No excuse for the dehydrated breastfed baby.

I read yesterday about how a mum "nearly starved her child due to breastfeeding pressure", but it's not the first time I've heard "pressure to breastfeed" quoted as the reason some infants end up back in hospital on drips, dehydrated, "starving".

The rationale for the argument is that mothers are so stubborn, adamant and determined to breastfeed this is putting babies at risk!

Those pesky mothers being adamant they want to give their child milk of their own species and not a second rate substitute!  If only they weren't so stubborn and would just use formula - there would be no problem right?

As my Nanna would have said "poppycock".

The media talks as though there is a group of people doing the "pressuring" of these poor mothers to breastfeed.  I think that's quite insulting to mothers!  The more research and information we have, the more we find out about what is in breastmilk, that's not in formula - the more pressure there is to breastfeed I agree.  But not from some external source, from mothers themselves!  Once I knew that formula wasn't "nearly as good" of course I "put pressure on myself" to breastfeed (granted my first had formula alongside breastmilk before I knew this!)  - just like I tried to find and save up for the safest car seat.

But even if every mother in the world was adamant about breastfeeding - this is still no excuse for a baby ever needing to be readmitted due to severe dehydration or "starvation" as the mother yesterday called it, due to breastfeeding "going wrong".

Why? 

Because from day one we can tell if a breastfed baby is getting enough, and we can tell this right the way through.  Sure a new mum might not know this, why on earth would she? But those health care professionals around her paid to support her through the postpartum period should right?  They are employed to ask the right questions, to be absolutely confident that baby is taking enough.

Of course there are times when "lactation fails" - maybe due to a retained placenta or a thyroid issue; there are times baby can't milk the breast effectively, and times something else other than mum's own breastmilk may be required (be that donated milk or formula)  Please do not think I am saying all mothers without question can breastfeed.  What I'm saying is there are so many signs things are not ok, and there are signs things are getting more serious, LONG before the critical stage.

Yet all the cases I hear about the "dehydrated baby", the mum was regularly seeing health care professionals and in the case yesterday even a "lactation consultant" (I use inverted commas as I'm not suggesting this was an IBCLC)  According to others the mum had "amazing support from health care professionals, family AND online"....

These are not mothers sat at home alone, not attending appointments and ignoring advice.

So tell me again how babies get to the severely compromised stage without a single HP picking up on this and taking positive action to prevent the situation deteriorating?

Weight would be continuously dropping and output would be nothing as expected as two big tell tale signs - but as you can see from the example protocols below; there is no excuse for a HP not picking up on a developing problem:

1.  Assessment of breastfeeding - at each postnatal visit. Any abnormal finding (see table) triggers further action - Management Plan 1.

Baby
Jaundiced and sleepy or difficult to rouse for feeding Engorgement or mastitis
Demanding to be fed fewer than 6 times in 24 hours and/or not sustaining an effective suckling pattern
Feeding very frequently, i.e. consistently more than 12 times in 24 hours
Consistently feeding for longer than 45 minutes
Unsettled after feeding

Breasts
Trauma to nipples, nipples misshapen or ‘pinched at the end of feeds
Engorgement or mastitis

Breastfeeding
Difficulty with attachment
No change in sucking pattern, i.e. from initial rapid sucks to slower sucks with pauses and audible swallows
Baby is ‘fussy’ at the breast - on and off the breast frequently during the feed, or refuses to breastfeed


2.  Assessment of output - at each postnatal visit, together with ongoing monitoring by the mother. Inadequate output (i.e. less than that specified - see table) triggers weight assessment and implementation of appropriate Management Plan.

Urine - number of wet nappies per day

DAY 1-2: 1-2 or more; urates may be present*
DAY 3-4:  3 or more; nappies feel heavier
DAY 4-5: 5 or more
DAY 7 & BEYOND: 6+ Heavy
* Urates are normal bladder discharges in the first few days but persistent urates may indicate insufficient milk intake.  Urine should be pale/clear.

Stools - number per day, colour, consistency
DAY 1-2: 1 or more, dark green/ black ‘tar-like’(meconium)
DAY 3-4:  2 or more, changing in colour and  consistency - brown/green/yellow, becoming looser (‘changing stool’)
DAY 4-5: 2 or more, yellow; may be quite watery
DAY 7 & BEYOND: 2 or more, at least size of £2 coin, yellow and watery, ‘seedy’ appearance

3.  Weight - at approximately 72 hours and again at least once prior to transfer to health visitor. Weight loss of 8% or more triggers further action.
Amount of weight loss & Management Plan indicated
8-10% of birth weight - Management Plan 1
10-12.5% of birth weight - Management Plans 1+2
>12.5% of birth weight - Management Plans 1+2+3

Management Plans
Plan 1

• Observe a full breastfeed - ensure effective positioning and attachment
• Observe for effective suckling pattern & milk transfer
• Ensure minimum 8 feeds in 24 hours
• Skin contact to encourage breastfeeding
•  Observe for change in frequency/amount of urine and stools
• Reweigh day 7 If weight increasing, continue to monitor closely and provide support. If no or minimal weight .

Plan 2
Follow Management Plan 1, plus:

• Refer to breastfeeding team/drop-in clinic
• For sleepy babies, consider ‘switch nursing’ & breast compression
• Express breastmilk after each feed and offer to baby by cup
• Consider referral to GP if infection or other illness suspected
• Weigh again in 24-48 hours. If no or minimal weight increase, move to Management Plan 3

Plan 3
Follow Management Plan 2, plus:

• Refer to maternity unit for review by paediatrician & breastfeeding team
• Frequent breastfeeds and expressing, using hospital-grade breast pump
• Carry out investigations* to determine ongoing care. This may include formula feeds by cup or intravenous fluids, if breastfeeding ineffective or EBM unavailable Reduce formula offered as .breastmilk supply increases. 
• Weigh again in 24 hours.
• Continue to monitor weight twice weekly until clear trend towards birth weight demonstrated

* In order to ensure safety, this particular hospital decided that a serum sodium level in excess of 150 mmol/l, when found together with a clinical picture of weight loss in excess of 12-13% and diminished urine and stool output - with or without jaundice - indicates a need for supplementation.
End


Clinical - yes.  But these are health care professionals, ultimately responsible for the life of a young infant.  As you can see, when everyone is aware what the red flags are - there is no reason any baby should reach the critical stage weeks down the line!

