Reflux - broken babies or profitable product?

As those who know me will testify, the subject of infant reflux (or gastrointestinal oesophageal reflux GOR)  is one that launches me on to my soapbox at a rate Dick Fosbury would have been impressed with.  So I thought a blog piece might save me repeating myself quite so often...

Reflux has to be one of the most over diagnosed and yet least understood conditions of the 21st Century.  Ask anyone above about forty and they look puzzled when you toss the term about - yet seemingly every other baby at a group now suffers from this rapidly spreading problem.  It seems to have replaced "colic" at the doctors surgery - new mother, baby crying a lot, back arching; ah that will be reflux.  Gaviscon prescription please!  I would love to know just how much Gaviscon's profits have increased since this new trend.

On the flip side, infants with moderate to severe reflux (which can cause serious issues from aspiration to oesophageal damage) seem to really struggle to get anyone to take their problem seriously, beyond Gaviscon!

What is infant reflux?
As those listening at Chemistry class might remember, the term "reflux"  (from medieval Latin reflūxus) means "flowing back".  So, when you tell your doctor your baby is frequently being sick (sometimes copious amounts) and he tells you the baby has "reflux"; he is simply repeating back to you what you told him, using a more impressive sounding word. 

If he adds "gastrointestinal oesophageal" he is telling you what is refluxing and where, ie contents from the stomach, into the oesophagus.  If the amount of sick isn't sufficient to be termed reflux - it's considered normal "posetting".  Generally reflux is forceful vomitting, whereas posetting is the effortless mouthful of milk infants can bring up after a feed (which can still look an impressive amount at the time, but isn't comparable to projectile).

If baby isn't vomiting, but is very unsettled for long periods (read as screaming!),  arching their back and displaying unusual feeding behaviour such as fussing, refusing or feeding very frequently - this is termed "silent reflux".

At the most extreme end of the scale the condition is termed GORD (gastrointestinal oesophageal reflux disease or Pathogenic GOR).  Babies with GORD suffer from excessive reflux which if not appropriately managed leads to complicationd such as; inadequate growth, failure to thrive, feeding aversions and oesophagitis, or atypical complications such as wheezing, pneumonia and chronic sinusitis.  It is more common in children with neurological impairments or physical abnormalities, and it is estimated around 3 in 1000 infants display symptoms of GORD.

Those who reflux without weight gain issues or apparent distress are labelled "happy spitters" and these babies are generally not medicated.

The vast majority of typical infants will outgrow reflux by around their first birthday - even those who suffer severely when younger.

So what's my problem?
A reason that is often given for around 60% of infants suffering from reflux, is that they have a weaker lower oesophageal sphincter (the muscular ring at the lower end of the oesophagus), making them more prone to refluxing stomach contents - but given the number now diagnosed with this condition, why are babies suddenly suffering en-mass from abnormally weak stomachs?   I don't doubt there are some with an unusually weak valve, or other physical condition, but I do believe these are the minority.

Infants suffering with moderate to severe reflux can be naturally very distressed, there can be risk of aspiration as discussed and it can be a worrying and exhausting time for parents.  Isn't just handing out mediction without investigation unfair?

Why?
Because several things are known to cause reflux - yet instead of looking at possible reasons why a baby is refluxing, the doctor (with little breastfeeding training or experience and likely pushed for time), deals with trying to stop the symptoms via medication.

Causes

Tongue Tie/High Palate - This in my experience almost always causes either reflux, wind or both.  If you had problems feeding previous infants, have experienced nipple pain during your feeding experience (even if this has now ceased) have a baby that is fussy/unsettled/hates being put down/hates the carseat/feeds for a long period or feeds very frequently - rule this out before you start cutting things you love from your diet!  Removing dairy in my opinion can potentially cause a reduction in symptoms - even if it's not the cause )more about dairy further down)... The tongue co-ordinates sucking/swallowing and breathing meaning any variation can cause further problems. (Brian Palmer also has also linked a restricted frenulum to acid reflux).  Baby may present just as an oversupply baby, ie milk running out of sides of mouth, loud audible gulping, spluttering.  Secondly baby needs to maintain a seal to form a vacuum when feeding, extremely difficult if you're tongue is restricted - causing increased intake of air again and difficulty obtaining fatty milk.  I'm halfway through a blog entry specifically focusing on this!

Gut Flora - Candida (thrush), antibiotics and various other triggers such as food intolerances are linked with a less healthy gut flora.  Probiotic supplement has been found by some sources to reduce colic/reflux symptoms.

Milk over supply/fast letdown - Reflux caused by a large supply or fast letdown is typically mild to moderate, and will in my experience usually manifest itself from around 3 weeks onwards, with 6 weeks being a prime time.  Mums often comment baby gulps, coughs, gasps, splutters, clamps down, pulls from the breast or guzzles.  Some find baby will feed until letdown - then pull off, arching and fussing or if it's severe refuse to latch at all.  Other babies just appear to be fast feeders and don't seem to suffer until later.  If mums have a large over supply, baby may display symptoms similar to that of a secondary lactose intolerance, as the infant struggles to produce enough lactase to digest all the lactose rich milk.  See foremilk/hindmilk and a lot of confusion, for further information about this.  If you think this may be the case, contact your local Lactation Consultant or registered Breastfeeding Counsellor who can discuss this further with you.

