Bonding Without Boobs - Guest Blog

I'm SUPER excited to share this guest entry with you from the fab Adam Glennon from Don't Drink and Sling sharing his take on "dadding" and exclusively breastfed baby:

While preparing for the birth of our son, the wife and I thought we had it covered. From hypnobirthing to half inflated birth pools, it was all under control. After the birth, Claire was gonna make cakes, drink sparkling wine and sleep for eight hours a night while our calm bundle of joy slept “right through.” Ah, to dream!

One minor issue we forgot to discuss, was . . . me. What was my job once he arrived? We planned the pregnancy, prepared for birth but we never discussed what it would be like for me. What type of dad was I going to be? What is a dad's role?

Leading up to the birth was easy. Feed the wife, scratch her back, and say nice things. Assist with difficult jobs like putting socks on and making cheese on toast, in that special way only I seem to know how. I also had a defined role during the labour; the knowledge gained during hypnobirthing gave me responsibility, meaning I was much more than a bystander. I felt useful because I was fundamental in assisting Claire and I hope I played my part successfully. I even caught the little purple, slimy alien when he popped out into the water like a torpedo from a submarine. That was a sight I’ll never forget. Passing Arlo over to Claire’s arms was a life enhancing experience.

Once the medical bits and bobs were sorted, Claire relaxed with Arlo, skin-to-skin and after a while it was my turn. Finally, I was able to experience the first snippets of physical entanglement with my son. Amazing. Beautiful. Not a crying moment, I was too happy to cry. You see, I’ve never cried through happiness. I’m not wired that way. I didn’t cry at our wedding and I didn’t cry on this night either. Maybe there's something wrong with me? I remember looking across at Claire and thinking, I wish I could cry now, I bet that’d make her happy. Then, and it was early morning at this point and I was knackered, I had a surprising thought, “What do I do now?”

He was too small to play Man Hunt and too young to drink wine. I pushed the thoughts away, we slept for a while and I woke three hours later feeling refreshed. My step-daughter, Becca, emerged from her pit and got in on the skin-to-skin action too and they shared some time together while my man duties began.

Clean the room, empty the pool and cook nice food. Crack open a bottle of sparkly and greet the few guests who came and went. It was a lovely, relaxed couple of days. Except Claire was struggling to feed Arlo. He couldn’t latch on and Claire’s breasts were becoming engorged. She was in pain, he was distressed and I felt completely useless. Eventually, when we were desperately contemplating buying formula, it happened. He fed and that boy has hardly been off the  boob since!

However, doubt reared its ugly head again as I watched Claire struggle with this natural birthright.

How do I emulate a feeling that comes so naturally to her? How do I bond without boobs? I felt like an outsider looking in on something beautiful. Like George in It’s A Wonderful Life.

I changed nappies, wore Arlo in a sling, tried to comfort him during the night but the truth is, the only comfort he required was from Claire’s  breast and that put me in a back-seat position. It’s one of those overlooked issues I think. A bottle fed baby gets passed around like a spliff at a party; everyone wants a bit. Breastfed babies are like those spoilt kids who make you sit and wait on the floor while they have extra turns on their Sega Mega Drive because, “It’s my game!” Nobs. You know who you are.

In my head, not being able to feed him seemed to take a bonding opportunity away from me. Was I being selfish? Immature? A bit of a dick? Jealous maybe? The problem was I wasn't educated in the ways of breastfeeding. I'd never been around it or considered that it would effect our lives so significantly. And it did. Claire was finishing her degree that year and when Arlo was six months old, he was with me for, roughly, four hours a day, three to four times per week.

Claire expressed, which wasn’t fun for her, but it provided Arlo with just enough liquid gold until she came home. So there I was, giving him a bottle of expressed milk like I'd wanted to and I realised,  it wasn't comfort to him, it was just fuel . Once he was finished suckling, he'd discard the bottle like it was a toy he'd gotten bored of. I couldn't use the bottle in the same way Claire used the boobs and I had to find my own way.

This is where sling wearing really worked for me. And, being the master of distraction, I found myself doing things I never expected. Funny faces and fart noises, no problem. But what calmed him the most, was singing. I was self-conscious at first and what I mean by that is that I felt like a bellend, but I've smashed it now. I make up silly songs about poo, flowers, the weather, willies, you name it, I've got a lyric. I can sing Five Little Ducks in a variety of accents now, I even added a new verse with monkeys. As he crawled I could chase him from room to room, over and over and over again until my shredded knees could take no more. Now he’s a toddler weighing around 20st of pure chub, I get a free workout while throwing him in the air and dancing around the kitchen to Rage Against the Machine (a band he likes for reasons unexplained) while making tea.

 

We have certain games we play outside and around the house that are just for us. I know his expressions. I know when to calm it down and when he needs a snack. I’ve learnt this and more through trial and error. He forgives me quickly when I make a mistake the same way I forgive him when he smashes a book or wooden toy into my face when I least expect it for the millionth time.

He’s my son and I’m his dad and one day when he’s bigger I’m gonna tell him all about those feelings so that one day, if he ever becomes a dad himself, he’ll know it’s okay to be vulnerable. He can cry through happiness if he wants to and he can bond without boobs. I might leave out the toy smashing in the face bit though. Don't wanna ruin the experience for him. Little punk!

Fed is Best? Infant Dehydration & the Consequences of Ignorance

Note: This is long and I apologise in advance - I know we all love 10 bullet point, read and run style entries ;) however I think it's a really important subject and I hope it helps to protect even one baby from what this dyad experienced.

As an International Board Certified Lactation Consultant (IBCLC), the first rule of practice is to always feed the baby.  Always, always, always, without exception.

Despite this, some feel IBCLC is synonymous with "hardcore breastfeeding fanatic"; someone who wants your baby at the breast at any cost, because formula is poison and should never be used by anyone trying to breastfeed. As I've pointed out numerous times, and demonstrate daily in practice this simply isn't true- at least not for me or the practitioners I know.


Recently some have suggested that if there's a chance baby could become dehydrated, it's safer to bottle-feed; that more hospitals implementing the UNICEF Baby Friendly Initiative (BFI) standards, could put babies at increased risk of insufficient milk intake.

Around the same time, I  also read a gut-wrenching blog post by Dr Christie del Castillo-Hegyi, MD, describing her journey when her newborn suffered hypernatraemic dehydration.  This is a severe condition when baby's serum sodium level becomes elevated, sometimes to dangerous levels which can result in long-term consequences and even death.

I contacted Christie who kindly agreed to let me use her story for educational purposes.  I thought we could start by looking at their journey and the support they received - before exploring typical weight patterns in the early days, rates of dehydration and how likely it is that baby will suffer dehydration.  We also need to know how to identify families at risk, what tools are available and how to resolve problems as they arise; highlighting the significance of infant feeding education to all healthcare professionals involved in the care of a young baby.