For more on this subject see: Is my breastfed baby getting enough? (and things you can do if not)

To see a similar plan used by another hospital to train staff click here. 

Organic Mum & Baby Set Winner!

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The irony in raising money for Comic Relief - if you still buy Nestlé...

So it's that time of year again when everyone starts thinking about red noses.  It seems to have become quite popular for celebs to attempt some sort of physical feat; in 2009 Chris Moyles, Radio 1 breakfast presenter, amongst others bravely ascended Kilimanjaro.  This year presenter Dermot O'Leary, Craig David and Radio 1's Scott Mills are trekking the Kenyan Desert.

Of course it's great that celebs are out there raising money (and of course their profiles) but you have to wonder if it's more of an "off-setting" than a true benefit. 

I mention Radio 1 twice as it whilst listening this year I was reminded of the irony.  During the breakfast show a  few weeks ago, the team sent "Comedy Dave" to the shop, he returned with treats that he named, he had bought "Toffee Crisps", which of course are made by Nestlé.  They've now announced Chris and Dave are raising funds for Comic Relief this year, by staying up for 36 hours on the air - wonder if they will sustain that with Nestlé treats?

So they're sweating their asses off climbing mountains to raise money, to then give money to a company that:

Contributes to the unnecessary death and suffering of infants around the world by aggressively marketing baby foods in breach of international marketing standards.  Nestle have consistently found to be responsible for more violations of the requirements than any other company.

http://www.babymilkaction.org

Of course Radio One aren't the only celebs in on the Comic Relief action; indeed this year the rather delectable James Corden has donated his entire fee for presenting the Brits to comic relief!  A figure estimated at £50, 000 - yet I wonder whether he would think twice at buying Nestlé's Flagship brand Nescafé?

James is due to become a dad in a couple of months, so perhaps he may become more aware of these issues if he isn't already?  Clearly he seems to be a man of conviction, who might appreciate that whilst the mortality rate for not breastfeeding in the Western World is comparatively low - in developing countries it has a huge impact:

"Every day, more than 4,000 babies die because they're not breastfed. That's not conjecture, it's UNICEF fact."

http://www.babymilkaction.org 

Maybe next year we will see his fee go to Baby Milk Action? ;)

Baby Milk Action was required to defend the statistic before the Advertising Standards Authority after stating in a Nestlé boycott advertisement - they did so successfully, and, as the ASA report notes, this was with the support of the World Health Organisation (WHO)

The WHO are very clear about the position:

Marketing practices that undermine breastfeeding are potentially hazardous wherever they are pursued: in the developing world, WHO estimates that some 1.5 million children die each year because they are not adequately breastfed. These facts are not in dispute.

Because of this The World Health Assembly (made up of the World's health ministries) adopted the International Code of Marketing of Breastmilk Substitutes in 1981.  This code prevents companies from promoting their products, and limit them to providing scientific and factual information to health workers. It is for health workers to advise parents, not companies with a vested interest in increasing sales.

The Code and Resolutions do not ban infant formula from being sold, marketed or used.

http://www.babymilkaction.org

It simply prevents insidious tactics being used.  

Nestle Nurses - source babymilkaction

In the past breastmilk substitute companies were quite open about marketing.  In effect what Nestlé did was to put sales women in nurses uniforms (with no nursing training) and they were sent into hospitals to give out free samples of Nestlé formula. The samples lasted until the mother's breastmilk had dried up - at which point mothers were forced to purchase formula.  Not too tricky in the UK, but in developing countries the cost of infant formula can equate to more than a weeks wages (if they earn).  The result was stretching of formula, by diluting it more than was recommended - but of course this is not the only problem.  Unsanitary conditions  meant that babies starved all over the developing world, whilst Nestlé profited.

Naturally when the tactics were exposed a Boycott ensued, "Milk Nurses" as these reps were called ceased and the boycott ended. Unfortunately Nestlé continued to aggressively markets in other ways - resulting in a further boycott that now spans 18 countries. (source babymilkaction)

Pakistan - bottlefed twin girl died next day.

Globally 3.6 million Infants die before they reach their first birthday and millions are malnourished because of inadequate and inappropriate breastfeeding and complementary feeding practices.

http://info.babymilkaction.org/news/campaignblog

Nestlé has rejected Baby Milk Action’s four-point plan aimed at saving infant lives and ultimately ending the boycott (ref. 4).

You can judge for yourself what you think of Nestlé's current marketing tactic here and here 

In 2007 The Guardian went under cover to see if indeed Nestlé had ceased practices they had promised.  You can read the full report here (an eye-opening read)

Despite this Nestlé is seemingly held dear in the hearts of the UK (or at least their cash is)  ITV who heavily support Comic Relief,
have used the new change in product placement advertising to introduce a Nescafé coffee machine into the studio - so they can advertise for Nestle whilst "This Morning" goes out on air....nice.

Of course Nestlé isn't the only offender, but they are the biggest.  If they stop violating the code others will follow suit.

The boycott has achieved amazing things over the years, indeed According to Nestlé's Global Head of Public Affairs, Dr. Gayle Crozier-Willi, Nestlé is widely boycotted. An independent survey by GMIPoll found it is one of the four most boycotted companies on the planet, the most boycotted in the UK, where Baby Milk Action is based.  With your support they could do even more.

What can you do?

According to Baby Milk Action:

Every little helps and the way we promote it is intended to make it as easy to support as possible. We target Nestlé's flagship product, Nescafé, while publishing a list of major brands so people can avoid the whole lot, which obviously has more impact. We produce 'Nescafé - No Thanks' cards that people can leave where Nescafé is sold requesting an alternative option.

If humans aren't your thing,  Greenpeace launched a campaign earlier this year; "Kit Kat - give the Orangutan a break", demanding Nestle stop using palm oil from Indonesian rain forest in said biscuit (incidentally Britain's biggest selling chocolate biscuit).  A practice pushing Orangutans to near extinction and causing conflicts over land rights and resources.  Meanwhile Kit-Kat gets a Fair Trade badge because the cocoa is  Fair Trade (and to be honest many are questioning that) Oh and if you're in the US, Hershey make yours and they haven'tt agreed to any of the certification programs in the cocoa industry. (Find out more about how Hershey is lagging behind here).