Latch/attachment problems - If baby is not well attached he is unable to milk the breast effectively.  This may prevent him from effectively releasing the fat and result in more lactose rich milk (along with perhaps several other issues).  Supply may decrease longterm with incorrect attachment, therefore if you think this may be the case contact your local Lactation Consultant or registered Breastfeeding Counsellor who can discuss this further with you.

Long feed spacings - Whereas in many countries, babies are fed little and often (the optimum way for a human infant) Western feed spacings are quite different.  Typically larger volumes or milk are transferred less frequently, because this fits with what women expect (based on a non breastfeeding culture).  Whilst some infants adjust to this pattern, others struggle with this unexpected strain on their gut.  The reason this problem may be increasing is also due to mum's diet becoming more calorific, which in turn may lead to larger volumes of milk per sitting.  Combine with a larger gap and letdown can easily become overpowering - hitting the stomach before refluxing straight back up!

In addition mums in the West are more like to do things we know contribute to the incidence of reflux; such as feed in positions which place baby laying down on their back fighting gravity, and then again in the cot, pram or moses basket after a feed.  Compared to other cultures, Western infants spend a lot of time on their backs (hence the increasing rates of Plagiocephaly/Flat Head Syndrome, but that's one for another post!).

Residual Birth Trauma - Long births, C-Sections, extremely fast births, posterior pregnancies and labours can all impact. Baby takes immense forces through the sacrum and occipital area (back of head) during labour, which can compress the nerves linked with digestion.  Furthermore if the diaphragm becomes distorted, it can compromise the ability of the gut to retain it's contents (ala reflux).  Some mums note amazing results with Cranio-Sacral Osteopathy - Annalisa Barbieri wrote an article about birth and osteopathy when her daughter was diagnosed with reflux.  A basic introduction well worth a read if the above describes your labour is this

Cow's Milk Protein Allergy - Unfortunately many paediatricians are still telling mothers if their baby doesn't have IgE mediated allergy (the typical hives, swelling etc) - it's not the cow's milk protein; absolutely not true.   There are at least 30 antigenic primary proteins in milk, which can get through the digestive tract intact and cause reflux.  These antigens can also be responsible for delayed immune responses, producing disease in any and all tissues.
 
Interestingly untreated allergy can lead to a litany of gastrointestinal, respiratory and/or dermatological problems; with increased rates of infection, particularly in the ears and sinuses.  This can result in pain, recurrent illness, poor growth, delayed development and failure to thrive.”  Now read back up to the symptoms of GORD and compare the two - how many cases of allergy are misdiagnosed and mismanaged as severe reflux?  Dairy can also hide in foods you would never expect, under various guises.  Many infants allergic to dairy also display a similar reaction to Soy products.  If you suspect milk protein may be an issue, look for information about "non IgE mediated allergy" and contact your location Lactation Consultant or Breastfeeding Counsellor and your Doctor.
 

Prematurity - Premature infants are more likely to reflux feeds than a term baby due to immature development and reduced muscle tone.  Again our culture gives much larger feeds, more infrequently than experts suggest biologically normal.

Will stopping breastfeeding help?
No.  Reflux is FAR more common in the non breastfed infant  Those fed by bottle typically have longer feed spacings, increased volume and increased exposure to cow's milk protein.  As discussed in this blog post, it's also a lot easier for bottle feeding mums to overfeed their baby causing reflux.  For the majority of mothers, introducing bottles full-time, also results in formula usage.  The impact of this on the health of the infant must therefore also be considered - the bacteria profiles of a breastfed and one receiving a breastmilk substitute are very different, some sources list overgrowth of bad bacteria as a reason in itself for reflux.  If this is suspected, pro and prebiotic supplementation may help the non breastfed baby.

If allergy to cow's milk protein is suspected, eliminating from mum's diet (in all forms mentioned above) prevents baby receiving any!

Updated 2011

Foremilk/Hindmilk and a lot of confusion!

Something that comes up a lot is the question of foremilk, hindmilk and how to ensure baby gets not too much of the first, yet enough of the latter.

So what’s the deal?

Recently in the world of breastfeeding support, there has been a movement to drop the terms “fore” and “hind milk”.

Breasts only make one type of milk and using two names proves confusing to many.

As the breast fills, the increased volume of milk causes the sticky fat globules to adhere to the walls of the alveoli and to each other. This means that when the letdown or milk ejection occurs and the milk moves down the ducts, that which is expelled first is lower in fat - because it has moved down without large amounts of fat (that’s still stuck higher up).

As this milk is released, it allows the fat to become dislodged and then this can also begin moving towards the nipple. Thus the milk gradually becomes fattier as volume within the breast decreases. At the end of a feed when the breast is nearly empty, fat moves freely and levels are at their highest.

"Foremilk" is just as valuable

Because the first milk can look more watery, it's common for people to feel it isn't as important or is less nutritious, yet this isn't the case.  Lactose fuels brain-growth and as the breast drains, the fattier milk help baby to feel fuller for longer.

The fact is that there is no magical amount of time to spend at the breast as there are too many variables.

We know that whilst most women are capable of producing roughly the same mean amount over 24 hours, the amount held in the “initial store” varies from mum to mum (NOT related to breast size).