Let's take a read:

"My son was born 8 pounds and 11 ounces after a healthy pregnancy and normal uneventful vaginal delivery. He was placed directly on my chest and was nursed immediately. He was nursed on demand for 20-30 minutes every 3 hours. Each day of our stay in the hospital, he was seen by the pediatrician as well as the lactation consultant who noted that he had a perfect latch. He produced the expected number of wet and dirty diapers. He was noted to be jaundiced by the second day of life and had a transcutaneous bilirubin of 8.9. We were discharged at 48 hours at 5% weight loss with next-day follow-up."

Normal uneventful delivery, baby was a healthy weight and fed immediately after birth before a pretty typical cue feeding pattern followed.  All sounds pretty standard at this stage, but newborns aren't born ravenously hungry as they've been nourished continuously via the placenta. The feed initiated typically within an hour or so after birth is primarily to deliver antibodies, immune agents or "baby's first vaccine" as many call it via colostrum - as this prompts rapid closure of the open junctions in baby's gut.  Many then take a longish sleep to recover from being born, before starting to search or "root" for food in earnest.  In practice I find if baby doesn't get enough during day two, boy will they let you know day 2 night...

Nappies: if we consider on the day they're born, newborns typically only need around 5-7ml per feed, producing the expected number doesn't require huge amounts in terms of intake.  How wet or soiled a nappy is can be tricky because parents may have no frame of reference as to what to expect in terms of output.

The amount baby needs increases rapidly after the first day, and so closely examining output at this time becomes far more informative - I often ask parents to send me photographs (which makes for an interesting camera roll alongside damaged nipples ;)) because I've known "3 soiled nappies" to be in effect 3 wet bottom burps.

Jaundice is noted which again doesn't and shouldn't really cause much concern at this stage:

"Approximately 70% of term newborns present with jaundice in the first week of life, and in most cases this jaundice it is a transient and benign phenomenon." here.

Christie's son had a level of 8.9 at this stage, which for those in the UK is 152µmol/L and below treatment levels (> 237µmol/L @ 42 hours) according to NICE.

Weight check: You would expect a loss at this stage, with the lowest point typically being around day 3 or 4 before regain starts.  5% is nothing that would typically ring any alarm bells and they were having a follow up the next day.

 "We were told by the lactation consultant before discharge that he would be hungry and we were instructed to just keep putting him on the breast."

I don't know whether this was an IBCLC as unfortunately the title "lactation consultant" isn't protected - often people (including hospitals and other healthcare professionals) use it to refer to those who aren't IBCLC certified - heck I've known parents call their keen friend "my lactation specialist"; however what is clear is that there was a missed opportunity in terms of ensuring parents were familiar with how to identify whether baby is taking enough versus signs that may suggest additional milk is needed.  Whether the lactation consultant intended to infer what she did or whether this was a misunderstanding in communication, it's concerning.

"Upon getting home, he became fussy and I nursed him longer and longer into the night. He cried even after nursing and latched back on immediately. He did not sleep."

This is the first red flag something isn't quite right - but how are parents to know this if they're not told?  On the contrary I find a lot of information talks about very frequent feeding in the first few days, how newborns like to be held and it's normal if they feed all. the. time.  

I recognise what people are trying to highlight is that, particularly as a newborn, a breastfed baby may want to feed more frequently than the 3-4 hours often quoted based on formula fed infants; they may not have a set pattern and may take a few closely spaced feeds before settling for a nap.  As more babies are formula fed than breastfed, the behaviours of formula fed babies are often held as the norm to which those breastfeeding are supposed to conform  - despite research consistently demonstrating this isn't the case (2).

However we also need to clarify that doesn't mean constantly, or not settling in-between, or crying and feeding all night - this tells us something is wrong.  Be that inadequate milk intake, illness or as per one baby recently, an unidentified dislocated shoulder from birth - it's not typical.  We need to be able to identify normal versus not to know when to seek help.

"By the next morning, he stopped crying and was quiet."

This is the second red flag and it's extremely concerning as it suggests baby may have exhausted his energy supply signalling for food, and so is "shutting down" to protect his vital systems.  As babies start to become "dry" and after a long period of crying, the sound changes and becomes hoarse until it resembles the noise made by a pterodactyl - anyone familiar with the sound hears it long before they've even clapped eyes on the baby in question.  If baby continues not to receive milk he will gradually become sleepier and more lethargic until he struggles to rouse.

"We saw our pediatrician at around 68 hours of life (end of day 3).

Despite producing the expected number of wet and dirty diapers, he had lost 1 pound 5 ounces, about 15% of his birth weight. At the time, we were not aware of and were not told the percentage lost, and having been up all night long trying to feed a hungry baby, we were too exhausted to figure out that this was an incredible amount of weight loss. He was jaundiced but no bilirubin was checked. Our pediatrician told us that we had the option of either feeding formula or waiting for my milk to come in at day 4 or 5 of life."

In the UK anyone who weighs your baby at this stage will calculate the percentage loss for you and 15% is an incredible amount of weight to lose. We know baby had lost 5% at the end of day 2 and so this equates to a further 10% bodyweight loss in 24 hours!  Nappy output would be reduced with this sort of loss (it can't come out if it hasn't gone in), however as discussed above it's not uncommon for confusion to occur even amongst health professionals.

It's also important to understand that this was a critical point in terms of intervention.  Some key things I would expect from a doctor running checks on a newborn at this stage:

1. Ask the parents how baby had been since discharge, including his feeding and sleeping patterns.
2. Recognise they were presented with a dehydrating infant, who would by now have dry lips and the inside of his mouth would feel the same.  He would be quiet, listless and more difficult to rouse. 
3. Recognise this was a huge weight loss for a newborn.  To put this in perspective it's like an adult weighing 10 stone one day and 8 1/2 the next.  
4. To check bilirubin levels following excessive weigh loss and jaundice
5. Admit the baby to hospital immediately

I was stunned to read that waiting until milk comes in was presented as a viable option, in fact I read it twice to ensure I had understood correctly.

