Articles published on this blog are my opinion only, and may not necessarily reflect the views of any organisations with which I am associated. Please be aware that articles posted on this blog are not intended as a substitute for professional medical advice. If you have a medical problem relating to breastfeeding, please seek further advice from a Lactation Consultant (IBCLC) or trained Breastfeeding Counsellor.

Sunday, 23 January 2011

If you leave the back door open...

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
(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

Friday, 14 January 2011

As easy as ACD?

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?
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A

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.
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C

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).
_______________________


D

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

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

Tuesday, 4 January 2011

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

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!

Sunday, 2 January 2011

The “Breasts Feeling Full = A Good Thing” Myth

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!
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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:
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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).
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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).





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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
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