Babies also feed at different rates; some will be fast, effective “power feeders”, and others take their time as though savouring every mouthful. Much like adults really, how often at a table is everyone ready for a round at exactly the same time?

So let’s look at how trying to apply the rules often suggested works out.

Take a mum with a pretty typical supply - she puts baby to her breast and he gets a nice hit of thirst quenching lower fat milk. As he feeds the fat levels start to increase and he’s just starting to feel satiated. Suddenly the mum (looking at the clock) realises baby has been feeding for the x minutes she was advised to feed for and swaps him over to the other breast.

Baby is met with more thirst quenching but lower fat milk, which fills up his tummy – but due to the overall lower levels of fat, he’s hungry again half an hour later, possibly windy and very unsettled too as his body struggles to breakdown the higher levels of lactose. 

Any unprocessed lactose can sit fermenting and symptoms can be very similar to those of a dairy or secondary lactose intolerance, colic or reflux.

Baby b in contrast, has quickly and effectively munched his way through mum’s smaller initial store and is ready for another big hit rather than the drip drip he is receiving. He’s had lots of fatty milk from the first breast and so quite enjoys more quenching milk, like a mid meal beverage. He might even go on to empty that one too…

So two babies have responded completely differently to the same course of action.

This time, instead of swapping at x minutes – this mum is concerned about sticking to one breast as advised to ensure baby gets hindmilk. This suits baby a, as this time he gets to finish his feed.

Baby b however is as mentioned, ready for more big guns – but instead is repeatedly coaxed back on to the first breast. Eventually baby gives up and falls asleep or remains unsettled, crying then windy and wants to feed again 30 minutes later.

See why there are no hard and fast rules?

The only way to know how long to feed your baby and on which breast is to watch the baby – they are the ones feeding.

When baby is feeding she will let you know she has finished with that side by either falling asleep or pulling away from the breast. This is likely to take roughly 10-20 minutes. Some babies do it in less and thrive, others slightly longer; but if baby is feeding for much longer ie 40 mins plus and then wants to do the same the other side or naps briefly and lightly before wanting to resume feeding (ie appearing hungry again) it may be worth seeking support to ensure baby is feeding effectively.

Babies can also pull away from the breast shortly into a feed due to discomfort and one reason for this might be they need to burp. So if baby pulls off after a few minutes of effective feeding - winding before reoffering the same breast can be an idea as sometimes they will then continue happily feeding.

If they had actually finished with that side, when reoffered baby will perhaps feed for a moment or two (or refuse outright) before repeating the sign to let you know they’ve done, ie sleeping or pulling away.

You can then offer the other side. Again there are no rules and if you need to run to the shops or drive to a baby group and baby is happy and content, you can always offer the other side when you get there or when baby lets you know they are ready for more. That’s the convenience and ease of breastfeeding over having to prepare and use something instantly.

Some babies will always have at least some of the second breast if not all, others will refuse – some will have two and some feeds and one at others.  It's generally polite to offer, rather like being offered the desert menu in a restaurant.

As you get to know your baby you will recognise roughly how long they like to feed, whether they get windy and so on – until which side becomes as instinctive as lifting your top. Each mother and baby combination is unique but following your babies cues ensures you meet the needs of your baby.

Give cow's milk to newborns, you're having a giraffe?

I know I was blogging about KMC, but as this news flash was shared on a list I read; I felt I HAD to blog it.

The headline reads:

Cow’s milk good for newborns.

Mothers who feed their babies cow’s milk in the first 15 days of life may be protecting their children from dangerous allergies later on, says a new study.

Perplexed I read on:

Women who regularly (daily) introduced their babies to cow milk protein early, before 15 days of life, almost completely eliminated the incidence of allergy to cow milk protein in their babies.

 says Prof. Yitzhak Katz of Tel Aviv University’s Department of Pediatrics, Sackler Faculty of Medicine.

Before he is apparently quoted as saying in one article:

Although the exact amount is still unknown, the paediatrician suggests a single bottle-feed at night for those mothers who are breastfeeding.

Now perhaps I'm overly cynical, but at this point alarm bells started ringing.  Any paediatrician with a sound breastfeeding knowledge (which one would surely assume essential to make a public statement such as this) would know the well documented effects of cow's milk protein entering the gut of a breastfed baby.

Secondly, given they claim the exact amount is unknown, making a suggestion to "give a single bottle daily" is highly unusual; not least because it contradicts worldwide recommendations which are based on extensive evidence.

So I decided to dig out the study.

The first thing I noticed?  The bottom of the study reads:

Supported by the Israel Dairy Board.

Aaah now thing are becoming clearer.  I then discovered Prof Katz - the one up there making statements, has declared a potential conflict of interest. 

Y. Katz has received research support from the Israel Dairy Board

aaaaah, bingo!  Let's think who might benefit if mothers introduced a bottle of cow's milk per day- wouldn't happen to be the dairy industry would it?

Holey data Batman!

Having tracked down a full copy of the study, I set down for a proper read....

What's jumps out as immediately really quite worrying is how this research has been misreported.

Science daily reads:

Many doctors suggest that whole cow's milk be avoided in the early months of an infant's feeding.  But new research from Tel Aviv University says that mothers who feed their babies cow's milk in the first 15 days of life may be protecting their children from dangerous allergies later on.