Many UK hospitals have now implemented breastfeeding management plans, and such a drastic weight loss would trigger NHS management plan 3:

Baby who has lost >12.5 – 15% of birth weight on day 3, or no/minimal improvement following management plans 1 and 2

• Refer immediately to paediatric staff – this is mandatory (baby may be admitted to S.C.B.U) – if baby is at home – baby will have to be admitted to hospital.
• Blood tests for fbc, U&E’s, SBR, septic screen and urine microscopy.
• CRP and blood cultures if clinically indicated.
• Breastfeeding management as per plans 1 and 2. Supplement with formula via cup only if breast feeds are ineffective and EBM volumes poor, if EBM volumes are good give EBM via cup. Top-ups may be instructed by paediatric staff for all feeds.
• Ensure this baby is receiving adequate volumes of milk intake for age.
• Frequent breastfeeding and use of electric pump to further increase milk supply. As the breastmilk supply increases; decrease the volume of artificial milk.
• May require naso gastric feeds or I.V fluids, but continue frequent breastfeeds and expressing if baby in SCBU.
• Observe urine and stool frequency.
• Re-weigh in 24 hours, then twice weekly weights, if weight has increased after 24 hours, until clear trend towards birth weight is demonstrated.
• Ensure that you are aware of any issues specific to the individual mother and have considered any potential impact on that individual situation. 

This is a far cry from go home and wait for milk isn't it?

The problem when young babies don't consume enough milk, is they can easily fall into a cycle of: signalling, trying to feed, running out of energy and falling back asleep again - rinse and repeat.  As this continues and the deficit between what baby needs and what they're taking increases, baby becomes more disorganised and less effective at the breast,  falling asleep more and more quickly. Once energy levels  fall sufficiently that baby is unable to signal and initiate feeding - things can quickly become dangerous.

"Wanting badly to succeed in breastfeeding him, we went another day unsuccessfully breastfeeding and went to a lactation consultant the next day who weighed his feeding and discovered that he was getting absolutely no milk. When I pumped and manually expressed, I realized I produced nothing."

"I imagined the four days of torture he experienced and how 2 days of near-continuous breastfeeding encouraged by breastfeeding manuals was a sign of this. We fed him formula after that visit and he finally fell asleep.

It's good the lactation consultant thought to test weigh the baby, but again I'm confused as to why none of the healthcare professionals supporting this family, appear to recognise or respond to the urgency of this situation, seemingly not picking up on any of the red flags or acting to trigger safeguarding protocols?

By this stage it isn't as easy as just "feeding the baby", as after such rapid and excessive loss a baby is very likely to be suffering hypernatraemic dehydration - meaning simply giving milk now have disastrous consequences.

The Royal Children's Hospital Melbourne state:

"Treatment can be complicated and potentially dangerous. Seek expert advice early. Too rapid reduction of the sodium in hypernatraemia can cause cerebral oedema, convulsions and permanent brain injury.  Close monitoring is critical."

As you can see on their page, rehydrating safely is a careful balance of delivering glucose and electrolytes at the correct level; this balance of fluids may need adjusting frequently to ensure rehydration isn't too fast or slow.

"Three hours later, we found him unresponsive. We forced milk into his mouth, which made him more alert, but then he seized. We rushed him to the emergency room. He had a barely normal glucose (50 mg/dL), a severe form of dehydration called hypernatremia (157 mEq/L) and severe jaundice (bilirubin 24 mg/dL). We were reassured that he would be fine, but having done newborn brain injury research, knowing how little time it takes for brain cells to die due to hypoglycemia and severe dehydration, I did not believe it, although I hoped it. "

I can't even imagine the panic and trauma of such a situation; it must be utterly horrifying, terrifying to find your baby unresponsive before seizing.  157mEq/L is a level most of us in the UK will never see in practice and the potential implications of such high levels are well documented.  The Royal Children's Hospital Melbourne state:

"In children with acute hypernatremia, mortality rates are as high as 20%. 

Neurologic complications related to hypernatremia occur in 15% of patients. The neurologic sequelae consist of intellectual deficits, seizure disorders, and spastic plegias. In cases of chronic hypernatremia in children, the mortality rate is 10%. 

Complications
Although seizures can occur because of hypernatremia per se, this is rare. They usually occur during the treatment of hypernatremia because of a rapid decline in serum sodium levels. 

Therefore, slowly correcting hypernatremia is important. 

Other complications include the following:

• Mental retardation
• Intracranial hemorrhage
• Intracerebral calcification
• Cerebral infarction
• Cerebral edema, especially during treatment
• Hypocalcemia
• Hyperglycemia"

"At 3 years and 8 months, our son was diagnosed with autism spectrum disorder with severe language impairment. He has also been diagnosed with ADHD, sensory processing disorder, low IQ, fine and gross motor delays and a seizure disorder associated with injury to the language area of the brain." 

This is where we can see the impact of a formula feeding culture really biting us on the behind.  Were this mum and baby harmed because they tried to breastfeed, or because they were failed by a system where they seemingly fell through the cracks of  inadequate knowledge and a lack appropriate protocols?   When it comes to paediatric health, does any other field of medicine function this way?

Term, healthy babies will try and alert their caregiver to the fact they're not receiving enough milk long before the situation becomes a dangerous one.

Normal weight loss:
According to current guidelines, a typical newborn feeding well can be expected to lose up to 5-7% of their birth-weight in the first 2-4 days.  It used to be widely accepted up to 10% was acceptable, but this was based on schedule feeding, routine separation of mothers and babies and so on.  As further research was completed it suggested a good amount of babies at 10% were showing early indicators of mild dehydration and overall, more went on to experience further problems than babies who lost smaller amounts.

However it gets much more complicated than this for a number of reasons.

The 5-7% is based on studies exploring mean weight loss, which may not allow for standard deviation (1,2). We also know some babies lose more weight or for longer than typical and yet are perfectly healthy (3). We need to tease apart the details of an individual dyad's situation, rather than making assumptions; factoring in the birth and what has taken place since. As one example, extremely large amounts of IV fluids may be passed by baby as urine after birth (5,6,7), leading to excessively wet nappies and a larger than typical loss that does not mean more food is needed. 

We then need to know what to do with that information.  Is mum not producing or is it (as is much more common) that baby isn't transferring enough?  Whether it's the former or the latter, the next question is why? This means people need to be appropriately skilled to examine the big picture and identify those who need additional help, and be able to provide or direct them to someone who can help resolve the issue.

Tools also exist that practitioners can use to monitor at risk babies, for example nomograms that show hour-by-hour percentiles of weight loss have recently been developed. This compares the data entered to that recorded for over 100,000 breastfeeding newborns along with subsequent outcome, to quickly identify those on a trajectory for greater weight loss and related morbidities- and so unnecessary intervention isn't forced upon a healthy dyad.  You can see an example in practice here.

Official Guidelines:
The American Academy of Pediatrics states:

“Weight loss in the infant of greater than 7% from birth weight indicates possible breastfeeding problems and requires more intensive evaluation of breastfeeding and possible intervention to correct problems and improve milk production and transfer.”

The International Lactation Consultant Association and the Registered Nurses' Association of Ontario specify that a loss of more than 7% of birth weight, continued loss after day 3, or failure to regain birth weight within a minimum number of days (i.e., 10 days or 2–3 weeks, respectively) are signs of ineffective breastfeeding.