When you think of how jam packed our shelves are of alternatives, is there really any reason not to?  Sure you may prefer a Nestlé brand, but when you think of the cost to others - is it really worth it?

Weeeeeeeeeeeelllllll unless you're a celeb that is, claims last year emerged that:

Nestlé is paying celebrities US$10,000 a tweet to push Nestlé products on Twitter, the social networking site.

http://boycottnestle.blogspot.com/2010/01/nestle-celebrity-tweets.html

Make of that what you will....

Share your experience - Kai's story

When I was 19 I gave birth to my first son, I always said I'd “try to breastfeed but if I couldn’t I wouldn’t get upset” Alex was born under very stressful circumstances, I'd lived with my partners mum most of my pregnancy after falling out with my mum, I couldn’t get on with her either and 8 weeks before Alex was born I turned up at my physc nurse and lost it after a bad argument (i had previously been diagnosed with Ante-natel depression) I got taken out and put in temporary accommodation, 12 miles from where i had been living, and i don’t drive, I was on crutches with SPD. After another HUGE argument my partner came with me, only for us to move again 4 weeks later. 

 

Alex’s birth was very bad, not an experience I wish to repeat, as soon as he was born he was taken to NICU for a few hours and then bought back to me. I had no idea what i was doing in hindsight, and I had no help from the ward, I remember waking up at 4am and asking the night staff why he hadn’t woken and why he kept coughing and being a bit sick, I got told to go back to sleep and leave him to it. I hadn’t even had a bath. I got in the bath and left him in the nursery, he did feed later but he was small, and as we found out later, sick. 

 

We discharged ourselves the afternoon after he was born, so we went home, me, my partner and Alex. I carried on feeding, he carried on being incredibly sick, the midwife came and weighed him at 4 days old, he’d lost, a LOT, we got taken back into hospital, I got told I was failing him. Turns out he had Gastro Reflux. I kept feeding him, with infant gaviscon to “help” he put on minute weight, at 4 weeks we were back in hospital, the local children's this time, who gave him stronger reflux medication. I went to see my health visitor the next day and she told me enough was enough, it was SMA gold (those specific words) to top up and that was it! 

 

That was the beginning of the end for us. I lasted another 12 weeks, with the formula slowly taking over, my partners mum, not helping by telling me I couldn’t breastfeed him after I ate chocolate, spicy foods, fizzy drinks, strong flavours. All the things i was, unfortunately, surviving on as a new young mum whose partner couldn’t take any time off work. 

 

So at 16 weeks I stopped, it broke my heart! I had zero support from anyone we saw, and we saw a LOT of health professionals with Alex being so ill, neither my mum or my partners mum, breastfed any of their children either, and non of my friends did. So much for I wouldn’t be upset!

 

When Alex was 9 months old I fell pregnant again. This time i would NOT be taken for a mug! I found out any online resource and read and read and read!!! Olli’s birth was 26 days late,  drug free and 1hr 18 minutes! A stark contrast to the pethidine, gas and air, epidural and 8 day labour I had for Alex. I picked him up, put him to my breast and cried when he latched like a pro!!!

 

Within 6 hours i was heading home on top of the world!!! My own midwife came to see us the next day, I told her my nipples were sore, she asked to watch him latch on and told me there was NO problems and why didn’t i go to the new Baby Cafe on Friday. I still didn’t feel that her insistence nothing was wrong was correct so again, turned to the internet and discovered he had a shallow latch, so i used the (controversial method) of using your thumb to open their mouth wider, it worked! By the time i turned up at our new Baby cafe I was comfy and happy!

 

Olli was 4 days old the week it began, we attended every week for the entire year the “youth” one was open, even training to be a peer supporter with them. Olli became the poster child for our Baby Cafe, he was worn in a sling, he was breastfed on demand and he packed on over 1lb a week EVERY week until he was 6 months old!!!!! He self weaned at 12.5 months and I cried for 3 days! In blessed hindsight, we introduced a bottle at bedtime at 11 months, He refused me one bedtime just after his birthday and I knew then I'd never get him back, I was right, i didn’t! 

 

Just after Olli turned 2 I was pregnant again! I was working at an active Baby cafe this time, had access to 2 top lactation consultants in the UK, had a wealth of knowledge, experience and support behind me! Amelia-Mae was born at home, drug free, in just under in 3 hours! Again, i picked her up, my first words to her were “Hello my beautiful princess, would you like some boobie?” 

 

She’s now 13 months, and as I write this is indeed having her beloved “Ba, Dis Ba, Dat Ba” (left and right LOL) we co-sleep full time, she’s worn, full time, she’s bf on demand, and always always has been, I have nursed her through her health problems (She has chest issues and kidney ones) I have nursed her in a church, on a train, a bus, a kids party everywhere I go, so does Amelia-Mae. 

 

I have met some WONDERFUL friends through breastfeeding support groups, online, through working for Baby Cafe. I am actually about to start work at our local children's and family centres as a breastfeeding support with some friends, and at the local hospital doing the “11 ‘O’ clock stop”! I have come so very very far from that scared 19 year old girl to a fully fledged mother of 3, passionate lactivist and peacefully parent! I thank breastfeeding for it ALL!!!!

 

Kai, Alex, Olli and Boobie babe Amelia-Mae!

Sex only in bed at bedtime please - we're British and have babies!

A story in the Daily Mail yesterday warned of the "dangers of co-sleeping".  Not the usual SIDS or overlaying though, instead this covered no sex, marriage failure and a clingy child - apparently all very real dangers of co-sleeping we should all be aware of.

"...it was a glorious day when, at three months, she moved to a cot in her own room." "Everything improved, especially my marriage — the baby’s beady-eyed presence in our bedroom turned out to be the ultimate passion-killer for me."

"A nationwide survey of 3,000 adults suggests that though 40 per cent of parents allow their young children to share the marital bed, at least every other night they aren’t too happy about it."

