overcome in the vast majority of cases.

Perhaps the visual aspect also plays a part? we are most used to bovine milk- skimmed is thin and watery, down to full fat which is rich and creamy.  Expressed breastmilk because of the type of protein and fats appears an almost blue colour, and is thinner in consistency than full fat milk; in contrast a bottle of formula appears much more as we expect a richy creamy milk to look.  A good (formula feeding) friend of mine once commented when my first was tiny, that my expressed milk “didn’t look very creamy or rich, was it filling enough?” (First baby didn’t sleep long periods and so the implication was obviously my uncreamy milk!)

Because non breastfed infants often gain more weight than breastfed after the early months, due to either wrong re-constitiuting of powder or overfeeding - perhaps this adds to the feeling formula offers something “more”?

As long as mum is consuming somewhere around the recommended calories per day (1500-1800) and not drastically below, diet has little impact on fat and calorie content of breastmilk.   It can vary mum to mum, feed to feed – but only volume of milk consumed has been correlated with growth.

Lastly the whole “big baby” statement makes so little sense if you think about it.  Those mums who do exclusively breastfeed for 6 months, do so not only when their baby is tiny, but when it is four or five months old too!  Even the chunkiest of newborns or young babies are smaller than this – so why would breastmilk be unable to sustain them when it  can do so fine with older bigger babies?  for those who become chunky – breastmilk made them so, how would it do that if so lacking?

So if anyone does work out what the magic more is, do let me know.

© 2010 milk matters

Study finds formula & follow on contain aluminium - which brands are worst?

Firstly let me clarify this is NOT an anti-formula post!  It's to raise awareness of this contamination issue, because if I were using it I would be campaigning like crazy to stop manufacturers completely ignoring this significant health risk and take action!  I also hope the data allows parents to select brands shown to have a lower concentration of contamination.

A study published in BMC Paediatrics, August 2010 - found formula can contain upto 40 times the level of aluminium found in breastmilk; which is 16 times that allowed legally in water.

A team from Keele Uni in Staffordshire tested 15 ready-made & powdered formula milks for aluminium.

"In both types of milk, levels were still unacceptably high.  Recent research demonstrating the vulnerability of infants to early exposure to aluminium serves to highlight an urgent need to reduce the aluminium content of infant formulas to as low a level as is practically possible.  Previous research strongly suggests aluminium could cause some toxicity in premature babies with illnesses such kidney disease; In a healthy baby you wouldn't see any symptoms or problems but there is concern that it can accumulate & cause issues in later years.  It has been linked to neurological diseases and bone defects in later life and there are even links with dementia. Everyone has aluminium in their bodies but infants are especially prone to absorbing it and are not so good at getting rid of it"

Dr. Chris Exley

What's perhaps most worrying about this study is that the highest levels of all were found in a milk designed for the most vulnerable; Cow & Gate Nutriprem, a specialised breastmilk substitute for premature babies, topped the list of liquid formulas by a significant amount.  The worst offenders for liquid formula after Nutriprem were Cow & Gate First Infant Milk, Cow & Gate Follow-On Milk & Growing Up Milk and Aptamil Follow-On Milk.  In general though the aluminium content of formulas prepared from powdered milks were significantly higher than ready-made milks (with the exception of Nutriprem) with the worst powders being Sma Wysoy Soya, Aptamil Follow-On Milk, Hipp Organic Follow-On Milk (dya think that will be organic aluminium ? ;)) and Cow & Gate Follow-On Milk.  So all in all Cow & Gate didn't fare too well!

As all manufacturers insist that aluminium is not knowingly added to their products, the suggestion is that these products are 'contaminated' with aluminium. The likelihood is that many of the individual constituents of the formulas are contaminated, which may include equipment used in both processing and storing of bulk products. In addition many of the formulas were packaged for sale using aluminium-based materials!