The Academy of Breastfeeding Medicine advises "Possible indications for supplementation in term, healthy infants [include] weight loss of 8% to 10% accompanied by delayed lactogenesis (day 5 or later).” (1)

Rates of Hypernatraemic Dehydration in the UK
A 2013 study analysing almost 1,000,000 births in the UK and Ireland found just 62 cases of severe neonatal hypernatraemia, equivalent to just seven in every 100,000 births and an individual risk of 0.007%.

No baby died, had seizures or coma or was treated with dialysis or a central line. At discharge, babies had regained 11% of initial birth weight after a median admission of 5 (range 2-14) days and none had long-term damage. (3)

NHS guidance also notes that excessive weight loss is a a late indicator of poor breastfeeding - we need to identify and address these cases before this point.  A number of factors are shown to increase risks, whilst technologies now exist to closely monitor those presenting with red flags (2,8,9,10) - all relevant health professionals should fully understand the process.  There needs to be protocols that trigger action from appropriately qualified and experienced specialists, including identifying babies who need urgent medical care.

If we explore the 62 babies in the above study:

• Infants presented at median day 6 (range 2-17) with median weight loss of 19.5% 
• 58 presented with weight loss ≥15%
• 25 babies had not stooled in the 24 h prior to admission

The answer isn't to short change women by telling them how they feed their baby doesn't matter - outpourings from emotional mothers all over the world clearly demonstrates that's simply not the case.  You can't quash the primal, instinctive drive a mother may have to nurture her young because of the inadequacies of those providing her care.  

What's more as numerous researchers highlight, there are risks to not receiving breastmilk and to early supplementation with formula (2, 11); so it's as important to prevent unnecessary intervention when a mum wants to exclusively breastfeed, as it is to ensure those who need it receive it.  It's our job to support families to meet their feeding goals and ensure their babies thrive and meet their optimal genetic potential.

In the context of not having any food, then of course "fed is best" - the risks of formula are miniscule compared to starvation.  However the wider implication of this statement is that as long as baby is fed, it doesn't matter what it is - which isn't the same thing at all is it?

1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3091615/
2. http://digitalcommons.uri.edu/cgi/viewcontent.cgi?article=1009&context=nursing_facpubs
3. https://www.ucsf.edu/news/2014/12/121546/study-shows-some-newborns-lose-weight-much-faster-previously-recognized
4. http://www.ncbi.nlm.nih.gov/pubmed/23512226
5. http://internationalbreastfeedingjournal.biomedcentral.com/articles/10.1186/1746-4358-6-9
6. http://www.ncbi.nlm.nih.gov/pubmed/22834720
7. http://pediatrics.aappublications.org/content/127/1/e171
8. http://pediatrics.aappublications.org/content/112/3/607.short
9. http://pediatrics.aappublications.org/content/135/1/e16
10. http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0100-879X2006000400015
11. http://ajcn.nutrition.org/content/98/2/521S.full

Nomograms:

http://pediatrics.aappublications.org/content/135/1/e16

https://www.ncbi.nlm.nih.gov/pubmed/26565592

Are You A Breastfeeding Bully? Stop The Bressure! TAKE 2

Although this was written late 2015, I only had the joy of it appearing on my timeline today.   The entry at "fabworkingmomlife" starts ok:

"Breastfeeding can be a beautiful, wonderful thing. But it isn't for everyone, and that perfectly fine. Some women choose to breastfeed while others choose not to, and those are simply two ways to feed a baby. Unfortunately, there are people who make women feel guilty for the choices they make. Well I'm here to say let’s put an end to the bullying and stop the bressure.  Some people might not even realize they are being breastfeeding bullies, so I have put together this little quiz to help identify what makes a bully.

I concur, well for the most part - personally I think it  would be fairer to give a nod to the pumpers, the mix-feeders rather than conclude there are only two ways to feed a baby. Furthermore it's probably not massively accurate to infer they''re two equal choices, but whohooo a quiz!

I became confused at the last  part though - to me a "breastfeeding bully" means you bully mums who breastfeed.  I therefore edited the quiz a tad :)

Are You a Breastfeeding Bully?

Yeah, I added the pic for interest...

• Do you judge other moms for not breastfeeding? (Don’t be so judgy!)
• Do you confront moms who are bottle feeding breastfeeding their child and try to tell them that bottlefeeding is better more convenient and acceptable in public? (Ever heard of MYOB?)
• Do you call  formula breastfeeding “poison” or “garbage” "gross" or say "ew"? Do you think mums should express or wear a cover? (Oh, so you never eat food from the supermarket? If you don’t grow all your food and say this, you are being a hypocrite Hey have you ever tried to feed a baby under a cover?)
• Do you stop being friends with someone if they formula feed breastfeed their child past the age you consider acceptable? (Some friend you are. She is better off not being friends with you anyway.)
• Do you think recognise that if you had an easy a hard time breastfeeding, then it should be easy for everyone else the women you see breastfeeding might have faced problems too? (Seriously, everyone’s different and have different challenges.)
• Do you give others dirty looks while you’re whilst they're breastfeeding your their child publicly? (I’ve seen it.and think "that’s not feeding your baby, that’s making a statement.")

If you answer yes to two one or more of that list, you’re a breastfeeding bully. Take a good look at yourself in the mirror and tell yourself to stop the bressure. (And also learn to mind your own business, because you don’t know someone’s situation and shouldn't try to push your own beliefs on them.)There is a difference between lactivist and being kind and being a bully. A breastfeeding advocate kind person raises awareness and supports mothers. Bullies just judge and shame others. It is no secret that I am a supporter of breastfeeding and yet I am struggling with it and having to supplement with formula. It isn't for everyone – not everyone can breastfeed, and not everyone wants to breastfeed – and that is OK! It doesn't mean you love your child any less and it doesn't mean your child will suffer for it (although unless she has a crystal ball, I'm not entirely sure she can predict whether that particular baby will suffer as a result of not receiving human milk?). Your baby will thrive and grow into a successful adult not because of how you fed him or her, but depending on how you parented and raised him or her.

I'd also like to add:

Similarly we need to recognise mothers are shamed for breastfeeding their babies and yet not being "modest" enough and judged for feeding longer than the first few weeks or months. We need to acknowledge mothers can feel unsupported and self conscious breastfeeding in public, concerned someone may embarrass them for feeding their child. We need to recognise the fundamental problem goes far deeper than how a mother feeds her baby, it stems from a society that encourages social competition between women based mainly on aesthetics; who is the most beautiful, desirable, sexy, nipped, tucked, lifted and waxed? Providing of course a woman is revealing her body for advertising or seduction or to appeal - it's a different story if she chooses to use her body to feed her baby, then we have this almost 1950's style mock coyness about a glimpse of flesh.  It's all about control, and we need to look further than other mothers.

