Category Archives: Breastfeeding

17 Jun

Breastfeeding support matters, but it’s not all about the individual

Will breastfeeding, too, one day have its historian-chronicler who tries to unravel the train of events leading to the early 21st century’s failed mass alternative-nutrition child-feeding trials?
– James Akre in the Huffington Post

I recently heard a talk by researcher and breastfeeding advocate Maureen Minchin (and interviewed her for Episode 15 of Sprogcast), in which she discussed exactly this question. Her new book Milk Matters picks up from and expands upon her 1985 book Breastfeeding Matters, a detailed and dense book covering both the political history of breastfeeding in modern times, and specific information on the management of breastfeeding which is useful for both mothers and health professionals alike. In person, her tone is as assertive and her views as uncompromising, as they come across in this book. In 1985, Minchin wrote “Those who conceal information, for the sake of sparing mothers anxiety, are doing greater harm.” She still firmly believes this.

Quoting, with irony, an old Cow & Gate advert, Minchin says that “what you feed them now matters forever.” Her milk hypothesis is that breastmilk is the bridge from the womb to the world, enabling the baby to develop a healthy microbiome, which regulates the immune system and optimises development. Furthermore early nutrition is the single biggest influence on gene expression following birth.

There is plenty of evidence for this, and emerging evidence that exposure to cows’ milk protein actively interferes with gene expression, triggering a trajectory of growth not only for the life of that baby, but if she is a girl, for her children and grandchildren too. More details about this can be found in her presentation here.

Minchin accurately predicted a backlash against honesty about the risks of not breastfeeding, and cites the huge vested interests of the baby milk industry, which has successfully divided mothers for decades, co-opting the phrase “breast is best” to create an aspirational ideal, and undermining breastmilk as the normal infant food for our species.

Why is it so hard to talk about breastfeeding in a positive and helpful way, that doesn’t incite an emotional response? The day after hearing Minchin speak, I was at the Association of Breastfeeding Mothers (ABM) annual conference in Birmingham, listening to speakers who truly understand the challenges of supporting individual mothers, in a social context that is not supportive of breastfeeding. The health, social, and emotional issues are the background noise against which we all work with mothers; but too much of what society knows about breastfeeding comes from a middle class media that categorises women according to the way they feed their baby. As Lactation Consultant Sally Etheridge pointed out at the ABM conference, “just because a mother isn’t breastfeeding, it doesn’t mean she didn’t want to.”

Earlier this year, a report in The Lancet demonstrated that the UK has the lowest breastfeeding rates in the world. Whose responsibility is it to change this? Those whose vested interests lie in women breastfeeding less would have us believe that anyone offering breastfeeding support is a member of the Milk Mafia, with an earnest belief in boosting those numbers bleeding nipple by bleeding nipple. Breastfeeding happens within a complex socio-economic context, and a focus on public health rather than on individuals does not preclude individual support. In fact the goal of most breastfeeding supporters is to help improve individual mothers’ experiences, to support their feeding decisions, and to empower women to make those decisions. According to researcher Heather Trickey at the ABM conference (also on the next episode of Sprogcast), it is not the responsibility of the feeding supporters, or of any individual mother, to improve breastfeeding rates; it is the responsibility of society, of the health services, of government. The only people who gain from pussy-footing around women’s feelings about breastmilk and formula are those who make a profit from exploiting mothers, to the detriment of public health.

[Cross-posted from the Huffington Post]

21 Mar

Media manages to shut Jamie Oliver up over breastfeeding. Nice one.

As soon as Jamie Oliver opened his mouth, it was open season for bashing the breastfeeding supporters once again. To be fair, his choice of words was poor. ‘It’s easy, it’s more convenient, it’s more nutritious, it’s better, it’s free,’ he said. Well, it’s certainly free.

Cue a whole cornucopia of articles arguing the rest of those points, largely from journalists who experienced a variety of difficulties in feeding their own babies, most of whom seem to be using this most inappropriate platform to debrief their feelings of guilt and anger and disappointment.

The typical argument goes something like this:

He’s a man. How dare he stand up for women?
It’s not even true. How dare he say that breastfeeding is a good thing? Lots of women can’t do it. I couldn’t do it.
Breastfeeding support is all about pressuring you to continue. All my friends said so too.