What makes me most cross about the study is it also states:

There has been a long and significant history documenting the contamination of infant formulas by aluminium and consequent health effects in children. Manufacturers of infant formulas have been made fully aware of the potentially compounded issue of both the contamination by aluminium and the heightened vulnerability, from the point of view of a newborn's developing physiology, of infants fed such formulas. There have been similar warnings over several decades in relation to aluminium toxicity and parenteral nutrition of preterm and term infants. To these ends the expectation would be that the aluminium content of current infant formulas would at the very least be historically low and at best would be as low as might be achieved for a processed product

The aluminium content of infant formulas measured herein are not significantly different to historical values and this lack of improvement in lowering their content suggests either that the manufacturers are not monitoring the aluminium content of their products or that the manufacturers are not concerned at these levels of contamination.

It is clear that aluminium in infant formulas is a significant component of early life exposure to this ubiquitous contaminant and as such every effort should be made by manufacturers to reduce the aluminium content of these products to an achievable practical minimum while at the same time manufacturers should be compelled to indicate the level of contamination by aluminium on the packaged product.  Aluminium is non-essential and is linked to human disease.

This link is another compelling reason why mothers should not use fluoridated water to make up formula powder (a topic I plan to blog about soon!).  There is evidence Fluoride in Drinking Water Increases Toxicity of Aluminum - with potentially fatal consequences.   As liquid formula contained generally lower levels, where possible this may be the safer option.
 
I hope those pro-formula or using it, DO something to force manufacturers to address this issue.  Write, email, petition, campaign!  It's not just for the lactivists ;)

The aluminium content of milk powders (P) used in formulas.
Commercial Name of Product N = 5	[Al] μg/g Mean (SD)	[Al] μg/g Range	[Al] μg/L*
Sma Wysoy Soya Infant Formula	4.3 (1.0)	3.7-6.0	629.0
Sma First Infant Milk	2.4 (1.4)	1.3-4.6	333.3
Hipp Organic Follow-On Milk	3.6 (1.6)	2.1-6.3	500.0
Hipp Organic Good Night Milk	2.9 (1.5)	1.7-5.5	406.0
Cow & Gate First Infant Milk	2.8 (0.6)	1.8-3.5	424.0
Hipp Organic First Infant Milk	2.7 (1.3)	0.2-4.2	394.4
Aptamil Follow-On Milk	3.1 (0.5)	2.3-3.8	592.4
Cow & Gate Follow-On Milk	2.5 (3.4)	1.7-10.8	477.8
*Based upon manufacturer's instructions for preparing the milk.
Burrell and Exley BMC Pediatrics 2010 10:63   doi:10.1186/1471-2431-10-63

The aluminium content of ready-made (RM) milk infant formulas.
Commercial Name of Product N = 5	[Al] μg/L Mean (SD)	[Al] μg/L Range
Sma First Infant Milk	267.9 (40.9)	210.1-322.5
Sma Follow-On Milk	245.8 (59.0)	174.5-309.8
Cow & Gate First Infant Milk	338.8 (34.8)	293.0-371.0
Hipp Organic Growing-Up Milk	175.5 (34.7)	131.4-236.8
Aptamil Follow-On Milk	296.1 (13.9)	279.3-314.2
Cow & Gate Follow-On Milk	303.7 (10.8)	285.3-316.8
Cow & Gate Growing-Up Milk	430.0 (214.8)	285.3-856.5
Cow & Gate Nutriprem 1	700.4 (93.6)	602.5-863.0
Burrell and Exley BMC Pediatrics 2010 10:63   doi:10.1186/1471-2431-10-63

New specialised infant formulas - evidence or experiment?

Something I've been wondering recently is how the safety of new breastmilk substitutes is established, what about those that are very different such as say lactose free or amino acid based?  If anyone has any further research links, please do share. Bear with me as this may be rambly!

Human milk is particularly high in lactose and infants produce "lactase" to break it down into glucose and galactose.  In fact human milk has the highest lactose level of all mammalian milk providing 40% of baby's energy requirements, particularly important to the rapidly growing brain and the nervous system. 