But the research never mentions whole cow's milk - it is discussing standard cow's based breastmilk substitutes when it refers to exposure to cow's milk protein.  Given all recognised health bodies state whole milk is NOT suitable for infants under six months due to health implications - what are the risks of reporting such as this?

Anyway moving on, as I'm far from finished!

The thing to remember here is that out of 13,019 infants - 66 infants were given diagnoses of IgE-cows milk allergy, with 48 patients fulfilled all criteria.

 59 patients were on a soy diet on the first examination for a period ranging from 16 to 120 days (4 months)

6 were fed with extensively hydrolyzed milk

and 1 consumed an amino acid–based formula

Total: 66

So where are the allergic babies breastfed for six months as per all recommendations?  The gut closes around this time, preventing cow's milk protein entering the bloodstream and thus is very significant in terms of allergy analysis.  The longest any mothers were breastfeeding who had allergic children can only be four months, as all 66 were on some sort of breastmilk substitute at their examination. 

Oooh hang on, here we go - the lowest risk after the first 2 weeks is when it's introduced at 6-7 months.

We do not have data to substantiate an explanation as to why the risk for IgE-CMA decreased for those exposed in the oldest age group (group IV) compared with the prior period (group III).

So, when prof above was suggesting all mums give a bottle per day, he should surely have specified if not within two weeks, wait until six months.  Weirdly he didn't - but again, that obviously wouldn't be because the study was funded by the dairy industry!

I also find it quite strange that ALL allergic infants were on non bovine breastmilk substitutes at their first examination.  Surely if a mother exclusively breastfed for say 3 months, then introduced cow's milk protein and found her child was allergic - would she not just cut that supplement back out and return to breastfeeding?  Why are all by 4 months at the latest on a substitute?

Then we get down to the bones of the paper and realise all the reporting is actually very misleading.  Researchers were:

Conducting a large-scale prospective study analyzing Cow's Milk Allergy  that was exclusively IgE mediated 

To do this they used the skin prick method..

The UK Dairy Council States:

Skin tests: this involves using either a test lancet or needle, which is first pricked in the food and immediately afterwards in the skin. The value of this test is limited since it measures only IgE mediated reactions and thus will yield negative results in non IgE mediated allergic responses. 

So researchers really were only searching for IgE allergies, as reactions caused by other antibodies cannot be detected through skin prick tests.  But, um, what about all the babies with a non IgE mediated allergy?  Where do they fit in the "give a bottle a day prevents cow's milk allergy" plan?

IgE-mediated allergy is the one many of us have heard about; the immediate hypersensitivity reaction including: hives, swelling, vomiting or anaphylaxic shock.  The last reason being one stated as to why the study is important - yet many sources state this extreme reaction is rare with dairy allergy compared to other food allergies.

The problem is that Non IgE-mediated allergy is actually far far more common.  It primarily affects the gastrointestinal tract and causes symptoms such as nausea, intestinal discomfort, diarrhoea and respiratory problems.  The damage to the tract results in a number of different allergic disorders including: gastroenteritis, milk-induced enterocolitis syndrome, proctocolitis syndrome, and allergic eosinophilic esophagitis.  These conditions can lead to pain, recurrent illness, poor growth, delayed development and failure to thrive.”

The British Medical Journal contains guidelines for the diagnosis and management of cow’s milk protein allergy in infants, so let's see what they say!

*clears throat*

Between 5% and 15% of infants show symptoms suggesting adverse reactions to cow’s milk protein (CMP),1 while estimates of the prevalence of cow’s milk protein allergy (CMPA) vary from 2% to 7.5%. Differences in diagnostic criteria and study design contribute to the wide range of prevalence estimates and underline the importance of an accurate diagnosis

Cow's Milk Protein Allergy may be immunoglobulin E (IgE) or non-IgE associated.

Whether breastfed or not, the guidelines go on to state:

Elimination diets and challenges are the gold standard for diagnosing CMPA

I wonder why researchers (supported by the dairy industry) might totally ignore more common non IgE cases?  hmmmm... oh no, wait!  Here it is:

In 381 cases the parents either complained about adverse effects that they considered CMP related, or alternatively, these parents avoided CMP exposure despite having discontinued exclusive or almost exclusive breast-feeding. A causal relationship between the complaint and CMP was ruled out in 244 cases among these infants.  In 71 cases, which will be described separately, a diagnosis of non–IgE-mediated adverse reaction to CMP was established

Right so where is the discussion about these infants?  how were they fed? How exactly did researchers rule out 244 cases and confirm 71 cases - did they use the BMA "gold standard".

All 381 parents of infants in whom an adverse reaction to CMP was suspected were interviewed by one of the investigators (N.R.), and their infants were invited for an examination

I guess that's a no then.  I can't find a single resource that claims non IgE allergy can be confirmed or denied by a chat and a physical exam!

In contrast to this study, two pieces of older research (not funded by the dairy industry) found that in susceptible families, breastfed babies can be sensitised to cow’s milk protein by the giving of just one bottle of bovine based formula in the first three days of life (Host, Husby & Osterballe)

Another found that when Serum IgE concentration was measured on the 5th day, high levels indicated a higher risk of developing allergic manifestations in formula-fed babies.  Family history was also significant. Manifestations suggestive of food allergy were hardly observed in breast-fed babies.  (Vandenplas & Sacre)
  
Ultimately, even if researchers really believe that exposure in the first two weeks could prevent rare IgE allergy; we know non IgE allergies are more common,  a lot harder to diagnose and cause conditions just as serious long-term.   Furthermore as discussed above, the gut of an infant changes with the introduction of bovine protein, increasing risks of a much wider range of conditions.  To suggest infants be given a bottle of cow's milk on the basis of this one study, is not only irresponsible, but really quite scary!