This argument is generally concluded with either “I actually fed my baby for 18 months but don’t beat yourself up if you can’t;” or “I gave my baby formula and she’s fine and I’m fine so shut up.”

And this is how journalists manage to perpetuate the social and cultural difficulty of breastfeeding. I have no problem with them reminding us that breastfeeding can be hard; this is supported by experience and by evidence. The sadly now-discontinued Infant Feeding Survey showed in 2010 the drop-off rate from around 80% to around 55% of mothers breastfeeding their babies by six weeks, and 34% at six months (none of this is exclusive breastfeeding, just a baby getting any breastmilk at all). The 2005 survey showed that 90% of the mothers who stopped by six weeks, had planned to breastfeed for longer. This is the statistic that we should be shouting about, because this represents all that guilt and anger and disappointment.

We need to stop setting up straw man arguments like the Smug Self-Righteous Lactivist, and ask why councils are closing down breastfeeding support services run by highly-trained breastfeeding counsellors and attended by huge numbers of mothers. To take one example, 17% of all new mothers attended the Hampshire drop-ins, and 98% of them would recommend the service to others. This doesn’t speak of pushy, pressurising, “well-meaning” (translation: “ineffectual”) supporters who spout about “breast is best” and insist you carry on no matter what.

Generally speaking, breastfeeding counsellors are trained to listen and support women (and sometimes men); to give them a safe space to figure out what they want to do and how they want to do it; and to share information to help with that decision making. Breastfeeding counsellors don’t use words like “easy” and “convenient,” mainly because their experience is of working every single day with women who are not finding it easy or convenient. Nor do they use such phrases as “breast is best,” since they are well aware that parents tend not to make feeding decisions on the basis of evidence about nutrition. No, parents make decisions on the basis of what’s happening to them at the time. Telling a struggling mother to continue doing something that is making her miserable, because it is best for her child, is contrary to the philosophies and the training of all the UK breastfeeding support organisations.

Yes, Jamie oversimplified breastfeeding in his statement on the radio, but that was a droplet compared with the oversimplification of the state of breastfeeding that followed, media-wide. Well done for enabling a backlash that prevented someone speaking out for supporting women.

11 Feb

My complaint to the BBC

Dear BBC

I wish to raise a complaint with regard to the choice of Clare Byam-Cook, who was represented as a “breastfeeding expert,” a “breastfeeding counsellor,” and a “lactation consultant” on Woman’s Hour on Monday morning. With respect, she is none of these things, and I am deeply unimpressed that BBC researchers were unaware of this, despite complaints every single time she appears.

The information given out by Byam-Cook about tongue tie, milk supply, and the baby’s latch at the breast were fundamentally incorrect. Since the purpose of this piece was to explore the reasons why women feel unsupported and do not breastfeed for long in the UK, I am surprised that this misinformation was perpetuated without comment. This is negligent of the BBC.

Byam-Cook was also allowed to talk about her video and book, and mention that she is available for private consultations. I understood that the BBC was required to adhere to certain standards about allowing advertising. If this had been advertised on ITV I would be making a complaint to the ASA, since her book contains many factual errors that would undermine the breastfeeding experience of most women.

Please do not bother to send me your standard response, as I have read it. I take issue with the statement that ” Unlike other breast feeding counsellors, she doesn’t believe that breastfeeding is the be all and end all.” As a Breastfeeding Counsellor, I am very well aware that breastfeeding is one part of the complex experience of becoming a parent, and I have supported parents in many different situations, making many different decisions. The word “counsellor” should convey to you that we listen and support individual mothers, without an agenda. Nonetheless, breastfeeding is an important public health issue, as shown in last week’s article in the Lancet; and the BBC has a responsibility to give out correct factual information, as well as the helpline numbers from the four reputable organisations whose counsellors are trained to support women in an evidence-based, parent-centred way.