"Consider what effects a lactose-free artificial infant formula could have on the infant fed on it" (health-e-learning)

So I had a Google to try and dig up research around the subject of lactose free formulas - but it seems to be really thin on the ground.  I can't find anything that compares the outcome of infants fed lactose free formula compared to those breastfed or fed a standard formula - either in the short or longer term.  In fact I can't find anything period that compares outcome when infants get their energy from something other than lactose... I'm sure before sale they would need to run trials to show infants gained weight and appeared to be developing normally? but where are these studies and what period is this considered over? has anyone studied areas other than just growth such as the nervous system, brain development or rates of illness?

So I had another Google.
I found one article that mentioned a study that compared the outcome for breastfed, standard cow's milk fed and soy fed over a twelve month period - a dig later I found it.

Growth and development during the first year of life of infants fed breast-milk, milk formula or soy formula
If you're interested in reading the abstract, you can visit the link above - I think the last sentence is the most telling:

Statistically significant differences were observed mostly between breast-fed and formula-fed infants.

So surely given this someone is going to focus on researching this and also over a longer period than twelve months? There are markers in breastmilk that suggest a much longer term impact - but who will fund it?  I'm guessing no breastmilk substitute company is going to be spending the money examining this...

I then googled to find any studies pertaining to the brain and found this 2010 study:

CONCLUSIONS: The development of brain electrical activity during infancy differs between those who are breastfed compared with those fed either milk (infant formula) or soy formula, but is generally similar for formula-fed groups. These variations in EEG activity reflect diet-related influences on the development of brain structure and function that could put infants on different neurodevelopmental trajectories along which cognitive and brain function development will proceed.

Ah well that's reassuring then.

None of the above touched on lactose free - if a standard formula can show significant differences, what about one that removes a large component?  Or what about one that is an entirely different make up such as free amino acid-based hypoallergenic versions.  I would be really interested in any research anyone has on these - the long term results of only being fed free amino acids has surely been studied before use, but I'm suspecting probably not?  Interestingly even those who promote this type of formula state it is only appropriate if extensively hydrolised formula cannot be tolerated - why if it's so good?!

I then had a news item delivered that described a new fat free formula - it was far lower in calories as skimmed milk was used, energy was derived from "protein concentrate"; but protein in breastmilk is low and a minimal contributor to energy - so again what is the impact of this sort of substitute?

During my hunt I also found studies where various other ingredients had been added to breastmilk substitutes to try and improve outcome - some appeared beneficial, others not so - but what about all the infants fed formula before the "latest must have ingredient"? what about the infants that don't fare well in the testing?

I also realised that:

Manufacturers may propose the addition of a new ingredient to infant formulas by demonstrating the safety, not the efficacy (the capacity to produce an intended effect under the realistic situation of product use), of the proposed ingredient.

So as long as a product has been shown safe for infants, it can go in the milk - at what point is the line drawn?  it appears manufacturers can change the makeup of formula as suits, providing they use substances shown to be safe (and as this article highlights they regularly do based on price).  But doesn't research covering formula study typical formulation rather than a situation where someone has removed the fat or lactose or changed composition significantly in other ways such as removing fat?

I can totally appreciate that for mums who have a seriously ill infant from food related conditions,  something like a specialised formula may feel like the only answer (and at times it may indeed be).  But what is worrying is that if a baby is refluxy/unsettled even after mum has cut dairy/soya from her diet - some specialists are suggesting a specialist formula as the next step; even for those breastfeeding.  Despite the fact we know breastmilk has factors that support normal gut development; often without even looking in baby's mouth to see if other reasons for a problem exist or contacting a lactation consultant,  ie not as a last resort.

What's even more worrying is that some sources state if we do not consume lactose, we stop producing lactase - and thus become lactose intolerant.  Making an accurate diagnosis pretty essential!

What we also need to remember is that specialist formulas are hugely profitable - and that whilst manufacturers are not allowed to market these directly to parents, they can market them to Health Professionals....

It feels as though infant feeding and babies are almost one big experiment - very profitable but at what cost?

My partner wants to share the feeding, natch!

I use the terms dads/partners simply for ease of reading in this post, but I also understand family dynamics come in a wide range of packages.  It is relevant to any significant other(s) supporting mum with a new baby so please don't be put off by titles.