Incubators out - Mums in!

If this is the first time you have heard this suggestion, you are probably thinking either that I've just landed from another planet; or am some radical, hippified, Neo-Luddite who has clearly lost it.  Not true, honest!

As this is a rather large topic due to it's impact on many different areas -I thought I might tackle it over more than one blog post, with this being an introduction to.  So it's mainly aimed at those not too familiar with the concept of using mothers instead of incubators - often called Kangaroo Mother Care (KMC) which includes Skin to Skin (STS)

Let's start by jumping back to pre-incubators.  Premature baby care was at this time poor; the majority of infants were born at home, often without a doctor readily available.  Preemies were just considered "weak" babies, and as a result many were considered too small to survive.  In general doctors were "in no position to extend their direct responsibility for the newborn", so perhaps not surprisingly death rates were as high as 85%.

Around the turn of the 20th century, America's first incubator hospitals for premature infants were built.  Alexandre Lion had developed the first incubator suitable for hospital use; but they were complicated, expensive, and the technology was hard to sell to hospitals.  To get round this Lion displayed the incubators and their premature residents at fairs and amusement parks, charging an admission fee to offset the cost of running the equipment.

Survival rates soared; in part because of the clean, warm environment and appropriate medical care - but also because after seeing the techniques used at the hospitals, parents were better able to care for their own premature infants.  Incubator hospitals challenged many of the social norms of the time, but ultimately were designed to make a very large profit.

From this point,  research surrounding vulnerable infants, (and the development of incubators) was based on one fundamental assumption; that the incubator was the best way to care for a premature or sick infant. Today developments are still constantly underway to try and create an ever more womb like environment; controlling oxygen levels and other vital systems, with an array of sensors, monitors and alarms. Nowadays they are highly advanced pieces of equipment, costing in the region of £30,000.

But what if this initial assumption was wrong? What if the whole foundation was based upon an assumption that was massively flawed? What if, creating a womb like environment wasn't the
optimum way to care for a baby that had been born and something else could increase survival rates more?

Dr Nils Bergman has been researching, practising and lecturing on KMC for twenty years and firmly believes an infant should not be separated from his mother.   What Bergman discovered is that separation causes something called the "protest - despair response"; the protest response is one of intense activity seeking reuniting, the despair response that follows, is a withdraw and survive response - temperature and heart rate decrease, caused by a massive rise in stress hormones.  When reunited with mother, there is conversley a rapid rise in heart rate and temperature.

The "protest-despair response" was first described in human orphans after WWII, and was subsequently studied in monkeys and then in many other mammals. "Separation distress calls" have been documented in rats and very similar distress calls have been identified in human infants.  Cot babies make ten times as many cry signals as babies held skin to skin, and Bergman believes there is not only physical but neurological implications to separating the dyad.

There is compelling evidence a baby should be with mum, and that in fact she is the perfect incubator.  The infant's temperature sits within a very narrow range, because mum's core temperature rises and fall as her baby requires - so much so STS has been proven better than an incubator for rewarming hypothermic infants.  KMC has also been shown to improve oxygenation, to the extent that STS is used successfully to treat respiratory distress.  Baby's breathing becomes regular, stable, and is coordinated with heart rate.

Despite all this, KMC is not about shunning technology; on the contrary all the usual modern technological equipment should be used alongside the mother. It is purely about keeping mum and baby as one unit.

Isn't this risky? is the first question people ask.  The fact is that in over seventy studies. not a single adverse outcome has been reported for KMC. On the contrary, time and again KMC infants have improved outcome over traditional methods of care - something widely recognised in available scientfic literature.

Why isn't it practised? is usually the next.  But, as I promised to keep this a short introduction - I think that's for another blog entry!

Breast Isn't Best...

This goes against the grain of everything you were told at antenatal classes, the posters dotted around the hospital and quite possibly every health professional you saw during pregnancy. But really, it's true.

Breast is best is actually just a really clever marketing campaign, but not originally from the people you might expect. In fact, it's a brilliant example of a very common marketing technique - and once you are aware of it, you can spot it around you on a daily basis.

Let's take chickens, a leap I know but bear with me. A normal life for a kept chicken is really quite simple. A hen house to keep them safe at night, an area for them to move about, scrat, food, water and you're pretty much done.

Veer away from these basic requirements and as you might expect you have problems. As Hugh Fearnley-Whittingstall has highlighted with his "chicken out" campaign,, remove their outdoor wandering/scratting area, coup excessive numbers together - and the result is unhealthy, underweight chickens. Unsurprisingly, they need large amounts of antibiotics and other drugs to keep them alive.

These chickens when mature look so bad with their deformed legs and lack of muscle tone, they would never sell; plus they are so scrawny and underweight they wouldn't make enough money for the producers.  This means a process called "plumping" is undertaken.  This is injecting salt water, sodium phosphate and "natural flavorings" (don't get me started on that one!) into the chicken pieces, until they look like something you might be prepared to eat. The legal limit is 15% "other stuff". This means a piece of "standard" chicken can contain more salt than a large serving of French Fries..