Kind regards
Karen Hall

11 Feb

How not to talk about breastfeeding on the radio

On Monday, BBC Woman’s Hour had what they described before the programme as a “ding dong” about breastfeeding. Ironically I missed the first fifteen minutes because I answered the phone, just as the programme started, to a mother who was concerned about her milk supply. Then I tuned in and cringed to hear the brusque tones of Clare Byam-Cook, a self-appointed “expert” on breastfeeding, telling listeners all about her magic techniques for getting babies to feed, and explaining where we, the trained breastfeeding supporters, are going wrong.

I have issues with the BBC allowing this person to promote her book and simultaneously undermine the work of the breastfeeding counsellors who criticise it. I’ve read her book and it’s hard to see how anyone could have much chance of breastfeeding for long, following its guidance. Callers to the show spoke of pressure, conflicting advice, and not being listened to. Byam-Cook dismissed the issue of tongue tie as “just a trend,” thus dismissing the experiences of thousands of mothers who have struggled to feed their babies precisely because of this. Estimates vary, but it seems that tongue tie affects 5-10% of babies, many of whom will be able to breastfeed, and some of whom are so badly tongue tied that they cannot drink from a bottle. Because it can be hard to identify a tongue tie, and midwives are not universally trained to do so, many mothers struggle with long or painful feeds, and many give up in despair. This is not a positive decision for them, and to hear that it’s a non-issue that doesn’t need to be resolved must hurt in so many ways.

Her fundamental lack of understanding of the way breastmilk is produced is shocking (“it is absolutely not true” that the more you feed, the more milk you produce). The well-established, basic principle is that milk removal creates milk production, therefore the more effectively a baby feeds (that is, on cue, for as long as he/she wants to, without discomfort for the mother), the more effectively the mother produces milk to meet that baby’s needs. Yes it is true that sometimes a baby feeds more (for longer, or more frequently) because the feeding is not effective; breastfeeding is complex, and breastfeeding counsellors are trained to listen to mothers and try to understand the situation so that they can offer appropriate support.

Listeners were also treated to her description of how to get a baby to latch on and feed (“mouth to nipple and squeeze the breast.”) Breastfeeding counsellors all over the country must have been banging their heads on the desk at this point; how many painful feeding experiences have we witnessed, where a woman has been told to squeeze her breast and force the baby on to it? No one-size-fits-all approach can ever be appropriate when we’re talking about human bodies, but there are strategies involving comfort, closeness, and biological reflexes that can make things much easier for both mother and baby.

I understand exactly why BBC Woman’s Hour invited Byam-Cook on to the show: a discussion between two International Board Certified Lactation Consultants about the shocking lack of support for new mothers would not have made such exciting radio. Or would it? As Dr Pat Hoddinott pointed out, the media has to share responsibility for the low breastfeeding rates in the UK, and shows like this are very much part of the problem, not part of the solution.

If you are a new parent and need some support with breastfeeding, there are several helplines run by women trained in listening, and with evidence-based knowledge about how breastfeeding works, including the NCT Breastfeeding Line 0300 330 0700 open 365 days a year, 8am-midnight. We talked about breastfeeding support in our very first episode of Sprogcast, which you can find here.

18 Mar

The value of breastfeeding in pounds, pence, and Brazilian dollars

This morning we are hearing on the news about a study from Brazil that demonstrates an economic value to breastfeeding, evidenced through measuring IQ, educational attainment, and income at the age of 30. It’s a fascinating study with a large cohort, followed up over 30 years, and of course it is causing the usual furore.

Here is the paper in full: Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age and I would recommend actually reading it before you commence your ranting, since I have seen on social media this morning so many straw man arguments standing up against it.

This research set out to examine the claim that “breastfeeding can also increase individual income, and thus contribute to economic productivity,” as previous studies have not demonstrated this. Inevitably detractors will argue that there is more to life than economic productivity, with which I would certainly agree. However the value of a study like this is in providing evidence of a real economic value to breastfeeding, which could sway policy makers into increasing funding for breastfeeding support and education. We already have plenty of evidence that breastfeeding rates would increase if effective support was more widely accessible; surely some fund-holding decision maker somewhere can join the dots?

What this research does not set out to do, is to judge individual women for their feeding decisions. And yet that is the strongest reaction I have seen today: this kind of report makes women feel guilty. Self-appointed and unqualified “expert” Clare Byam-Cook called the research controversial on TV this morning. The controversy is in this kind of response to it, not in the research itself. The research does not say that you are a bad parent if you don’t breastfeed, and it does acknowledge the many other factors in both nature and nurture that contribute to the outcomes measured – but the researchers did control these variables quite thoroughly and still demonstrated a correlation.

