CMPA in the Breastfed Baby & How Long Does Dairy Really Stay in Breastmilk?

It's not uncommon for parents to be told it takes 2-6 weeks for dairy to leave breastmilk (depending on the advice giver). This can naturally lead to some parents choosing to switch to a hypoallergenic formula, with the belief this will result in a more rapid removal of milk proteins for baby and thus relief of symptoms.

It's of course therefore that we're basing such a big decision on an evidence base, but this is actually where the problems begin.

"β-lactoglobulin (β-Lg), which is not expressed by humans, has often been monitored as a cow's milk marker. With specific concern to cow's milk allergens, exogenous β-Lg has been detected in only a limited number of mothers' milk samples, and its presence is not related to atopic or non-atopic conditions."

The search for cow's milk allergens in breast milk has been the subject of fervent research. Human and bovine β-casein, αs1-casein, and α-lactalbumin share a medium to high degree of sequence homology (53, 31, and 73% homology, respectively) and, hence, a certain immune cross-reactivity" (1)

There's a lot more info on the link I'll drop below, but in short - the protein they were tracking, doesn't appear to be linked to symptomatic babies. Symptoms didn't correlate with the appearance or removal of this, and many mothers didn't consistently show it in their milk.  Oops

Scientists of course got back on it, and identified peptides fragments - or teeny tiny bits of broken down proteins, which both appeared to correlate with consumption AND symptoms.

They found that peptides could be identified very rapidly after consumption, leaving milk quickly  with a maximum of 6 hours recorded in a 2019 study.  Authors established peptides, not proteins was a far more effective way of tracking a constituent via breastmilk and thus future studies can explore this further for other food groups.  

"Dietary peptides were already detected at 1 h (T1) after the consumption of cow's milk and peaked after 2 h, whereas none of them was detectable 6 h (T5) after the oral load." (1)

This means there is very little delay removing dairy when mum stops eating it.

This blogger and mum of a baby with allergies, who also happens to hold a Ph.D. in Cellular and Molecular Biology got digging when they were diagnosed:

"What I found was SHOCKING.
It typically takes 2-8 hours for breast milk to be clear of food allergens after ingestion.
Ingested food allergens do not always make their way to breast milk. 

Mind. Blown. Scientists have conducted several studies of breast milk at different time intervals after ingestion by the mother. For instance, one lab gave 23 women a serving of peanuts. Only half of them ended up with detectable levels of peanut protein in their milk. The milk that did contain the allergen peaked in concentration between 1-2 hours and steadily decreased from there [1].

So why didn’t my doctor tell me this?

The question emerges: WHY would doctors say it takes 2 weeks? WHY would online articles spread this lie?
I believe the answer is two-fold. First, scientific research explains that it may take up to 2 weeks for the infant to be clear of symptoms. This is the case whether the child is placed on hypoallergenic formula OR breastmilk in conjunction with an elimination diet (let’s call this hypoallergenic breast milk). So, while mothers may be clear of allergens, their infant will likely continue to show symptoms for a few more weeks."

Her blog is great, well referenced and worth a dig around if you have a baby with allergies.

Why do symptoms persist for 2 weeks if I slip up and have dairy then?

It can take up to 4 weeks for the intestinal mucosa to heal after it has been exposed to an allergen. This may be more rapid in babies receiving breastmilk due to the growth factors and pre/probiotics, anti-inflammatory constituents etc (2,3)

In practice if dairy is the issue, we see a very rapid response via breastmilk removal, which echoes the science above.

This means parents can be confident that once they stop consuming dairy, their breastmilk is rapidly clear and they can continue breastfeeding if they wish.

1. Picariello G, De Cicco M, Nocerino R, et al. Excretion of Dietary Cow's Milk Derived Peptides Into Breast Milk. Front Nutr. 2019;6:25. Published 2019 Mar 12. doi:10.3389/fnut.2019.00025
2. Brill H. Approach to milk protein allergy in infants. Can Fam Physician. 2008;54(9):1258–1264.
3. Czerwionka-Szaflarska M, Łoś-Rycharska E, Gawryjołek J. Allergic enteritis in children. Prz Gastroenterol. 2017;12(1):1–5. doi:10.5114/pg.2017.65677

What Breastfeeding “Cluster Feeding” Is and Isn’t...

Cluster feeding. 

We hear these words a lot in clinic. Sometimes, quite often in fact  - what the person is describing is NOT cluster feeding; it’s a feeding problem that is being mislabelled and like an epidemic it’s spreading.

First if you’re breastfeeding fine, you’re happy, baby is happy and they’re gaining normally - you don’t need to worry about this post at all.

This post is for those who have either a baby who is growing much more slowly than expected, or who is gaining normally but consistently needs a million feeds per day to do so (outside of normal growth spurt behaviours which we’ll come onto). In short the pattern really isn’t sustainable.

Cluster feeding is a process term, healthy babies who are gaining weight well - typically start (in my experience from around 3-5 weeks of age).

Because breastmilk is rapidly digested, babies need to feed frequently - every few hours. If baby wants to sleep a longer stretch of say 5/6 hours, baby may need more food to last this long.

Baby therefore takes several or more full feeds quite close together, often around early evening time, signalling again (typically) 20-30 mins after the last feed- before dropping into a longer sleep spell. This is thought to allow baby to fill their whole digestive system, so excess hunger doesn't occur during this longer gap.

Babies tend to fall into two camps - those who cluster feed and have a longer sleep stretch, and those that don’t and keep to them same pattern during the day of 2-4 hours. I can once remember dad of newborn baby number 3 - asking when they started that cluster feeding so you get more sleep?!

