If you didn’t like that study, how about this one?
Potential economic impacts from improving
breastfeeding rates in the UK
Supporting mothers who are exclusively breast feeding at 1 week to continue breast feeding until 4 months could save at least £11 million per year by reducing the incidence of three acute infections in children.
Elisa Albert in The Guardian: My friend breastfed my baby
The only people I know who did just fine in the postpartum period are those who score the triumvirate: well cared for in birth, surrounded by supportive peers, helpful elders to stay with them for a time.
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.
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.
Sweet Sleep is a La Leche League publication, written by some of the well-known names in the LLL world: Diane Wiessinger, Diana West, Linda J. Smith and Teresa Pitman; and as such it sets out a very definitely baby-centred philosophical position, as you might expect. It very nearly does manage to achieve a balanced tone with regard to the fact that not all families breastfeed, and even includes a chapter on how to cope if you don’t have this powerful parenting tool available to you (adoptive families, for instance), but its subtitle clearly states “for the Breastfeeding Family” and this is where its real strength lies.
There is a wealth of advice available online, from health professionals, and among families and friends, for parents who want techniques to “train” their babies to sleep. Sweet Sleep fills a gap for the parents who want to work within their babies’ normal development, with gentle nudges from stage to stage, but allowing for kind and responsive parenting.
Sweet Sleep is packed with practical suggestions, and sensibly begins with a chapter full of immediate ideas for getting more sleep tonight. It focuses straight away on the Safe Sleep Seven, which are rules for emergency bedsharing. Given that statistics show unplanned bedsharing to be far riskier than planned bedsharing, helping parents to plan for it is a really good place to start.
It goes on to explain normal sleep, drawing on anthropology, biology, and worldwide cultural practices. This is followed by safety information, gentle nudges for different ages and stages, and suggestions for different scenarios such as premature babies, twins and so on. The chapter on SIDS and suffocation is comprehensive and well-explained; and finally the book offers suggestions for talking to supportive and non-supportive people about an attachment parenting approach to coping with nights.
This book is well-referenced throughout, and illustrated with quotes from the authors’ own stories and from other families. Once too often I found myself frustrated that the authors touch on a point and promise to explain it more in a later chapter, making me dip about in the book rather than reading it through as I wanted to. I was not particularly surprised that the section on Getting Help/Giving Help only mentions La Leche League, when there are quite a number of other organisations, including NCT, who could also support parents in these situations.
On the whole I found this book useful both in terms of practical help for parents of co-sleeping/breastfeeding babies, and ways of thinking/talking about risk and responsiveness, which I find a lot of new parents and parents-to-be worry about. It’s good to have a book that supports parents to follow their instincts and find their own rhythms.
DISCLOSURE: I was sent a free review copy of this book by Pinter and Martin Publishers. To order your own copy with a 25% discount, just follow the link and use the discount code KH25 at the checkout.
Views expressed here are my own, and do not represent the views of NCT.
This weekend, Dr Ben Goldacre stood on a stage in front of hundreds of NCT Practitioners, volunteers and staff, and told us that we “push” breastfeeding. “Because you do,” he said, with a cheeky wink. “You’re the breastfeeding nazis.”
There was a sort of silent stunned gasp, followed by a burst of laughter; it was the funniest thing, a great ironic deconstruction of the name-calling rubbish (with acknowledgement to my colleague Kerry from whom I pinched that description). It was funny the second time he said it, too. After a while I was much reminded of my eight year old son and how he repeats the joke until you have to sit him down and explain that we’re really over it now.
We were treated to Goldacre’s standard comedic romp through the Daily Mail’s war on cancer, his low opinion of Gillian McKeith, and a selection of amusing headlines that can be achieved by cherry-picking statistics. Lucky us, we got a little extra bit on research statistics, and then a worked example using Brion et al’s 2011 article entitled What are the causal effects of breastfeeding on IQ, obesity and blood pressure? This study does contain flaws, and I wondered if Goldacre had also read this commentary, though on reflection if he had read it, its conclusion might have helped him to write a conclusion of his own:
Although the collective evidence suggests that breastfeeding—initiation, longer duration or exclusivity— may very well exert a modest protective effect on childhood and adolescent obesity, it no longer appears to be a major determinant. Nevertheless, because breastfeeding also reduces infection and allergy-related outcomes and probably increases IQ, World Health Organization recommendations for 6 months of exclusive breastfeeding remain a just and justifiable policy around the world.
