Ask the Armadillo - making up infant feeds, what's the deal?

Q.  Dear Armadillo
Would you consider an article about making up infant formula please?  I've read you have to use water hotter than 70 degrees and make the feeds up as required, but a lot of mums I speak to don't do this as it's quite new information and babies have been fine for years without it and over cleaning is just as bad.  Who is right?
Sarah

A.  Hi Sarah
You are correct that Department of Health guidelines are to use water of at least 70 degrees and discard a bottle after two hours (some sources suggest one if baby has been drinking from it)  but there does generally seem to be quite a lot of confusion over the guidelines and whether they are applicable to countries such as the UK & US where water contamination is not an issue.  I wanted to answer this question as for mums not breastfeeding, it's important to make the alternatives as safe as possible.  I should add at this point that I generally had quite a laissez-faire attitude to sterilisation of things when mine were little - I mean once they were crawling on the floor and chewing things that had been on it, I didn't really see much point ensuring toys were sterilised.  I do also think generally that over use in the home of things like antibacterial sprays on every surface, bleaching floors constantly etc carries more risk than the germs they protect from.  Breastmilk substitutes however are a little bit different.

Unlike ready to feed liquid milk, a tin of powder is not sterile and there are risks of contamination all the way through the process - starting with the raw ingredients, during production after pasteurisation and thirdly in the reformulation or in the can at home.  Because of this there are different problems associated with reconstituting incorrectly.

Let's start with the most serious risks.

Without a doubt these are are Enterobacter sakazakii and Salmonella.  The first is a bit of an interesting one as it is found in the gut of healthy humans (probably as an intermittent guest) as well as in the gut of animals and in the environment.  A 2005 study found the prevalence in infant formula varied from 0 to 12% in samples from five different companies.  To give more of an idea of frequency, a 2010 study found 9 out of 149 samples were contaminated with E Sakazakii.

When it strikes it can be extremely nasty, and there are strong links with meningitis, septicemia, and necrotizing enterocolitis.   In the outbreaks reported 50-70% of the infants who contracted the disease died; for those who survive, severe lasting complications can result in various problems including neurological disorders

The trouble with breastmilk substitutes is that they provide the perfect environment for bacteria to grow and thrive, and in 50-80 % of cases powdered infant formula is both the vehicle and the source (direct or indirect) of E. sakazaki induced illness, whilst no exclusively breastfed infants have to date been reported to have Enterobacter sakazakii infections (WHO).
 
Because of the high mortality rate, when links with disease were made investigations immediately began as to how to best minimise risks; scientists discovered boiling water at 70 degrees resulted in a more than 4-log reduction in E. sakazakii levels.  Furthermore, not leaving the made product to sit around prevented any remaining pathogens from increasing  to dangerous levels, a risk that increases further once the enzymes from baby's saliva have entered the mix.  This is really important as in the above mentioned study, 8 of the 9 cases of contamination were low and therefore mixing with water of an adequate temperature and using immediately is likely to reduce this risk to a nominal level.  However using water that is too cool, then leaving the milk to sit around can very quickly lead to high levels of harmful bacteria.
 
Although found less frequently in breastmilk substitutes, more people have heard of Salmonella; it can cause anything from mild diarrhoea, vomiting and cramps to the rarer Salmonella bacteremia which can result in septicemia and meningitis.  Again using water at 70 degrees minimises risks.
 
Because formula contamination rarely hits the news unless it's a large "official outbreak" which is less common, many people are under the impression that the risk of formula contamination is negligible; but WHO feel differently:

Is the risk similar in all regions and countries?

There have been reported cases of Enterobacter sakazakii infections due to contaminated infant formula in only a few developed countries. It is likely that there is a significant under reporting of  infections in all countries. The absence of reports is probably due to a lack of awareness of the  problem rather than an absence of illness. In general, the limitations of current surveillance systems in most countries would add to the explanation for the lack of reported cases. Since infant formula is widely used, the presence of Enterobacter sakazakii in infant formula and its potential effects in infants could well be a significant public health problem in most countries.

Another condition heavily linked with incorrect preparation of infant formula is gastroenteritis, often called stomach flu.  Symptoms include diarrhoea, sickness and stomach cramps - in people able to consume enough fluids it is generally not serious; however infants and young children are at risk from loss of fluids and may need to be hospitalised for treatment to correct or prevent dehydration.
Sue Battersby, a midwife stated in a 2009 report:

Formula is not sterilised and bacteria can be present. When it is made up or stored incorrectly there is a big risk that it could cause gastroenteritis. "Formula fed babies are five times more likely to be admitted to hospital with gastroenteritis, which in the majority of cases is preventable."

It's as usual all about risks rather than certainties - not every baby who drinks milk prepared incorrectly will become ill and nor is meticulously following the guidelines a guarantee baby will remain well; but for the sake of the extra few minutes is it really worth the risk?  Of course good hygiene such as sterilisation of bottles and other equipment (domestic dishwashers usually are not hot enough), effective hand washing and careful storage all contribute too .  My personal experience is that gastroenteritis is still common at 9-24 months, when many parents relax a little - whilst this may be ok for other items such as toys, things that come in contact with breastmilk substitutes are still prime breeding ground.

For people who say they didn't do it with other children and theirs have always been fine, I always think that given the advancements in what we know about bacteria and how to reduce the risks of it - why ignore this?

Is it hard to do in practice?

