The funny-shaped woman

Milk to go! Breastfeeding in a sling.

2011-10-11T21:29:00.002+01:00

When I got my first sling, I flicked through the instruction booklet and noticed that it mentioned there was a way of breastfeeding your baby in the sling. I remember thinking that breastfeeding in a sling would be a pretty cool trick to master, particularly because my baby always seemed to decide he wanted feeding every time I was standing in the school playground. Very convenient (!).

However, I quickly discovered that even tying my wrap sling was a skill which took several attempts to learn: during my first attempt, I managed to tie my legs together, resulting in an uncoordinated, comical dive across the living room, much to my husband's great amusement...

Once I'd mastered tying my wrap sling, I wore my baby practically everywhere and every day, but it wasn't until I had my 3rd baby that I mastered breastfeeding in my sling.

I have found and compiled some useful video instructions demonstrating how to breastfeed in different types of sling.

How to breastfeed in a stretchy wrap sling:

(Or not... this baby doesn't want to perform... hehe)

How to breastfeed in a non-stretchy / woven wrap sling:

Clear instructions with pictures can be found here

How to breastfeed in a ring sling:

How to breastfeed in a Mei Tai:

How to breastfeed in a structured carrier (like the Ergo):

The ability to breastfeed in a sling is a really useful skill, especially if you have older children to chase after. However, it's not absolutely necessary, so don't worry if you don't get the hang of it!

As one of the wise ladies on my facebook page once said:

"Breastfeeding is a skill. Babywearing is a skill.
Learn the two before combining them"
~Kai Blackley

I can't rescue you, BUT...

2011-09-13T17:44:00.005+01:00

When I read "Don't ask me to save you" by Kath Harbisher, the Singing Doula, I found the article struck a particular chord with me, in the voluntary work I do as a breastfeeding peer supporter. So, with Kath's kind permission, I echo her words here:

When I meet you after the birth of your baby, I don't want you to ask me to rescue you.

When I meet you, you might still be coping with the aftermath of a traumatic birth, or a birth which wasn't what you'd hoped for. You may recently have been discharged from the care of a health professional you have come to depend on for advice. Or your care before or during birth might have been fragmented. You may be struggling to bond with your baby, on top of all the other things you have to learn as a new parent. You might not have got off to a great start with breastfeeding. You might still be coming to terms with the loss of a previous breastfeeding relationship.

You might not even realise that you are asking me to rescue you. And I understand that - I've been there.

But please don't ask me to rescue you. Because I can't do that.

Because "when most women talk about birth trauma and bad birth experiences, when you dig down to the root of the emotions, more often than not, it's about loss of power and control [...]. It's about having your decisions and choices questioned, ignored and over-ruled. Sometimes it's about things, to which you never consented, being forcibly done to you against your will. It's about being made to feel stupid and insignificant for believing you had choices at all." (1)

I appreciate that you might not yet have had time to process your birth experience, or recognise that this may be how you're feeling. I can see that you might not be the happy, empowered, self-confident mother you could be. But I still cannot rescue you.

I cannot give you advice, because if I give you advice about your breastfeeding relationship, I become just another person who's telling you what to do. I become just another person making decisions for you which might be wrong for you or your baby, ignoring the fact that there may be more than one way forward, that you have choices. If I do that, I am disempowering you. If I do that, I am simply making you walk from one cage to another. Or trapping you even more in the prison you're already in. And even if your birth experience was everything you'd hoped for, I'd still run the risk of trapping you. And if I do that, I am failing you.

But what I can do is show you a way out of your prison.

I can offer you ideas, information and support so you can start making your own informed choices about your breastfeeding relationship. Every breastfeeding relationship is unique: I can show you where to find further information so you can evaluate it for yourself, and you can choose a way forward which feels right for you and your baby. And I can support you, because you are your baby's mother, and I have faith that you will make the best and safest feeding decisions on behalf of your baby.

I can show you the way along a different path: a path along which you might take ownership of your breastfeeding relationship, find empowerment through informed choice, and find your own voice to start speaking up for yourself and your baby. A path along which you can set yourself free.

___________________________________________________
Find support after a bad birth:
Birth Crisis (UK)
Solace for Mothers (USA)
The Birth Trauma Association (UK)

___________________________________________________

References

(1) Harbisher, K (2011) Don't ask me to save you
___________________________________________________
Thanks
Many thanks to Kath Harbisher for her thoughts, input and kind permission to use her article.

Am I a food martyr? - Breastfeeding the allergic baby and making dietary sacrifices

2011-07-18T17:15:00.008+01:00

"You never really understand a person until you consider things from his point of view [...] until you climb into his skin and walk around in it."

~ Atticus, To Kill A Mockingbird - Harper Lee

When I support a mother to breastfeed, I am trying to see the world from her perspective; to appreciate the challenges she might be facing, and if she wishes, offer her ideas and information so that she might choose a pathway through her breastfeeding journey which works for her and her baby. There are however, some obstacles to breastfeeding I struggle to imagine what they would really be like to experience.

For just over a year now, I have observed a friend of mine breastfeeding a baby with multiple allergies, almost unable to fathom what it would mean to face something like this myself. Before I continue, I must point out that "Food sensitivities in breastfed babies are not nearly as common as many breastfeeding mothers have been led to think" (1). If you are concerned that your breastfed baby may have a food sensitivity, this article on Kellymom is essential reading, and contact an appropriately qualified breastfeeding specialist (UK telephone helplines are listed on the right).

Along with everyone else, I greatly admired what I perceived to be a deed of heroic undertaking when my friend eliminated a long list of everyday foods from her diet in order to continue breastfeeding her baby. She insisted that she wasn't doing anything extraordinary, but I thought she was just being modest, doubting that I would be capable of such sacrifices myself. And I told her so. And one day she finally turned around and challenged me to live for a week on her diet... and I heard myself accepting.

I admit I panicked a bit as the agreed week drew closer. Wheat, dairy, eggs, soya, meat, nuts and nightshades (includes tomatoes, potatoes, red peppers, aubergines, chilli, paprika and cayenne) were strictly off the menu, so I found myself wondering what on earth I was going to eat. And I very nearly wimped out of it: I am still breastfeeding two babies myself and I didn't really know what I was doing meddling with my food intake - perhaps the whole idea had been a bit rash? However, curiosity got the better of me... and a promise is a promise after all.

Why was I bothering to do this? I was asked. If I was in that situation, wouldn't it be easier to just give my baby some kind of hypoallergenic formula? I simply wanted to understand how to better support mothers like my friend. Support is key to a successful breastfeeding relationship. Supporting a breastfeeding mother of an allergic baby means first and foremost respecting that she is a breastfeeding mother, and that her baby is breastfeeding. She shouldn't have to endlessly justify herself for eliminating foods from her diet and continuing her breastfeeding relationship. The breastfeeding itself isn't actually the problem: it is certain foods in the mother's diet that the baby cannot tolerate. Eliminating those foods eliminates the problem. If the mother switches to infant formula, there is a long list of ingredients to check, and there are absolutely no guarantees that the baby will tolerate that either. Even if it did, not breastfeeding places the mother and baby at much greater risk of developing other short and long-term health problems. Why introduce so many other risks for the sake of a chance that it might solve just one problem?

The week got off to a bad start. Life with four children is rather hectic, so I ended up diving almost completely unprepared into my first day. No preliminary research, no recipes, practically no idea what I was in for. Would the breastfeeding mother of an allergic baby realistically have time for a huge amount of preparation before starting an elimination diet?

After the initial shock of the first couple of days, I realised that eliminating that long list of foods from my diet wasn't the painful experience I'd expected it to be. Although rarely included on my usual shopping list, alternative foods are actually plentiful and delicious. I found that the real challenge for the mother of an allergic infant is that there is a lot to learn, and fast. And everything she learns, she learns as she goes.

It's a steep learning curve, and lack of time is an issue. It takes time for a mother to inform herself about making changes to her diet. Potential vitamin deficiencies need to be looked into - I decided that taking a vitamin supplement would be a wise move for me, especially since I was learning about a new diet as I muddled along, and I wasn't confident I had every vitamin and nutrient covered. Finding alternative foods and figuring out ingredient substitutions which work well in recipes can be a tricky and time-consuming business at first, and can require quite a bit of experimentation and creative thinking, especially if she's eliminating a lot of foods from her diet. It takes time to become fluent in ingredient-speak, to become conversant in all the different words for an ingredient you have to avoid, all the different ways manufacturers sneak different forms of these ingredients into their products. It takes time to find a range of products she can eat, recipes she can work with, to cook from scratch if necessary. And, as I learnt from one or two catastrophic culinary experiments, there is far less room to make mistakes on a diet like this - she can't just order a takeaway if she messes up an evening meal. And would a new mother realistically have time to indulge in culinary experimentation? Being the mother of a new baby is demanding at the best of times, but add in parents who are already exhausted from caring for a baby who has been unusually fussy and unhappy for some time, as well as all the things a mother needs to know in order to successfully navigate her way through breastfeeding a baby with food allergies, and it is very easy to see how starting out can be daunting.

Support is vital to breastfeeding mothers of babies with food sensitivities - they simply have different needs to other breastfeeding dyads.

There are a number of ways that relatives, friends and breastfeeding supporters can make life easier for breastfeeding mothers of allergic babies, especially during the first few weeks while they adjust to their new eating habits. The mother might need:

help with researching information about eliminating foods from her diet, especially with picking out the information that is relevant and useful to her. Useful organisations and websites include:

Kellymom's article Dairy and other Food Sensitivities in Breastfed Babies - a goldmine of information and links
Botanical food family list from the Calgary Allergy Network - don't forget to check out the rest of this informative site too

Living Without - a magazine for people with allergies and food sensitivities

foodsmatter.com - articles, research reports and recipes for all sorts of food allergies

Pig in the Kitchen - great blog by a family catering for children with multiple food allergies

The Vegan Society - plenty of ideas for those avoiding meat, fish, dairy or eggs

Coeliac UK - information for those avoiding gluten

Wheat-free.org - information for those avoiding wheat

Eggless Cooking - ideas for those avoiding eggs

Go Dairy Free - information for those avoiding dairy
How To Do A No Nightshades Diet

Tomatoes are Evil - hilariously obsessive anti-tomato website

We know they're in there...
Image credit: Tomatoes are Evil

extra pairs of eyes to read food labels, which is a time-consuming job. Arm yourself with a list of the ingredients she has to eliminate from her diet and check ingredients lists in the supermarket for her, making notes of the foods she can eat. Even better: go shopping for her!

help with looking for recipe ideas. Offer to find her some quick and easy recipes which are safe for her to eat.

help with cooking. Make her something she is able to eat: a meal, a tasty treat, or a nutritious snack. Remember the takeaway isn't an option, so make her a meal she can freeze, just in case an experiment with new ingredients doesn't go to plan.

to get out of the house occasionally. Why not invite her to your house for lunch or dinner and make a meal which caters for her dietary requirements? Make sure you eat the same meal as your guest. Or find a restaurant or cafe which would be prepared to cater for her dietary requirements, and invite her to eat out with you. Make sure she can take the baby with her and that the establishment is positive about breastfeeding.

company. Two heads are better than one! Offer to accompany her on her special diet for a few days and see what new foods and recipes you come up with together. You'll end up with a much better understanding of what everyday life must be like for her.

I have been struck not so much by the hardship of making dietary 'sacrifices', but by the realisation that this journey can be a lonely one. Every mealtime is a reminder that the mother has stepped away from the crowd, that she is flying solo at a time when it is natural to desire to connect with others sharing similar experiences. In the UK, where in 2005 just 22% of infants were exclusively breastfed at 6 weeks of age (2), breastfeeding has been the road less travelled for a number of years. So if when she breastfeeds, a mother is already treading the road less travelled, breastfeeding a baby with food intolerances is a journey even fewer mothers have taken. I was lucky: my friend guided me through many of the problems I encountered, so I wasn't completely alone. In reality though, it's hard to find the much-needed community of mothers who can share their experiences of breastfeeding an allergic baby and make the path easier to tread for those that follow. After a week or so of trawling the internet, I found just one online forum: Breastfeeding babies with food allergies/intolerances/sensitivities, hosted by the Australian Breastfeeding Association. The triumphs of getting together with other people to pool ideas can be enormous: imagine our delight when we created a proper birthday cake for my friend's baby's first birthday!

