Toxic Breastmilk?

"'Cocktail of chemicals' found in UK mothers' breast milk due to home furnishings" 

The Telegraph

Household chemicals blamed as UK mothers have highest levels of toxins in breast milk

Daily Express

And yet again I wondered who really funds these clickbait headlines.

The paper that provoked such a media response is an environmental audit called "Toxic Chemicals in Everyday Life".  It explores the toxic contamination of our environment, the impact to wildlife, the food chain and society as a whole - with a particular focus on the aftermath of the Grenfell Tower fire. It discusses the levels of toxin exposure we face and how these can affect our health.

They note that toxins from fire-retardant sprays for home furnishing are at significant and worrying levels in everything they tested - from newborn cord blood to the urine of adults.

What's truly bizarre is that the media ran with the breastmilk angle - which is only noted briefly in one of the subsections, and frankly is a drop in the ocean in terms of the level of the problem.

The relevant section reads:

"44. Flame retardants have been detected in air, soil, water, food, wildlife and humans. They are present in homes and offices via dust and on surfaces including windows, floors and carpets.151 Exposure occurs when additive flame retardants leach from goods into the air, dust and surfaces.

So in short, flame retardants (PBDEs) have contaminated everything from the air in your home, to the soil your food is grown in. Oh and the formula you have to use if you don't breastfeed.

"152 Breast Cancer UK suggests the US and UK have the highest levels of flame retardants in human body fluids."

I dug out the Breast Cancer UK briefing which states:

"In general, the USA and the UK have the highest recorded levels of flame retardants in human body fluids (36). The highest concentrations of legacy PBDEs in mothers’ milk have been detected in American women, and the second highest levels in those from the UK (37). Elevated levels of PBDEs have also been found in human blood serum in Californian children at 5 times the US average, and 10-100 times the European and Mexican average"

Oh, so hang on Daily Express - UK mothers don't have the highest levels, Americans do. 

Reference 36 is a 2008 study exploring the US population - it highlights that there are significant differences recorded depending on area and age.

Reference 37 is a 2009 review with particular focus on external exposure routes (e.g. dust, diet, and air) and the resulting internal exposure to PBDEs (e.g. breast milk and blood).

So let's pause a moment to consider that yesterday's headlines were in fact based on a TEN YEAR OLD study...

They note that fats contain higher levels of contaminants presenting an important exposure pathway for humans. This includes foods like fish, dairy products and breastmilk,

They state blood serum levels are 10 times higher in the US in their study than in Europe.  Yet they  couldn't find ten times the difference in the food chain.

But do you know where they did?

Dust

"The ingestion of dust conveys the highest intake of BDE-209 of all sources, possibly also of other PBDE congeners. The PBDE exposure through dust is significant for toddlers who ingest more dust than adults.
Indoor air and dust concentrations have been found to be approximately one order of magnitude higher in North America than in Europe, possibly a result of different fire safety standards."

To compare breastmilk, researchers searched for recorded data from different countries. We're not really comparing like for like, since not all data compared is from the same time period, nor using the same techniques or sample sizes. In the context of contaminants this is a significant flaw, because even within the same area, research highlights massive variations from sample to sample based on their immediate surroundings; some data pooled was samples from 10 people, some from 100, we have no idea what the ages of the sampled were (as the previous study highlights, the older we are - the higher our toxin level).

Everything tested recorded higher in the UK than other parts of Europe, in the one data sample we provided - blood serum, dust etc.

Peeing your pants about breastmilk, is like realising the entire second floor house is on fire, about to burn to the ground - and you make a public announcement your ashtray downstairs in the basement has just caught alight, distracting everyone from the actual imminent disaster.

What the media also fail to recognise - is that by scaremongering against breastmilk, not only will infants continue to be exposed (via the placenta, maternal blood flow, infant formula, the air they breathe and so on), but parents may wrongly believe it to be beneficial to their infant to not receive breastmilk.

In fact - this is like swapping the water you were pouring on the fire to cooking oil.

Exposure to environmental chemicals has been linked to dysregulation of the immune and reproductive system, diseases like cancer - and are known to alter the gut bacteria (microbiome).

Numerous studies have demonstrated that breastmilk is significant in terms of the developing microbiome, contains factors that assist regulation of the immune system and in short, assist the body in dealing with the effects of exposure (1-8).

It's time some media sources started sorting fact from fiction, before they write their headlines.