Guidelines suggest using water that has been boiled and left for no more than around 30 minutes.  For a couple of pounds it's worth buying a thermometer and checking the temperature of your water a couple of times to get a feel for how fast it cools.  It is just as important not to add boiling water to the powder as manufacturers suggest this may damage vitamins/nutrients.

If baby has a rough feeding routine, you can then build in cooling time when at home.  If going out and about, carrying the powder in a sterilised container, water in a flask and then combining the two when required works - again worth checking the temperature a few times if there's risk it could have cooled.  I've heard a lot of mums do this at night too!   Another option is to keep cooled boiled water in the fridge, and work out how much needs to be added to the boiling water to get an appropriate temperature.  If you decide to use thermal bags for carrying ready made bottles, it's even more important to check temperatures after storage as many mums report large differences in how long milk remains at temperature.

Hope that answers your question - it also neatly dispels the myth infant formula is a handy, convenient alternative!

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_084165.pdf

Guilt if you breastfeed, guilt if you don't....

Whilst we hear lots about how non-breastfeeding mums are made to feel guilty, the emotions of a breastfeeding mother seem rarely discussed.

Perhaps it's because only a tiny percentage are still exclusively feeding at 4/5 months? Or perhaps it's just because it's considered "best" anyone doing it must therefore feel splendid?

I noted several years ago on mainstream parenting forums, that the number of mums who commented they felt pressured or "guilted" into stopping breastfeeding wasn't negligible.

It seems for as many mums who feel guilty bottle feeding, there are as many who feel our culture is generally anti-breastfeeding and works against the breastfeeding mum.

The scenario generally goes like this - mum is having some sort of problem, most people don't know enough to help resolve breastfeeding problems and so the well meaning health professional, partner or other family member (who often genuinely want to help) reverts to what they know - not breastfeeding.

Mothers are told that introducing a bottle will make life easier; perhaps if baby is unsettled or suffering with colic, not gaining weight as well as hoped or if mum is very tired.  Breastfeeding can be undermined with "hungry infants" as mothers read tales from others whose baby was never settled until they had a substitute - or the relative who points out baby is obviously not "full" and he takes after his dad as he was always hungry and needed a bottle too - after all he's a big baby....

Some mums speak of "anti breastfeeding relatives", who go beyond just trying to help and imply mum is being selfish by breastfeeding; instead they want to cuddle and give a bottle.  Other talk about relatives repulsed that mum is going to breastfeed in public and friends who doubted just milk from mum would be "enough".

Then add in to the equation that we are still discussing whether it's even appropriate for mothers to feed their baby human milk in public.

Mothers it would appear feel judged however they feed.

For mums who don't want to stop breastfeeding, a range of emotions can follow.  Self doubt, confusion, mingled with hormones and tiredness.  Some speak of feeling "selfish" for wanting to continue when their baby would probably be happier on a bottle; others say they feel guilty for making things hard for the family, by being stubborn and wanting to continue when everyone is saying bottle feeding is "good enough".  Some with feel guilty at using NHS resources in a bid for help, others that they've been told older siblings would understand bottle feeding better.

As the baby gets older many hear that surely he should have a bottle as well by now, or won't he get too attached if you don't get him off it?  Surely you must want freedom?  Give a bottle so I can take him whilst you go out!

Mums comment they feel guilty they are "too attached" as they don't always want to leave baby or concerned they are "addicted to breastfeeding", because they don't want to stop even though baby is now not newborn and even guilt they enjoy the bond with their baby!

Breastfeeding guilt comes in many guises and it's interesting to see how it's dealt with.  I can't tell you how many breastfeeding calls I take start with "I hate breastfeeding and want to stop", but quite often a further chat highlights what the mums means is "I hate the current situation and want it to stop".   The fact is problems are common and help is sparse.  For many, especially those with a difficult or traumatic birth or with only non breastfeeding peers- breastfeeding can be hard, really hard!

Mums are often told "if it's getting hard, don't feel bad if you have to give a bottle - not everyone can breastfeed" (when the opening question was in no way related)  or "giving a bottle was the best thing we did!", sometimes followed by the old classic "happy mum = happy baby".   Perhaps by now not knowing what else to do, mum decides to stop, and for a while at least does feel better - because the situation has stopped, or because the dad or relatives are now happy, or the health professional has now relaxed since she is working with a substance she understands and can measure.

But what is often forgotten is that breastfeeding is a deeply emotive, primal drive - and down the line women can easily feel short changed they didn't get the experience they expected.  When partners are back at work and no longer doing nightfeeds with gusto, and the health professionals have backed off.   In fact the last infant feeding survey found 71% of mums would like to have breastfed for longer, and it's not uncommon for feelings to change from relief to uncertainty.   At that point of course, the breastfeeding guilt switches to bottle feeding guilt - the one we hear so much about. 

And so the cycle continues in a society which seemingly effectively support nobody...

Some quotes from mums about their breastfeeding experiences found on parenting forums (all reproduced with authors permission)

"My son is now 11 weeks old and exclusively breastfed. From day one my mother in law has asked me when I intend to give it up and when am I going to give him solids. She still asks me now, every time I see her.  She doesn't like that she can't settle him because I am the only one with the mil,k and will say 'well if mummy would just give you a bottle I could feed you, but she doesn't so I can't".  I could express for her if I wanted to and I have done once or twice, but this doesn't seem to satisfy her so I don't bother anymore.
I've also had a lot of pressure from my sister in law (who doesn't even have kids) to combination feed. She thinks I should only breastfeed once in morning and once before bed. I don't know why but she thinks it would be easier for me though, as I would have to sterilise and make up bottles!"