The great news is that once the initial hard work is done, it really pays off. I noticed that once I'd tracked down alternative foods, it was simply a matter of getting into good habits: managing my food shopping differently, paying extra attention to food labels, changing my store of basic ingredients, and changing the recipes I use regularly. It's worth remembering that the baby may not outgrow his need for a special allergy diet once weaning starts and he grows older, which means that the mother has got a wonderful head start on knowing which foods are safe for him to eat, and she's already in the habit of being able to provide for his dietary requirements.

The rewards are great: the immediate reward is a much happier, healthy baby. I am amazed at the difference my friend's dietary changes made to her baby. Changing my diet had some unexpectedly positive effects for me too: by mid-week, I realised I didn't actually miss many of the foods I wasn't allowed to eat; in fact, I was surprised to discover how much better I felt and how much more energy I seemed to have. By the end of the week, I decided that some of the alternative foods I'd discovered were here to stay.

My friend was right. This 'restricted' diet wasn't such a huge sacrifice after all. And so my perspective on the issue has changed completely: if I had a baby who couldn't tolerate some of the foods in my diet, of course I'd be motivated to make changes to my eating habits and carry on breastfeeding! Eliminating foods isn't martyrdom or a mark of supreme alpha mummy dedication. It is simply adaptation. It is accepting that, in a society which all too often decries breastfeeding as "The Problem" and touts infant formula as "The Solution", for every breastfeeding problem there is a breastfeeding solution. The truth is not that cutting foods out of your diet is hard; it is that we mothers are far more resilient and resourceful than we give ourselves credit for. Biology isn't stupid. If it encounters an obstacle it changes, adapts in order to survive. Examples of this are everywhere in nature - so why do we react with so much surprise when this same behaviour is displayed within a breastfeeding dyad?
_____________________________________________________________________

Recipe: An extra-special birthday cake

This cake is adapted from a recipe I found here, and is wheat-free, gluten-free, egg-free, soya-free, nut-free, nightshade-free and vegan.

Dry ingredients:
120g polenta (granules, not the ready-made stuff)
150g rice flour
150g light muscovado sugar
3 teaspoons baking powder
Wet ingredients:
Juice & rind of 1.5 lemons
200ml olive oil
150ml warm water
150ml coconut cream

Mix all of the dry ingredients together in a bowl, then beat in all of the wet ingredients using a fork. The resulting mixture will be quite sloppy & should almost fill the cake tin. Bake at 180 degrees C for about 45 minutes, or until the top of the cake is cracked, and when the centre of the cake is tested with a skewer, it comes out clean.

To make a gorgeous chocolate cake, the lemon rind and juice can be substituted with about 50g cocoa (look for cocoa which is made from 100% ground cocoa beans).

The recipe also makes very nice cupcakes... mmm...

Last edited: 21/07/11

_____________________________________________________________________

References

(1) Bonyata, K (2011) Dairy and Other Food Sentitivities in Breastfed Babies

(2) NHS Information Centre (2007) Infant Feeding Survey 2005

Cupcake Challenge

2011-06-24T23:34:00.002+01:00

A few weeks ago on facebook, I spotted that someone had come up with a fundraising idea for my local hospital. Upon reading the poster, I signed up immediately: dubbed a "Cupcake Challenge", it presented me with an opportunity too irresistible to miss. The winner was set to win all the funds raised to donate to a hospital ward or charity of their choice. Purely by accident, the "Cupcake Challenge" was held during Breastfeeding Awareness Week, so it seemed fitting to create cupcakes in the hope of raising some funds for the hospital's breastfeeding peer support programme.

These were my entries...

"yummy mummy milk"

One for my Welsh friends: "llaeth mam" (mummy milk)

"baby's first immunisation"

"every feed counts"

- inspired by the UKAMB's slogan "every drop counts"

"fresh milk daily"

- inspired by dairy tankers.

I've always wanted to borrow this slogan for the benefit of breastfeeding!

"supply on demand"

"meal deal"

"the wonder isn't the bra"

-inspired by Best for Babes in the US

"life-saving equipment"

- also inspired by Best for Babes in the US

"experts in infant nutrition"

- inspired by flicking through a few infant formula websites. I just thought I needed to point out who the real experts are...!

Foremilk and Hindmilk: In Quest of an Elusive Arbitrary Switch.

2011-05-10T13:00:00.022+01:00

Over the course of her breastfeeding journey, it is almost inevitable that a mother will encounter the terms "foremilk" and "hindmilk". There is certainly no shortage of confusing and conflicting advice on the concept, which has led to a lot of misunderstanding.

What do the terms "foremilk" and "hindmilk" mean?

In The Breastfeeding Answer Book, "foremilk" and "hindmilk" were defined as follows:

"Foremilk" is the milk the baby receives when he begins breastfeeding, which is high in volume but low in fat (1).

"Hindmilk" is the milk near the end of the feeding, which is low in volume but high in fat (1).

Actually, the terms "foremilk" and "hindmilk" only really refer to samples of breastmilk taken right at the beginning of a feed ("foremilk") and samples of breastmilk taken right at the end of a feed ("hindmilk"). Even then, the advantage of using these terms is debatable.

Why?

A photo on Wikipedia "helpfully" shows two 25ml samples of human breastmilk: "foremilk" on the left and "hindmilk" on the right:

The problem with showing a sample of breastmilk from the start of a feed together with a sample of breastmilk from the end of a feed is that it tells us nothing about what happens to the breastmilk in between the two samples. Mothers end up mistakenly believing that their breasts make two different types of milk, and wonder how long they must feed for before the "foremilk" magically switches over into "hindmilk" (2).

So if the terms "foremilk" and "hindmilk" are misleading and there's no "magic switch" from one to the other, what really happens?

Since The Breastfeeding Answer Book was published in 2003, research in human lactation has advanced (2), so we now understand more about how breastmilk is produced:

Your breasts make just ONE type of milk

There is no magic switch between two different types of milk over the course of a feed. In fact, there is no sharp distinction between breastmilk at the start of a feed and breastmilk at the end of a feed (3). "Milk does indeed change consistency during a feed - but this happens gradually rather than suddenly" (4).

Why does the consistency of breastmilk change over the course of a feed?

The answer lies in what happens to the fat in breastmilk when breastmilk is

produced:

Your breasts are continuously making just one type of milk, containing 'sticky' fat globules that tend to stick to each other and to the milk ducts in the breast as breastmilk is produced (2,3,5).

stored in the breast:

Breastmilk produced between feeds moves down towards the nipple and collects in the breast, leaving increasing amounts of fat globules 'stuck' together further up the milk ducts (3).

and emptied from the breast:

When let-down occurs, the milk ducts dilate (5) and the milk is ejected from the breast. The milk removed at the beginning of a feed may be lower in fat because the fat globules are still 'stuck' further up in the milk ducts (6). As the feed progresses, multiple milk ejections occur (5) and the breast is emptied, more and more fat globules become dislodged and the breastmilk increases in fat (3,6). This has the overall effect of a gradual increase in fat content of breastmilk in each breast independently as milk is removed.

How do we know that the increase in fat is gradual?

Studies involving several mothers have been conducted in which samples of breastmilk were taken at intervals over the course of a feed. The evidence from these studies suggests that the fat content of breastmilk increases gradually as the breast becomes progressively emptier over the course of a feed (7,8).

It's much easier to explain this gradual increase in fat content using pictures...

...so, revealing the crazy lengths I'm prepared to go to so I can prove a point, I visited The Countess of Chester Hospital, where several wonderful people enabled me to take consecutive small samples of breastmilk from one breast only over the course of one pumping session, and professionally photograph the results. The samples were then taken to the Cheshire and North Wales Human Milk Bank, where the fat content of each sample was analysed.

This is the snapshot we got of the gradual increase in fat content of my milk over the course of one pumping session:

A snapshot of my breastmilk:
At the time the samples were taken, I was tandem feeding. My youngest baby was just over 8 months old, had started baby-led-weaning, and was still about 90% breastfed.
Each test tube contains around 6ml of breastmilk.

Note the gradual colour change of each breastmilk sample. This is the gradual increase in fat content from the beginning of a feed (test tube 1) to the end of a feed (test tube 12).

Remove test tubes 2-11, and the result is a picture similar to the one on Wikipedia:

This shows a sharp contrast between the breastmilk at the very beginning and the breastmilk at the very end of a feed only - it tells us nothing about what happens to the breastmilk in between the two samples. Only the photo containing all 12 test tubes shows the complete picture: a gradual increase in fat content.

So what's that stuff that rises to the top of expressed breastmilk?

When breastmilk is left to stand for a while, it separates into two layers. This isn't the separation of "foremilk" from "hindmilk"; it is simply the fat in the milk rising to the top, not the separation of two different kinds of milk (4).

The reason this separation doesn't occur in a bottle of cow's or goat's milk you buy in a shop is that this milk has been homogenised.

"Whole homogenised milk is identical in fat and nutrient content to whole standardised milk however it has undergone a process known as "homogenisation" which breaks up the fat globules in the milk. This spreads the fat evenly throughout the milk and prevents a creamy layer forming at the top." (9)

After a while, the breastmilk in our test tubes separated into two layers (click on the image to open a larger version in a new window):

Note that the breastmilk in test tube 1 does, in fact, contain a layer of fat.

Note also the increasing thickness of the fatty layer that collects at the top of the breastmilk from test tubes 1-12. This further demonstrates a gradual increase in fat content from the beginning of a feed (test tube 1) to the end of a feed (test tube 12).

Again, removing test tubes 2-11 shows only a sharp contrast between the thin fatty layer that rises to the top of the breastmilk at the very beginning, and the much thicker fatty layer that rises to the top of the breastmilk at the very end of a feed.

This photo tells us nothing about what happens to the breastmilk in between the two samples. Remember: only the photo containing all 12 test tubes shows the complete picture: a gradual increase in fat content.

Showing us pretty pictures is nice, but how much fat did the breastmilk samples actually contain?

Before I continue, I must stress that this is just a snapshot of my breastmilk. It is unlikely that the results shown here will be an exact reflection of what happens to every mother's breastmilk. However, it does provide a rough idea of what happens, so here are the results of the analysis of each sample of my breastmilk:

TS = Total Solids, ie. the bulk of the rest of the milk
Protein, carbohydrate, fat and TS values are in grammes per 100ml

If looking at raw data isn't your thing, here's a line graph showing the amount of protein, fat, carbohydrates and total solids present in each of my 12 breastmilk samples (fat content is shown in red).

The graph clearly shows there was a gradual (if slightly wobbly) increase in fat content as the breast is emptied. Quite plainly, there is no arbitrary "magic switch" between two different types of breastmilk during a feed.

Remember, though, that all of this is just a tiny piece in a vast breastfeeding jigsaw...

Although it is true that the fat content does gradually increase as the breast is emptied, it is important to understand that the difference in fat content between milk at the beginning of a feed and milk at the end of a feed can vary greatly from mother to mother. Not only this, but it can vary greatly over a 24 hour period, even among individual mothers (2). The difference in fat content can also depend to some degree on the amount of time elapsed between each feed (this is truer the younger the baby is) - another reason why it might not be a good idea to wait for your breasts to "fill up" before a feed.