I first wrote about this in a dispelling myths article a few years ago, but I've noticed it still pops up a lot online:

"I want dad to be able to get involved in the feeding so he can bond",

"We're going to mix feed so dad can help with night feeds",

"My partner says I will need to rest and so we plan to introduce a bottle ASAP, so he can be involved in all aspects of caring for baby".

Most people probably don't see anything wrong with these statements, it all sounds perfectly reasonable; indeed I remember uttering similar with my first, it's just what "non extremists" do right?  I confess I started out a very "mainstream" mum (by the apparently essential labeling system parenting seems to demand) but the more I trained, read and experienced, the more I began looking for evidence rather than opinion - and the more I wondered about dads, bottles and bonding.

 

How ever did dads bond before common bottle use?  Are men too intended to lactate? perhaps that's one for another blog post!  If not what is their role?

Certainly for a long period in time, babies and children were "women's work", (although prior to this evidence suggests care of infants was shared in many societies) but as the change in communities happened so came "modern man” - someone who shared the chores, cooking and childcare.

Dads feeding became something marketed by the artificial breastmilk substitute companies; "feed the baby to bond and help out your partner, be the good dad" was born! It fits great with the hands on dad thing and women proudly announce their husband or partner of course wants to get involved with feeding - like a badge of good parenting. Some of you might remember the advert recently for a follow on milk, it showed a dad pacing with baby at night and the voice over "I promise to do my share of the night feeds"?

The concept is actually a rather nifty idea on a couple of levels. Firstly whether mum breastfeeds is heavily linked with the support (or lack of) received from her partner, secondly mums also buy into dads sharing night feeds because as mentioned above, it makes seemingly logical sense in today's society to share all care.

When mum experiences problems, partners of course want to help resolve things. In fact I often say dads are "solvers".

Often they have no idea how to help with breastfeeding though and in absence of other ideas, infant formula may be suggested to “give mum a break” – the problem can be solved with a bottle! double whammy. Many understandably don't know how much this can impact in the early weeks - perhaps by reducing how effectively baby milks the breast resulting in soreness for mum, or how the fast easy flow of the bottle can cause baby to be impatient and fuss at the breast (particularly if supply is low and so milk flow slower) . Many don't realise that ”help” in the form of a bottle can compound whatever problem mum was having initially, reduce supply - increasing the need for further supplementation and longer term actually cause far more problems than it appeared to solve. Even if they did, many are not aware of the risks of not breastfeeding to baby or mum, or the impact of a bottle of artificial milk.  This can put a lot of pressure on a mum who feels torn by what she has previously been told, but also has a shared sense of lack of other options or coping strategies - how many get good breastfeeding education prior to having a baby?

In practice many mums struggle to express much in the early days, and if they do they may end up so full if a feed is missed they have to express anyway at the same time dad is giving the bottle. If it's before supply has settled, expressing can kick start an oversupply for mum - handy if it's planned for a return to work (as some mums do) not so much so for the new mum wondering why she has enough milk to feed half the street.  Some mums hate expressing, some babies hate bottles and sharing the feeding can end up a lot more work than mum just feeding baby.

But who decided men feeding babies was bonding or that this was the best role for dads/partners to assume?

Before you start yelling at the screen, hear me out.  The hormone oxytocin plays a hefty part in the bonding process; it has been shown to influence trust and social attachment between mammals, plus feeling good, relaxed, connected and less stressed or anxious.  Breastfeeding produces high levels of oxytocin, but it’s not a hormone exclusive to breastfeeding – other things also produce it at different levels. A 2009 study of 80 couples showed:

The more the men in the study cuddled their babies, the more their oxytocin levels rose. It’s like a feedback loop; the more you touch, the more oxytocin you have; the more oxytocin, the more you touch. But you need to initiate this feedback loop, by holding and touching and kissing your baby.”  (Fieldman 2009)

So if the cradling, gazing into baby’s eyes and interacting with them causes oxytocin, does the plastic bottle in hand actually increase it any? Couldn’t dads who want an exclusively breastfed baby do just the same minus bottle? Do dads actually find bottle feeding a bonding experience - or more of a bonding experience than other things they do with baby? Could bottle feeding actually just be considered bonding because it’s been suggested to us that it is, because of the culture we live in?