"I would love it if everyone knew how hard it can be, and how when we're struggling in the first few weeks, to have your partner, mum, well anyone saying just give him a bottle - get some sleep - combination feed so you can rest - IS NOT HELPFUL.  What we need in those first few weeks of horrendous problems if we face them, is for someone to stand next to us like a football coach urging us on and telling us how good we are doing. We need someone to recite all the normalities of the problems. We need to hear the stories of success and hope!  I really wish my family and friends had known what I have since learnt on my rocky path of breastfeeding."

"I didn't manage to breastfeed my first through exhaustion, pressure to bottle feed from family and poor advice from midwives. Second time around, I had the exhaustion and the pressure to bottle feed BUT I had amazing support from a good friend of mine who is a trained breastfeeding peer supporter.  Every time I had a wobble and almost gave in to the pressure, she was there explaining what was happening and why;  her encouragement was and is fantastic and really made the difference.  This time baby is 8 months and we both still love breastfeeding."

So what do you think?  Got guilt?

Breastfeeding, SIDS & Guilt - At what cost?

Many parents are surprised to learn that not breastfeeding has been linked with increased rates of SIDS.  Despite it's importance, it is often never mentioned at antenatal classes or by Health Professionals; so one day I decided to ask one why.

"Tell mothers not breastfeeding makes their baby more likely to die?" she stuttered red faced, although I had suggested something earth shattering.  Heavens no we couldn't tell them that! Imagine how guilty they would feel if they decided not to breastfeed!  And me?  I was firmly moved mentally into the "breastfeeding loony" camp.

And there it is again, guilt - the new black.  The guilt culture extends to more areas of parenting than any poor unsuspecting new parent could begin to imagine, but at what cost?

A meta analysis of 23 SIDS studies revealed 19 studies found not breastfeeding increased the risk of SIDS. The combined analysis indicated that artificially-fed infants were twice as likely to die than their breastfed peers. 

A recent German study found that artificial feeding at one month, was associated with double the risk of SIDS. Artificial feeding and only partial breastfeeding in the month prior to death were also linked with increased incidence. In this study 73% of SIDS deaths were before 6 months and being artificially fed doubled the incidence at all ages throughout infancy.

The link between feeding method and SIDS is no secret - in fact it's recognised by FSID:

Breastfeeding reduces the risk of cot death
"Research* shows that babies who were at least partly breastfed were one-third less likely to die as a cot death than babies who were never breastfed.
FSID Director, Joyce Epstein, says: “There are so many reasons why breast is best, but there are none that can be stronger than potentially saving your child’s life. We encourage every new mum to breastfeed.” (FSID)

How breastfeeding is protective is still topic of hot debate, as the cause of SIDS is multifactorial; studies have been adjusted to rule out social, economic and cultural differences, yet the link is clear. Research suggests that infection, combined with immature brain stem (in the form of periodic breathing) at a critical time of development, may cause the major proportion of SIDS cases.

As artificially fed infants have no passive immunity from their mother, they are  more likely to suffer infection and experience slower maturity of the central nervous system.  The microflora of an exclusively breastfed and formula fed baby are different, with good bacteria dominant for breastfed, and far higher rates of pathogenic bacteria colonisation for those who are not.

Research from Adelaide's Women and Children's Hospital has found that a possible cause of Sudden Infant Death Syndrome (SIDS) is a strain of golden staph bacteria:

"What's of particular note is that staph aureus, this golden staph, very commonly carries lethal toxins and as part of our research we found two-thirds of SIDS infants actually carry these lethal toxins in their intestines, as it happens," he said."

Another suggestion is that vaccines may be linked, and there is also evidence that a breastfed and non breastfed infant's body responds differently after vaccination, with those non breastfed showing increased side effects.

Low Serotonin levels have also been identified as a possible trigger - Jack Newman discusses why formula fed infants have lower levels:

"There is another neurobiological mechanism involved in the development of brain serotonin, tryptophan a precursor amino acid essential for the development of brain serotonin which is richly present in colostrum and breastmilk but absent in formula milk. Thus, two distinct and different neurophysiological mechanisms have been identified that contributes to deficits in brain serotonin: a) failed physical affectional bonding in the maternal-infant/child relationship (sensory processes); and b) the amino acid tryptophan present in colostrum and breast milk but absent in formula milk (neurochemical processes)."  Read more here 

They also sleep more deeply, with a study finding that during the active sleep phase, breastfed infants are significantly more rousable than formula-fed infants at two to three  months of age.  Dr Brian Palmer D.D.S has found a link between SIDS and suboptimal development of the facial muscles and jaw, caused by the unnatural sucking action from a bottle and pacifier.  Breastfeeding encourages a wide palate and so an unobstructed airway, which means protection may be as much down to the act of breastfeeding as breastmilk itself.

Really when we look at the thousands of live constituents breastmilk contains; hormones, antibodies, stem cells, cancer fighting cells etc etc, which we know impact on the baby's body massively, what is the cost of depriving baby of this?

But whilst everyone was told "place baby on backs at the foot of the crib, use appropriate bedding and ensure the room temperature remains at 18 degrees", how many got the lowdown on the links with infant feeding?  How many have read there is "no proven link"?

When there is evidence suggesting more than a casual link, and no unbiased evidence suggesting otherwise - why is this?