As a breastfeeding support worker who scrapes a living and works mostly in a voluntary capacity, I appreciate anything that might influence future policy making, and I rail against society-imposed guilt imposed on individual mothers who make hard decisions in difficult circumstances, when effective support has not been available to them.

29 Dec

Tongue Tie: the other side of the divide

Recently I read a blog post about one mother’s experience with her baby’s tongue tie. It was a familiar story: the tongue tie was not picked up for several weeks, during which time breastfeeding was painful and the baby fed ineffectively. By the time the tongue tie was divided, the mother’s milk supply was severely compromised because of that ineffective feeding, and shortly afterwards, she took the decision to stop breastfeeding completely. She feels angry and let down by the health professionals who did not diagnose the tongue tie sooner, by the NCT for not telling her about tongue tie in the antenatal breastfeeding session, and by society for insisting that breast is best, and making her feel like a failure.

I have heard this story so many times, and after reading it I spent quite a lot of time reflecting on why I find it so painful to read, and also on just why it is such a common tale.

What is tongue tie?
Definitions of tongue tie vary from source to source, but all seem to agree on the basics:

Tongue-tie is a problem that occurs in babies who have a tight piece of skin between the underside of their tongue and the floor of their mouth. – NHS Choices.

UNICEF adds that this tight piece of skin stops:

the tip of the tongue from protruding beyond the lower gum. It varies in degree, from a mild form in which the tongue is bound only by a thin mucous membrane to a severe form in which the tongue is completely fused to the floor of the mouth.

Note the varying degree. When a tongue is bound by a thin mucuous membrane, this is usually visible even to the inexperienced practitioner, as you can see it at the tip of the tongue, and it often causes the tip of the tongue to be heart-shaped rather than pointed. “Completely fused” would probably also be obvious. However, there are all the degrees in between these two, which are much harder to spot, harder to diagnose, and harder to resolve. Most practitioners agree that an assessment of the function of the tongue is actually far more useful than making a diagnosis on the basis of what you can see in the baby’s mouth. There is a good tool for assessing both; however I feel that this still misses out a hugely important factor: the mother’s experience.

Suspect and Signpost
As a Breastfeeding Counsellor, my remit with regard to tongue tie is to suspect, and to signpost. I’m not clinically trained, nor am I insured to feel about with my fingers under a baby’s tongue. I do have a number of years’ experience in supporting breastfeeding mothers, and it would appear that there is absolutely no situation where it’s completely obvious what to do. In the last few years I have seen a tongue tie so severe that a Lactation Consultant later said that the baby would not have been able to bottle feed, never mind breastfeed; this was not picked up by the hospital midwives or paediatrician. I have seen clumpy little tongues on babies who pile on weight regardless, owing to their mothers’ robust milk supplies. I have seen mouths with every appearance of a a tongue tie, which on referral to the NHS clinic have come back with the diagnosis ruled out. I have witnessed a midwife dismiss tongue tie as “definitely not,” and gone on to support that mother to finally have it divided six weeks later. I have seen babies whose tongues look completely normal, but on listening to the mother’s story I hear familiar warning bells; and having tried everything we can think of to improve positioning, there is no improvement. I can suspect tongue tie all I want, but if the clinicians to whom I signpost parents disagree, then mothers are left with very little they feel able to do.

So if tongue ties are so variable in both appearance and impact on function, what sort of clinical training would grant me the apparently magical ability to diagnose consistently and reliably, and send mothers and babies to get the treatment they need? So while I am, in theory, supportive of NCT’s ongoing campaign for better services for babies with tongue tie, I have some reservations about how this might be done. In fact, as usual, I feel that it would be helpful to campaign for better services to support parents of newborn babies, full stop.