But what about help during the night?
Although the early weeks of life with a new baby can be hard for new parents, once these have passed it’s a lot easier to breastfeed at night than either person bottle feeding; if baby is co-sleeping or in a co-sleeping cot attached to the side of the bed, nobody even has to sit up. Compare that to the requirements to prepare substitutes safely and it’s a whole different ball game. 

I also think it's a bit of a myth that if men feed the mother gets more sleep - believe me when baby is up and hungry nobody in close proximity is sleeping through it; when it's your baby, you wake!  Another myth is that men need to feed to comfort baby - if baby suffers from colic or is unsettled it can be amazing what even a change of arms can do.  With slightly older infants, if you are confident they are satiated and they are refusing the breast -  dad can offer a clean little finger to suck and a comfy pair of rocking arms

A couple of studies have shown exclusively breastfeeding maximises sleep, particularly if co-sleeping/co-cot sleeping. A study from 2004 found the exclusively breastfeeding mothers slept approximately 20 minutes longer than mothers who were mix feeding (Gay et al). Another study examining quality of sleep found breastfeeding mothers got an average of 182 minutes of slow wave sleep, compared to 63 minutes for those exclusively bottle feeding. Slow-wave sleep is an important marker of sleep quality, and those with a higher percentage of slow-wave sleep report less daytime fatigue. (Blyton et al., 2002).

Whilst dads are often very keen to help out with bottle feeds in the first couple of weeks, I do have to wonder what percentage carry on with as much gusto once the new baby tiredness has kicked in and paternity leave has finished. Don’t some have jobs that need them to be on the ball at work?  If mum is still on maternity leave and doesn’t need to get dressed till noon, isn’t it more likely she will end up doing more night feeds during the week anyway if they’re both shattered?

What can dads do?
I’m firmly of the opinion that “having a breastfed baby” is the responsibility of everyone connected to baby - and partners/husbands/dads even grans absolutely have an extremely significant job! But is the right role at the end of a bottle?

One mum commented:

Frankly I think my husbands parenting skills are in no way diminished by his physiological inability to lactate, and find it a bit insulting that he has to be "included" in this way, as if he has no other role.

The truth is that there is lots of ways dad can help mum, bond, really enjoy the new baby and support breastfeeding:

1. Get support - if problems arise perhaps dad can help locate some support in the area and go along with mum.  On the breastfeeding helpline we get lots of calls from dads and often they can be amazing hands on support when given information and a chance. If you’re still pregnant, why not get your partner reading up on how to tell if breastfeeding is going as expected and what to do if not?

2. Skin to skin -  produces heaps of oxytocin and many babies are comforted by the broad warm chest of dad, just as they are snuggled against mum’s curves.  Mums think nothing of hopping into bed for some newborn snuggles, time out for skin to skin with dad can be just as bonding.
3. Bathing baby - ditch the baby bath and hop in together.  Warm water produces oxytocin, as does skin contact and so both mums and dads report it being a great bonding time (and stops the screaming that can accompany some newborns in the bath!)
4. Wearing baby - popping baby in a good baby carrier and heading off for a walk can give dad some one on one close contact time with baby and give mum chance for a bath and a snooze! If they don't fancy heading outdoors, many babies are content snuggled up pottering round the house.
5. All together now - laying down to breastfeed can give mum chance for a well earned nap. If dad snuggles up too, he can keep an eye on baby (so mum can relax more) One dad in particular commented cuddling up with mum and baby when feeding made him feel particularly included.
6. The collect and deliver – instead of expressing, some mums prefer to feed baby and then dad takes over care, before delivering baby back when hunger strikes.  By the time they baby is a few weeks old, mums can often do this without waking fully - especially with the assistance of dad.  As an added bonus the hormones delivered during the feed help mum drift nicely back off to sleep…
7. Clean, cook, tidy!  - mum has done pregnancy and labour and deserves a babymoon.  If mum gets help in these other areas it can help her relax and enjoy this time.
8. Massage for mum – an upper back and shoulder massage before a feed can be excellent in the early days; often mums hunch their shoulders when trying to breastfeed in mainstream positions, resulting in tension and stress across shoulders and the back of the neck.  There is also an acupressure point between the shoulder blades near the neck, linking the nerves in the upper spine with the breasts; massaging this helps trigger the milk ejection reflex (letdown) in some mums and can be beneficial when nursing or expressing.  At the very least mum should end up feeling more relaxed.