This is of course followed by the obligatory professor of sleep, warning never to start co-sleeping! (despite the fact it is shown to increase breastfeeding rates and improve quality of sleep, leaving mothers feeling better rested) If it's too late, use star charts to bribe the child into their own room (and those are his words).

I'm a bit unsure where the three month thing comes from, the SIDS guidance is baby should be near you until six months when risks reduce?

It was just this sort of thinking that left me adamantly refusing to co-sleep with my first - she barely slept and I was a walking zombie; despite following every "rule", resisting all "sleep props", following the "napping laws" eg dark room, set times etc - none of it worked and nor did she develop "healthy habits".

I've had a Google but can't turn up this survey (if you find it do let me know) as I wonder who were the 3000 mums surveyed?  Did these mums choose to co-sleep, or did they end up doing so because their child was such a bad sleeper it was a last resort?  How were the infants fed?  Were the group educated about normal expectations? Was this group compared to a survey of non co-sleepers to see if they reported higher rates of relationship satisfaction and indeed more sex?  Several studies suggest relationship satisfaction levels for men drop in the first twelve months postpartum - heck babies are blinking tiring, all consuming beings for a while, regardless of where they sleep!

The mums who have shared as a last resort may feel dissatisfaction because modern parenting books often tell them the norm is their child should be sole sleeping for twelve hours at six months (based on no evidence whatsoever).  They may feel resentful their child isn't conforming or blame themselves - had they only not given in the child would now be sleeping as expected, the old "rod for your own back".

Why can't families find something that works for them and meets the needs of everyone?

Families are now more insular then ever before and instead of lots of help from cousins/aunts and siblings, most parenting falls squarely on the shoulder of the parents.  In addition people often relocate away from family and then throw working into this mix - life can be a chore of childcare runs, work and washing/cooking/cleaning! 

Dad or partner may not be home until 7/8 pm, if the commute is long sometimes even later - putting a lot of  pressure on some mums, and indeed the family unit.  But why always the assumption someone's needs have to go unmet?  What works varies family to family and some even have a mix! Co-sleeping together some nights, with dad hitting the spare bed when he needs and ditto mum doing the same - there are no rules...If co-sleeping maximises sleep for everyone and stops (usually) mum having to traipse around the house to other rooms at all hours - leaving her better rested to cope with everything else, is this really likely to be a marriage breaker? 

Some parents have their toddlers awake until they go to bed, then all head off to the family bed together; others put the child into a bed or a cot until they wake during the night, and then bring them into the family bed - why has everything got to be all or nothing? Parents who feel forced into having children around all evening because they expect them to be asleep, or because they are tired out and need a break - are likely to feel entirely different come bedtime than those who have chosen to co-sleep and have other strategies in place for me/couple time.

Don't forget clinginess!

Something also apparently, inevitably caused by co-sleeping.  Firstly did I say how much I dislike this word?  Why must we always use negative terms to describe childhood behaviour society considers less desirable? 

Is it really so weird that a child needs its mother?  If some have a more intense need, why is that automatically deemed to be a problem?  What about the reasons why a child may have a stronger need or heck what if it's just the personality of the child?

The Daily Mail article is perhaps quite telling:

Perhaps more surprisingly, the practice didn’t seem to make children happier: most parents felt it made them clingy.

Sally and her husband Jim (who initially seemed happy with the idea) invested in a kingsize bed all three of them could all share. But Sally admits the effect on her marriage were anything but positive.

‘He (her son) was so cuddly,’ says Sally.'  I was working so hard during the day that I felt I didn’t see enough of him'.

'Jim and I used to have rows about it,’ she says.

The result was predictable: Jim and Sally divorced after he found himself a new woman. And Sally is now finding it hard to persuade eight-year-old Tom that he might prefer to sleep by himself".

It's interesting the parents surveyed felt co-sleeping made the child clingier. I wonder how you quantify what has caused "clinginess" in your child? Did they start co-sleeping because the child was clingy or did they choose to co-sleep from the start, in which case how do they know how clingy their child would or wouldn't have been had they slept alone?

Clearly the scenario above is a situation in which at least one person's needs were not being met.  The husband voiced that despite being initially for the idea, he began to feel left out and also that he did not see enough of her.  The mum admits she was working hard and long hours with an au-pair and so naturally felt if they didn't co-sleep she would hardly see her child.

This is about far more than the family bed, though this may have ultimately been the "final straw" that brought things to a head sooner. It's about communication (or lack of) and despite the husband stating his dissatisfaction, nothing changed to improve things. 

Perhaps if they had communicated more effectively, between them they could have negotiated some time together - maybe by both finishing work earlier on a particular day or getting childcare to have time out together? (they had a live in au-pair after all) devising a routine to get baby settled earlier and give some time in the evening - whatever.

Potentially there could have been far more quality time, how much did he see of his wife whilst she was asleep next to him? Clearly in addition the work/home balance was severely out of whack, and this is all down to a shared sleep space?!

Let's also not forget that whilst the lives of adults have changed, so have the lives of children.  Gone are the days of hanging on mother's apron strings until school or short spells at playgroup began; instead childcare away from the family often begins young as a requirement for work, for some that's almost full time office hours or longer.

While this may be an essential part of modern life for many - what about the infant's need to spend time with his mum (just like the husband has that need) do we expect them not to have that?  If mum feels like she's not spending enough time with her child, why would we not expect the child to feel the same?  Yet if an infant tries to demonstrate this need, they are labelled clingy. In contrast we call this demand from an adult vital to maintaining a healthy relationship.

What the mainstream media also always seem to forget, is those people who have found some sort of co-sleeping that works for them and who actively choose to co-sleep, why don't we ever hear about them?

Are the British really so boring that sex can only happen at bedtime in a bed?

With my first child (non co-sleeper) I was so wiped out that any time I got into a bed, my only focus was sleep!

I asked parents on Facebook whether they agreed co-sleeping had caused sex or their relationship to suffer.  Here are some of the replies:

Hmm... well I co-slept with all of them... including twins and... let's put it this way... I have five children!The result was predictable: Jim and Sally divorced after he found himself a new woman. And Sally is now finding it hard to persuade eight-year-old Tom that he might prefer to sleep by himself".