The fuller the breast,

the lower the fat content of the milk
the greater the difference in fat content between the breastmilk at the beginning and end of a feed (2,3)

The emptier the breast,

the higher the fat content of the milk
the lower the difference in fat content between the breastmilk at the beginning and end of a feed (2,3)

This is not simply a case of the longer the feed, the higher the fat content: if there is a shorter gap between feeds (such as during periods of cluster feeding), the milk at the beginning of a feed may not necessarily be low in fat (2,10).

"Babies can show a wide variety of feeding patterns, suckling for varying lengths of time and at varying intervals over the course of a day, and maintain a healthy weight" (4,10)

Whilst fat is important, we can and do get far to preoccupied with the issue of fat content - take another look at the graph showing the amount of protein, fat, carbohydrates and total solids present in each of my 12 breastmilk samples:

Did you spot the line labelled 'TS' (Total Solids)? That line represents all the other components of breastmilk which are important too!

The most important thing to remember is this:

In the vast majority of cases, as long as you are:

breastfeeding on cue
and allowing your baby to come away from the breast spontaneously at the end of a feed,

there is no need to worry about what's in the breastmilk your baby is getting. ALL of the components of breastmilk are essential for the growth and the physical and mental development of your baby, not just its fat content.

Last edited: 25/09/11
_________________________________________________________

If you liked this article, please consider making a small donation to Cheshire and North Wales Human Milk Bank (a charity which does a fantastic job of getting breastmilk to our most vulnerable babies), without whom this article could not have existed.

_________________________________________________________
Many thanks to:

Lynda Coulter (Cheshire and North Wales Human Milk Bank) for very kindly agreeing to analyse the samples of my breastmilk.

Janet Beech and Linda Gendler (Cestrian Ward, The Countess of Chester Hospital) for entertaining my mad idea and helping to co-ordinate the experiment.
Becca Williamson (Bosom Buddy breastfeeding peer supporter) for being my extra pair of hands.

Jenni Ross (Medical Photography, The Countess of Chester Hospital) for taking such excellent photos of my breastmilk samples.
_________________________________________________________

This article has been republished as a guest blog on Acorn Pack

_________________________________________________________

References

(1) Mohrbacher, N et al (2003) The Breastfeeding Answer Book
(2) Mohrbacher, N (2010) Worries About Foremilk and Hindmilk
(3) Bonyata, K (2005) I'm confused about foremilk and hindmilk - how does this work?
(4) Jay, E (2009) Where does fore-milk end and hind-milk begin (and does it actually matter)?
(5) Pediatrics. 2004 Feb;113(2)361-7
(6) Thomas, C (2010) Foremilk/Hindmilk and a lot of confusion!
(7) Exp Physiol. 1993 Nov;78(6):741-55
(8) Paediatric and Perinatal Epidemiology. 2002 Oct;16(4)355-60
(9) The Dairy Council (unknown) Varieties of milk
(10) Pediatrics. 2006 Mar;117(3)e387-95

Putting pizza back on the menu

2011-04-02T09:00:00.007+01:00

Life is full of quietly inspiring people. One such quietly inspiring person is a friend of mine, who is generous and kind and always seems to be helping everyone else out, but asks very little of others herself. Life wasn't easy for her after the birth of her youngest baby: he always seemed unsettled, was an expert producer of green nappies, had trouble gaining weight and spent his entire little life scratching constantly at his inflamed skin. As time went by, it became increasingly apparent that this fussiness was not normal. Thinking he must be allergic to something, she tried eliminating various foods from her diet to see if it made any difference. Avoiding some foods seemed to make small improvements, but she could never quite put her finger on the exact culprit. After enduring this for months, she took him to have a test to find out whether he was allergic to anything. When the results came back, the list was surprisingly extensive. Her baby has multiple food intolerances, including some serious, life-threatening allergies. The cuplrits are:

wheat
dairy
eggs
soya
tomatoes
potatoes
red peppers
aubergines
chili
cape gooseberries
tobacco smoke

Obviously, the baby cannot eat anything on this list now that he has started solid foods. But my friend cannot touch anything on this list either. Because she is breastfeeding him, and the allergens from these foods have been passing into her breastmilk.

Most breastfeeding mothers don't have to watch what they eat because most babies have no problems with what their mother eats (1). So most breastfeeding mothers can eat whatever they like (hurrah!). However, a few babies will have obvious reactions to certain foods their mother eats (1). My friend has one such baby.

When I read the above list, I felt slightly overwhelmed: but those foods are in everything! Even specialist foods for people with allergies substitute foods on that list with other foods which are also on the list. What would my friend eat?!

Yet I watched in awe as she just got on with eliminating each of the foods on the blacklist from her diet. And I watched as her baby went from being a miserable, unsettled baby who struggled with weight gain, irritated skin and never slept, to being a happy, bright, chirpy little fellow with flawless skin and a healthy appetite. The difference has been dramatic.

For further information about breastfed babies and allergies, please take a look at:

Bonyata, K (2010) Dairy and other Food Sensitivities in Breastfed Babies

So, what's the obvious thing to do for a dear friend whose diet has been impossibly restricted? Invite her round for Pizza Friday of course! (What can I say? I love a culinary challenge!)

Feeling confident I could create a wheat-free, tomatoless, cheeseless pizza, I did a bit of research, scratched my head over ingredients lists in the supermarket, and transformed my kitchen into a laboratory of experimentation. Everyone thought I was completely mad (I'm not disputing that), especially when I explained that I would not be eating normal pizza myself: no, I would be joining her in eating this creation! ...And, with a little help from my husband (he made the pizza base) I did it!!! The result was delicious, and surprisingly like pizza too, albeit a bit more orange.

The following recipe is dedicated to all the unsung heroes out there who have to make dietary sacrifices for a happy breastfeeding relationship. Different people have different allergies, but I'm sure that with a few inventive tweaks here and there, this recipe can be altered to accommodate most people's requirements.

Harry's Special Pizza

The pizza before baking.

(I didn't get a photo after it had baked - it got polished off too quickly!)

Pizza Base (makes 3)

175g brown rice flour

175g gram flour

2 tablespoons olive oil

half teaspoon salt

220ml warm water

1 teaspoon yeast

1 tablespoon sugar

Mix the sugar into the warm water until it has dissolved. Add the yeast to the mixture (this activates the yeast) and leave for 10 minutes.
Place the brown rice four, gram flour and olive oil in the bowl. Sprinkle the salt around the outer edge of the contents of the bowl.
Make a well in the centre of the contents of the bowl and add in the yeast mixture.
Knead the mixture together until dough forms.
Cover bowl with a damp cloth and leave to rise (preferably overnight).
Knock the air out of the dough, knead and separate into 3 balls.
Sprinkle brown rice flour onto a kitchen surface & roll out one of the 3 balls into a pizza base.

No-mato passata

3 medium carrots
1 small onion
a third of 1 butternut squash
a quarter of 1 beetroot
1 clove garlic
a dash of cider vinegar
rosemary, thyme, sage, oregano and basil to taste

Juice the carrots, onion, butternut squash, beetroot and garlic in a juicer. Scoop the pulp out of the juicer and place in a saucepan. Add the vegetable juice and a little water.
Add the cider vinegar and herbs and allow to simmer until the passata has reduced enough to be able to spread on the pizza base.

Cheese-free topping

1 can cannellini beans, drained & rinsed
2 cloves garlic
olive oil
pinch of salt and black pepper

Heat the oil in a saucepan, add the garlic and cook until softened. Add the beans, salt and pepper.
Take the saucepan off the heat and use a hand blender to blend it into a creamy "cheese".

I can't take the credit for this topping: I found it on No Meat Athlete, who found it in Robertson, R (2010) Vegan on the Cheap.

To assemble the pizza, spread some of the no-mato passata evenly on the base. Then flatten chunks of the "cheese" and place it on top. I added ribbons of butternut squash and chopped onion.

Bake for about 10-15 minutes on about 180 degrees C (in a fan-assisted oven). As the pizza dries out a bit during baking, brush all over with a little olive oil about halfway through.

Served with rocket, this pizza is delicious! It's also completely vegan. And for my friend, it means Pizza Friday is well and truly back on the menu.

Enjoy!

Mini pizza party bites

________________________________________________________
References
(1) Bonyata, K (2010) Dairy and other Food Sensitivities in Breastfed Babies

Introducing... the maxillary labial frenulum

2011-03-27T13:00:00.007+01:00

Thoughts on breastfeeding with an upper labial tie

If your baby is struggling to latch properly and it's all a bit of a mystery, it might be worth checking for an upper labial tie.

Currently, there isn't much information about upper labial ties and breastfeeding, so I have done my best to piece together the research I have found in the hope that someone will find it useful. Some of the information I have included is from my own experience of feeding my own 4 children, all of whom have upper labial ties.

What is an upper labial tie?

Inside your mouth, there is a small fold of tissue which runs between your upper lip and gum (you can feel it with your tongue). This is called the maxillary labial frenulum (or frenum). Most people have no significant frenulum attachment (1), but sometimes this frenulum attaches further down the gum, or runs between the front teeth and attaches behind them, causing restricted movement of the upper lip. It's similar to tongue tie, but involving the upper lip and gum instead. An upper labial tie can occur on its own or in conjunction with a tongue tie (2). It's also possible to have a lower labial tie (involving the bottom lip and gum).

The quickest and easiest way to find out whether a baby has an upper labial tie is to lift up his upper lip and have a look!

Most babies will have no significant frenulum attachment(1).

image reproduced with kind permission from Dr. Lawrence Kotlow DDS, PC

Some babies will have a maxillary frenulum which attaches into the gum above the front teeth. This is not normally a problem, as there should still be enough upper lip mobility in order to achieve a good latch.

images reproduced with kind permission from Dr. Lawrence Kotlow DDS, PC

In some babies, the maxillary frenulum attaches just in front of the anterior papilla (that's the small bump of tissue on the upper gum just behind the area where the upper front teeth grow) (2).

images reproduced with kind permission from Dr. Lawrence Kotlow DDS, PC

Some babies (mine included) will have a maxillary frenulum which attaches into the papilla (the small bump of tissue just behind the area where the upper front teeth grow) and extends into the hard palate behind the front teeth (2).

images reproduced with kind permission from Dr. Lawrence Kotlow DDS, PC

"It is very important to understand - the tightness of the frenulum can vary, and the degree of tightness can make a major difference as to any consequences."(3)

My children's dentist, Dr Chris Caldwell, has the following tip: if your baby has an upper labial tie, lift up his upper lip, stretching the frenulum. If the papilla blanches when you do this, the upper labial tie is likely to be a significant problem.

Healthcare professionals working with breastfeeding mothers and babies tell me upper labial ties are uncommon (is this simply because we aren't checking for them?). My children's dentist disagrees: they're fairly common, though they're not usually severe enough to cause major problems.

How might an upper labial tie affect breastfeeding?

Because an upper labial tie restricts movement of the upper lip, it may be difficult for the baby to latch effectively to the breast (3,4). Once latched onto the breast, the baby's upper lip may be tucked inwards, resulting in a shallow latch (5). The baby may be a 'clicky' feeder who takes in a lot of air during a feed. Breastfeeding may be painful for the mother. An older baby's upper teeth may dig into the breast during a feed, causing indentations or damage. Some babies will be able to breastfeed with an upper labial tie; others will have difficulty. The ability to breastfeed effectively depends on a range of other factors also affecting the mother (eg. breast anatomy, milk supply) and the baby (eg. oral anatomy), all of which may create further obstacles or make breastfeeding easier.

Ideas for improving the latch of a baby with an upper labial tie

If your baby has an upper labial tie and you are struggling with breastfeeding, seek help from a qualified breastfeeding specialist (such as a breastfeeding counsellor or lactation consultant).