Over the years I've started wondering about guilt, and I think for the most part our emotions are our own, there are few occasions when someone can make you feel something.   What I mean is, take this article - a first time pregnant mum might think wow, didn't know that.  A breastfeeding mum might feel wow, glad I stuck with it and be reassured.  A mum who has felt she has little choice but to stop breastfeeding might feel guilty.  But which of those did I cause? 

Can passing evidence based accurate information cause anything, or is it far more likely that it's down to the person receiving the information?  Lets take the non breastfeeding mum again - within that group you might have someone who knew all this, decided to formula feed anyway (ie decided for them the risks were still comparatively small, and compared to their current situation were a better option) or you might have the mum that didn't know and wished she had as she had decided not to bother trying, because she had been sold the concept formula was "just as good".  Or you might have the mum who tried everything and the support failed her, who instead of blaming those who should have helped her, fruitlessly blames herself....another in an identical situation might rightly blame those who were supposed to inform her, and not blame herself for something she didn't even know!  It all depends on the person receiving the information...

For me the guilt culture has gone too far when it stops us giving mums the information they need to make their "choice" - the thing so many claim is a mother's right.  What about a mother's right to the facts?  Isn't it insulting to mothers to assume all would feel the same emotion upon receiving the facts?  Perhaps they could ask the mother whether she would like to know the facts as we best understand them, or the airy fairy version they think you can handle?  At what point will someone take legal action because information was withheld from them?

As we always say "an informed choice is a happy choice."

UPDATE July 13th 2011
(Reuters Health) - Babies who are breastfed - especially those only fed breast milk, and not formula as well - are less likely to die of sudden infant death syndrome, or SIDS, suggests a new analysis of past studies.

Breastfeeding could be linked to SIDS because it protects infants against minor infections that have also been shown to make sudden death more likely, the authors note. The World Health Organization, among other medical groups, recommends that mothers breastfeed their babies for the first six months of life.

In the new review, Hauck and her colleagues combined data from 18 studies that asked mothers of infants who had or hadn't died of SIDS about whether they breastfed the infants.

Combining the results, the researchers found that the rate of SIDS was 60 percent lower among infants who had any amount of breastfeeding compared to those who didn't breastfeed, and more than 70 percent lower in infants that been breastfed exclusively - without any formula - for any period of time. (insert from AA - if breastfeeding is the norm, breastfeeding cannot reduce the risk of anything - not breastfeeding is what increases the risks, as these figures demonstrate)

That led the authors to conclude that any breastfeeding helps protect a baby against sudden death.

"We found a protective effect even after controlling for factors that could explain the association," Hauck said. "For example, the link remained even when the authors took into account the fact that women who smoke cigarettes are less likely to breastfeed, and also may be more likely to have an infant die from SIDS".

You can read the full story here:http://pediatrics.aappublications.org/content/128/1/103.full

UPDATE May 17th 2012:
Australia - Breastfeeding now on SIDS prevention list

BREASTFEEDING has been added to the list of things mothers are advised to do to protect their baby from sudden infant death syndrome, with experts saying there is clear evidence breastfed babies have less than half the risk of dying unexpectedly.

"We can definitively say breastfeeding is protective as a specific risk reduction," Adjunct Professor Young said. "Babies that are breastfed tend to arouse more easily, and we also know the components of breast milk are such that babies are meant to feed more frequently, which means they are easier to rouse.

"Breast milk contains immune benefits that cannot be replaced by artificial formulas, no matter how hard the industry tries to improve their ingredients.

"We know that breastfeeding reduces the respiratory and gastro-intestinal infections that children experience, and we know that about 45 per cent of babies that die suddenly and unexpectedly had an illness in the previous two weeks."

  Full story here: http://www.theaustralian.com.au/news/health-science/breastfeeding-now-on-sids-prevention-list/story-e6frg8y6-1226358205528

RELATED POST: DO PACIFIERS PROTECT AGAINST SIDS?

Ask The Armadillo - follow on formula con linked to impaired development

Q. Hi Armadillo,
I've got a Q for you!  I'm confused (and so are a lot of mums I speak to) about this claim by follow-on milk producers that breastfed babies and those weaned onto cows milk are going to be short of iron. Can you shed any light?
Many thanks,
Jude

A. Hi Jude
Ah the giant marketing machine that is follow on milk, and it's huge iron count. Yes, how did the human race manage before it?

An interesting fact you may or may not be aware of, is that until the 1980's/90's there was no such thing as "follow on milks". They were developed partly because the market for young baby infant formula was saturated (s'always about the money), and partly to dodge the new regulations that were starting to appear which banned the promotion of young baby infant formula.

Follow on milk (for infants over 6 months) was not restricted in these regulations, because it did not exist! So manufacturers then moved to advertise their similarly packaged and branded follow on milk, because parents very often mistake these adverts for young baby formula. There have been numerous follow on adverts banned because they used infants that were too young or because they used misleading statements. In fact, when a 2005 survey asked 1,000 new mothers and pregnant women, two thirds (60%) said they had seen or heard advertising for young baby infant formula in the past year. Worryingly more than a third of women who had seen formula advertising said that the message conveyed was that infant formula is 'as good as' or 'better than' breastmilk. Clever huh?

The "very large iron scam" as I fondly like to term it, is almost as clever - but not quite...