I think it has spiced up our sex life. We have to be more creative. Like I saw on a t-shirt once, "Co-sleepers get dirty... in the garden." Lol

I always wonder do these people not have sofas? or, a la postman always rings twice, kitchen tables? ;-D

Do these people not have any imagination? DH and I have not slept in the same bed for the last 13 years. He got kicked out after baby no 4, because he snores and no one got any sleep. We have managed another five babies since then, so def hasn't caused us any issues ;-)

Being too tired to do the deed with a small person to take care of is a FAR bigger reason for less frequent nooky than co-sleeping could ever be. If you both WANT to get amorous, you will find a location to do it. If one of you doesn't, you will find an excuse - and 'the bed is occupied' is an excuse - not a reason!

You can read the full replies here - hardly the picture we so often hear about.

Many parents find the transition to sole sleeper an easy one - infants often want their own space as it starts to get more cramped, and choose to head off to their own room if they feel there isn't an immense pressure to do so. The older the child is, the less intense the mummy need becomes and the shift is very often easier than with a tiny baby. Some parents are happy for the child to leave the bed when they choose, others give a gentle helping hand:

My son co-slept until he was around 3 1/2.  At 2 he helped us decorate his bedroom, picked the covers, curtains and nightlight as we felt him having input would result in somewhere he felt happy.  At first he showed little interest once the decorating novelty had worn off, but we noticed as he's got older he has started going and playing in "his" bedroom for longer periods of time and choosing to nap there.  Then he progressed to going to sleep there and coming in with us when he woke, until finally declaring he was going to sleep all night in his bed at around 31/2 which he did.  He will happily tell us he's tired and wants to go to bed and seems to have a really healthy relationship with sleep.  (summarised from an email received)

Our son was 2.5 years old when he started sleeping in his own bed. My daughter was 9 weeks old at the time and we were sleeping well together, but we went for a sleepover at my Sisters and he slept on a blowup bed in his cousins room. I decided I would try him in his bed the following night, just to see how we'd get on. He thought it was brilliant because he was being a 'big boy' like his cousin. We haven't looked back since. He still sometimes wakes in the early hours around 5am and comes and joins us for an extra hour or two, but that's fine by me :)

When my boy was eighteen months we moved house and I was seven months pregnant so we introduced him to his toddler bed. We pushed it really as he probably would have liked to stay with us a bit longer but he did get quickly used to going to sleep in his bed and being put back there if he woke during the night

Read more here:

The fact that co-sleeping results in clingy children and broken marriages is nothing more than a myth.  Sure some co-sleeping families will divorce, just as cot sharing families do - but it's about a whole lot more than a family bed.

Share your experience - Lorna's Story

I had always assumed would breastfeed if I had a baby. My mum had my brother, sister and me in the late 70s/early 80s, and was about the only person she knew who breastfed, but she was adamant that it was the right thing to do - even when midwives in the hospital tried to dissuade her, and actually fed my sister formula while my mum was asleep (she was livid when she found out!). Throughout my childhood, whenever we were out and there was someone breastfeeding, my parents would always say supportive things about it, so I had nothing but positive influences.


While I was pregnant, I read some books to familiarise myself with aspects of raising a baby including breastfeeding, but to be honest, I just assumed I would pop the baby on and it would work - I realise now from many friends' experiences that I was quite naive to assume it was always so easy. As it happens, I was one of the lucky ones, and although I had a difficult birth (long, induced labour, forceps delivery, losing a litre of blood and needing a blood transfusion), and my baby daughter didn't get to breastfeed until two hours after the birth as I was unwell, she latched on straight away when she was put to the breast, and from that point on, I had no troubles at all. I never had any pain, or any mastitis, or any of the problems I hear about, for which I'm hugely grateful! The only "problem" was a big oversupply, which meant I leaked profusely from the other breast, and also between feeds. Rachel was on the big side of normal when born (8 lbs 12), and fed what felt like the whole time, day and night, for the first few months, but I knew this was normal, so I didn't see it as a problem.

At around four months, I did notice my breasts didn't feel so full, and when I mentioned it to my GP, she said my milk was probably drying up! Fortunately, thanks to sites like yours, I knew this was nonsense, and just carried on as usual. I exclusively breastfed for 6 months, then did baby led weaning, until my daughter was 13 months. At that time, I'd been feeling extremely unwell for a few months - so nauseous that I couldn't eat - so I weaned my daughter then. I eventually found out, after much pestering GPs, that it was Coeliac disease, and once I started to feel a bit better, I did think about re-lactating, but I never did. I do regret that now, as I know she's missing out on so much, as am I.

That's my story, anyway. I had a great and very easy experience with breastfeeding, and while I know I'm lucky to have had no problems, I hope it shows that it can just be very easy and unproblematic!

Lorna.

Starting Solids - Can Babies Be Ready Before 6 Months & How Will I Know?

Continued from Part 1 - Starting Solids - The Facts Behind Today's Media Hype

Please note the term weaning in this article is used in the typical UK sense of starting solids and beginning the transition to weaned (which may ultimately take years) rather than the more often US meaning of "stopping breastfeeding".

What the evidence behind the six months weaning guideline suggests, is that the vast majority of breastfed infants don’t nutritionally need solids until around this time, ie there is no perceived risk in waiting as breastmilk contains everything a baby needs:

"The evidence does not suggest an adverse effect of exclusive breastfeeding for 6 months on infant growth on an overall population basis, i.e. on average."

THE OPTIMAL DURATION OF EXCLUSIVE BREASTFEEDING REPORT OF AN EXPERT CONSULTATION, WHO

The above recommendation was endorsed by the Scientific Advisory Committee on Nutrition (SACN) when in September 2001SACN agreed that:

"There was sufficient scientific evidence that exclusive breastfeeding for 6 months is nutritionally adequate but that due to current practices in the UK there should be some flexibility in the advice."

The Department of Health added to this:

"Although there is no evidence to suggest that giving a baby solid food before six months has any health advantage, it is important to manage infants individually so that any deficit in growth and development is identified and managed appropriately.  All infants are individuals and will require a flexible approach to optimise their nutritional needs".