By the umpteenth repetition of the breastfeeding nazi joke, I had the impression that Goldacre did not quite understand what NCT does, and while I have no evidence for this assertion, I’m pretty sure he hasn’t read our excellent Infant Feeding Message Framework [pdf]. Reading through the reasons women give for stopping breastfeeding, it would appear that for mothers, the evidence itself is not the highest priority when it comes to evaluating the experience, and that is where NCT comes in, to support parents in the situation they are in: non-judgemental, respectful support where support is asked for.
Ben Goldacre told us he doesn’t care about breastfeeding, he cares about misuse of evidence, and nobody in the room would have disagreed with that. But I would have liked him to have been a bit more thorough in his own research and understanding of how NCT supports parents.
…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.
This follows Dean’s birth story, here.
Day One.
I’m back in at 10am, Claire has got 1 hours sleep but looks great on it even if she doesn’t feel it. Alexander has had his first attempt at breastfeeding and it’s not going well. Claire is frustrated at not being able to get the right position and when she does he latches on, takes a few sucks and falls asleep. Blowing on his face, tickling his tummy or pinching his feet wake him for a few more gulps and then he’s back in the world of nod.
This is how it’s been all night and we are slightly concerned, but the midwives are ok with it. In fact, listening to other conversations around the ward this seems to be a common theme. Read More
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
Dr Mark Porter on Radio 4’s Inside Health last week had an interesting piece where a particular type of dental problem in children was attributed to extended breastfeeding.
Molar incisor hypomineralisation is described by Professor Monty Duggal, Head of Paediatric Dentistry at the Leeds Dental Institute as “pain and sensitivity in their back molars and also unsightly marks on [children’s] upper front teeth.” This appears to be a relatively new phenomenon, occurring in the last 15 years, and reportedly affects up to 16% of children in the north of England.
Importantly, Professor Duggal explains that this is a perinatal event; that is, something that happens around birth. He then goes on to suggest that new Swedish studies show a link with extended breastfeeding without introduction of solids. He defines extended breastfeeding as breastfeeding beyond six months, which of course is outside the perinatal period.
This raises a few questions for me. We know that in the UK, 23% of babies are still breastfed at six months, but fewer than 2% are exclusively breastfed. Current Department of Health guidelines are to introduce solids at around six months, and the vast majority of parents do it before this time. So I was curious to know where a large enough sample of babies who were exclusively breastfed beyond six months could be found, which perhaps is possible in Sweden where breastfeeding rates are higher, but even so that’s hard to tie up with the stated 16% Molar-incisor hypomineralisation figure for the UK. The Professor’s recommendation to introduce some solids by six months is hardly ground-breaking, but my concern would be that “by six months” would make parents feel they need to start earlier than that, which is not supported by the Department of Health.
With no reference to the Swedish study, it has been hard to follow this up; but I have found an interesting webpage that collates 40 studies of Molar-incisor hypomineralisation from different countries. Without PubMed access, I can only read the abstracts, but few of them mention breastfeeding at all, and this one from 2008 explicitly finds no link with breastfeeding. A 2012 study co-authored by Duggal doesn’t mention breastfeeding in the abstract, but does find a link with lower socio-economic status. Which is interesting in that we also know lower socio-economic status is correlated with shorter duration of breastfeeding. These figures don’t stack up.
On the basis of this interview and my subsequent reading, I cannot see a basis for Duggal’s claim that “they’re nutritionally not fully supported” in the context of dental issues; however it is well-established that breastmilk is a nutritionally complete diet until around the age of six months, when complementary foods are usually needed.
Finally I discovered that Dr Mark Porter is heavily involved with baby milk manufacturer Cow & Gate. Some cynics might feel that such a vested interest in not breastfeeding should be declared whenever there is an article about breastfeeding on the show.