The first step is to work on optimising the baby's latch in order to improve milk transfer: for some babies, this may be all that is needed to breastfeed successfully. In the hope that someone somewhere will find this information useful, I am sharing ways of overcoming an upper labial tie which worked for me and my babies:

A baby with an upper labial tie needs to be encouraged to accept the breast more deeply in his mouth. After much experimenting with more traditionally-taught breastfeeding holds (such as the cross-cradle hold), I initially found a variation of a technique called "exaggerated attachment" (adapted from 6) yielded some success:

Cup your breast underneath with your hand (if you're using your right hand, your right hand cups your right breast).
Use your thumb to tilt your nipple back so it points away from the baby's nose. This makes the breast under the nipple bulge forwards.
When the baby gapes, his bottom lip and chin should come into contact with the breast first.
Using your thumb, quickly roll your nipple forward into the roof of the baby's mouth.
Then, as you take your thumb away, lift your thumb to catch the baby's upper lip and gently flick it outwards.

I've done my best to demonstrate this latching technique below (please excuse the change of holds part way through - it's hard to get good clear photos of a baby latching on!).

Although this technique helped my baby to stay on the breast, we still experienced slow weight gain, which improved after we learnt breast compressions.

Using a 'laid-back' or 'biological nurturing' position marked a major breastfeeding breakthrough for us. Catherine Watson Genna BS IBCLC suggests that "increasing head extension will allow the infant to grasp the breast sufficiently"(4) - I have noticed that this is naturally encouraged through self-attachment to the breast in a biological nurturing position. Biological nurturing, coupled with very frequent, on-demand feeds resulted in successful breastfeeding for us, despite an almost embarrassingly imperfect latch. And, as my baby grew bigger, his ability to latch vastly improved.

What if I'm considering having my baby's upper labial tie divided?

Because of the way the human face develops in the womb, an upper labial tie can occur on its own, or in conjunction with a posterior tongue tie. If your baby has an upper labial tie and you are debating whether it is the cause of any breastfeeding problems, it is worth getting someone to check for tongue tie. In some cases, dividing the tongue tie may resolve the feeding issues.

In the UK, it's not easy to find a practitioner who will divide a baby's upper labial tie. People who may be able to help you find a practitioner with the skills to divide a baby's upper labial tie include:

a Lactation Consultant (IBCLC)
the Infant Feeding Coordinator at your hospital
a paediatric dentist
a university dental school

It is worth considering that the procedure involved in dividing an upper labial tie is different to tongue tie division, and may require general anaesthetic. This really does depend on the skills of the practitioner carrying out the procedure: some will prefer to use a laser for the division; others may be more confident using a scalpel. Further information about the division of upper labial ties can be found here:

Dr. Lawrence A Kotlow DDS PC - articles
Dr. Brian Palmer DDS - Frenum Presentation
Dr. Brian Palmer DDS - Breastfeeding and Frenulums
please note: these are non-UK links

The decision to divide an upper labial tie is an individual one, based on evaluating the severity of the tie, whether it is impacting on breastfeeding, and whether it is possible to find a practitioner who will divide the tie.

What is the evidence suggesting that lip tie division is of any benefit to breastfeeding?

In addition to the websites above, I have found just one journal article suggesting that the division of an upper labial tie might benefit breastfeeding. It is a case report of one baby whose latching difficulties remained unresolved after a tongue tie division, but was able to breastfeed successfully after an upper labial tie division.

The rest of the evidence is anecdotal:
Spanjer, P (2000) What a difference a day makes, La Leche League
(2009) Lip tie clipping, Heidiopolis
(2009) Breastfeeding update... A nurse who knits (unsure whether lip tie clipping was helpful)
(2011) The trouble with frenulums and The last snip, Becoming Daizee (not yet clear whether lip tie division was successful)
(2011) Tongue Tie Q&A and Micah's First Perfect Latch, the mommypotamus

The lack of documented supporting evidence is likely a result of lack of funding to undertake research in this area, coupled with a lack of awareness that an upper labial tie can affect breastfeeding, and a lack of skills to divide an infant's labial tie. I wonder how many mothers have ended up bottle feeding as a result of an upper labial tie?

What could other impacts be of not having my baby's upper lip tie divided?

"There are no medical or dental benefits of having a tight [...] labial frenulum. There are many major medical and dental consequences that result from tight frenulums." (3) These consequences very much depend on the severity of the tie.

Apart from breastfeeding problems, an upper labial tie has been linked with:

having a gap between the two front teeth (2,4)
poor lip mobility, affecting smiling and speech (2)
increased dental decay on the upper front teeth (2)

Good dental hygiene is of particular importance for a baby with an upper labial tie. Although breastfeeding alone may not cause tooth decay, breastfeeding in conjunction with an abnormal maxillary frenulum attachment may be a contributing cause of tooth decay in a breastfeeding infant (7). This may be because the area around the upper labial tie is difficult to clean, so food particles remain trapped in the oral mucosa.

A study undertaken in 1999 found that although human breastmilk did not cause tooth decay, adding a small amount of sugar to breastmilk did cause tooth decay (8). Therefore it would be wise for children with an upper labial tie to avoid sugary foods which, in conjunction with breastmilk, might accelerate tooth decay.

There is some evidence suggesting a link between childhood tooth decay and low levels of vitamin D (9). Breastmilk is naturally low in vitamin D, so vitamin D supplementation may be a consideration for a breastfed baby with an upper labial tie.

An upper labial tie can cause dental issues later on, so even if you decide against having the procedure done in infancy, your child's dentist may suggest dividing the upper labial tie when your child is older. "Tight frenulums rarely go away by themselves (3)"; however, they can sometimes break: my eldest child accidentally tore hers on a badly-aimed dinner fork, and one of my sons fell and tore his in the skate park. My two youngest sons also have severe upper labial ties. Despite overcoming the obstacle of their upper labial ties without having them divided and breastfeeding them both successfully, I probably won't be able to help that momentary feeling of having been just a little bit short-changed if I'm told a division is necessary in future.

Last edited: 15/09/11

_________________________________________________
References

(1) Kotlow, L (2006) Diagnosis and Treatment of the Maxillary Frenum
(2) Ktolow, L (2010) Why can't my baby breastfeed: The effects of an abnormal maxillary frenum attachment
(3) Palmer, B (2003) Breastfeeding and Frenulums
(4) Watson Genna, C (2008) Supporting sucking skills in breastfeeding infants Jones & Bartlett, p203
(5) West, D & Marasco, L (2009) The Breastfeeding Mother's Guide to Making More Milk Mc Graw Hill, p91
(6) Abbett, M (1997) A Mother's Guide to Breastfeeding (6th ed), p9
(7) J Hum Lact August 2010 vol. 26 no. 3 304-308
(8) Pediatr Dent. March - April 1999 vol. 21 no. 2 86-90
(9) JCDA December 2008/January 2009 vol. 74 no. 10 863-864

Icecreamist extremist?

2011-03-07T22:31:00.006Z

In February, radical Covent Garden ice-cream parlour, the Icecreamists, rapidly became famous for the creation of breastmilk ice-cream, sold for a staggering £14.99 a scoop (1) before it was seized by Westminster Council, who feared it may not be "fit for human consumption"(2).

Reactions to the breastmilk ice-cream have been interesting, to say the very least. Some have criticised the Icecreamists for using breastmilk as a 'cheap' publicity stunt; others have taken issue with the way in which the breastmilk ice-cream was publicised.

The publicity photos: why does breastmilk ice-cream need to be accompanied by Calpol, Bonjela and a bottle?

Whilst I cannot pretend to know what the Icecreamists were actually trying to achieve through a publicity photo such as this, the image does make an interesting and clever point, regardless of whether this stroke of genius was intentional or not.

Victoria Hiley, the donor who supplied the breastmilk for the ice-cream, described her experience as a "burlesque adventure"(3). And, in publicising their breastmilk ice-cream, the Icecreamists have indeed served us up a daringly burlesque image, beautifully censuring society's hypocrisy regarding human breastmilk.

Breastfeeding is an emotive, political issue: there are potentially serious risks involved in not breastfeeding, but the government provides shockingly little protection to mothers, infants and its healthcare system from aggressive advertising from the infant feeding industry. For babies, breastmilk is a matter of life and death: "Every day, more than 4,000 babies die because they're not breastfed. That's not conjecture, it's UNICEF fact." (4) Yet here, breastfeeding is trivialised, frivolously transformed into ice-cream, apparently in the name of pushing the boundaries of acceptability. And the Icecreamists push the boundaries further still: pharmaceutical medications and feeding bottles are treated in a coarsely trivial manner, presented as mere condiments on a tray. The overall effect borders on the grotesque, which upon reflection, is quite brilliant (even if it was just accidental).

My point is that everybody seems to have been so distracted with whether the idea of breastmilk ice-cream is attractive or repulsive that all but the most informed amongst us have rather dismissed its accompaniments.

The bottle in the photo is manufactured by a company which is renowned for breaking the World Health Organisation (WHO) International Code of Marketing of Breast-milk substitutes and subsequent World Health Alliance (WHA) resolutions. Yes, feeding bottles and teats do in fact fall within the scope of the WHO Code (5). The WHO states that "Given the special vulnerability of infants and the risks involved in inappropriate feeding practices, usual marketing practices are therefore unsuitable for these products"(6). It explains that "feeding bottles [...] carry a high risk of contamination that can lead to life-threatening infections in young infants"(6). Furthermore, the inappropriate use of feeding bottles can adversely affect a mother's breastmilk supply, confuse the baby and lead to breast refusal(see 7), which can potentially jeopardise a breastfeeding relationship and expose the infant to the risks associated with not breastfeeding. Yet has any of the media coverage raised an issue with the feeding bottle?

A further accompaniment to the breastmilk ice-cream is Calpol. "Voted best health product by readers of Mother & Baby magazine four years running"(8), and with sales of "twelve million packets and bottles" each year (8), you may be forgiven for wondering what the issue with Calpol might be. However, Calpol contains "FIVE E-numbers, some of which have been banned in other parts of Europe and the US"(9). For further information about Calpol and its associated risks, read the Analytical Armadillo's article here. Yet, despite media coverage of the potentially harmful effects of Calpol in 2008/9, it managed to escape media attention when placed on a platter next to breastmilk ice-cream.

Also accompanying the breastmilk ice-cream is Bonjela. Commonly used on teething babies, Bonjela is another over-the-counter medicine which has received fairly recent media attention. Some forms of Bonjela are unsuitable for children under 16 because they contain a substance called choline salicylate, which carries a risk of Reye's Syndrome, a rare but potentially fatal disease of the brain and liver(10). Bonjela teething gel, which is aimed at children over 2 months old, does not contain choline salicylate, but it does contain Lidocaine hydrochloride and Cetalkonium chloride. I wonder how many people spotted that the breastmilk ice-cream is served with the unsuitable adult version? The media missed that too.

So, take the burlesque image of the breastmilk ice-cream, served with a bottle, Calpol and Bonjela. The overall concept is both attractive and repulsive: it is practically an invitation to choose the item you find most repulsive. The most informed amongst us would probably choose the feeding bottle, Calpol or Bonjela. Yet of course it is the least offensive, most normal item that causes international outcry: the breastmilk, which is "confiscated as a biohazard and described as "nausea inducing" by Lady Gaga"(3). By the way, Westminster Council, that was the wrong answer...

The breastmilk itself is nothing other than normal. This normal food contains myriad beneficial ingredients, including vitamins, fats, antibodies, minerals, stem cells, antiviral and antibacterial components, human growth factors and "about a hundred constituents that cannot be replicated in formula" (11). Breastmilk is not only completely safe and suitable - but actually specifically designed - for human consumption. Furthermore, the donor providing breastmilk for the ice-cream "had a blood test to rule out the few infections that are transmitted through breast milk" (3), which is exactly what happens when a human milk bank donor provides breast milk to be consumed by society's tiniest and most vulnerable human beings. In view of this, I rather feel that the attention the breastmilk ice-cream received was somewhat out of proportion.