Infant Reflux & Nice Guidance - is Current Practice in the UK, Really Best Practice?

I've observed a big increase in the past 15 years in the diagnosis of reflux.  The number of babies prescribed reflux medication, including proton pump inhibitors (PPI) such as omeprazole has similarly skyrocketed.  The most recent data I could find was to 2004 and diagnosis rates have only continued to climb:

" In the 6 years from 1999 to 2004, there was a >7-fold increase in PPI prescription. One of the PPIs, available in a child-friendly liquid formulation, saw a 16-fold increase in use during that 6-year period." (1)

I wrote about reflux several years ago here and questioned how much profitability came into play,  but even I was a tad shocked when a commentary in the Journal of Paediatrics highlighted the following:

"The rise of prescriptions owes a lot to advertising, specifically to use of the term “acid reflux.” Before the mid-1990s, this term was hardly ever used in clinical practice; the medical terms were and are “GER” and “GERD.” In the mid-1990s, rules around direct-to-consumer (DTC) advertising were relaxed in the United States, and expenditures on broadcast advertising for drugs began to ramp up by multiples.23 Around this time, marketers for pharmaceutical companies began to promote and popularize the term “acid reflux” in the increasing advertising blitz for acid-suppressing drugs, both PPIs and H2RAs. “Acid reflux” became embedded in the popular lexicon thanks to the strategy devised by those “not so Mad Men.” The reasoning was simple: if reflux is possibly present—whether physiologic, acid, or non-acid—and you choose to call it acid reflux, it naturally follows that it requires an acid-reducing drug! This manages to blur the lines between normality and pathologies and, with an uncomplicated message to the marketplace, bypass the need for the subtleties of clinical diagnosis. In 2005, PPI sales grossed approximately $13 billion in the United States alone, and the drug on which the most DTC advertising was spent was a PPI."

This increase has brought with it more questions from parents, so I decided to explore the evidence and rationale versus any long-term risks.  If a baby is suffering damage of the oesophagus or is at risk of aspirating acid, the risks of medication may be minor in comparison.  If not, the risks may outweigh benefits.

The first surprise I got, and what I  want to explore in this blog, was when opening the NICE guidance, updated Feb 2015:

"1.2 Initial management of GOR and GORD
1.2.1 Do not use positional management to treat GOR in sleeping infants. In line with NHS advice, infants should be placed on their back when sleeping.
1.2.2 "In breast-fed infants with frequent regurgitation associated with marked distress, ensure that a person with appropriate expertise and training carries out a breastfeeding assessment."

The very first suggestion NICE make for reflux is that someone fully evaluates a feed. That one slipped under

the radar didn't it?

Anyway, hands up if that happened for you?

Anyone else wondering what constitutes a "person with appropriate expertise and training"?

I decided to ask parents via a poll how often their healthcare providers had indeed, fully evaluated breastfeeding as a first course of action.

342 people responded

The results won't be much of a surprise to many:

First the "No" votes: 318

Some comments left on Facebook included:

and

Next the "YES" votes:27

And this is where it gets more complicated in terms of "appropriate expertise and training":

11 yes votes were placed anonymously and 17 were named.  From the 17 identified respondents I asked for more information (at the mercy of Facebook deciding whether to hide your message in some never to be found folder!)  They are as follows:

• Had clicked yes but meant no 

• GP followed the guidelines well, suggesting she attend a local feeding group for an assessment to rule that out as a potential cause of reflux She said:  "We went on to have posterior tongue tie diagnosed which was revised and reflux symptoms reduced dramatically"

• One replied her paediatrician had referred then to the infant feeding team whilst still in hospital, a tie was treated but the problems didn't resolve.  Further assessment however suggests baby still has a tongue tie..

• Health visitor (HV) had undertaken the assessment and found no tongue tie present - training undertaken by HV: 3 day Unicef course. No IBCLC or equivalent or similar, no training in diagnosing ties.  Baby medicated with ranitidine for 6 months

• GP checked if a feed had been observed and it had twice, both on children's ward and again by a midwife in hospital who both said it was fine. However independently of this her health visitor asked a peer supporter to check for a tongue tie, one was found and treated which resolved symptoms. 

• Had a feeding assessment, tongue tie discovered and treated which resolved the problem, but from her own digging not due to suggestion from a health professional.

• (names removed for privacy): After crying down the phone at my HV, she sent a community nursery nurse over to see me stating she was her 'breastfeeding expert'. She checked baby for tongue/lip tie and then watched me through one feed and said immediately that my daughter had silent reflux. It could be an indication of something else bothering my child. She told me what to say to my GP and by that evening, we had a prescription for ranitidine. The nursery nurse called me after a couple of days to check things had improved and came back a week later to weigh my daughter and check feeding positions for reflux etc. My daughter had lost a lot of weight and was still unsettled and she suggested at that point that with the mucus nappies, it was highly likely there was a milk allergy. Again she told me exactly how to deal with my GP.  

• "I went to my local children's centre as I was having difficulties. They suggested a specialist breastfeeding clinic (run by the children's centre) where a lady watched me breastfeed. She couldn't see anything wrong with the latch, thought perhaps baby couldn't cope with speed of flow, but suggested some different techniques and if they didn't work to see my GP."

• "It was a health trainer we saw and was referred by our health visitor. Re the reflux my daughter has a mild posterior tongue tie but it was not treated as it did not impact on feeding."

• " I went to a breast feeding cafe support group and went to see community midwives. Should say both of them repeatedly missed the diagnosis of TT which was v disappointing."

Next blog - Omeprazole, what the research really says...

Supernanny or Superninny? Jo Frost does breastfeeding, badly.

You'll probably want to sit down before I present this gem, or pour a large drink, drop a herbal tincture or any combo of the above that floats your boat.  Thanks to the lovely Lynsey at Mothering Matters for sharing this by the way, although I think she could have proffered similar warning ;)

From the book "Jo Frost, Confident baby care"

Before we get to the section I want to share, I had a read of what came before.

Jo tells us she's fine with demand feeding a newborn, but by about 4 weeks it's time to start establishing a routine, she calls this "setting firm ground".  What's more she wants you to record the times you feed in your "baby log", which apparently also includes keeping details of your entire diet - cos we all have time for that with a new baby.  Forget preening and snuggling, catching a nap, who has time when there are accurate records to be kept?

Apparently:

"There's controversy over whether women should feed in public.  I think that's neither here nor there"

and

""baby should not throw up too much"

So now you know.

To me it feels like someone has spent some time with Google and a few breastfeeding sites, took a heap of information out of context and knocked it together....

Clean hands - a given.  Your hands should be clean to hold your baby as that's basic hygiene, nothing to do with breastfeeding particularly.