Let's picture accurate labelling of these products.  The first - standard chicken, easy.  The second hmmm "substandard battery chicken; includes antibiotics, salt, flavours, reduced protein and increased fat levels".

I'm thinking the second isn't going to be a big hit in store.

Retailing is about pounds kerchinging into the till, not accuracy - and so the marketing bods step in.  

The normal chicken is elevated to "best" and they give it a cool name like "free range", "organic", "finest" or "taste the difference".  Lots of different ways to describe a chicken that has in reality, only had an existence which at least met the basic requirements.

This allows the substandard, modified chicken to neatly slip in behind, taking the label "chicken".  Good old standard chicken.  Realistically, what is being sold as "standard" is in fact anything but.  No mention of the health implications of eating something which is now considered more fat than protein, no mention of the injected substance, or how you are actually paying for this because chicken is often sold by weight. Nope - it's just "chicken".

Supermarkets sell more "standard chickens" than any other type - and not just because of the price tag.  In fact, even if the price difference was nominal, sales would still be higher. This is because the vast majority of people believe standard is "OK".  Fair enough it might not have quite as much flavour as the "fancy one", but then they didn't home grow the carrots or make the gravy from scratch either. OK does most of us pretty well and this is what the marketing people understand. But let's not forget, in reality it's not standard, it's substandard that is cleverly marketed.

This happens in all areas of retail - tomatoes ripened on the vine, where they are supposed to be and thus actually taste as they should, are "finest".  Those picked early and ripened in boxes during transportation leaving them more like tasteless balls of water are "standard".  Sausages that have more meat than fillers are "finest" and so on and so forth.

So back to breastfeeding.

Breastmilk is the bog standard, normal substance a human infant is built to consume - there's nothing best or superior about it. A survey a few years ago asked mothers whether they would buy a "value" formula, unbranded and in plain packaging - rather like the blue and white stripey budget tins at the supermarket.  Absolutely not was the overwhelming response - the perception was that value branding compromised on quality, whereas standard ranges are "OK".  It might not be "best" but it was fine.

"Breast is best" is a slogan straight off the back of a milk tin and when you understand the marketing it's very clear why. With breastmilk substitutes it actually has a double benefit that isn't seen in other areas of retail.  By law manufacturers are required to state on the tin that their product isn't as good as breastfeeding - as we saw above, should parents get a sniff of substandard they're off and so yep, it's time to call in those marketing bods again.

If we say breastfeeding is best, not only does that allow our product to slip in as "OK", but parents also (unaware of the laws) think we are mightily honest telling them upfront another product is "better" and so trust us; building loyalty and belief in whatever other information we give them. Given most mums will end up using a breastmilk substitute, costing around £700 per year - we can afford to spend a fair bit on advertising to really drive this message home.

Clever huh?

Next time someone tells you breast is best - let them know, it 's really not at all, it's just normal.

NB - the image on the right is a carton of Aptamil which violated UK laws.  The carton claimed it was "closest to breastmilk" and also contained probiotics to "support the immune system".  The Advertising Standards Agency ruled these claims unfounded and that they must be removed from packaging.  The new label said: "Inspired by breastmilk" - which again was non-compliant with the regulations (Which are very clear!)  Milupa was then bought out by Danone who relaunched with a new ingredient, branded as IMMUNOFORTIS.  The Advertising Standards Agency found once again they had broken the advertising code clauses on substantiation, truthfulness and comparison.

RELATED POST: How Breast Is Best Came To Be

Bottle feeders - please stop twisting it.

I am a self confessed people watcher.  I love nothing more than sitting watching the world go by, as all the colourful characters it is filled with wander past - and last Friday was no exception.  Sitting on the terrace of a quaint cafe, window boxes overflowing, sun beaming down, both children occupied, drinks ordered; I sat back watching people mill about.

Before long a couple with a baby arrived and took a seat next to us.  Dad ordered the drinks whilst mum sorted baby's bottle for a feed, and my first thought was what a cute baby; only a few months old and with obviously doting parents. The mum caught my eye and I smiled as she adjusted her position to move baby's face out of the sun, remembering those early months when the world seems to stop and revolve around this tiny being.

Mum started feeding the baby, positioning him in the crook of her knee so she could have her drink and use her mobile - and I went back to the business of watching people passing down the lane.

After a while my attention was drawn back in their direction with the movement of her shifting him for winding. I smiled to myself again as she carefully supported his wobbly young baby head and he produced a burp his dad would have been proud of, before she laid him back down to resume his feed.

Only baby had other ideas. Obviously satiated he turned his head away from the bottle and tried to shift slightly; mum and bottle followed. He turned away again, twisting from side to side to try and prevent the teat re-entering his mouth. Still it followed and as mum finally managed to squeeze it past his lips, she twisted it quickly to release milk. Baby took a few gulps before again releasing the bottle and turning his head. Mum winded baby again, picked up the bottle and examined how much was left - before the game of cat and mouse resumed; the baby unable to make it any more obvious he didn't want more (after all two or three month olds can't physically push someone away) the mum ever determined to get more milk in.

I packed up and we left the courtyard, my mind still on the obviously loving mother who I suspect had no idea what the impact of her behaviour could be long term.