And so to raising a satirical eyebrow to society's hypocrisy over human breast milk:

Breastmilk is hailed as "liquid gold". The slogan used to promote breastfeeding proclaims "breast is best," yet paradoxically it is revolting, icky, "nausea-inducing", a bio-hazard, "unfit for human consumption". At the same time, the bottle, the Calpol and the Bonjela all escaped media attention because they are accepted as normal in our society. The Icecreamists have now created an infant formula ice-cream. I'd like to believe it's because the world is still reeling from the brief phenomenon that was breastmilk ice-cream, but I can't help but note that this new ice-cream hasn't provoked quite the same reaction.

The Icecreamists tweet about their new 'formula' ice-cream, which has had disappointingly little impact in the wake of Baby Gaga.

Last updated: 08/03/2011

____________________________________________________

References

(1) Williams, Z (2011) Breastmilk ice-cream: the taste test in the Guardian 27/2/11

(2) BBC (2011) Baby Gaga breast milk ice-cream seized for safety tests BBC News London

(3) Hiley, V (2011) Lady Gaga and my breast milk burlesque in the Guardian 7/3/11

(4) Baby Milk Action (2004) Your Questions Answered in www.babymilkaction.org

(5) World Health Organisation (2008) The International Code of Marketing of Breast-Milk Substitutes Frequently Asked Questions, p1

(6) World Health Organisation (2008) The International Code of Marketing of Breast-Milk Substitutes Frequently Asked Questions, p4

(7) Australian Breastfeeding Association (2005) Breast Refusal

(8) Crompton, S (2009) Is Calpol bad for children? in The Times 24/1/09

(9) Thomas, C (2010) Calpol - It's paracetamol Jim, but not as we know it! in Analytical Armadillo 11/10/10

(10) Teething Babies.co.uk (2010) New Advice on Teething Products www.teething-babies.co.uk

(11) Thomas, C (2010) Ask the Armadillo - what's in breastmilk? in Analytical Armadillo

Moving beyond guilt

2011-02-11T10:10:00.011Z

There are two phrases about infant feeding I've been hearing constantly over the past 10 or so years, and I can't stand either of them. One is "breast is best" (it isn't, by the way - it's normal), and the other is:

"Nobody should make a mother feel guilty for bottle feeding her baby."

As much as I loathe that statement, it's annoyingly impossible to disagree with, so I'm forced to admit that I agree with the sentiment itself: of course it is wrong to make a mother feel guilty for bottle feeding her baby. And you won't find me preaching otherwise. Ever.

So why do I hate that phrase with a passion?

1. It implies that somebody is making mothers feel guilty for bottle feeding their babies.

Whether we are conscious of it or not, that suggestion is embedded in the language structure of the phrase itself. Take a closer look:

"Nobody should make a mother feel guilty for bottle feeding her baby."

I've underlined "nobody" because that word is what puts the phrase into what is known in grammatical terms as the 'negative'. Look at what happens when this negative statement is converted into a (grammatically) positive one. For this particular negative: "nobody", there is a corresponding positive: "somebody". So mentally, we process that statement not only as "Nobody should make a mother feel guilty for bottle feeding her baby" but also as "Somebody is making mothers feel guilty for bottle feeding their babies."

In 1961, Walter Ulbricht (East German communist leader) famously announced that "Nobody has the intention of erecting a wall" ("Niemand hat die Absicht, eine Mauer zu errichten."). Evidently somebody did: just over a month later, the Berlin Wall was built.

So, if "somebody is making mothers feel guilty for bottle feeding their babies," down with that somebody! Who is that somebody anyway?

Well, the media would dearly love you to believe in the 'Breastfeeding Mafia'... which is actually about as real as the Tooth Fairy (sorry to disappoint anyone).

2. It immediately closes any dialogue between bottle feeders and breastfeeding advocates.

Over the course of a discussion handling sensitive issues and uncomfortable truths surrounding infant feeding (the risks associated with formula feeding is highly explosive - for me it has been the hardest topic to face after formula feeding my first baby), it isn't long before someone says something to the effect of:

"Nobody should make a mother feel guilty for bottle feeding!"

Immediately, a wall is thrown up between bottle feeders, who perceive themselves as being made to feel guilty and resent it (I've been on this side of the fence), and breastfeeders, who end up justifying their reasons for tackling the issue and having to defend themselves by explaining they're not actually trying to make anyone feel guilty (and I've been on this side of the fence too). Everybody ends up feeling upset and frustrated.

I remain optimistic: even the Berlin Wall came down eventually.

Guilt is not a good emotion. Guilt is damaging. Guilt makes mothers blame themselves. Guilt makes us block out the truth. Guilt builds up barriers. Guilt stops us from communicating with each other, when in actual fact, bottle feeding mothers and breastfeeding mothers need to be working together on the same side. Because lactivism is not just about protecting breastfed babies, but is also a vital demand for the protection of babies fed on infant formula. As long as 'guilt' gets in the way, mothers and babies are losing out.

Over and over again, the inevitable 'guilt' accusation pops up... but is 'guilt' even the right word?

3. It implies that what bottle feeding mothers should feel is 'guilt'.

I didn't breastfeed my first baby for as long as I'd planned to. After a brief, disastrous breastfeeding experience, I became a formula feeding mum. Deep down, I was devastated, but I kept telling myself it was OK. It had to be: from my perspective, my breastmilk clearly hadn't been good enough for my baby: I'd been told by a health professional that I had to formula feed. After all, I loved my baby, and everyone wants to give their baby the best, right? Somewhere in amongst all the leaflets and adverts I'd been handed I read that "Nobody should make a mother feel guilty for bottle feeding her baby", and not knowing what else to call that empty feeling deep down inside, I labelled it 'guilt'.

The growth chart, based on formula fed babies. The black arrow indicates the point at which we introduced formula (11 weeks). Look at what happens to the crosses plotted on the chart after that point. At the time, that "evidence" alone was enough to convince me that my breastmilk hadn't been enough for my baby. What might have happened if I'd been well supported in breastfeeding?

Now I've had the chance to analyse how I felt after my first breastfeeding relationship ended, I wouldn't describe any of those feelings I had at the time as 'guilt'. "Guilt is the wrong word"(1). Yet we keep on telling mothers "you shouldn't feel guilty" and in doing so we keep on handing them that "inaccurate and ineffective"(1) word: 'guilt'. And frankly, it's insulting.

Some well-informed mothers choose not to breastfeed. Other well-informed mothers "struggle unsuccessfully to establish breastfeeding, and turn to bottle feeding with a sense of acceptance"(1) because they know they did the best they could with the information and support they had at the time. And shared milk hasn't always been a viable option. Do we really expect these mothers to feel 'guilt'?

And then there are mothers like I was, who are not well-informed. They struggle unsuccessfully with breastfeeding and end up bottle feeding because they lack support, receive poor information, are given bad advice, and are bombarded with misleading advertising claims. But these women, too, are doing the best they can with the information and support to which they have access. These mothers end up formula feeding not through informed choice, but because they are failed. These women are failed by a system which does not value breastfeeding enough to mandate sufficient qualifications in breastfeeding for healthcare professionals offering support and advice to breastfeeding mothers. These women are failed by a government which does not protect mothers, babies or its healthcare system from aggressive advertising from the infant formula industry. And yet these women are supposed to feel 'guilty'?

Years later, I realise that I ended up bottle feeding my daughter not because my breastmilk wasn't good enough, but because the advice and support I received wasn't good enough. I now understand that with better information and support, I could have been the breastfeeding mother I wanted to be. How do I feel about it now? Guilty? Certainly not!

When Diane Wiessinger posed the following scenario:

"You have been crippled in a serious accident. Your physicians and physical therapists explain that learning to walk again would involve months of extremely painful and difficult work with no guarantee of success. They help you adjust to life in a wheelchair, and support you through the difficulties that result. Twenty years later, when your legs have withered beyond all hope, you meet someone whose accident matched your own. "It was difficult," she says. "It was three months of sheer hell. But I've been walking ever since." Would you feel guilty?"(1)

women replied that they would feel "angry, betrayed, cheated"(1).

Let me pose another scenario:

A pregnant woman hopes for a natural birth at home, but at the end of her pregnancy her health care provider informs her that she needs an induction. She goes into hospital to be induced, but the induction fails and she ends up having a C-section delivery. It wasn't the birth she wanted, but the hospital staff supports her through her birth and helps her to cope with the difficulties she faces as a result. Years later, she meets a mother who was told she needed to be induced under the exact same circumstances, but she gave birth naturally at home. "Challenging the system was probably the hardest thing I've ever faced," she explains, "but I did my research thoroughly, evaluated the risks, stood my ground and got the birth I'd hoped for." Should the first woman feel guilty?

Would you even consider saying to this woman "Nobody should make you feel guilty for the way your birth turned out"? After all, that woman achieved the best birth she could with the information and support she had at the time. Perhaps the words angry, betrayed, cheated might fit this scenario too? Perhaps you can think of other words?

Although 'angry, betrayed, cheated' are a much better description of how I feel about ending up bottle feeding my daughter, they don't quite cover it completely.

After the birth of my second child, I wanted to breastfeed again, this time with better information and support. I succeeded in breastfeeding him for 1.5 years, which was a very empowering experience, but it didn't resolve how angry, betrayed, and cheated I still felt as a result of my first breastfeeding experience. The problem was, although I'd done it again (and successfully this time), I could never get my breastfeeding relationship with my first child back. It was gone forever, and I still felt a deep sense of loss.

And then the realisation hit me: what I'd felt all those years was, in fact, grief.

All those years, I'd been grieving the loss of a breastfeeding relationship.

Recognising that I felt grief was the start of a journey towards finding peace with my first breastfeeding experience. Understanding that I felt grief was like having a heavy weight lifted from me:
It was suddenly OK to feel angry.
It was OK to feel hurt.
It was OK to feel disappointed.
It was OK to feel cheated.
It was OK to feel betrayed.
It was OK to evaluate my experience in its own right, rather than compare it unfavourably with other peoples'.
It was OK to explore my feelings rather than believe I needed to block them out. In fact, I realised that labelling them as 'guilt' and suppressing them hadn't helped me in the slightest. That women should feel 'guilt' and just 'shut up and get on with it' is convenient only to a society which does not want to admit that it does not value or protect mothers and babies enough.

Knowing I felt grief allowed me to explore infant feeding issues with eyes unclouded by guilt. I learnt about the risks of infant formula feeding, and this time I felt shocked and angry: why did nobody inform me that the infant formula I'd fed my daughter had been recalled earlier that year? Why is there no public demand to subject infant formula to more rigorous testing and make it safer for our babies? I learnt about the impact of infant formula feeding on developing countries, and this time I felt shocked and angry at what the money I'd spent on infant formula had contributed to: why aren't more people campaigning for these irresponsible companies to operate ethically?

After I allowed myself to be true to my own feelings over the loss of my breastfeeding relationship, I began to notice them gradually changing. I'd have good days, when I'd feel more accepting of what had happened, and there'd be bad days, when I'd feel really low and tearful about it. But as time went by, and I opened my eyes to the lessons learnt from my experience, my feelings developed into something positive.

And I was more than the grief I felt from the loss of my breastfeeding relationship: I trained as a breastfeeding peer supporter and began to offer other mothers and babies the information and support I wished I'd had after the birth of my first baby.

It was OK to find peace with my breastfeeding loss.

So let's stop handing mothers the word 'guilt' and start talking with them to find out how they really feel about their breastfeeding experiences. We need to validate mothers' feelings and experiences, and accept that it's OK for mothers to grieve the loss of a breastfeeding relationship. We need to accept that it's OK for mothers to be true to their own feelings and find peace with their breastfeeding loss.

Then we might all be able to move forward in creating positive changes in our society for the benefit of all mothers and babies.

_________________________________________________________
References
(1) Wiessinger, D (1996) Watch your language Journal of Human Lactation, Vol. 12, No. 1, 1996

If you leave the back door open...