Because obviously pre the 80's babies weren't all wandering round iron deficient.  No mammal biologically needs the milk of another species to survive and thrive, otherwise the human race would have died out long before follow on milk was around.  Even babies not having breastmilk after twelve months, don't need cow's milk or follow on formula to remain healthy.  Some babies are more at risk of deficiency, such as those born preterm, or if mum has diabetes - if you are unsure, check with your healthcare provider.

Before I go any further, it's important to understand the different types of iron we can consume.  Heme iron is found in animal foods that originally contained haemoglobin, such as red meats, fish, and poultry;  iron in plant foods such as lentils and beans is arranged in a chemical structure called non-heme iron, and it's this form of iron that is added to iron-enriched and iron-fortified foods. Heme iron is better absorbed and more bioavailable than non-heme.

Now, the recommended daily iron allowance (RDA) for a child 1-3 years is around 6 mg/day. 
So take the advert with the giant cup of milk, and wow imagine having to drink all this to give your baby the RDA -  gosh yes, mammoth!  But hang on, infants at 6 months plus aren't reliant solely on milk - at this point they are starting to consume solids and take iron in their diet too, by twelve months most are eating a good varied diet - so their intake is a combination of iron in milk + iron in food.  If their daily iron requirements are met in just a couple of beakers of "high iron formula", isn't baby very quickly at risk of being well over the daily recommended allowance if they eat much?

Nowhere in this marketing plan does anyone mention the risks of too much iron, but many source suggest that too much is just as bad as too little.

A study published November 2011 found infants who received iron fortified infant formula have poorer long-term developmental outcomes.

Betsy Lozoff, M.D explored long-term developmental outcomes after ten years for infants who were given iron-fortified formula. In a randomised controlled trial they followed up 473 children after ten years. Between 6-9 months of age 244 were in the iron-fortified group and 229 in the low-iron group

Researchers gathered data on their IQ, arithmetic skills, VMI (visual-motor integration), motor functioning, visual perception and spatial memory.

At the age of ten the researchers detected no significant differences in the iron status in the children of both groups. 4.1% (9) of the infants and 6.9% (17) of the ten-year-olds were diagnosed with iron deficiency in the iron-fortified group.

The children in the iron-fortified group scored lower in every outcome measured at ten years, with statistically significantly lower scores in spatial memory and VMI, compared to those in the non-iron group. They showed suggestive trends that did not reach statistical significance in arithmetic skills, motor coordination, visual perception and IQ.

Furthermore:

The lowest ten year follow-up scores were found among the infants with the highest hemoglobin scores who had been given iron-fortified formula. However, the highest scores were among the iron-fortified formula infants whose hemoglobin levels at six months of age were the lowest.

The authors wrote:

"In conclusion, this study indicates poorer long-term developmental outcome in infants with high hemoglobin concentrations who received formula fortified with iron at levels currently used in the United States. Optimal amounts of iron in infant formula warrant further study."

http://archpedi.ama-assn.org/cgi/content/short/archpediatrics.2011.197

So this considers US levels - I decided to investigate how things stood in the UK.

In the study fortified formula was mean 12.7 mg/L and non fortified was mean 2.3 mg/L

SMA Stage 2 Follow On Milk - 12 mg/L
Aptamil Follow On Milk - 10 mg/L
Cow & Gate Follow On Milk - 10 mg/L
Hipp Organic - 10 mg/L

Any unabsorbed iron sits providing the perfect environment for harmful pathogens to live and feed and for cancer cells to thrive.  Excess iron also creates free radicals, which have been linked with everything from heart disease to ageing.  Someone who feels very strongly about this issue and probably presents "worst case scenario" is Ray Peat - but a quick google of "iron causes free radicals" or "risks of too much iron", finds this is not a new concern to many.

Add to this the risks of aluminium from follow on tins - and it's hardly appealing....

Those who don't know very much about breastmilk will tell you how low it is in iron compared to breastmilk substitutes (which as the above study shows is likely to be a good thing!)  Something further to consider is only 7-12% of the total amount in substitutes is absorbed to be used by baby - compared to at least 50% in breastmilk. The result from larger amounts in formula is a lot of excess iron that can't be used by the body.

The iron in breastmilk (NOT related to maternal intake during lactation),  isn't just "any old iron", and it's not just wildly floating around.  It's bound with a glyco protein called lactoferrin.

Human lactoferrin carries the iron and as it is also bactericidal and antiviral to many harmful pathogens including E coli, protecting the iron by reacting with the cell membrane of bacteria it comes in contact with; it is also an effective anti fungal against Candida.  Breastmilk also contains high levels of lactose and vitamin C, further aiding absorption.  There is never any spare iron sitting round to cause problems.

As mentioned above, iron is obviously also found in foods.  Red meat is a fantastic source of heme iron for young children as it also contains the essential B vitamins and zinc- I always find it very confusing when parents use the 6 month guideline to introduce solid foods, and then use foods such as baby rice (irk!) or plain veg - which are from an introduction plan aimed at prematurely weaned infants and offer little nutritionally. 

If a baby is having plain doorstep milk from a year instead of formula (and really, why line their pockets a moment longer than you need to?)  ensuring you offer other iron rich foods instead is recommended.  Chicken livers are very high at 12.8 mg per 3 1/2 oz serving, beef tenderloin offers approx 3mg per 3oz and dark turkey approx 2mg.  Good non heme sources include soya beans at around 8.8mg per cup (although some debate this claiming some proteins found in soybeans can also inhibit absorption), followed by pumpkin seeds (4mg per 30g) lentils, beans, potatoes, broccoli, spinach, mushrooms, raisins and wholewheat bread (see all the sources of iron that creep in?) plus of course fortified cereals. 