Use an ice pack on your nipples before nursing. This will apparently have the double bonus of reducing pain and "help them to stand up".  Help what stand up a friend asked?

Most full term babies with a normal suck and latching technique do not need nipples to be erect (or er "stood up") before attaching - babies breastfeed they don't nipple feed.  If all mums needed ice to breastfeed, we would have an inbuilt freezer in our abdomen.  Even if mum has flatter nipples baby will often quickly draw them out when latching without any assistance.

Sometimes if nipples are particularly flat or inverted, or if baby has a tongue tie or is a bit less co-ordinated initially due to say a difficult birth, helping them protrude more can help baby attach more easily.  This would usually be done by mum gently rolling between her thumb and finger and then using a latching technique that assists further if needed.

If additional stimulation is required, touching them with a moist cold cloth, a breastpad that has been in the freezer (isn't as cold as an ice pack), using a pump for a few seconds or a nipple eversion tool are all generally preferred by mothers - typically you would only try an ice pack if more convenient/easier methods work.  It isn't a normal thing most people have to do and I can count on one hand the amount of women who've needed ice, in fact I could probably count them on one finger.

Even then it's important to be clear about how to use the cold stimulation, i.e. just a brief touch to stimulate the nipple.  For some mums ice and cold can exacerbate any discomfort or cause vaso-constriction (which means the blood vessels in the nipple tighten and do not let enough blood through) which is extremely painful.

Cold can also cause a slow milk ejection reflex (MER) or "letdown", which could impact on the quality of the feed and how much milk baby can transfer.

For these reasons the majority of women prefer to use cold or more often cool items to soothe after a feed if needed rather than before.  It's important to note this if baby is latching and feeding well there shouldn't be any pain to reduce.

Avoid soap, wash after each breastfeed with vinegar to sterilise the nipples.  At this point I want to give a slow hand-clap to Jo's publisher.  That this could make it past everyone without a raised eyebrow or an edit, oh the shame.

First, the warning Jo forgot - please don't ever apply neat vinegar to your nipples, at least not unless you fancy running the risk of developing chemical burns.

Second, the only thing a mum needs to do after breastfeeding is clip up her bra (if she's wearing one), cuddle her baby and maybe consume some cake. What are we trying to do, make breastfeeding as complicated and time consuming as possible? Can you imagine in the middle of your favourite cafe heading off to vinegar your nipples post-feed?  Purlease!

It's a tad worrying Jo thinks nipples are sterile, how does that even work unless you bath in Milton? (Perhaps I shouldn't give her ideas).  In fact microbes inhabit just about every part of the human body, living on the skin, in the gut, and up the nose; there are 10 times more bacterial cells in your body than human cells. Basically we are the sum of our bacteria.

"Good bacteria" is found around the nipple and areola of healthy pregnant and breastfeeding mothers (which also have glands that secrete an oily substance called lopoid fluid to lubricate and protect them) - and Jo wants mothers to use a disinfectant after every feed, potentially disrupting this delicate bacterial balance, stripping lipoid protection and leaving mum at risk of what?

The only time I've seen vinegar suggested has been to treat Candida, i.e. the mum's bacteria is already out of whack.

We then move on to baby's microbiome, the balance of which is directly linked to his immune system.

What's the impact to his gut flora if mum wipes her nipples with vinegar solution and then baby wants to feed shortly after? We've learnt recently that antibacterial soap can cause disruption linked to diseases including obesity, diabetes, irritable bowel disease, colon cancer, multiple sclerosis and asthma.

What's the result if he has an undiagnosed sulphite allergy or is sensitised to them as a result of exposure?  In Canada sulphites feature in the list of top 10 allergies so it's not that out there.

We should also note that wiping nipples in vinegar solution is an old fashioned weaning technique.  Not surprising given the taste - using Jo's techniques we potentially already have cold, vinegary damp nipples. Delish!

Third, air drying doesn't prevent cracking, a baby latching well to the breast prevents nipple damage (as Jo herself says only a few pages earlier). Air drying after applying a small amount of breastmilk can be soothing if nipples are sore, but the skin isn't broken - if it is moist wound healing becomes more appropriate to prevent a scab forming.

Know what might crack nipples though Jo?  Repeatedly applying vinegar to them after every feed.

Moving on, teabags on the nipples?  Why not? Eco-friendly way to recycle your brew, cheap and effective!

Leaking can happen any time day or night in the early weeks, and I think the triggers listed are more relevant to mothers of older nurslings that don't regularly leak but can still get caught off guard in situations that trigger the release of hormones - such as during sex or when a baby signals hunger. Techniques like applying pressure with arms can be handy when parted from baby and in a public place, but aren't usually relevant in the early weeks of breastfeeding when mum can use the heel of her hand if needed.

For many women leaking in the early days can be a smidge more than "bothersome" to the point of needing a "thick cotton bra top" *cough*. It's not unusual for mums to wear pads constantly for the first few weeks or months and to need to change them frequently.

I also wouldn't recommend mums prone to leaking opt for a cotton top rather than pads.  Pads are absorbent, wick liquid away from the skin and you can whip them out and change them easily.  Sitting for any period of time in a damp, cotton top however is a prime environment for fungus and bacteria to grow.

If your nipples are painful pump milk for a day to give them a rest - and perhaps now would be a good time to get some help too?  Unless Jo has a magic breastfeeding wand that means after a day's rest mum's nipples magically won't become sore again when she resumes feeding?

Lastly use whatever sort of nursing bra you bloody well want.  Front fastening doesn't even make sense, all breastfeeding bra's open at the front so you can breastfeed, otherwise well it would just be well a bra wouldn't it?   Front fastening versus rear fastening is about taking the whole bra on or off, which isn't anything to do with breastfeeding?

As for underwires, I'm not sure what evidence Jo is referring to as I couldn't dig out an underwired bra study; neither it seems could Carmit Archibald ob-gyn, who says:

"The concern about wearing an underwire bra while nursing stems from the idea that the wire could inhibit blood flow and hamper milk production or lead to a clogged duct or even mastitis.
However, there's no real evidence that underwire bras are linked to lactation problems. Any reports of such issues are largely anecdotal"

and

"Your best bet: Let your own experience and comfort be your guide. If your underwire bra is uncomfortable, don't wear it."

I wish that were the end, but unfortunately Jo hasn't quite finished spreading her own delicious brand of bullshit just yet.

Next she tells us (and it took me a moment to squeeze past her mahoosive ego and process this) that "she's not opposed to pumping", after all one bonus is it allows dads to feed to bond.  I'm not entirely sure what qualifies her to be opposed to pumping or not, given to my knowledge she's not qualified in lactation, has never fed a baby and it isn't her body or baby up for discussion?  With all due respect who gives a toss whether Jo is "opposed" or "agreeable", if a mum wants to express that's her decision.