1. Pannaraj PS, Li F, Cerini C, et al. Association Between Breast Milk Bacterial Communities and Establishment and Development of the Infant Gut Microbiome. JAMA Pediatr. 2017;171(7):647–654. doi:10.1001/jamapediatrics.2017.0378
2. Van den Elsen LWJ, Garssen J, Burcelin R, Verhasselt V. Shaping the Gut Microbiota by Breastfeeding: The Gateway to Allergy Prevention?. Front Pediatr. 2019;7:47. Published 2019 Feb 27. doi:10.3389/fped.2019.00047
3. Alba Boix-Amorós, Fernando Puente-Sánchez, Elloise du Toit, Kaisa M. Linderborg, Yumei Zhang, Baoru Yang, Seppo Salminen, Erika Isolauri, Javier Tamames, Alex Mira, Maria Carmen Collado. Mycobiome profiles in breast milk from healthy women depend on mode of delivery, geographic location and interaction with bacteria. Applied and Environmental Microbiology, 2019; DOI: 10.1128/AE
4. Cacho NT, Lawrence RM. Innate Immunity and Breast Milk. Front Immunol. 2017;8:584. Published 2017 May 29. doi:10.3389/fimmu.2017.00584
5. Hsu PS, Nanan R. Does Breast Milk Nurture T Lymphocytes in Their Cradle?. Front Pediatr. 2018;6:268. Published 2018 Sep 27. doi:10.3389/fped.2018.00268
6. Laura M'Rabet, Arjen Paul Vos, Günther Boehm, Johan Garssen, Breast-Feeding and Its Role in Early Development of the Immune System in Infants: Consequences for Health Later in Life, The Journal of Nutrition, Volume 138, Issue 9, September 2008, Pages 1782S–1790S, https://doi.org/10.1093/jn/138.9.1782S
7. Molès, J‐P, Tuaillon, E, Kankasa, C, et al. Breastmilk cell trafficking induces microchimerism‐mediated immune system maturation in the infant. Pediatr Allergy Immunol. 2018; 29: 133– 143. https://doi.org/10.1111/pai.12841
8. Babak Baban, Aneeq Malik, Jatinder Bhatia, Jack C. Yu. Presence and Profile of Innate Lymphoid Cells in Human Breast Milk. JAMA Pediatrics, 2018; DOI: 10.1001/jamapediatrics.2018.0148

Babies 'don't need tongue-tie surgery to feed' - Rapid Response

"Babies 'don't need tongue-tie surgery to feed" is today's BBC headline, which had reached my inbox before I opened my eyes this morning (thank you readers).

We know the media sensationalise studies, so you want to know what it really says right?

Course you do, let's go.

112 babies who had been referred for tongue tie treatment, were assessed by "Speech and language pathologists, who examined the infants' ability to breastfeed prior to a surgical consultation".

112?  That's really one step beyond "large classroom experiment".

My next thought was:

Wow, do Speech and Language Therapists (SALTs) have breastfeeding training in the US?

So I of course asked the man in the know, Dr Ghaheri. His reply:

"Er no".

Errrrrm ok then.

He continues:

"Their professional organization (ASHA) doesn’t recognize TT as being a problem in breastfeeding, solid foods or speech. They are not the practitioner of choice when it comes to breastfeeding pathology either."

I want to clarify this early on (then probably repeat it 10 times throughout this piece for those who will still miss it) - NOT ALL BABIES WITH A TONGUE TIE NEED A RELEASE TO BREASTFEED WELL. At least I'm assured this is the case - people rarely ring an IBLC to say their baby has a tie but hey, they're feeding great and don't need our support.  

This study is exploring infants who were diagnosed as tied and symptomatic with feeding problems, thus had been referred and recommended for release. This means anyone not experiencing a feeding problem from their tie, wouldn't be included in this study.

I pushed on. The SALTS then:  

"offered techniques for mothers to address any feeding difficulties prior to surgical intervention was developed. Infants either found success in feeding and weight gain through this program or underwent procedures."

Ok, that sounds fair enough right?  Try other techniques such as improving attachment, positioning and so on. Indeed these interventions are listed. 

Brace yourself.

"If sleep state regulation was determined to be the primary issue (with the baby falling asleep and transitioned to a nonnutritive sucking pattern causing maternal nipple pain/ injury/prolonged feeding), interventions included arousal actions such as applying a wet facecloth or tapping the infant’s foot."

I had to stop and take a moment here to suck air through my teeth.