It is important to ensure baby doesn't consume too much doorstep milk ie to the detriment of solids intake.  Cows milk is very low in iron naturally, so if baby is filling up on that and refusing foods, there is increased risk of deficiency.  In addition too much calcium is also known to inhibit iron absorption, whilst offering foods rich in vitamin C alongside iron rich foods, assist.

Hope this answers your question?
AA

UPDATE - The Advertising Standards Authority have banned the "iron count advert" as misleading.

Mother & Baby - Their response to the Press Complains Commission

This blog began back in June with my first posting: Mother & Baby, sorting fact from fiction.  I decided at the time to complain to the Press Complaints Commission, really with issues with one line of the article in particular.  A lot I think could be classed as opinion (although completely incorrect and misleading) but as I say one line really annoyed me more than the others; it was:

Formula milk is not toxic, lacking in nutrients, Or in any way bad for a baby’s health when prepared properly– and we can all read the back of a packet for instructions.

How can Mother & Baby claim breastfeeding reduces risks of various conditions, and then in the same breath claim formula milk doesn't make a child less healthy?  It's the exact same statement phrased a different way!  If breastfeeding reduces the risk of say gastroenteritis, then not breastfeeding (ie using formula) increases the risks of gastroenteritis!  Yet Kathy Blundell made a clear statement this is untrue; her claim doesn't read as opinion, but as a fact.

Anyway. here is Mother & Baby's response to the Press Complaints Commission:

July 14th 2010


Dear William

Thank you for your letter of 1 July detailing two complaints received at the PCC.

Both complaints are reacting to a one-page opinion feature by Deputy Editor Kathryn Blundell in our July issue who – for reasons explained in the piece – decided to go straight to bottle-feeding. It was her choice, and this was an account of her personal experience, which the feature made abundantly clear. Readers could choose whether or not they agreed with Kathryn, and it is clear that a few vocal individuals, including the two complainants, strongly disagreed with Kathryn’s choice and her reasoning. But we defend our right to publish that opinion, and defend Kathryn’s right to express it has her ‘Viewpoint’.

Context is very important too. Mother and Baby promotes breastfeeding as the norm. Last summer we used a cover of a model breastfeeding her baby, a first for the UK magazine industry. We also conducted a campaign “Lets Make Britain Breastfeeding Friendly” and we went on GMTV to back this up. I personally wrote a piece in the Daily Mail saying how outrageous it was that women are often made to feel uncomfortable. We offer help and advice to women on a monthly basis on this very issue: our May edition included a six page ‘get started and stick with it’ feature, our July issue (the one complained of) had a feature on the best breast pumps, and our next issue carries expert advice on surviving painful feeding in the early days.

Further, in the feature Kathryn herself states “ Sure breast milk has the edge over infant formula – it’s free, it doesn’t need heating up and you can whip up a feed in the middle of the night without having to get out of bed. Then there are all the studies that show it reduces the risk of breast cancer for you, and stomach upsets and allergies for your baby.” Read as a whole, and in proper context, I do not think that anyone should reasonably have concluded that Mother and Baby were saying that breast was not best. (COMMENT INSERT: why is it best if formula isn't in any way bad for a baby's health as Kathy claims?)

If these complaints are to be considered further, and by default Kathryn’s piece is not considered simply as an opinion piece, we would be obliged to ask for the opinion of medical professionals. For example, we would need to look at whether the research Miss Cole refers to on ‘breast sagginess’ was peer reviewed and published, and how the opinion and conclusion of those doctors sits with the general body of medical opinion. Similarly, we would need medical opinion on the ‘extensive evidence’ on the risks of formula feeding that Miss Cole again refers to, and to understand how that research fits with the general body of medical opinion and research to the contrary. We would also need to have opinion on whether it would be possible to feel tipsy (as opposed to drinking one unit of alcohol) and safely breastfeed. Our view is that it is not be appropriate to ask the PCC to adjudicate on matters of opinion such as these.

You should be aware that we have been inundated by supportive emails and letters of Kathryn’s ‘Viewpoint’ article (43 in total which we are happy to make available in anonymous form for the PCC to see) applauding her honesty: in their opinion we have made readers feel ‘normal’ and less of a ‘failure’ for not managing to breastfeed – a situation which is incredibly common.

Please do call me if you would like to discuss any of this further, and I am sure you will let me know if you wish me to expand on anything.

Yours sincerely

Editor
Mother and Baby

Lara Williams @ The Guardian - you should be VERY ashamed...

Until the last few months, I've always been a bit of a Guardian fan - but recently, you gotta wonder what's going on?  Has the economic slump got so bad they have decided to write a la tabloid style?  Fact no longer seems to be the foundation of a piece; instead the article I read today was not only misinformed, but downright fictional!  Hmmmm maybe some staff trades have taken place as the Daily Mail, hardly known for their progressive journalism, seems to be producing some startlingly good pieces!

For anyone who hasn't had the pleasure - here is the article by Lara Williams:

I should state at this point that I don't agree for a moment with Gisele Bündchen that women should be forced to breastfeed - heck we can't even manage to support those effectively who want to do it, let alone those who don't!  But Gisele is obviously informed as to the facts and I think however clumsily, was trying to emphasise it's importance, rather than suggesting the police force (who locally seem to struggle with teenage boys) move on to hormonal women!

Where to even start responding to this piece has taken an age, how to correct so much rubbish without turning it into a twelve page posting?