Why Wait?

In short what the body of evidence suggests is that solids should not be introduced before 4 months (or 17 weeks to be precise) - this is very clear (1).  After this point studies considering outcome become more conflicting when examining risks.

Take gastroenteritis - some indicate increased rates in those receiving solids before six months, whilst others suggest little significant statistical difference between 4-6 months in developed countries.  Note this data is only applicable to introducing foods, not breastmilk substitutes. (2,3)

Regarding other health issues WHO state:

"The evidence does not demonstrate a protective effect against respiratory tract infection (including otitis media) or atopic disease, in infants exclusively breastfed for 6 months compared to infants exclusive breastfed for 4–6 months"

However data from the 2006 National Health and Nutrition Examination Survey showed that:

"US infants who were exclusively breast fed for more than six months had lower risk of pneumonia and recurrent otitis media than those breast fed for four to six months."

These are just a couple of examples selected from a large body of evidence, but as you can see it quickly becomes confusing.  There are likely to be a number of reasons for this; firstly the definition of "exclusive breastfeeding" varies from study to study.  The WHO review states::

"Because the definition of “exclusive breastfeeding” in studies in the systematic review often included infants who were predominantly breastfed, the term is used here to include both true exclusive breastfeeding and predominant breastfeeding, as defined by WHO."

This suggests that should studies examine infants exclusively breastfed in the true sense, the results would be more compelling.

Secondly a not insignificant percentage of the studies are observational and so bias must be carefully evaluated, thirdly study parameters may differ eg an often cited study regarding solids and gastroenteritis is the Belarus PROBIT, however this studies exclusive feeding to three months or six months - not four or five (10).  Another consideration is that infants are unlikely to all mature at an exact pace, with gut development happening somewhere between 4-6 months for most infants and thus some were ready and some weren't.

"Most of the body’s systems are maturing and growing rapidly at 4-6 months and the timing and rate of weaning should take account of considerable individual variation." (1)

An issue often raised is iron, however when birth and mother's nutrition are typical - there is nothing to suggest a baby should need supplementation pre solid readiness - and some discussion that doing so may be harmful.

"The data on iron status were conflicting but suggests that there may be a need for iron supplementation where newborn babies have suboptimal levels." (2)

Dewey found risks of iron deficiency increased in infants with a birth weight lower than 3kg who are exclusively breastfed for six months (5); however anaemia in the mother and routine early clamping of the umbilical cord are also predisposing factors (6).  Ted Grainer PhD has an interesting discussion paper here, warning that we should ensure infants are indeed deficient before supplementing infants younger than 6 months, otherwise it may lead to reduced growth or increased susceptibility to infection.

The Guideline

A guideline has to be a simple message that can easily be understood and implemented by as much of the population as possible.  As the majority of infants are weaned following a parent led approach, recommending a six month weaning guideline prevents those who are not ready being exposed to solids early, whist providing adequate nutrition for the vast majority; thus is a practical choice for a guideline.

Ultimately there is no compelling evidence to suggest any benefits to routinely introducing solids pre six months and some evidence suggesting potential risks during the 4-6 month period; making it more about why to introduce solids than why not.

As we discussed in part 1 many do not understand why a guideline exists, nor the detailed evidence behind it – pushing the guideline to six months has reduced the amount of infants receiving solids before four months.

What is gut maturity?

As discussed in this blog entry, at birth an infant has what is often called an “open gut” to allow immunological properties in breastmilk to slip easily into baby's bloodstream.  In very simple terms, "good bacteria" actively works to destroy any harmful pathogens, and also coats these gut spaces to prevent germs accessing this ,route.

By around six months these spaces have closed in preparation for the introduction of solids. However we also know that once something else is introduced into the gut other than breastmilk,the protective coating is destroyed and the number of potentially harmful pathogens increases.

Therefore if the gut is still “open”, both good and bad have direct entry to the bloodstream which can potentially increase risks of infection.

Department of Health Recommendations.

"At about six months babies are ready to be moved onto a mixed diet.

Try giving solid foods when your baby:

• can sit up

• wants to chew and is putting toys and other objects in their mouth

• reaches and grabs accurately.

• It is normal for babies aged three to five months to begin waking in the night when they have previously slept through. It is not necessarily a sign of hunger

• and starting solids will not make your baby more likely to sleep through the night again.

Weaning is also easier at six months. If your baby seems hungrier at any time before six months, they nay be having a growth spurt, and extra breast or formula milk will be enough to meet their needs.  Ask your health visitor for advice, especially if your baby was premature. Solid foods should never be introduced before four months."

The NHS weaning leaflet states:

"By six months, your baby will be developing the skills to sit up, hold objects and put them to his or her mouth, and will show signs of being interested in the food you and your family are eating.

When to start:
At about six months babies can easily be moved onto a mixed diet. Try giving solid foods when your baby:
1. Can sit up
2. Shows interest in solid food
3. Picks up food and puts it in his or her mouth
4. Wants to chew and may have teeth"

The age at which infants can sit up, (note it does not say “unaided”, baby needs to be able to sit upright in say a highchair or on your lap, to ensure a clear passage of food from mouth to stomach) shows interest in solid food, wants to chew, reaches and grabs accurately and puts in mouth -  varies massively from baby to baby. Just like sitting, crawling and grabbing do.

What about infants who are displaying all the above signs but isn’t the magical six months?  What about those that are six months and not interested or displaying signs?

Readiness for solids & physical development:

What is interesting is as the information within the guidelines above suggests, several studies including those involved in forming the guideline, indicate readiness to eat is about a lot more than just “gut closure”.

Baby develops the skills to not only pick up food, but also bring it to their mouth (as per their “grabbing accurately” point) they need to have lost the tongue thrust reflex for any of that food to make it into the mouth.

Baby then needs to process and chew the food (as per the “wants to chew” point) and finally move food to the back of the mouth and swallow. This is actually a pretty complex set of skills! “External readiness” appears to develop in tandem with gut development – so by the time baby can pick up food and eat it, they are ready to digest.