Should you decide to pump though, according to Jo you can only keep breastmilk in the fridge for 24 hours - a whole 6 days less than the evidence based guidelines quoted by the Breastfeeding Network and shared by UNICEF.

I wonder if the actual plan is to make parents so knackered, they won't cotton on to how crap her advice is? Baby logs, sterilising nipples, air-drying them, throwing away perfectly good milk - I'm grateful nobody gave me these "top tips" first time around.

Parents are then told they need to defrost their milk by running it under warm water, not hot so as to not kill the antibodies.  This doesn't make any sense as the milk is frozen, applying hot water to the outside of the bottle or bag will kill antibodies how?  The milk would have to thaw and heat to be at risk of antibody damage, and even then we know most immunoglobulins survive flash pasteurisation at a rolling boil of 100°C.  There's no mention of the easiest method of thawing milk which is just to leave it overnight in a bag in the fridge, you can either serve chilled if baby enjoys or bring it to body temp.

Debra Abbas, a midwife and infant feeding lead (RM, IBCLC) with over 25 years experience says says:

"Much of this advice is not evidence based and parents should be cautious about following guidance from sources such as this.  I would instead encourage parents to contact their midwife, health visitor, local infant feeding team, breastfeeding support group, breastfeeding counsellor or International Board Certified Lactation Consultants (IBCLC)". 

An Open Letter to Jamie Oliver about Breastfeeding

Dear Jamie

Whilst I haven't had chance to keep up with all the media furore that has followed your breastfeeding comments, I've read enough of the same old knee-jerk replies to fill in the gaps.  It's really quite fascinating what some can extrapolate from about 35 words isn't it?

Unlike others I feel dads and partners can be critical to feeding outcome, and I struggle to accept that in 2016 we are trying to deny men the right to comment on something that has serious long-term implications for both their baby and its mother. Should we dismiss the opinions of male obstetricians, midwives and gynaes too?

Infant feeding is different to sugar or junk food though, so I hope you're braced; it's a beast that divides the masses like no other.  You don't simply have to convince governments and corporations to step up, you also have to negotiate the complex minefield of those completely failed by a system, living in a society which as this quite clearly highlights, makes it virtually impossible for the vast majority of mothers to have a hope in hell of feeding their babies as long as they intended. 

And to be honest Jamie, quite a few are pretty pissed off about that.

I'm a tad unimpressed with the whole situation too to be honest, particularly the newest trend to try and silence all discussion surrounding infant feeding for fear of offending, well, everyone.  Honestly if I hear the words "mummy wars" one more time, I fear I may lose it entirely.

The great infant formula marketing machine (protecting its multi billion pounds profits), has done a great job of shutting down dialogue by suggesting mothers should feel guilty or are being judged, they have the boobs so it's all their responsibility right?  But take it from them, the people generating vast profit from you not breastfeeding, you're doing fine...*cough*

Anyway, they've worked tirelessly to understand their market and generate loyalty from their customers, despite serving them up aluminium laden cans and follow on milk containing bonkers levels of iron which may impact on development.  This means those who should be shouting the loudest they have been failed, are instead the first to defend those who were ultimately pretty key to them failing.  Many call for respecting the decisions of others, all without realising it's often a mere illusion of "choice" and in fact women are being played on a giant scale.

Irony much?

Some find breastfeeding easy from the start, some manage to get the support to work around problems and eventually find it easy, convenient and free. Others don't.  And yes, sometimes those pissed off mums become angry when they learn that actually they didn't fail, they were failed - and some become vocal; you probably know them as the "breastapo".

Plenty work hard to stop this message reaching profitable parents; state it's easy and you're either smug and superior or a judgemental "breastfeeding Nazi". In fact the bullying of marginalised mothers is so normalised in our society, that even doctors in the public eye feel it's acceptable.

This means we only hear one voice and it continually reinforces how impossibly hard breastfeeding is. How it's "optimal" (like eating 100% clean with daily gym workouts, and I'm sure you of all people will realise most people don't aspire to that), but hey not doing so is "OK", don't be "extreme".  Despite the fact that mothers in the West are not intrinsically broken, today we don't plan to breastfeed, we plan to try - and I understand why.

This leaves us in a tricky position and a giant catch 22 situation.    Many feel the best way to stop parents feeling the emotions they do, is to pretend how you feed your baby doesn't really matter.  Being happy matters, a happy mum = a happy baby.  Nobody seems to question how being happy helps to prevent the myriad of health implications of feeding choice, in fact debate often turns to trying to dismiss those too, but the alternative is problematic.

When humans hear something that contradicts what we believe to be true, or which creates internal conflict in relation to a choice or decision made, it triggers something called "cognitive dissonance".  This is a super uncomfortable state for us, and one we immediately try and resolve - typically by dismissing the new information (where possible) as untrue, often ultimately resorting to anecdote (e.g. I wasn't breastfed and I'm fine).

When we address the general public, we are reaching parents who NEED information if they're going to have any hope of making an informed choice.  We are reaching those who have never had children and who are ambivalent.  But we also have to recognise that from health professionals, to bloggers, to celebs, many are carrying their own baggage and will be triggered.  When this happens nobody listens, anger fuelled shouting just results in one big noise.

Lactation isn't Russian roulette, old wives' tales or a random unpredictable event that is inevitably horrific and painful to begin with.  It's biology, it has a scientific journal and in the same way we try and investigate why people can't conceive, rather than suggesting adoption at the first appointment ((because it may be "fixable") - exactly the same holds true for feeding. There's also loads we can do around and immediately after birth to facilitate an organised co-ordinated baby, who is in the best possible position to establish feeding and prevent problems arising.  We can tell parents what the very first sign of a problem looks like and who to call, but who even talks about that when half the people helping don't understand it themselves?  

Change can't happen when simultaneously cutting vital services, au contraire it would mean stepping up and paying for the support needed.  It would mean moving away from relying on the volunteer breastfeeding organisations, who as it stands are already propping up the failing service; most (and I speak from experience) work tirelessly, taking calls in their homes often at unsociable hours, driving to visit parents, without pay, because they recognise there are such gaps in the care parents receive - because they've been there themselves and because they care.

I've met so many mothers who are frustrated or angry, in pain or struggling with a baby suffering reflux or colic as a result of their feeding technique.  The resulting contradictory emotions at odds with instinct and combined with hormones, can make them feel like they're going mad.  This is often diagnosed as post-partum depression, because mum is tearful, or more emotional than expected - but after weeks of no sleep, a baby that doesn't settle and knee jerking pain at every feed, with not a single member of her care team trying to establish why; it's hardly bloody surprising.

We are failing parents who are doing the best they can, with the knowledge and help they have at that time, and then turning around and telling them it's their fault.  Misogyny and politics are rife, a blind eye is turned to something that costs the NHS millions and millions of pounds and we mislead both parents and healthcare professionals with the language used. 