Let's start with that good old issue pulled out at every opportunity:

Choice

To make a choice you have to be in possession of facts, otherwise where's the choice?  I absolutely fully, truly and utterly support choice.  If a woman knowing all the ins and outs, decides not to breastfeed - that is her choice?  It might not be the choice I would make, I might not agree with the implications given the cost to the public health care system, or the impact on the environment BUT (and it's a big but) as breastfeeding quite obviously involves breasts, which are attached to another person - it's not a one way process and women can have deep and personal reasons about not breastfeeding.  Luckily we don't live in Indonesia!

Lara states:

Breast milk formula is getting closer and closer to having the same nutritional properties as breast milk, and it could be argued that it is more or less equal.

Well you could attempt that argument, but if it's to someone who has a clue the result is likely to be either  a) hearty laughter as people think you're being funny or b) people take pity on your utter ignorance and try to educate you.  Oh and what on earth is "breastmilk formula" ?

The trouble is in the UK "constituents of breastmilk" doesn't feature on the curriculum.  The vast majority of women have no clue about the ins and outs of either feeding method pre children - and then, their baby is born into a culture where the vast majority use a supplement, and writers like Lara actually earn money for writing an article that undermines breastfeeding further.  The sad thing is women like Lara are writing about a topic of paramount importance to the public, with such a blatant lack of knowledge and doesn't even realise it!  Likely neither will the vast majority of readers.  Perhaps I should write some articles on triple bypass heart surgery?  I have zero knowledge or experience but hey the Guardian doesn't seem to care about that - c'mon nowadays McDonalds is nearly as nutritious as homegrown organic, and many doctors are saying now that diet has nothing to do with coronary health....honest

So this choice, what about the women who choose to breastfeed, that IS their choice - but fail to get support or for people to realise how important it is to them, or "feel guilty" for asking for help as everyone is telling them to "just give a bottle", or does choice only work when you are choosing to default from the norm?

The fact is that breastmilk substitutes are in no way close to breastmilk, they might be "closer" than they were a year ago or two, but what does that mean when there are still at least a hundred constituents that substitute manufacturers can't hope to replicate?  As I always say, I might be financially closer to that Bentley than I was at 18, doesn't mean I'm anywhere near close! (but that's the clever marketing often used)

Formula is a static, dead product.  Breastmilk is a living fluid like blood containing a myriad of amazing constituents that many don't even begin to understand, and which impact in an astonishing number of ways.  For any health professionals working with breastfeeding mothers, those involved with lactation or anyone with a basic sciencey background who wants the full lowdown - I would highly recommend http://www.health-e-learing.com/ BE01 "Breastmilk Composition & Function".  A fully referenced course which is eye opening!

I think perhaps the worst line in the article is:

many doctors now argue infants in these very early stages of life are unlikely to develop infections anyway

Is Lara for real?  Seriously?  I actually had to read this line several times - young babies are no longer amongst the most vulnerable in society (along with the elderly)  the cost of treating their infections as stated in the Infant Feeding Survey was obviously made up?

Newborns are very susceptible to illness; they have a tiny fraction of the immunity they will develop as adults, and furthermore their immature system has also yet to learn how to respond effectively.  Any harmful pathogen or germ has the potential to invade and spread VERY quickly.

The newborn is in a very special situation when leaving the sterile and protected environment of the mother's uterus. The infant has to handle many new demands. Besides taking in food, the infant also has to meet a new environment which includes the presence of a multitude of microbes. Without an adequate defense against infectious agents, the neonate runs a very high risk of acquiring threatening infections. From this point of view, the neonatal period and the first year of life are the most dangerous times in man's life.

1.# Hanson LA (2007) The role of breastfeeding in the defense of the infant

This is why breastmilk contains a whole passive immune system perfectly matched to the infant.  The antibodies that are at very low levels are abundant in breastmilk, providing defense against infection ; directly seeking and targeting problem pathogens, directing immune cells, teaching the immature system what needs responding to and how, plus a whole host of other things - hormone regulators, cancer targeting, and cells that can change into other required cells; and this is only scratching the surface.

If anyone knows a doctor making the claims Lara says -  PLEASE send them my email address as I would love to hear their rationale!

Anyway, to finish I thought I would re-write some of Lara's article the right way up, taking breastmilk as the norm (which given it's milk of the same species is where it should be!)

Whereas once artificially feeding was accepted as ok - infant formula is now emphatically worst.  Breastmilk substitutes are said to reduce intelligence, and reduces ability to fend off illness, amongst a multitude of other disadvantages.

There runs a vast gamut of studies advising women not to artificially feed. The Copenhagen-based Centre for Advanced Food Studies has found artificially fed babies develop a less sophisticated palate. A Million Women "nun" study found that when testing women who had breastfed against actual nuns (who had never breastfed, for obvious reasons), those who had not breastfed were more likely to develop breast cancer. Artificial feeding it would seem, isn't blessed.  But as important as research is, the authenticity of reasons to not formula feed are diluted. And a woman's right to have a choice gets lost along the way.

Non breastfed babies are more prone to infection than their breastfed counter parts

This fascination with breastmilk substitutes is yet further removal of a woman's agency over her own body. Women's bodies, and what they chose to do with them, are laid out for public consumption and comment. What's more, this reinforces the emphasis of anyone and everyone as caregivers.