2011-01-23T13:25:00.007Z

When the media erupted into a frenzy of "Breastfeeding may harm babies" headlines in the immediate wake of the release of an article entitled "Six months of exclusive breastfeeding: how good is the evidence?" published by the British Medical Journal (BMJ), everyone seemed surprised at the BMJ's apparent slip-up in the quality of its content.

Everyone, it seemed, except me. Call me cynical if you like, but I can't say I was too surprised.

A mother embarking upon a breastfeeding journey with her newborn baby (myself included) is usually blissfully unaware that breastfeeding is political. Nutrition in infancy has a lifelong effect upon that individual. It also means big money. To those passionate about infant health, minimisation of risk to both breast and formula fed babies is crucial. So it is incredibly frustrating when those of us who feel strongly about infant health issues are misinterpreted as "pushing breastfeeding" or "forcing women to breastfeed". Few people, it seems, give much thought to just how much pressure mothers are under to formula feed and introduce solid foods prematurely. Yet, despite all the associated risks, mothers are under immense pressure to formula feed and wean early - after all, infant formula and baby food manufacturers represent a multi-billion pound industry with an enormous advertising budget. And money is power.

The UK government does, to some extent at least, recognise that this pressure from advertisement by the baby feeding industry exists and is a problem. New mothers and babies are particularly vulnerable groups of people, so some laws are in place in the UK which protect mothers and babies from the aggressive promotion of infant formula and baby foods.

Or do they?

30 years ago saw the birth of the World Health Organisation (WHO) International Code of Marketing of Breast-milk Substitutes, which aimed

"to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use of breast-milk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution"(1).

However, not only has the UK repeatedly failed to implement the WHO Code in its entirety, but the UK laws intended to offer mothers and babies protection from the promotion of breastmillk substitutes are weak and riddled with loopholes, and the baby feeding industry is only too happy to take advantage of them.

One such area where mothers and babies remain unprotected from the promotion of breastmilk substitutes is in scientific publications. For example, at the end of 2010, the BMJ ran this full-page advertisement for infant formula on the back cover of one of its issues:

"close to [...] breastmilk":
"information of a scientific and factual nature" (2)
...or creating "a belief that bottle-feeding is equivalent [...] to breast feeding" (2)?
Aha! There it is, in the small print - the obligatory "breastmilk is best" line. Thank goodness I brought my magnifying glass... But would a busy healthcare professional really read the small print?

OK, so it's not illegal in the UK to advertise infant formula in a scientific publication (see 2)... So what's my problem?

The first issue here is that such advertising neatly undermines the UK's ban on direct advertising of breastmilk substitutes to mothers (of babies under 6 months) by advertising them to health professionals instead: the very people a mother will turn to for advice and support if she encounters breastfeeding problems. Although such adverts are required by law to contain "information of a scientific and factual nature"(2), it is still advertising. Advertising is NOT information-giving. Advertising is selling. Advertising is the art of persuading people to buy or choose things that might not even be necessary. As the National Childbirth Trust put it, "Parents have a right to make decisions on how they feed their baby based on impartial and accurate information from health professionals, not based on advertising and promotional messages from commercial interests."(3) Yet can mothers really trust that the breastfeeding - or indeed formula feeding - information they receive from health professionals is truly 'impartial' or 'accurate' if the health profession remains unprotected from advertising and promotional messages from the infant feeding industry? If advertising of one brand makes no difference to BMJ subscribers' practices, why does SMA pay to advertise in the BMJ? (paraphrased from 4)

The second issue is that journals aimed at medical professionals, such as the BMJ and the British Journal of Midwifery (BJM) (5), are clearly accepting financial support (in exchange for advertising space) from the infant formula industry. They also publish research and other articles on human lactation. The problem with this is that, in pharmaceutical research for example, industry sponsorship has been associated with increased odds of a pro-industry conclusion (see 6, 7). In light of this, if journals are in receipt of sponsorship from the infant formula industry, how confident can we be that the articles they select for inclusion will be free of any kind of bias towards the infant formula industry? At the same time, such publications expect to be taken seriously as leading authorities in the field of human lactation. This of course begs the question: which do they support - the infant feeding industry or infant health? Can a respectable medical publication realistically expect to support both?

Here the BMJ apparently distance themselves from the journal article they published via a tweet to The Leaky Boob...

but are medical journals really powerless against how their articles are interpreted by the press?
Read the BMJ's press release and decide for yourself!

The concerns I raise over infant formula advertising in scientific/medical journals are not new: "The [WHO] Code and subsequent relevant WHA resolutions call for a total prohibition of any type of promotion of products that fall within their scope in the health services" (8). The WHO's International Code "makes no exception for any type of advertisement" (9). Furthermore, an EU directive issued in 2006 stated that Member States "may [...] prohibit" the advertising of infant formulae in scientific publications (10). And, shortly after that, the Baby Feeding Law Group, Baby Milk Action and the NCT issued a response to the Food Standard Agency's proposals for regulations on infant formula and follow-on formula, in which it recommended a change in the law to prohibit all advertising of infant formulae, restricting the infant formula industry to the provision of information of a scientific and factual nature to health professionals (9). This could have been a significant step forward in both safeguarding breastfeeding and ensuring the health of babies fed on formula too - at last mothers could have had access to impartial formula feeding information: all too often, mothers who find themselves formula feeding are abandoned in a sea of competing brands and distorted 'facts' designed to fit an advertising agenda. However, the Advertising Association, together with industry, fought against this, and lists "revers[ing] a policy by the Food Standards Agency to ban infant formula advertising in professional/scientific publications" amongst its achievements of 2008 (11). Who benefits from such an 'achievement'? Breastfed babies? Formula fed babies? Healthcare professionals? Or the infant feeding industry? If advertising in scientific publications wasn't effective, would they seriously have bothered to fight this?

The simple fact that it is not illegal to advertise infant formula in scientific journals does NOT make it OK. Infant feeding should NOT be about how much we can get away with. It should be about protecting both breastfed babies and babies fed on formula. This isn't an issue of moral guardianship - this is about commercial morals. It is unethical to place profit above infant health.

Rather than promoting and sustaining a formula feeding culture through advertising breastmilk substitutes, medical journals like the BMJ and the BJM have a responsibility to provide professionals with accurate, impartial information about infant feeding. It is time for journals to comply with the WHO Code and subsequent WHA resolutions. The fact that it is not illegal to advertise infant formula in scientific journals does not mean journals cannot choose to refuse to do so. High profile journals such as the BMJ and BJM are in a wonderful position to lead the way in creating and implementing voluntary policies to ban all infant formula adverts in their publications. A voluntary ban on infant feeding industry adverts in scientific journals would be instrumental in:

preventing the infant feeding industry from using medical/scientific journals to undermine breastfeeding and breast milk donation through normalising bottle feeding and influencing health professionals' decision-making via advertising, and so potentially exposing fewer babies to infant formula feeding and its associated risks
giving scientific journals greater freedom to impart truly factual, impartial information about breastfeeding and infant formula (remember: advertising is NOT information-giving; advertising is selling)
making scientific journals less beholden to the infant feeding industry, decreasing the likelihood of selection of articles for publication which have an obvious bias towards the infant feeding industry

As recommended by the WHO Code and subsequent WHA resolutions, scientific journals should also ensure that the "information provided by manufacturers and distributors to health professionals regarding products should be restricted to scientific and factual matters" (8).

No, the media might not pounce on this story with quite as much glee as the infamous BMJ article, but if scientific journals voluntarily complied with the WHO code and subsequent WHA resolutions, it might just prevent the publication of dodgy, damaging research papers with obvious bias towards the infant feeding industry... and the public embarrassment and deterioration of reputation which inevitably follows.

But if you leave the back door open, what can you expect?

__________________________________________________________

Undoing the damage done to 6 months of exclusive breastfeeding...

Read the infamous BMJ article:
Click here to read the BMJ opinion piece.
Click here to read the BMJ's press release.

Now read the responses:

An excellent analysis from Analytical Armadillo
Responses from official organisations:
World Health Organisation
Unicef Baby Friendly Initiative
Baby Milk Action
Royal College of Midwives
La Leche League GB
Also worth reading are the rapid responses on the BMJ website

Information on Baby-Led Weaning can be found here:
Baby Essentials that Aren't, Part 7: Baby Food by Eco Child's Play
Guidelines for implementing a baby-led approach to the introduction of solid food by Gill Rapley on Kenniscentrum Borstvoeding
Rapley Weaning .com
Baby Led Weaning

__________________________________________________________
Bibliography & References

(1) Baby Feeding Law Group Why the UK Law must change if it is to protect infant health
(2) The Infant Formula and Follow-on Formula (England) Regulations (2007), Regulation 21
(3) NCT Campaign to protect mothers and babies from the effects of formula advertising
(4) Palmer G (2009) The Politics of Breastfeeding. London: Pinter & Martin, p317
(5) Royal College of Midwives Infant Formula Advertising Statement
(6) Beasley A & Amir L (2007) Policy on infant formula industry funding, support or sponsorship of articles submitted for publication International Breastfeeding Journal 2007, 2:5
(7) Bekelman J et al (2003) Scope and impact of financial conflicts of interest in biomedical research: A systematic review JAMA 2003 , 289:454-465.
(8) World Health Organisation (2008) The International Code of Marketing of Breast-Milk Substitutes Frequently Asked Questions, p5
(9) Baby Milk Action Line by Line response to Food Standards Agency proposals for Regulations on

Infant Formula and Follow-on Formula

(10)COMMISSION DIRECTIVE 2006/141/EC of 22 December 2006 on infant formulae and follow-on formulae and amending Directive 1999/21/EC Official Journal of the European Union, Article 14
(11) Advertising Association Advertising Association Acievements in 2008

As easy as ACD?

2011-01-14T21:25:00.001Z

Getting the facts straight about vitamins for breastfed babies over 6 months old

Suggest that my breastmilk is in some way deficient, that it does not contain every nutrient my baby needs, I can feel my hackles rising. One such occasion was the moment I was ‘reliably informed’ that I should be giving vitamin supplements to my baby because ‘breastmilk hasn’t got enough “stuff” in after the first 6 months’.

“Stuff”? “Stuff”?! What “stuff” exactly…?

Well, it appears that the latest “stuff” in question is vitamins A, C and D. According to the Healthy Start website, “the UK Department of Health recommends a daily dose of vitamins A, C & D for breastfed infants from 6 months” (1) because “young children may not get enough vitamin A, C and D from their food” (2). Hmm...

Elsewhere though, the information is different: For the vast majority of healthy, full term breastfed babies, vitamin supplements are unnecessary (3). “There are certain cases where a vitamin supplement may be needed for a breastfed baby during the first year, but these cases are the exception, not the rule” (4).

So what’s all this fuss about vitamins A, C and D then?

_______________________

Vitamin A, according to Healthy Start, can be obtained from:

whole cows' milk
orange, red and dark green vegetables such as carrots, red peppers, tomatoes, sweet potato, pumpkin, apricots, mangoes, broccoli
oily fish (2)

Hang on a minute… isn’t there something pretty vital missing from this list?

“Breastmilk is a natural, excellent source of vitamin A” (4).

When a baby reaches 6 months of age, it is a myth that breastmilk changes and is no longer enough for a baby’s needs. What actually changes is the baby’s need for certain nutrients (5). Very gradually, a baby begins to need more from his diet than breastmilk (5), so “complementary foods are needed to provide enough vitamin A” (6). However, “breastmilk continues to be a major source of vitamin A to 24 months and beyond” (6). Breastmilk is also an important source of fat, which must be consumed to ensure good uptake of vitamin A by the body (6).

In fact, NOT breastfeeding increases the risk of:

vitamin A deficiency
infections that can reduce a baby’s vitamin A stores.

A large study in Bangladesh found “a 74% reduction in the risk of vitamin A deficiency among breast fed children” (7) aged between 6 months and 3 years compared to non-breastfed children. “Vitamin A deficiency is rare in breastfed babies even in areas of the world where vitamin A deficiency is widespread” (4).