Much as I hope you can make a dent Jamie, I fear the backlash from your own audience may prevent you from making the difference/contribution you could to breastfeeding in the UK.

Edited to Add:
Thank you for all the positive feedback and mahoosive share rate!  I've been told off for not offering to extend a hand of support to Jamie if needed. I didn't because I don't really expect Jamie to read my letter, let alone need help from me given how many thousands of people are blowing up his news-feed.  But of course Jamie, call me anytime ;)  

Breastfed Children at Risk of RICKETS

Or so the Daily Express told me today.  And if the Daily Express says it in capitals, it must be true right?

Yawn.

Even before opening the study I'm wondering how such dodgy reporting makes it past any editor with a modicum of self respect.

Breastfed children aren't at risk of rickets because they're breastfed; breastmilk doesn't magically sap their vitamin D stores leaving them depleted and deficient.

The Express article goes on to say:

"According to the UK Department of Health, all infants and young children aged six months to five years should take a daily supplement containing vitamin D in the form of vitamin drops, to help them meet the requirement set for this age group of 7-8.5 micrograms of vitamin D per day. 

However, those infants who are fed infant formula will not need vitamin drops until they are receiving less than 500ml of infant formula a day, as these products are fortified with vitamin D."

This means when formula fed infants are taking less than 500ml of vitamin D fortified formula, they too are at risk of rickets without supplementation.

UNICEF state to give formula to a year - meaning this is really valid for all mums who have infants older than 12 months not drinking formula.

According to the royal college of paediatrics and child health:

Rickets was common in Victorian times and was eradicated by the use of cod-liver oil and fortifying food with Vitamin D. It is the commonest childhood complication of vitamin D deficiency (VDD) and is caused by a lack of dietary calcium or problems with the supply, metabolism or utilisation of vitamin D. There are many possible reasons for this - lack of good quality sunlight in the UK, not exposing ourselves to sunlight (covering up with clothing, sun creams, staying indoors, and immobility).

So rickets can actually be caused by either lack of dietary calcium or vitamin D deficiency.  Most people take it as given we get enough calcium, others aren't so convinced.

Anyway the study in question was exploring infants 1-5 years, with the mean age being 24.5 months.

It's a group of "urban Canadian children" that were studied; so I of course wondered what the diet of a
typical urban Canadian kid was like. Not great as it goes. Some key points I found:

"A notable proportion of the diets of 1-3 year-old children contain total fat in quantities below the recommended range. (http://www.hc-sc.gc.ca)"

Since vitamin D is fat soluble, this may not accurately represent those with a different diet.

The final analysis included 2508 children, the average age of which was 24.5 months.   They read the levels of serum 25-OHD (generally considered the most reliable method) as a marker of vitamin D levels and the average was 32 nanograms per milliliter.  130 or 5% of the children had levels less than 20 nanograms per milliliter (considered deficient).

This next bit is key:

The median total duration of breastfeeding was 10.5 months (IQR = 6–14 months)

Anyway let's plough on. 

53% of children in the study received vitamin D supplements whilst the rest didn't.

What they discovered was infants who were breastfed and given a vitamin D supplement remained within totally normal levels, regardless of how long they were breastfed.  Those over 12 months who didn't receive a supplement were more at risk of experiencing a drop.

The researchers add:

"Age, total daily milk (cow’s milk and formula) consumption, skin type, and season of blood sampling were statistically significant covariate"

Meaning their diet, skin type and what time of year they were tested in, all impacted on the outcome.

For those that don't know, vitamin D recommendations are tricky and vary widely.  It depends on your skin pigmentation (the paler the less sunshine is needed, the darker the more), how strong the sun is i.e. how close to the equator you are and how much you get via other sources like diet.

This means probably quite obviously that those at the biggest risk of vitamin D deficiency are those who:
a: Have a darker skin type and live in location where sunlight levels are low
b: Are born to mothers who are vitamin deficient.
c. Are frequently covered heavily (particularly head) when outdoors or who spend little time outdoors.
d. Don't either eat foods containing d or fortified with

The connection in this study is really quite simple.  An infant who continues to breastfeed is less likely to consume cow's milk (or drink smaller quantities), something showed to be an influential factor in the study. And what you might not know, is due to the dark winters, all Canadian milk sold according to food law is fortified with vitamin D - thus breastfeeding toddlers aren't getting or are getting less of this supplement.

In the end they concluded absolutely nothing that we didn't already know:

"Vitamin D supplementation during breastfeeding beyond age 1 year may minimize the risk of serum 25-OHD levels less than 20 nanograms per milliliter".

Let's remember that by 1 year of age, breastmilk isn't supposed to be the only source of vitamin D for an infant, far from it.   Indeed breastmilk is usually considered insufficient to prevent vitamin D deficiency in exclusively breast-fed infants if sunlight exposure is limited.  And of course, along with sunshine, there is also diet.

I did start out including diet in this entry, but it became too long - therefore I've split in and will post all about food and D shortly.

Give the breastfed baby via their mother?
We know the amount of vitamin D in breastmilk depends upon mom's vitamin D status, yet an option that rarely mentioned is to supplement the breastfeeding mums to increase amounts available via breastmilk.  Studies have repeatedly shown supplementing mum to be a satisfactory option which is as effective as supplementing baby direct.

Supplement anyway, UK levels are set too low?

There has been lots of speculation recently over whether UK levels are too low, with some countries recommending much higher amounts.  It's not really that simple though (what is?). 

First going beyond deficiency and normal levels, into therapeutic use of vitamin D to prevent or treat other diseases - the evidence is actually not as cut and dried as some would have you believe.

This 2014 review looked promising when researchers concluded:

 "Despite a few hundred systematic reviews and meta-analyses, highly convincing evidence of a clear role of vitamin D does not exist for any outcome, but associations with a selection of outcomes are probable."

But as you can see from the rapid responses here, it has been criticised for containing too many flawed studies that warped the overall findings.  Other studies have some now asking if we've been wrong about the benefits of vitamin D, and whether low levels associated with disease might be correlation rather than causal.

It also isn't (according to many) easy as just isolating one vitamin and throwing huge amounts into the human body.  The way that vitamins and minerals work together is interconnected. How well vitamin D works depends on the amount of other vitamins and minerals that are present in your body. The other vitamins and minerals needed to help vitamin D work well are called cofactors.

"To get the most benefit from vitamin D, you must have other cofactors in your body. Vitamin D has a number of cofactors; the ones listed below are the most important.

• Magnesium

• Vitamin K

• Zinc

• Boron

• Vitamin A "

from here

In short not getting enough vitamin D increases an infants risk of getting rickets, not breastfeeding.