With an insurmountable myriad of things to worry about as a new mother, whether to artificially feed or not is something you should feel able to decide for yourself. According to the Department of Health, ninety nine out of a hundred mothers use breastmilk substitutes for the first six months.

Here is the Daily Mails offering for yesterday

Calpol - It's paracetamol Jim, but not as we know it!

Hands up if you give Calpol to your kids?  Now keep them raised if you knew it contained FIVE E-numbers, some of which are banned in other parts of Europe and the US or that it had been heavily linked to asthma, eczema and hayfever?

To many parents Calpol has become synonymous with infant pain relief; rather like "Hoover" or "Tannoy" - the brand has become so big, you rarely hear the word paracetamol mentioned.  But take a closer look and in reality the two are far from identical products.

In case you're thinking I'm having a bout of "Neurotic Mother Syndrome", it seems I'm not alone with my concerns.  Research by The Food Commission has found that just 1 of 41 medications intended for children was additive free; many contained a cocktail of colourings, sweeteners and preservatives that can trigger allergic reactions such as rashes, eye irritation, stomach upsets and diarrhoea.

The researchers said that:

While some additives were needed to help children to take unpalatable medicines, the quantity of substances banned for use in food and drink for the under 3s raised concerns. They called for warnings on all medications that could trigger allergic reactions

So, let's take a look at what's in Calpol:

Maltitol liquid, glycerol, polysorbate 80, sorbitol (E420) solution, methyl parahydroxybenzoate (E218), propyl parahydroxybenzoate (E216), ethyl parahydroxybenzoate (E214), dispersible cellulose, xanthan gum and purified water. carmoisine (E122)

To many, the list above doesn't mean much - so I will break it down further:

E122- the bit that makes it pink.  A suspected carcinogen; banned in Austria, Japan, Norway, Sweden and the US.  May cause allergic reactions.  Hyperactive Children's Support Group identifies E122 as a likely cause of mysterious and sudden cases of ADHD-like hyper-activity.

E420 - A paraben preservative, can cause stomach upset.  It is not allowed in foods intended specifically for babies or young children.

E218 - Suspected hormone disruptor.  May cause allergic reactions (possibly delayed)  Hyperactive Children's Support Group identifies E218 as a likely cause of mysterious and sudden cases of ADHD-like hyper-activity.

E214 - Suspected hormone disruptor, banned in France and Australia.  May cause allergic reactions (possibly delayed)

E216 - Suspected hormone disruptor  May cause allergic reactions (possibly delayed)

Hmmm suddenly that cute  baby on the box, isn't looking quite so appealing!  But as Calpol own a 70% share in the £70 million pound 'pain and fever' industry, I'm guessing they're not going to be rushing to make changes anytime soon - but why would they?  Have you seen how many Calpol fan groups there are on Facebook?  In contrast, although manufacturers claim reactions are rare, a poll on http://www.patientsville.com/medication/calpol_side_effects.htm found 70% of users reported a mild or moderate reaction (the link highlights some interesting ones!)  Which begs the question, experts in pain relief, or experts in marketing?

Surely they need it when unwell?

If you really feel your child needs medicating (and I will come on to that in a moment), you can obtain generic paracetamol suspension from your pharmacist; even these sometimes contain excessive gunk, so checking the bottle is well worth the time; ditto Ibuprofen.  Some parents are choosing to follow the Europeans and use suppositories with young children- neatly side-stepping the how to make it taste nice issue (even with a host of E numbers, many parents report difficulty in administering a liquid to a resistant child!).  Plain Paracetamol isn't entirely risk free; apart from the possible listed side effects (which are quite rare when used appropriately), a 2008 study of 200,000 children found using the drug in the first year of life increased the risk of hay fever at age 6 by 48 percent, the risk of eczema by 35 percent and almost tripled the chances of wheezing attacks when given once per month under 12 months old.  The more paracetamol a child had in the early years of life, the higher the risk.  Ibuprofen has it's own list of possible effects.

Paranoid parent panic!
 
So what are parents to do?  In reality the vast majority of illnesses will be tackled just fine by the child's immune system without any intervention; but what many parents are unaware of is that medicating a temperature can actually hinder this process and cause a range of other problems.  The body causes a fever for several reasons:

• Certain parts of the immune system work more effectively at a higher temperature
• A higher temperature prevents many germs from functioning well and growing (making them easier to tackle) and destroys others. 
• Fever is one way of activating and 'educating' the immune system to respond when needed.

Forcing the body to cool down, not only makes the immune system function less effectively, but also allows more germs to thrive, survive and potentially repeatedly cause colds and further illnesses.  Most sources state temperatures up to 39 C (102 F) rarely need any action besides cuddles and comfort, but many parents are scared of fevers and wary of a "wait and see approach" - with some believing pain killers actually contribute to helping the child fight the illness.

An alternative approach?

Whilst hunting how best to treat my daughters manic temperature last weekend, I found a study in the Cochrane Database which found sponging with warm water was as effective as Paracetamol at reducing temperature.  Several sources also state this is likely to reduce fever faster than medication.

The proportion of children without fever by the second hour after treatment did not differ significantly between those given paracetamol and those sponged.  The statistical test showed significant heterogeneity between the groups receiving paracetamol or physical methods.

It is however very important to never use cold water when sponging.  Although your child may feel hot, cold water causes the body to attempt to raise it's temperature - if you child starts to shiver, you should stop sponging!

For full guidelines on how you should deal with a temperature by ensuing hydration, observing for serious illness and monitor temperature - this is a handy summary.