News flash - babies fall asleep when the flow of milk isn't worth staying awake for because their attachment is shallow. Tapping a baby or applying a cold wet cloth, may temporarily wake the baby, who will take a few more sucks/swallows before nodding back off again.

Next:

"If volume or rate of breast-milk flow (tongue clicking, gulping, or pulling off the nipple) appeared to be the primary issue, modifications included the following strategies to slow the flow of milk: placing the mother in a supine position (gravity to slow flow), expressing milk prior to breastfeeding, and/or placing the mother and baby in a side lying position."

If a baby is in a shallow latch, they will often perceive the breastmilk supply to be too fast. We can see video examples of that here: with a tongue tie. However with a deep latch, the flow is easily tolerated as we can see here: post tongue tie release.

"If previously-diagnosed reflux appeared to be the primary issue (eg, arching, pulling off nipple), verbal reassurance to continue gastroesophageal reflux disease medication treatment was provided"

Woah woah woah. Wait a moment.

First - pulling on and off the nipple and arching can mean many things.  It can mean "hey the milk has stopped", "I have trapped wind/gas" (top or bottom end), "my mouth is sore" or "my neck is stiff in that position".  Since when did the assumption these symptoms mean reflux become a given?

Shallow latch and feeding technique can cause reflux (NICE) - indeed the baby in the clips above was symptomatic prior to release. It seems though we're just ignoring that in this study and carrying on with medications.

This is where my alarm bells really started ringing.

The authors opened this paper with the statement:

"Inpatient surgical release of lingual frenulums rose 10-fold between 1997 and 2012 despite insufficient evidence that frenotomy for ankyloglossia is associated with improvements in breastfeeding

This is a rather confusing claim, since there are really quite a lot of studies exploring tongue tie and breastfeeding (1-15), my list isn't exhaustive. They consistently demonstrate breastfeeding improvement, none evidence any risk of significant harm and they include is comments such as:

 "No complications were reported with frenotomy."(2)

and

"Ankyloglossia, which is a relatively common finding in the newborn population, adversely affects breastfeeding in selected infants."(4)

and

"This review of research literature analyses the evidence regarding tongue-tie to determine if appropriate intervention can reduce its impact on breastfeeding cessation, concluding that, for most infants, frenotomy offers the best chance of improved and continued breastfeeding. Furthermore, studies have demonstrated that the procedure does not lead to complications for the infant or mother." (6)

and

"Frenotomy is a safe, short procedure that improves breastfeeding outcomes, and is best performed at an early age" (7)

and

"After lingual frenotomy, changes were observed in the breastfeeding patterns of the the tongue-tied infants while the control group maintained the same patterns. Moreover, all symptoms reported by the mothers of the tongue-tied infants had improved after frenotomy."(8)

and

"Tongue-tie is not uncommon and is associated with breastfeeding difficulty in newborn infants." (10)

and

This should provide convincing evidence for those seeking a frenotomy for infants with significant ankyloglossia.(15)

Apparently not.

What we should perhaps also explore some other stats too.

Prescriptions of a a child-friendly liquid formulation of a popular reflux medication (PPI), saw a 16-fold increase in use between 1999-2004.  Between 2006 and 2016, prescriptions of specialist formula milks for infants with cow’s milk protein allergy (CMPA) increased by nearly 500%. (16)

If we want to talk about things lacking an evidence base - let's start here.

"There was no significant difference for both outcome measures while taking either omeprazole or placebo.  Compared with placebo, omeprazole significantly reduced esophageal acid exposure but not irritability." (17)

and

"PPIs are not effective in reducing GERD symptoms in infants. Placebo-controlled trials in older children are lacking. Although PPIs seem to be well tolerated during short-term use, evidence supporting the safety of PPIs is lacking." (18)

and

"As more extensively discussed below, the inappropriate use of acid suppressive drugs has been indeed associated with consistent modifications in the intestinal microbiota by inducing gastric hypochlorhydria, delaying gastric emptying and increasing gastric mucous viscosity [48]. In adults, chronic acid suppression has been linked to an increased risk of small intestine bacterial overgrowth (SIBO). Although not reaching statistical significance, a trend towards an increased risk of SIBO has also been recently observed in children under long-term PPIs therapy (6 months) [49]. Apart from SIBO, the chronic use of acid suppressive agents is a well-known risk factor for gastrointestinal (acute gastroenteritis, Clostidium difficile infection, candidemia and necrotizing enterocolitis) and extra-intestinal (lower respiratory tract infections, community acquired pneumonia) infections, particularly in infants." (19)