It is well documented that non breastfed infants are at higher risk of obesity both in childhood and in later life, and how the feed is delivered appears to play a large part.

A study in May 2010 of over one thousand older infants, found those who had had more than two-thirds of their feedings via bottle in early infancy, were twice as likely to routinely empty their milk cups as toddlers who'd had less than one-third of their feedings via bottle. This was the case regardless of whether it was breastmilk or a substitute in the bottle. Whilst only 27% of toddlers exclusively breastfed in the first six months routinely finished their cup or bottle, this figure sat at 68% for those exclusively bottle fed.

Losing the ability to self regulate intake has life-long impact, as a popular adult diet book now highlights. Paul Mckenna's "I can make you thin", is based upon re-learning what your body's sated cues are. Focusing on consuming each mouthful s-l-o-w-l-y (for exactly the same reason - to give your body chance to recognise it's full) and stopped when you are full (even if it's scrummy chocolate cake!).  In fact he claims there is no need to calorie count (or live off salad), providing you only eat what your body requires and stop when full - you will obtain and maintain a healthy weight.

So why is bottle feeding linked to reduced appetite self-regulation?

Firstly, bottle fed infants receive a later satiated cue than their breastfed counterparts. Breastmilk isn't released in one constant stream like a bottle, mum has multiple let-downs during a feed, resulting in regular pauses. These "breaks" slow the feed down, and allow baby to recognise satiety and stop feeding, long before the stomach is over full. As soon as a breastfed baby stops sucking, milk ceases immediately.

In a bottle fed baby, the feed is more parent led - once the bottle is upturned, milk is released and each suck swallow pattern causes the teat to refill and more milk to be released. Baby can have finished the bottle, long before their system has had chance to recognise they are full.

Secondly, as observed in the cafe, before an infant can physically push the bottle away, the only thing they can do is turn their head and try and prevent it entering their mouth. Eventually mum will often manage to get the teat in, milk flows and baby is forced to swallow, usually at least a couple of times before they manage to force the teat out with their tongue and again turn their head.

In both the above scenarios, the ability to only eat to satiation is being overridden from a very young age - instead infants are used to finishing the lot and feeling overfull. The over feeding stretches their stomach to accommodate the larger amount of milk, so next time after consuming the same amount - they may no longer feel sated.  At the "worst case" end of the spectrum you end up with a baby consuming vast amounts of milk, yet still not settling or appearing full - maybe even suffering colic from his distended stomach.  An older report found found bottle fed babies consumed approximate 30,000 more calories per year than a breastfed infant - which the authors felt was due to a combination of incorrect preparation and tactics to encourage infant to drink more or finish each bottle.

Many babies prefer small, more frequent feedings as they have small stomachs and again this mimics the breastfed baby; however, bottles shouldn't be used as the primary way to comfort baby - if he appears hungry shortly after a feed and weight gain is good, consider offering a clean finger or pacifier (Sears)  If your baby is taking above the guidelines on the tin per 24 hours, contact your health care provider for advice.

The risks increase again with the introduction of solids - which may account for at least some of the 27% of breastfed infants who has diminished appetite regulation. Mums tend to spoon feed purees much faster than a baby could feed themselves (ie baby led weaning) and again, this gives the system little chance to recognise satiation and encourages over-eating.  As with bottles, mums often employ all sorts of tactics to encourage their child to consume more - from distracting with a toy whilst they shovel it in, to playing aeroplanes.

Can a bottlefeeding mum do anything to reduce the risks?

• An average bottle feed should take approximately ten to twenty minutes. Regularly pausing to slow the feed down and mimic a breastfed pattern, can help baby recognise sated cues earlier. It also prevents guzzling!
• Hold baby regularly when not feeding, to prevent baby asking for food in order to be held. 
• Non nutritive sucking (ie comfort sucking) is important to babies. If not breasfeeding, consider offering a finger/thumb or pacifier between feeds, so baby doesn't have to feed to meet this need. 
• Watch baby closely for his cues. If he turns, twists or pushes the teat out with his tongue - he's finished. He may need winding and will perhaps then take more, or he may repeat his behaviour to indicate he is satiated. 
• Some sources suggest that mums may confuse signs of overfeeding with an intolerance to a particular breastmilk substitute, and may try swapping brands to reduce symptoms. Watching your baby closely and observing for any of the following behaviours can help to reduce the risks of overfeeding.

 Is baby getting too much formula?

Signs that your baby may be consuming too much at each feeding are:

• a lot of spitting up or profuse vomiting immediately after the feeding  
• colicky abdominal pain (baby draws his legs up onto a tense abdomen) immediately after feeding  
• excessive weight gain

 If these signs of overfeeding occur, offer smaller-volume feedings more frequently, burp baby once or twice during the feeding, and occasionally offer a bottle of water instead of formula.  (Sears)

Formula feeding mums, start shouting. Loudly!

A huge amount of the comments I read online contain the line "I tried to breastfeed but...." and what follows can be anything from the simple "boys are hungrier" or "I have fair hair and therefore feel pain more acutely", to some real heart rendering stories of what mums have been through in order to try and succeed.

As someone who did manage to breastfeed, but gave some formula pre six months to my first (on the advice of a health professional!) I felt angry when I first read reports highlighting how evidence has shown for years, that this undermines some of the health reasons for breastfeeding. Nobody had told me this pre supplement and unfortunately for my daughter she developed eczema so severe we were placed under the care of a dermatologist.