So why does Healthy Start recommend a vitamin A supplement for breastfed babies from 6 months?

“In the UK, 1 in 2 children under 5 do not have enough vitamin A in their diet” (8). It’s worth noting here that the survey quoted by Healthy Start did not include any breastfed babies aged 0-18 months; in fact it did not look at any children under 1.5 years old.

That said, some breastfed babies are more at risk of vitamin A deficiency, such as those babies born to mothers who were deficient in vitamin A during pregnancy (6), but this is rare in higher income countries such as the UK.

_______________________

Vitamin C, according to Healthy Start, can be obtained from:

“fruit and vegetables, especially blackcurrants, kiwi fruit, citrus fruits, tomatoes, peppers and strawberries. Potatoes, sweet potatoes and mangoes are also good sources” (2).

Again there’s something missing:

breastmilk contains high levels of vitamin C (3).

So why does Healthy Start recommend a vitamin C supplement for breastfed babies from 6 months?

“The role vitamin C plays in iron absorption is particularly important in children under 4 years old” states the Healthy Start website (1).

Aha! Do I spot the myth that breastmilk cannot provide a baby with enough iron after 6 months?

“Those who don't know very much about breastmilk will tell you how low it is in iron compared to breastmilk substitutes” (9). It is now generally accepted that giving breastfed babies iron supplements can cause more harm than good: “the baby’s delicately balanced use of iron may be jeopardised and digestive problems […] may result” (3).

Hmm, so iron supplements are out, then. Hey, vitamin C aids iron absorption, so how about promoting vitamin C as another line of defence against those pesky low levels of iron in breastmilk?

That might seem logical, but the way breastfeeding works is far, far cleverer than it first appears. Comparing iron levels in breastmilk with breastmilk substitutes isn’t helpful because looking at the amount of iron alone doesn’t explain what actually happens to the iron once it reaches the baby’s gut. Although the amount of iron in breastmilk is small, it is highly bioavailable, meaning it is well absorbed (3). Only around 4% of the iron in iron-fortified formula is absorbed (3), meaning that the amount of iron in formula has to be much higher to begin with (9), resulting in a lot of leftover iron that can cause problems in the baby’s gut. By comparison, around 50% of the iron in breastmilk is absorbed (9). But that’s not all: “high lactose and vitamin C levels in human milk aid in the absorption of iron” (3).

_______________________

Vitamin D is the one everybody’s talking about.

Quite rightly, Healthy Start states that:

“Summer sunshine, not food, is the main source of vitamin D in the UK” (1).

Although around 80-90% of our vitamin D comes from sunlight (10), some vitamin D is found in foods:

oily fish such as sardines, kippers, salmon, eel, pilchards and trout
meat
eggs
food fortified with vitamin D, such as margarine and some breakfast cereals (1) (please note that milk is not fortified with vitamin D in the UK)

Sorry if I’m disappointing anyone, but this time I’m not going to pick on Healthy Start for missing anything vital.

On the other hand, I’m not going to start harping on about how breastmilk is deficient in vitamin D either. Because those that do entirely miss the point:

Breastmilk is naturally low in vitamin D.

OK, let’s get this straight: breastmilk is a food. Human beings are not designed to get most of their vitamin D from food, but from sunlight exposure.

With this in mind, “Health professionals and lactation consultants are challenged to counsel all mothers on prevention of vitamin D deficiency without undermining the breast-feeding relationship.” (11)

It’s worth pointing out here that fruit and vegetables are poor sources of vitamin D. Yet would anyone give out advice to stop giving fruit and vegetables to children simply because they lack vitamin D? Why is this? Because depriving a child of all the other vitamins and nutrients in fruit and vegetables would have a potentially catastrophic effect upon that child’s health. It’s a no-brainer really.

Similarly, human breastmilk is naturally low in vitamin D. So why undermine a mother’s confidence in breastfeeding, or advise her to stop altogether? What would the impact be of depriving a child of a major source of highly bioavailable vitamins, minerals and nutrients? What would the impact be of depriving a baby of antibodies, anti-viral and anti-inflammatory components and other immune factors (see 12), particularly at a time when that baby’s gut is potentially being exposed to an increased number of pathogens through the introduction of solid foods? All of these components and more are found in breastmilk - a baby’s normal food. What are the risks of depriving a child of breastfeeding? Think about it!

The good news is that the small amount of vitamin D which is present in breastmilk comes in a highly bioavailable form which is very easily used by the baby (13). However, this amount alone is too small to prevent rickets (a disease caused by vitamin D deficiency) (3). In fact, because of the way vitamin D works inside our bodies (you may be surprised to find out that it's actually not really a vitamin - it's a prohormone with a bit of an identity crisis), an increasing body of research is indicating that vitamin D deficiency may be linked to a vast range of other diseases (see 1, 10 & 14), not just rickets. This is why adequate sunlight exposure is important.

Adequate sunlight exposure, according to Healthy Start, could be achieved through spending about 15-30 minutes outside a few days each week in the summer (April-September) between 10am and 3pm with some skin exposed (1). However, other sources dispute whether this is really enough (10).

Although “research has shown that breastfed infants can maintain sufficient vitamin D status solely through adequate sunlight exposure” (14), “international organisations like La Leche League International and UNICEF acknowledge that vitamin D supplementation is necessary when sunlight exposure is inadequate and that some infants have a higher risk of vitamin D deficiency than others” (15).

Risk factors for vitamin D deficiency in the UK include:

babies whose mothers are vitamin D deficient during pregnancy/lactation (1, 3, 11, 13, 15)
darker skin (1, 2, 3, 10, 11, 13, 15) Darker skin needs to be exposed to sunlight for much longer in order to make sufficient vitamin D.
staying indoors during daylight hours (10, 11, 13, 15)
living at more northerly latitudes (1, 11, 13, 15)
living in areas where sunlight is blocked by buildings/pollution (3, 15)
using sunscreen (3, 11, 13, 15)
covering most of the body when outside (1, 2, 3, 11, 13, 15)
frequent substantial cloud cover (10, 11)
lead exposure (15)

As you can see, there is no 'one size fits all' answer to whether breastfed babies (or indeed mothers) should choose vitamin D supplementation. Ask yourself:

Does your baby receive an adequate amount of sunlight exposure?

Do any of the above risk factors apply to you and your baby?

You may like to undertake some further research before you feel you can make an informed decision about whether or not to supplement your breastfed baby with vitamin D. The following information sources are a good place to start:

Bonyata, K (1998) Does my baby need vitamin D supplements? http://www.kellymom.com/nutrition/vitamins/vitamin-d.html

La Leche League International resources on Breastfeeding and Vitamins

http://www.llli.org/NB/NBvitamins.html

Gillie, O (2004) Sunlight Robbery: Health benefits of sunlight are denied by current public health policy in the UK http://www.healthresearchforum.org.uk/reports/sunlightrobbery.pdf

(please remember that research and medical information change over time, and that some of these sources provide information primarily aimed at mothers and babies who do not live in the UK)

Should you decide to supplement your breastfed baby with vitamin D, here are some questions worth considering:

Do the benefits of vitamin D outweigh the fact that vitamins A and C in the Healthy Start drops are unnecessary for nearly all breastfed babies?
Are there any other ingredients in the vitamin A, C & D supplement that you want to know about before giving it to your baby?
Is there a vitamin D only supplement available for your baby?

As much as the comment that ‘breastmilk doesn’t have enough “stuff” in after the first 6 months’ made my inner rebel bristle, I realise that mothers and babies do need vitamin D, either through positive changes to diet and lifestyle to ensure sunlight exposure, or by supplementing with vitamin D.

Right, sardines on toast, anyone?

_____________________________________________________
References & Bibliography

(1) Healthy Start: Vitamin Supplement Recommendations http://www.healthystart.nhs.uk/en/fe/vitamin_supplement_recommendations.html (accessed 11/12/10)

(2) Healthy Start: Healthy Start Vitamins http://www.healthystart.nhs.uk/en/fe/healthystart_vitamins.html (accessed 11/12/10)

(3) Mohrbacher, N & Stock, J (2003) The Breastfeeding Answer Book La Leche League International p604-7

(4) Bonyata, K (1998) Does my baby need vitamins? http://www.kellymom.com/nutrition/vitamins/vitamins.html

(5) Rapley, G & Murkett, T (2008) Baby-led Weaning (London: Vermillion), p54

(6) Rehydration Project (2001) Facts for Feeding. Breastmilk: A Critical Source of Vitamin A for Infants and Young Children http://rehydrate.org/breastfeed/facts-breastmilk.htm

(7) Mahalanabis D (1991) Breast feeding and vitamin A deficiency among children attending a diarrhoea center in Bangladesh: A case-control study. BMJ; 303:493-496. (found at http://www.bmj.com/content/303/6801/493.abstract)

(8) Gregory JR Collins DL et al (1995) National Diet and Nutrition Survey: children aged 1½ to 4½ years London HMSO in Healthy Start: Vitamin Supplement Recommendations http://www.healthystart.nhs.uk/en/fe/vitamin_supplement_recommendations.html (accessed 11/12/10)

(9) Thomas, C (2010) Ask The Armadillo - follow on con? http://www.analyticalarmadillo.co.uk/2010/08/breastfeeding-q-ask-armadillo.html

(10) Gillie, O (2004) Sunlight Robbery: Health benefits of sunlight are denied by current public health policy in the UK http://www.healthresearchforum.org.uk/reports/sunlightrobbery.pdf

(11) Hottya, M (2004) Sunlight and Vitamin D: Exposing the Benefits New Beginnings, Vol. 21 No. 4, July-August 2004, p. 124 http://www.llli.org/NB/NBJulAug04p124.html

(12) Thomas, C (2010) Ask the Armadillo – what’s in breastmilk? http://www.analyticalarmadillo.co.uk/2010/10/ask-armadillo-whats-in-breastmilk-but.html

(13) Bonyata, K (1998) Does my baby need vitamin D supplements? http://www.kellymom.com/nutrition/vitamins/vitamin-d.html

(14) Will, H et al. (2009) Vitamin D Requirements During Infancy: Reading Between the Lines Leaven, Vol. 45 No. 1, 2009, pp. 2-6. http://www.llli.org/llleaderweb/LV/LVIss1-2009p2.html

(15) Good Mojab, C (2002) Sunlight Deficiency and Breastfeeding BREASTFEEDING ABSTRACTS, November 2002, Volume 22, Number 1, pp. 3-4. http://www.llli.org/ba/Nov02.html

“But I breastfed my baby and he still got asthma!”

2011-01-04T19:17:00.001Z

The following article was first published on Dispelling Breastfeeding Myths:

When the breastfeeding facts fail us

One December night last year, I dialled 999. My 9-month-old baby was already struggling to breathe, and it was getting worse: his constant, moany cries became weaker and weaker as he worked himself into a state of utter exhaustion. By the time the paramedics arrived, he was pale, listless and silent. We were blue-lighted into the hospital, and ended up on Children’s Ward, where he spent the following four days on oxygen and steroids. We eventually went home with asthma inhalers. Although the diagnosis wasn’t asthma (doctors don’t tend to diagnose asthma until a child is much older), it was clear he’d been having severe respiratory problems.

Suddenly it all made sense: my third baby had been a fantastic, contented little fellow… right up until he hit around 6 months old, when he became the baby who never slept. We blamed teething, and wondered whether it was something to do with starting solids. Perhaps he was just a grizzly baby? Of course, there was no shortage of those quick to blame breastfeeding, and I felt under immense pressure to ‘just give him a bottle’ to get him to sleep. Stubbornly, I refused to believe that this could be a breastfeeding problem (and was eventually proved right), but sleep-deprived and confused, we never realised that the poor child couldn’t breathe.