"Using the available information on the development of infant's immunologic, gastrointestinal and oral motor function, the expert review team concluded that the probable age of readiness for most full term infants to discontinue exclusive breastfeeding and begin complementary foods appears to be near six months or perhaps a little beyond.  They also felt that there is probable convergence of such readiness across the several relevant developmental processes."

The same paper also states:

"Unique needs or feeding behaviours of individual infants may indicate a need for introduction of complementary foods as early as 4 months of age, whereas other infants may not be ready to accept other foods until approximately 8 months of age." (7)

Note this paper suggests some infants may be nearer eight months - a point to remember for later.

"Weaning should not start before neuromuscular coordination has developed sufficiently to allow the infant to eat solids. The majority of infants should not be given solid foods before the age of four months, and a mixed diet should be offered by the age of six months”. (1)

However on a practical basis, practitioners understood this policy to mean that infants should be introduced to solids food at 4 months!  In reality the researchers found most infants were somewhere between 4-8 months when developmentally ready for more.

Ready to help themselves?

What many parents are not aware of is that the Department of Health Infant Feeding Recommendation also states:

"Parents should be advised of the risks associated with weaning before the neuromuscular co-ordination has developed sufficiently to allow the infant to eat solids.  Solid foods should not be offered before four months (COMA) However, if an infant is showing signs of being ready to start solid foods before six months, for example, sitting up, taking an interest in what the rest of the family is eating, picking up, and tasting finger foods then they should be encouraged."

It would logically also seem to make sense that development of the gut would keep up with physical skills - if baby could pick up and consume food developed before gut maturity, this would require an adult to constantly prevent the child accessing food

Going back pre science and guidelines, how would anyone have known to prevent a child eating until the magical six months? From a biological development perspective it also makes little sense that an infant develops sufficiently to be able to self feed if this could then potentially result in increased rate of infection – which without technology may have easily been life threatening eg gastroenteritis. 

If we buy into the concept that baby is often meant to be held close in slings and suchlike, this often makes an interesting time when it comes to food. I chatted to some mums about this recently online:

“I’ve always left D on my hip whilst eating meals, but recently found I had to move my plate further and further away, as he made ever increasing lunges to access the food. He would look at me, chewing intently and making it so obvious it wasn’t the empty bowl, or the spoon he wanted to explore – he wanted the food!! I found myself wondering whether to ignore all my instincts and D’s cues because he was three weeks short of the guideline. In the end he took the matters into his own hands and managed to roll himself over to a snack I had put on the floor for a moment and helped himself to some toast! He chewed and swallowed like a pro, giving huge smiles and was obviously very pleased with himself.”

Another mum commented:

“The guideline is ok providing you can get your toddlers to understand it! At 5 months, R simply helped herself to her sister’s plate of rice cakes! She had a lick and a taste before throwing the food and moving on to something else. The next night however she literally dived head first into her sister’s meal and had a good chew on some broccoli. What has been interesting to watch is how slowly she’s starting solids compared to her puree weaned sister. She has licked, squidged, chewed and spat out and seems to be following a clear pattern of progressing skills."

Of course the guideline can seem to cause as much concern the other way:

"L is my first daughter following two boys and had no interest at solids at seven months (unlike the boys who both dived in with gusto).  I was quite worried and spoke to my Health Visitor who suggested breastfeeding her less often to try and encourage her to eat, but that just resulted in lots of crying and no more eating.  I then borrowed "My Child Won't Eat" from the Analytical Armadillo and after a chat began to see food in a different light.  I felt more relaxed once I stopped preparing special meals that were always just tipped on the floor and instead just shared what the rest of the family were eating, more confident she would eat when she needed to and was ready..  A couple of weeks later she started tasting bits and now has a great diet, her favourites are what I always considered "adult foods" before, spices, herbs, salads and even olives!"

Parent Led

Something else to consider is the all the when to start solids research is based on infants spoon fed purees. An approach which most often follows a parent led decision to start solids.

The parent assesses readiness and takes over the process of moving food to the infants mouth. The food being nearly liquid may be consumed earlier and almost certainly in much larger amounts than infants self feeding. Parents base this decision of readiness, sometimes on false signs such as “increased waking” which may have been due to a developmental spurt or early teething, or baby demanding larger volumes of milk. This leads to some infants receiving solids way before there are external signs of physical readiness and indeed perhaps before the gut closes.  This may also be important in the allergy debate as the amount of a food consumed seems to also be influential (as covered in part 1) 

Self feeding - Baby led

Gill Rapley introduced to the mainstream, something mums have been doing for years “baby led weaning”. This is allowing infants to continue self regulating their own intake by self feeding.  Baby chooses when to start eating, and what to start with - parents simply make a range of foods accessible eg no salt, no sugar and rich in iron, zinc and B vits and baby helps themselves.  You can also find more resources at Gill's site.

Due to increase popularity of this method, more research is becoming available which is positive.

In a study entitled "Is baby-led weaning feasible? When do babies first reach out for and eat finger foods?" Researchers found out of 602 infants, 56% had reached out for food before age 6 months, but 6% were still not reaching for food at age 8 months

Authors concluded:

“Baby-led weaning is probably feasible for a majority of infants, but could lead to nutritional problems for infants who are relatively developmentally delayed.” (due to them not reaching out for finger foods at 8 months)" (8)

But remember the point from the study earlier that found some infants could be eight months before developmentally ready? (7)

This author assumes it may lead to nutritional problems - but if indeed the external skills and gut do indeed develop in tandem, not reaching could indicate an open gut and potentially increase infection risks?  If nutritional status is compromised, would supplements make for a better choice? Furthermore as there are studies suggesting breastmilk is nutritionally adequate to meet the needs of some infants until closer to nine months - could it also be possible that those infants not reaching at 8 months are at an earlier stage of development and do not yet need complimentary nutrition?  This should surely all be explored...