and

"Several micronutrients require an acidic environment for optimal absorption. Iron, vitamin C, and vitamin B12absorption are dependent on the intestine's acidic environment. Several studies and case reports describe associations of omeprazole with altered calcium, magnesium, and vitamin B12 absorption. To date, there have been no prospective trials evaluating the effect of proton pump inhibitors (PPIs) on iron absorption.
Conclusions:
Existing data support the conclusion that the acid-suppressing effect of omeprazole can have important clinical implications for vitamin and mineral therapy. Clinicians should be cognizant of this issue in practice. Further studies exploring the relationship of PPIs and iron deficiency are warranted, especially in high-risk populations such as the elderly." (20)

And presumably infants.

I won't bore you with however many more studies and turn this into a reflux post, if you're interested you can read more here. The point is, there are recognised and potentially significant risks associated with reflux medications. As a result, current recommendations are to minimise use whenever possible, giving as a last resort not a first line response; it makes no logical sense as a preferred treatment pathway compared to frenulotomy.

The question this study really asks is - can we breastfeed tongue tied infants ie, provoke weight gain and not suffer nipple trauma, even when the baby is tied.

We of course all know that a lot of the time - yes you can!   2/3rd of the time according to this study. We can employ multiple compensatory strategies. 

Many do constantly jostle their babies awake and feed them 20 times per day to provoke gain or because it's the only way baby settled.

They may give reflux medications, keep baby upright an hour after feeds, use a specialist milk or undertake a restricted diet, at times completely unnecessarily:

"Inappropriate elimination diets have been imposed on pregnant and lactating women and their infants to prevent allergies without scientific evidence proving their efficacy. Even when well indicated in infants and children diagnosed with an allergy, the type of dietary products to eliminate and the duration of such elimination are not always logical."(21)

They may accept their baby is "higher needs" and sleeps badly or has "wind" or is "fussy" as they won't be put down or settle for long.

They may use techniques such as expressing before a feed, reclined feeding or catching the first "letdown" in a muslin.

They may accept they won't take a bottle and feed hourly.

Any family being offered tongue tie division should always be offered the option of doing nothing -  to carry on managing the situation as they have been up until this point, with added tips and tricks for positioning, wind and colic management, expectations and so on.

The problem though is, especially in the patriarchal world of medicine - often the only things valued as markers of "successful breastfeeding" are weight gain and nipple pain. "Symptoms of reflux" are medicated rather than looking the resolve the problem and mothers are told to rub their baby with wet flannels to keep them awake.

These studies don't consider maternal satisfaction levels and overall well-being - is this sustainable in terms of getting through a day?  Is this situation conducive to good mental health for family members?

As usual, social media comments sum things up best:

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1. Ghaheri BA, Cole M, Fausel SC, Chuop M, Mace JC. Breastfeeding improvement following tongue-tie and lip-tie release: A prospective cohort study. Laryngoscope. 2017;127(5):1217–1223. doi:10.1002/lary.26306
2. Srinivasan, A., Al Khoury, A., Puzhko, S., Dobrich, C., Stern, M., Mitnick, H., & Goldfarb, L. (2018). Frenotomy in Infants with Tongue-Tie and Breastfeeding Problems. Journal of Human Lactation. https://doi.org/10.1177/0890334418816973
3. Emond A, Ingram J, Johnson D, et al. Randomised controlled trial of early frenotomy in breastfed infants with mild–moderate tongue-tie Archives of Disease in Childhood - Fetal and Neonatal Edition 2014;99:F189-F195.
4. Messner AH, Lalakea ML, Aby J, Macmahon J, Bair E. Ankyloglossia: Incidence and Associated Feeding Difficulties. Arch Otolaryngol Head Neck Surg. 2000;126(1):36–39. doi:10.1001/archotol.126.1.36
5. Elvira Ferrés-Amat, Tomasa Pastor-Vera, Paula Rodríguez-Alessi, Eduard Ferrés-Amat, Javier Mareque-Bueno, and Eduard Ferrés-Padró, “Management of Ankyloglossia and Breastfeeding Difficulties in the Newborn: Breastfeeding Sessions, Myofunctional Therapy, and Frenotomy,” Case Reports in Pediatrics, vol. 2016, Article ID 3010594, 5 pages, 2016. https://doi.org/10.1155/2016/3010594.
6. Edmunds, Janet & Miles, Sandra & Fulbrook, Paul. (2011). Tongue-tie and breastfeeding: a review of the literature. Breastfeeding review : professional publication of the Nursing Mothers' Association of Australia. 19. 19-26.
7. Sharma, S., & Jayaraj, S. (2015). Tongue-tie division to treat breastfeeding difficulties: Our experience. The Journal of Laryngology & Otology,129(10), 986-989. doi:10.1017/S002221511500225X
8. MARTINELLI, Roberta Lopes de Castro, MARCHESAN, Irene Queiroz, GUSMÃO, Reinaldo Jordão, HONÓRIO, Heitor Marques, & BERRETIN-FELIX, Giédre. (2015). The effects of frenotomy on breastfeeding. Journal of Applied Oral Science, 23(2), 153-157. https://dx.doi.org/10.1590/1678-775720140339
9. BAXTER, R., HUGHES, L.. Speech and Feeding Improvements in Children After Posterior Tongue-Tie Release: A Case Series. International Journal of Clinical Pediatrics, North America, 7, jun. 2018. Available at:<https://www.theijcp.org/index.php/ijcp/article/view/295/254>
10. Sopapan Ngerncham, Mongkol Laohapensang, Thidaratana Wongvisutdhi, Yupin Ritjaroen, Nipa Painpichan, Pussara Hakularb, Panidaporn Gunnaleka & Penpaween Chaturapitphothong (2013) Lingual frenulum and effect on breastfeeding in Thai newborn infants, Paediatrics and International Child Health,33:2, 86-90, DOI: 10.1179/2046905512Y.0000000023
11. Hogan, M. , Westcott, C. and Griffiths, M. (2005), Randomized, controlled trial of division of tongue‐tie in infants with feeding problems. Journal of Paediatrics and Child Health, 41: 246-250. doi:10.1111/j.1440-1754.2005.00604.x
12. Ankyloglossia: Assessment, Incidence, and Effect of Frenuloplasty on the Breastfeeding Dyad
Jeanne L. Ballard, Christine E. Auer, Jane C. Khoury
Pediatrics Nov 2002, 110 (5) e63; DOI: 10.1542/peds.110.5.e63
13. Shaul Dollberg, Eyal Botzer, Esther Grunis, Francis B. Mimouni,Immediate nipple pain relief after frenotomy in breast-fed infants with ankyloglossia: a randomized, prospective study,Journal of Pediatric Surgery,Volume 41, Issue 9,2006,Pages 1598-1600,ISSN 0022-3468,https://doi.org/10.1016/j.jpedsurg.2006.05.024.
14. A Double-Blind, Randomized, Controlled Trial of Tongue-Tie Division and Its Immediate Effect on Breastfeeding. Janet Berry, Mervyn Griffiths, and Carolyn WestcottBreastfeeding Medicine 2012 7:3, 189-193
15. Efficacy of Neonatal Release of Ankyloglossia: A Randomized Trial Melissa Buryk, David Bloom, Timothy Shope Pediatrics Aug 2011, 128 (2) 280-288; DOI: 10.1542/peds.2011-0077
16. Van Tulleken Chris. Overdiagnosis and industry influence: how cow’s milk protein allergy is extending the reach of infant formula manufacturers BMJ 2018; 363 :k5056
17. Double-blind placebo-controlled trial of omeprazole in irritable infants with gastroesophageal reflux. Moore, David John et al. The Journal of Pediatrics, Volume 143, Issue 2, 219 - 223
18. Efficacy of Proton-Pump Inhibitors in Children With Gastroesophageal Reflux Disease: A Systematic Review. Rachel J. van der Pol, Marije J. Smits, Michiel P. van Wijk, Taher I. Omari, Merit M.Tabbers, Marc A. Benninga. Pediatrics May 2011, 127 (5) 925-935; DOI: 10.1542/peds.2010-2719
19. Rybak A, Pesce M, Thapar N, Borrelli O. Gastro-Esophageal Reflux in Children. Int J Mol Sci. 2017;18(8):1671. Published 2017 Aug 1. doi:10.3390/ijms18081671
20. Humphrey, M. L., Barkhordari, N., & Kaakeh, Y. (2012). Effects of Omeprazole on Vitamin and Mineral Absorption and Metabolism. Journal of Pharmacy Technology, 28(6), 243–248. https://doi.org/10.1177/875512251202800604
21. Lifschitz, C. & Szajewska, H. Eur J Pediatr (2015) 174: 141. https://doi.org/10.1007/s00431-014-2422-3