I never thought anything like this would happen. After all, isn’t breastfeeding supposed to protect against a multitude of diseases and allergies, including asthma?

Research suggests:

Breastfeeding is “associated with a lower incidence of asthma in young children” (Asthma UK 2008)

So where does this leave those of us whose breastfed children are at some point hospitalised because of respiratory illness or go on to develop asthma?

Perched on the hospital bed with my baby, the situation did strike me as being a bit odd: I was breastfeeding my baby, yet here we were – in hospital. I’d breastfed my baby, but he’d become ill anyway. But by that point, breastfeeding had become such an integral part of my identity as a mother, that the idea of ‘giving up’ breastfeeding because it apparently hadn’t protected him from respiratory illness was absurd. If anything, my baby’s illness made me more determined to continue breastfeeding, for longer.

A few months later, I bumped into a mother with a baby about the same age as my third child. It turned out that both babies had been hospitalised with respiratory problems at about the same time. The mother explained that her older child had asthma and had been formula fed. When her second baby came along, she’d made a real effort to breastfeed because she’d heard it would protect against asthma. And then that baby too ended up in hospital with respiratory problems. So she’d decided it was pointless continuing to breastfeed, and switched to formula.

So why would two breastfeeding mothers react in such different ways?

Part of the problem is that mothers aren’t always given all the facts:

Yes, research suggests:

Breastfeeding is “associated with a lower incidence of asthma in young children” (Asthma UK 2008)

Which is usually as much as a mother will learn about breastfeeding and asthma.

But there’s more to it than that! Research also suggests:

Breastfeeding is associated with “lower instances of persistent wheezing and coughing” (Asthma UK 2008).
Asthma and wheeze are “resolved significantly earlier in breastfed children than those who were not breastfed” (Asthma UK 2008)

A bigger part of the problem is that breastfeeding facts always assume “breast is best”: in other words, breast is special, extraordinary, superlative. If breastmilk is “best”, its nutrients, antibodies and other constituents become above and beyond requirement. If breastmilk is “best”, the protection from disease it offers is a nice bonus, but not really necessary. And imagine the disillusionment when your baby gets sick despite being breastfed, especially if you’ve made a special effort to do so! In reality though, breastfeeding is just a normal, biological function.

If breastmilk is normal, it becomes necessary, therefore NOT breastfeeding carries a risk, so the question becomes:

“what is the impact of depriving a child of [breastmilk]?” (Thomas 2010a)

If the above research findings on Asthma UK are presented from the perspective that breastfeeding is normal, the same research suggests:

NOT breastfeeding is associated with a higher incidence of asthma in young children.
NOT breastfeeding is associated with higher instances of persistent wheezing and coughing.
Asthma and wheeze take significantly longer to resolve in children who were NOT breastfed than those who were.

NB: NOT breastfeeding includes not only artificial milks, but also the introduction of solid foods prior to 6 months of age.

Next time you read a statement about the benefits of breastfeeding, why not try changing it around so it becomes a statement about the risks of NOT breastfeeding?

MYTH: If I breastfeed my baby, he won’t develop asthma.

FACT: Evidence suggests that babies who are NOT breastfed are at HIGHER risk of developing asthma. However, if my breastfed baby develops asthma, he is accounted for in the statistics too: he simply belongs in the smaller group of children who are breastfed and do develop asthma.

So, if your baby does have respiratory problems or develops asthma, is there any point in continuing to breastfeed? Absolutely! When your baby is sick, this is when your baby most needs you to breastfeed him. Breastfeeding still makes sense because:

NOT breastfeeding could increase the number of times your child experiences breathing difficulties.
NOT breastfeeding means any respiratory problems could take longer to resolve.
Your breastmilk contains antibodies, anti-inflammatory components and other constituents that help your baby to fight respiratory illness (and other illnesses besides). NOT breastfeeding would deprive him of these.
“Sick babies are more likely to [breastfeed] than to take anything else by mouth, so [breastfeeding] is important to keep baby hydrated.” (Bonyata 2002)
“Sick babies need more comforting. What better way to do this than at the breast?” (Bonyata 2002) Comfort sucking (or non-nutritive sucking) at the breast is of huge neurological, psychological and physical importance to a baby (Thomas 2010b), particularly when that baby is sick.
This issue is just one tiny part of the greater breastfeeding picture: there are so many other reasons to carry on breastfeeding!

Bibliography and References

Asthma UK (2008) Breastfeeding protects against childhood asthma

Bonyata, K (2002) My baby is sick – should I continue to breastfeed?

Thomas, C (2010a) Ask the Armadillo – what’s in breastmilk?

Thomas, C (2010b) Baby is using you as a dummy – it’s just for comfort!

The “Breasts Feeling Full = A Good Thing” Myth

2011-01-02T16:57:00.004Z

When I asked Anne of Dispelling Breastfeeding Myths to produce an article on this topic, the last thing I expected her to say was, "Why don't you try writing one yourself?" Wondering what I could possibly contribute to the blogging world of breastfeeding, I took up her challenge. Anne kindly published the resulting article on Dispelling Breastfeeding Myths; it was then republished by Flintshire Feeders, a Breastfeeding Peer Support Programme in North Wales. A wonderfully supportive and inspiring lady (see for yourself on her facebook page), Anne has encouraged me to start blogging, so brace yourselves!

_____________________________________

Here's the article:

Nearly nine years have passed since my first (fairly disastrous) breastfeeding experience. One of the things I recall is feeling a sense of pride because I frequently got a really full feeling in my breasts: I could feel I was producing plenty of milk. I would wait for my breasts to feel full – and, if I’m honest, fairly uncomfortable - before I latched my baby on, believing the full feeling was a good thing: it indicated nature’s bottles were full of milk ready for a feed. So I was understandably confused when I was told my baby’s weight gain was too slow and she was failing to thrive. Lacking proper information and support, the only advice I received to remedy this was to give her formula top-ups, which spelt the end of our breastfeeding relationship.

Thankfully, I have since received far better breastfeeding support, have gone on to successfully breastfeed three subsequent children (two of whom I am still breastfeeding) and have become a LLL breastfeeding peer supporter. Though I now realise that the experience I had with my first baby is not uncommon: I often encounter mothers who, like I did, believe they need to feel full before they feed their baby, and who worry unnecessarily when their breasts no longer feel full.

MYTH: Breasts are like bottles, which empty and need to be refilled. I need to wait for my breasts to fill up before I feed my baby.

FACT: Feeling full isn’t necessarily a good thing. This full feeling means milk is accumulating in your breasts, which tells your body it is making too much milk. This milk isn’t being used by your baby, so your body thinks there is no demand for it, and starts to reduce your milk supply. Frequent removal of milk is key to building and maintaining a good milk supply.

This might seem like crazy, upside-down logic, but it works. For those who are interested, here’s the sciency bit:

_________________________________________________________

THE UPSIDE-DOWN SCIENCE OF MAKING MUMMY MILK

FACT: If your breast is full, your milk production is SLOWER.

FACT: If your breast is emptier, your milk production is FASTER.

“Evidence exists that there are two interacting mechanisms regulating the rate of milk synthesis.”

~ van Veldhuizen-Staas 2007

The first mechanism involves Feedback Inhibitor of Lactation (FIL). FIL is a whey protein present in your milk, which is thought to slow milk production in each breast independently when it is full. When milk accumulates in the breast, FIL accumulates in the breast and milk production slows down.

The second mechanism involves prolactin and prolactin receptor sites. Inside your breasts you have milk-making cells (called lactocytes). On the membranes of these milk-making cells are prolactin receptor sites. Prolactin receptor sites behave a bit like locks: they need a key to make them work. This key is called prolactin. Prolactin is “the major milk-stimulating hormone” (West & Marasco 2009, p6) that travels along your bloodstream and temporarily binds to the prolactin receptor sites (the locks), which then sends a message to the milk-making cells to stimulate milk production (a little bit like starting the ignition in your car). It is thought that as the breast fills with milk, the shape of the milk-making cells change, so that prolactin can no longer bind to its receptor sites. This tells your body it is making more prolactin than it really needs, so your prolactin levels drop. Milk synthesis slows, and eventually stops.

Frequent removal of milk is important because:

FIL is removed from the breast. This speeds up milk synthesis.
Prolactin can bind effectively to prolactin receptor sites on lactocytes, which stimulates more milk production. Your baby’s suckling at the breast actually increases prolactin levels in your blood, which increases milk production. Prolactin levels are highest after frequent feeding “when the breast is most fully drained of milk” (LLL GB 2009) (this is usually at night).

_________________________________________________________

If you didn’t 'get' all that, don’t worry! The most important bit to remember is this:

FACT: If your breast is full, your milk production is SLOWER.
FACT: If your breast is emptier, your milk production is FASTER.

Your body is constantly fine-tuning your milk supply to exactly meet your baby’s needs. This means there may be occasions when your breasts will feel fuller, including:

when your milk “comes in” a few days after the birth of your baby. Your body doesn’t yet know how much milk your baby (or babies!) is likely to demand. So your body may simply respond with copious milk production, resulting in an (over)full feeling in your breasts.
at certain times over the first few weeks as your body is fine-tuning your milk supply.

As long as you are feeding on demand, the initial overzealous milk production is gradually adjusted and continually regulated to exactly meet your baby’s needs. As your milk supply becomes more efficient, your breasts lose their feeling of (over)fullness and will feel soft most of the time.

MYTH: If my breasts feel empty and my baby still wants to feed and feed and feed, it means something is wrong.

FACT: Feeling empty is actually a positive thing! This empty feeling means your baby is removing milk efficiently from your breasts, which tells your body to make more milk. If your baby wants to continue suckling on a breast that feels empty, this tells your body that your baby is demanding more milk, and so your body starts to increase your milk supply. Allowing unrestricted suckling at the breast is important for helping your milk supply adjust appropriately to your baby’s needs.

Feeling empty does NOT mean you’re not producing enough milk for your baby, or you need to give your breasts a break to allow your milk supply to ‘catch up’. Feeling empty does NOT mean your milk is too thin or drying up, so there’s no need to supplement with artificial milk or introduce solid foods prematurely. There is no need to worry about whether your baby is getting enough milk if he/she is gaining weight well and producing plenty of wet and dirty nappies. Feeling empty does NOT mean you need to worry that your baby is using you as a dummy or that your baby needs a pacifier.

In fact, there is evidence that supplementing and use of dummies could cause more harm than good: if your baby is sucking on an artificial teat, he is not stimulating your breast, and so the messaging system which tells your body to keep up with his demand for milk is disrupted.

Normal breastfeeding behaviour includes periods when baby needs to feed more frequently, such as:

cluster feeding (which often occurs in the evenings),
during growth spurts
around developmental milestones (such as rolling over or crawling).

Although frustrating and tiring, these periods of increased breastfeeding are absolutely normal. They soon pass. During these times, your breasts will feel very soft. Although you may notice that your milk flow is slow,this doesn’t mean your milk production is slow!

FACT: If your breast is emptier, your milk production is FASTER.

Your body is constantly fine-tuning your milk supply to exactly meet your baby’s needs.Your body does not like to waste precious resources(West & Marasco 2009, p10). As your body becomes more efficient at supply and demand, your breasts will feel soft most of the time. This is normal. Milk production is designed to succeed (West & Marasco 2009, p13).

East & Coastal Kent NHS

______________________________

References:
Mohrbacher, N et al (2003) The Breastfeeding Answer Book
Abbett, M (2008) A mother’s (and others) guide to BREASTFEEDING Issue 8
La Leche League of Great Britain (2009) Breastfeeding Peer Counsellor Programme
Van Veldhizen-Staas, C (2007) Overabundant milk supply: an alternative way to intervene by full drainage and block feeding in International Breastfeeding Journal 2007, 2:11 doi:10.1186/1746-4358-2-11
West, D & Marasco, L (2009) The Breastfeeding Mother’s Guide to Making More Milk
www.kellymom.com/bf/