A 2010 study found:

"A controlling maternal feeding style has been shown to have a negative impact on child eating style and weight in children over the age of 12 months. Seven hundred and two mothers with an infant aged 6-12 months provided information regarding weaning approach alongside completing the Child Feeding Questionnaire. Mothers following a baby-led feeding style reported significantly lower levels of restriction, pressure to eat, monitoring and concern over child weight compared to mothers following a standard weaning response. No association was seen between weaning style and infant weight or perceived size. A baby-led weaning style was associated with a maternal feeding style which is low in control. This could potentially have a positive impact upon later child weight and eating style." (9)

Lastly in 2011 a descriptive study investigating the use and nature of baby-led weaning reported:

"Six hundred and fifty five mothers with a child between 6 months and 12 months of age provided information about timing of weaning onset, use of spoon-feeding and purées, and experiences of weaning and meal times. Those participants who used a BLW method reported little use of spoon-feeding and purées. BLW was associated with greater participation in meal times and exposure to family foods. Levels of anxiety about weaning and feeding were lower in mothers who adopted a BLW approach." (10)

Mums also often note the difference in amount consumed, Those self feeding gradually increase amounts as skills develop - whereas those spoon fed puree are suceptible to consume larger volumes more quickly (displaing breastmilk) and are more likely to suffer constipation.  This may be because mum can feed baby much quicker than baby can feed themselves, meaning by the time baby realises they are full they have potentially already overeaten.

Gill Rapley conducted some small scale research and found:

“The babies who participated in the research were allowed to begin at four months. But they were not able to feed themselves before six months. Some of the younger babies picked food up and took it to their mouths; some even chewed it, but none swallowed it. Their own development decided for them when the time was right. Part of the reason for this study was to show (based on a theory of self-feeding) that babies are not ready for solid food before six months. It seems that we have spent all these years working out that six months is the right age and babies have known it all along!”

I have to confess that my own experiences from supporting mothers have seen some infants eat (evidence in nappy!) before six months. However all have also been advanced in other areas – perhaps crawling or bum shuffling, grabbing with accuracy and comparable to six month olds developmentally.

Perhaps it’s not at all about nutrition.

Despite several papers suggesting infants are around six months before being developmentally ready to eat solids, the study showed around half had reached for food by this age. Therefore perhaps the squidging, exploring, mushing, bashing and licking before food becomes more important nutritionally, is all part of the same developmental continuum?

"Messy play stimulates the senses. The tactile experience gained helps little ones experience a variety of textures. Babies and toddlers are developing eye hand coordination and fine motor skills. What looks like a mess on the surface is truly a learning experience for your child."

Patricia Hughes (Bachelor’s Degree in Elementary Education)

Think of just what a sensorial experience food is; hot, cold, hard, squidgy, rough, smooth. Think of the range of smells, tastes - it's a sensory party!

What is introduced may also influence outcome...

As discussed in this blog post, what we introduce is also significant. Whilst breastmilk alone is suitable until six months, this doesn’t therefore mean a few bits of fruit and veg are “extras” - solids displace breastmilk.  What's more there is also evidence that solids reduces the bioavailability of iron from breastmilk - so if we are shifting from exclusive feeding, it makes sense to ensure the foods replacing the breastmilk are nutritious, calorific and aren’t going to increase risks of deficiencies such as iron.

There is no clear rationale for limiting diet to veg or fruits – if the gut has closed (which we are waiting for anyway before introducing solids) the theory of food proteins passing into the blood stream and triggering allergy wouldn’t appear to hold.

Do I advocate early weaning – absolutely not I advocate the 6 month guideline. Do I think that alongside keeping this guideline in mind we should also use an element of instinct and common sense; absolutely. If mums don’t try and second guess when baby is ready for solids, but simply waits and watches her infant. A plastic spoon and bowl whilst others are eating will no longer pacify – instead he will attempt to get food and watch you intently frantically chewing along, many become very vocal in their frustration of not getting food if they want it.  If weaning is to be puree on a spoon, waiting until six months would appear the most sensible approach - followed by feeding slowly and carefully watching baby's cues, with plenty of time for baby to enjoy the sensorial element via touch.

Dr Jack Newman states:

"The best time to start solids is when the baby is showing interest in starting. Some babies will become very interested in the food on their parents’ plates as early as four months of age. By five or six months of age, most babies will be reaching and trying to grab food that parents have on their plates. When the baby is starting to reach for food, grabs it and tries to put it into his mouth, this seems a reasonable time to start letting him eat. There really is no reason to start on a specific date (four months, or six months). Go by the baby’s cues"

Summary:

• The curent recommendation is to introduce solids around 6 months. (WHO, Department of Health)
• There are no reasons to routinely introduce solids earlier than six months, and potentially health implications of doing so. (WHO, Department of Health, SACN)
• Solids should not be introduced before four months (SACN)
• If an infant is showing signs of being ready to start solid foods after four months and before six months, for example, sitting up, taking an interest in what the rest of the family is eating, picking up, and tasting finger foods then they should be encouraged. (Department of Health)
• Readiness varies depending on the infant and is typically between 4-8 months - however for parents who have decided to wean using a puree it may be sensible to wait until 6 months to ensure they do not overfeed baby and displace essential nutrients in breastmilk (7)
• Susceptible infants may need iron supplementation earlier, however status should be confirmed as there may be risks to supplementing an infant with normal levels. (WHO, Department of Health, SACN)
• As solid food influences iron absorption from breastmilk, first foods offered when baby is showing signs of readiness should be nutritious, high in easy to absorb iron and other essential vitamins and minerals. (COMA, SACN)

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Formula or Solids? If baby isn't gaining weight as expected, appears ever hungry but isn't showing signs of readiness, plus what about formula fed infants? coming up in part 3!

1.  COMA 199423. 
2.  Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database of Systematic Reviews 2002, Issue 1.
3. Arch Dis Child 2009;94:148-150
4. Promotion of Breastfeeding Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus.  JAMA. 2001 Jan 24-31;285(4):413-20
5. Dewey et al 1998 
6. Mercer, 2002
7. Developmental Readiness of Normal Full Term Infants to Progress from Exclusive Breastfeeding to the Introduction of Complementary Foods" Naylor and Morrow, 2001

8. Matern Child Nutr. 2011 Jan

9. Maternal Control of Child Feeding During the Weaning Period: Differences Between Mothers Following a Baby-led or Standard Weaning Approach. Matern Child Health J. 2010 Sep 10.

10. A descriptive study investigating the use and nature of baby-led weaning in a UK sample of mothers. Matern Child Nutr. 2011 Jan;7(1):34-47