In conversation with one of the lead breastfeeding midwives at a local hospital, she expressed irritation at the number of referrals she gets where tongue tie ends up being ruled out. In accordance with NICE guidelines, she would prefer conservative management of tongue tie, and better help with positioning and attachment for all mothers. It seemed that she felt the people providing breastfeeding support in the community should be doing a better job. Apparently this is a widely-held view among health professionals and parents alike, so here I’d like to point out that most of our work is done on a voluntary basis, nor do we get paid for the time we spend doing training, and in many cases we pay for our own training.

As one of those who works in the community providing breastfeeding support, I do have the advantage of being able to spend time listening to a mother and observing her baby feed. If I suspect a tongue tie then I will always explain this to the mother and inform her of her options. I don’t make the decisions for them, and I do explore positioning and attachment, and other things that might improve breastfeeding for both of them. The options I inform her of will always include a referral to someone who can rule tongue tie in or out, but frankly anyone who is 100% certain that they can rule a tongue tie in or out at a glance needs supervision.

The NHS is not in a position to grant every midwife the specialist skill of identifying tongue ties, and the experience to do so, overnight. The voluntary organisations even less so. This is simply impossible, never mind the cost, the fact that tongue tie division is an invasive procedure, and – I’m afraid – the lack of clinical evidence to support it. Here is the NICE guideline on that:

Current evidence suggests that there are no major safety concerns about division of ankyloglossia (tongue-tie) and limited evidence suggests that this procedure can improve breastfeeding. This evidence is adequate to support the use of the procedure provided that normal arrangements are in place for consent, audit and clinical governance.

Hindsight
Once I fractured my wrist. Initial x-rays showed no fracture, but six weeks later as it had healed, the x-ray clearly showed where the fractured bones were knitting together. Mothers who realise later on that their babies have or had a tongue tie can look back and understand why they had such difficulty breastfeeding, and this can only feel bitterly disappointing, on the basis that if it had been diagnosed and treated, everything would have been fine. In fact not all tongue tie divisions are successful; some regrow and some are just not completely divided. Many babies seem able to breastfeed despite a tongue tie; and many retrospective diagnoses are probably just plain wrong. This brings us back to increasing support for parents, training midwives not just in identifying tongue tie but in effective all-round breastfeeding support, and supporting the voluntary breastfeeding organisations to do more.

Because it’s true that health professionals and parents may focus on the suspected tongue tie to the exclusion of any other breastfeeding issues, particularly improving positioning and attachment, which could sort things out much quicker and – if it really isn’t a tongue tie – more effectively.

I can completely understand the anger that mothers feel when their breastfeeding experience has been disappointing or unhappy, and I understand why those mothers may feel that their experience is universal and if only the NHS and breastfeeding supporters could learn from it, we’d all do a better job. And I agree that we need to keep on listening to mothers and not focus solely on diagnostic tools. But I don’t think tongue tie is something that either we just don’t understand, or want to keep secret. It’s simply more complicated than 1. spot tongue tie; 2. divide tongue tie; 3. all is well.

Views expressed here are my own, and do not represent the views of NCT.

03 Sep

Breasts against the patriarchy!

…to take a stance that you control what a woman does with her body is an assumption that you have power over her. You are dictating what is appropriate behavior. You are trying to “get her” to do what you want. If she doesn’t comply, then you obtain assistance to “get her” to do so. Here’s the deal: every time you prevent a woman from choosing what she does with her body, you are acting in a violent manner.

One man’s response to a request that his wife not breastfeed their baby in a public place, from Empowered Papa.

12 Nov

Incentivising Breastfeeding

Much excitement this afternoon when I was asked to speak to Anne Diamond on BBC Radio Berkshire, with a response to the news that researchers from the University of Sheffield are running a study where 130 new mothers are offered £200 vouchers if they breastfeed their babies. This is aimed at mothers in communities where breastfeeding rates are low, with the intention of increasing initiation rates and reducing health inequalities. The Guardian has a good explanation of the project and some responses to it here. Read More →

30 Sep

Baby Weight Charts

A couple of weeks ago, The Times reported that the UK baby weight charts were “skewed to promote breastfeeding.” The Times article is behind a paywall, but I picked up on it on another website. According to these reports, using weight charts based on exclusively breastfed babies will make formula fed babies seem to be overweight; the overall impression was a rather paranoid assumption that this was being done in order to make mothers breastfeed. Read More →