9. Massage for baby – There are lots of reported reasons to massage your baby, again oxytocin is linked.  Why not see if there is a DVD or book as a "how to", or even a newborn group you could all attend together if your partner has leave.    
10. Music & dance – A 2010 study by psychologists found that infants respond to the rhythm and tempo of music and find it more engaging than speech. They like to move in time to the music so get dads to flick on the stereo, and try a few different styles to find their groove.
11. Snacks - in the early days very often as soon as mum feeds, hunger and thirst strike!  having a partner on hand to deliver snacks and water is fantastic.  If dad really wants to go for it, perhaps he could even bake healthy nutritious snacks?  including seeds, grains and the essential good quality dark chocolate.
12. Protector - ok so for cave woman this would likely have been from some big ass tiger, whereas nowadays it tends to be from general interference from a host of well meaning people.  If dad is championing for mum, encouraging and helping if problems arise - not only is mum far more likely to succeed, but others will also be less quick to undermine.  If they do, dad will be in the know enough to step up and protect what is ultimately not only a significant factor in his partners long term health, but the corner stone of his baby's.

Ask the Armadillo - making up infant feeds, what's the deal?

Q.  Dear Armadillo
Would you consider an article about making up infant formula please?  I've read you have to use water hotter than 70 degrees and make the feeds up as required, but a lot of mums I speak to don't do this as it's quite new information and babies have been fine for years without it and over cleaning is just as bad.  Who is right?
Sarah

A.  Hi Sarah
You are correct that Department of Health guidelines are to use water of at least 70 degrees and discard a bottle after two hours (some sources suggest one if baby has been drinking from it)  but there does generally seem to be quite a lot of confusion over the guidelines and whether they are applicable to countries such as the UK & US where water contamination is not an issue.  I wanted to answer this question as for mums not breastfeeding, it's important to make the alternatives as safe as possible.  I should add at this point that I generally had quite a laissez-faire attitude to sterilisation of things when mine were little - I mean once they were crawling on the floor and chewing things that had been on it, I didn't really see much point ensuring toys were sterilised.  I do also think generally that over use in the home of things like antibacterial sprays on every surface, bleaching floors constantly etc carries more risk than the germs they protect from.  Breastmilk substitutes however are a little bit different.

Unlike ready to feed liquid milk, a tin of powder is not sterile and there are risks of contamination all the way through the process - starting with the raw ingredients, during production after pasteurisation and thirdly in the reformulation or in the can at home.  Because of this there are different problems associated with reconstituting incorrectly.

Let's start with the most serious risks.

Without a doubt these are are Enterobacter sakazakii and Salmonella.  The first is a bit of an interesting one as it is found in the gut of healthy humans (probably as an intermittent guest) as well as in the gut of animals and in the environment.  A 2005 study found the prevalence in infant formula varied from 0 to 12% in samples from five different companies.  To give more of an idea of frequency, a 2010 study found 9 out of 149 samples were contaminated with E Sakazakii.

When it strikes it can be extremely nasty, and there are strong links with meningitis, septicemia, and necrotizing enterocolitis.   In the outbreaks reported 50-70% of the infants who contracted the disease died; for those who survive, severe lasting complications can result in various problems including neurological disorders

The trouble with breastmilk substitutes is that they provide the perfect environment for bacteria to grow and thrive, and in 50-80 % of cases powdered infant formula is both the vehicle and the source (direct or indirect) of E. sakazaki induced illness, whilst no exclusively breastfed infants have to date been reported to have Enterobacter sakazakii infections (WHO).
 