If a mum (for whatever reason) feels she has to swap totally, and is then hit with article after article about risks of formula feeding - it's not really a surprise she feels something. The vast majority of mothers (however they feed) love their children immensely and I firmly believe mothers do the best they can, with the information and support they have at that time.

Realistically when we look at what little chance most stood of actually succeeding in the first place, I really think it's time we started shifting the blame away from vulnerable mothers, and over to where it actually belongs! Because really, it's not fair that not only are these mothers missing out on something amazing, but they then get to carry the burden of it not working!

We frequently hear that around 97% of mums can breastfeed multiples, we know that over 80% of mums initiate breastfeeding; so why then do we have only a tiny percentage of mums still breastfeeding after the first few weeks? The fact is there is an important part of the first sentence missing; it should read "Around 97% of mums can breastfeed, with the right support".

I used the Chinese meal analogy in my last blog post, for anyone who didn't read here it is again:

"Imagine you had grown up only ever witnessing and tasting your local cuisine. Someone hands you a Chinese menu and instructs you to cook a dish, giving you no recipe and only a vague description of what it is. You've never heard of half the ingredients and what's more everyone around you seems to be doing "fine" on the local food anyway. You seek help but unfortunately whilst you can hunt out some trained and qualified chefs in your area, the vast majority themselves made do with local cooking - so they are not really sure when you ask trickier questions. Where do you start? This is often the position a new breastfeeding mum finds herself in."

Effective support is extremely hard to find, and what makes it even harder still is how does the new mum recognise good support from bad? Before children I would have thought it pretty safe to assume that any health professional responsible for an area of care, would have to be competent at doing so. Unfortunately with breastfeeding that's simply not the case - and the vast majority of mums who aren't breastfeeding but wanted to, have received terrible support.
 
How do I know? Because even if I forget the years supporting mums, and everything I have seen and overheard in the community - every reason I have read over the last few days bar one, has been something that could have been easily prevented or overcome with the right help. Instead mums are left believing they simply couldn't breastfeed.

I wonder how many non breastfeeding mums had a class when pregnant which covered how to get breastfeeding off to a good start? How many were given full details about how the type of birth you have and what medications you use can impact on breastfeeding? Whilst obviously women can't help needing intervention or a section (especially given current rates) were they told what to expect in this situation, and things they could do to help establish breastfeeding if it arose?

If mum needed drugs in pregnancy, how many found their health care provider checked whether they would impact on lactation, and if so sought a suitable alternative to enable mum to breastfeed?

How many had a class which told dads how they could effectively support breastfeeding?  What they could expect as "normal" and what were signs help was needed? What they could do to be really involved and to bond with baby without needing a bottle - and what things they might want to avoid, as they can appear to be help but actually have a negative impact.

 How many were advised of what needs to happen in the first hour after birth, what baby expects on a biological level at this time, and what we know to be the impact of veering from this? How many were shown clips of the "breast crawl" and how important time for just parents and baby to be is?

How many were told the actual differences in breastmilk and substitutes, rather than one is better than the other - and exactly how this impacts for everyone?

How many were shown how a baby latches on, how you can ensure they are breast and not nipple feeding and how you can tell whether they are effectively feeding and taking large amounts of milk rather than just nibbling?

How many were told exactly how you can easily tell extremely quickly whether baby is receiving enough (there is absolutely no need to "see" what's going in to ensure this!) without even getting out a set of scales?

Once baby arrives, how many mums were visited after birth by someone specialised in lactation - who didn't grab their breast or the baby and roughly "help him on", but who instead had the skills to observe, listen and perhaps if needs be understand what problems may be likely to occur depending on the situation, and be ready to help overcome them?

How many mums who were in agony, had shredded nipples or a baby who was never settled, were seen not by someone who said things "looked fine" and "stick at it, things will click", but instead referred immediately to someone who could quickly identify the issue and help get things back on track?

How many mums who had problems pre pregnancy known to interfere with milk supply such as thyroid issues, were checked ASAP after birth to ensure levels were compatible with lactation?

How many were told what to expect in the early weeks and months? What cluster feeding is or when the typical fussy spells are, how these would display and perhaps most importantly of all, where they could get help quickly if they needed it?

The trouble is this pattern is cyclic - if mothers knew demanding better care could make a difference and therefore did so, services would improve; yet until services improve and rates increase - mothers don't know to demand better care!

Why are mothers carrying the can for this?

So, whilst my general rule is I never give advice. I'm going to break it to give a piece.

If you want to breastfeed and things aren't working, perhaps you're finding yourself sliding towards formula feeding when you don't want to. Shout! Shout loudly! Ask to see the infant feeding co-ordinator (most hospitals in the UK have them both in hospital and in the community, but often they never get to hear about mums with problems!) ask anyone who comes near your breasts what their qualifications are - if you are unsure what qualifications someone needs to have in order to best be able to help you, read this.

If you are now formula feeding and didn't want to, instead of blaming the breastfeeding mafia - focus your feelings where they belong and shout loudly at those that let you down (I do mean by way of formal complaint, rather than abusive behaviour :)) and didn't give you the support you needed, when you needed it. If mums want change, we have to make it happen.