Because of the high mortality rate, when links with disease were made investigations immediately began as to how to best minimise risks; scientists discovered boiling water at 70 degrees resulted in a more than 4-log reduction in E. sakazakii levels.  Furthermore, not leaving the made product to sit around prevented any remaining pathogens from increasing  to dangerous levels, a risk that increases further once the enzymes from baby's saliva have entered the mix.  This is really important as in the above mentioned study, 8 of the 9 cases of contamination were low and therefore mixing with water of an adequate temperature and using immediately is likely to reduce this risk to a nominal level.  However using water that is too cool, then leaving the milk to sit around can very quickly lead to high levels of harmful bacteria.
 
Although found less frequently in breastmilk substitutes, more people have heard of Salmonella; it can cause anything from mild diarrhoea, vomiting and cramps to the rarer Salmonella bacteremia which can result in septicemia and meningitis.  Again using water at 70 degrees minimises risks.
 
Because formula contamination rarely hits the news unless it's a large "official outbreak" which is less common, many people are under the impression that the risk of formula contamination is negligible; but WHO feel differently:

Is the risk similar in all regions and countries?

There have been reported cases of Enterobacter sakazakii infections due to contaminated infant formula in only a few developed countries. It is likely that there is a significant under reporting of  infections in all countries. The absence of reports is probably due to a lack of awareness of the  problem rather than an absence of illness. In general, the limitations of current surveillance systems in most countries would add to the explanation for the lack of reported cases. Since infant formula is widely used, the presence of Enterobacter sakazakii in infant formula and its potential effects in infants could well be a significant public health problem in most countries.

Another condition heavily linked with incorrect preparation of infant formula is gastroenteritis, often called stomach flu.  Symptoms include diarrhoea, sickness and stomach cramps - in people able to consume enough fluids it is generally not serious; however infants and young children are at risk from loss of fluids and may need to be hospitalised for treatment to correct or prevent dehydration.
Sue Battersby, a midwife stated in a 2009 report:

Formula is not sterilised and bacteria can be present. When it is made up or stored incorrectly there is a big risk that it could cause gastroenteritis. "Formula fed babies are five times more likely to be admitted to hospital with gastroenteritis, which in the majority of cases is preventable."

It's as usual all about risks rather than certainties - not every baby who drinks milk prepared incorrectly will become ill and nor is meticulously following the guidelines a guarantee baby will remain well; but for the sake of the extra few minutes is it really worth the risk?  Of course good hygiene such as sterilisation of bottles and other equipment (domestic dishwashers usually are not hot enough), effective hand washing and careful storage all contribute too .  My personal experience is that gastroenteritis is still common at 9-24 months, when many parents relax a little - whilst this may be ok for other items such as toys, things that come in contact with breastmilk substitutes are still prime breeding ground.

For people who say they didn't do it with other children and theirs have always been fine, I always think that given the advancements in what we know about bacteria and how to reduce the risks of it - why ignore this?

Is it hard to do in practice?

Guidelines suggest using water that has been boiled and left for no more than around 30 minutes.  For a couple of pounds it's worth buying a thermometer and checking the temperature of your water a couple of times to get a feel for how fast it cools.  It is just as important not to add boiling water to the powder as manufacturers suggest this may damage vitamins/nutrients.

If baby has a rough feeding routine, you can then build in cooling time when at home.  If going out and about, carrying the powder in a sterilised container, water in a flask and then combining the two when required works - again worth checking the temperature a few times if there's risk it could have cooled.  I've heard a lot of mums do this at night too!   Another option is to keep cooled boiled water in the fridge, and work out how much needs to be added to the boiling water to get an appropriate temperature.  If you decide to use thermal bags for carrying ready made bottles, it's even more important to check temperatures after storage as many mums report large differences in how long milk remains at temperature.

Hope that answers your question - it also neatly dispels the myth infant formula is a handy, convenient alternative!

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_084165.pdf