Cluster feeding can also occur during growth spurts. This tends to be more random, can happen any time of day or night but is short-lived.  If baby is feeding well, settled and suddenly has a day or two of crazy manic feeding before things settle again - this is often what people refer to as a “growth spurt”, as this behaviour drives up mum’s milk supply with more frequent and effective milk removal.  Cluster feeding can also be comforting if baby needs some help to sleep, is unwell or just because.

I don’t believe many babies not back at birthweight at the appropriate time (10-14 days for an average sized baby) cluster feed - these babies are feeding frequently to get a longer stretch, but in a bid to try and pull enough calories.

They may fall asleep quickly, rouse when put down and for all their intense efforts they’re prone to getting the label “lazy”. Instead of clustering, these babies are interjecting their feeds with a powernap.

Sure they may take a longer sleep stretch if they’re exhausted from very frequent feeding during the day, but this isn’t the same as that outlined above. It can however be difficult to tell apart, which is why ensuring your support team has at least one certified person.

Feeding every 20-30 mins all day with the occasional hour gap IS NOT clustering. 

Not gaining enough to track a centile despite feeding frequently IS NOT clustering.

Growing normally but with a feeding frequency day in and out that isn’t sustainable, IS NOT cluster feeding.

I keep hearing parents fobbed off with the claim it’s just what breastfed babies do. Leaving parents feeling guilty they can’t sustain these intense demands. Since we’ve normalised a problem, the risk is mum things she’s not able to sustain what others clearly can.

I overheard a conversation recently in our waiting room between a mum who had called back for a quick check, and one who had just arrived with a feeding problem. As the new mum was outlining the problems they were experiencing, she kept diminishing with - but I’ve not had one before it’s probably just what babies do, or it’s probably something I’m doing or I probably just need to learn to wind him better and so on.

When the other mum said she’d had all those problems and then outlined what feeding was like now - the first replied it gave her such hope and she’d been told it was just was breastfed babies do, or perhaps he’d just “prefer” the bottle.

There are always the exceptions to the above, but you can seek support and chat it through with someone if you’re unsure or things feel unmanageable :)

Response:Guardian Letter to a Lactation Consultant

On Saturday The Guardian printed an anonymous “parent piece” from a mother who has a bad experience with a “lactation consultant” and her tongue tied baby.

Many aren’t aware that “Lactation consultant” is neither a recognised nor protected title. Your sister’s, friend Margaret who breastfed for half a day can call herself one.

Similarly, there isn’t an NHS job titled “lactation consultant” either (unlike I believe in the US) - so who this person was or what their qualifications are is incredibly unclear.

International Board Certified Lactation Consultant (IBCLC) is a certified title (although not registered and so ultimately poorly protected) , yet 90% of the time when someone says “lactation consultant”, the person doesn’t hold this certified title.

Unlike in the US, many hospitals in the UK don’t employ a certified IBCLC, even under a different title - although some do.Parents therefore often refer to anyone who helps them breastfeed as the lactation consultant.

As an IBCLC I cringed at the claims of what someone supposedly said, or perhaps implied.

So this certified lactation consultant is going to add another perspective:

1. No mum should be spending 12 hours a day feeding their baby. If someone feels overwhelmed, it’s important that the wants and needs of the parents are central to any “plan” established. I have seen plans set by some hospital staff with little breastfeeding experience, that have no gap for sleeping or eating. Instead two hourly feeding and pumping around the clock may be suggested, which is of course completely unsustainable.
2. Some mums want to use a hospital grade pump, other don’t. Some want to try a nipple shield, some don’t.
3. I’m unsure why a lactation consultant would ask a mum if she’s “fixed the tongue tie”, since this isn’t something a parent can do at home? If baby had a tongue tie diagnosed, when and by whom? Why is this "lactation consultant" not aware of if/when this is happening? It's all very confusing.
4. Frenugreek is a herb typically taken for low milk supply, which can follow a shallow latch associated with tongue tie. I’m not a huge fan personally, but some swear by it.
5. I’m not sure what poor garlic did wrong - a large study found that when breastfeeding mothers consumed garlic, their infants stayed at the breast and breastfed longer (1). And since an increase in breastfeeding can lead to an increase in the breast milk supply, this may be one of the reasons garlic can help breastfeeding mums make more breast milk.Which any certified IBCLC would likely know...

So what appears to have happened here is mum has been discharged attempting to breastfeed a tongue tied baby, with the first mention of support being after a problem has arisen.

The shallow latch meant baby couldn’t pull a full feed, despite feeding at the breast and so was still hungry afterwards. To try and provide more milk for the still hungry baby, mum has expressed - yet many are not given appropriate guidance on how to drain their breasts effectively with a pump. This means mums can invest significant chunks of time, for little milk removal. Some mums struggle to express well even if they have oodles of milk - triggering the milk ejection reflex is a learnt art and even then, some mums don’t respond to a pump the way they do a baby.

As a result of the reduced milk removal though, mum’s supply may reduce further despite her dedication - rather like pushing a boulder up a hill. This can quickly become understandably overwhelming.

The next section again leads me to question whether this was a certified IBCLC:

“more lactation cookies, more mother’s milk tea, more essential oils, more water, more calories, more nutritious calories, more hand expression, more, more, more.”

Lactation cookies and tea aren’t on the whole evidence based, and certainly not routinely recommended in the UK (much more popular in the US) - they tend to have more popularity on parent to parent social media pages.

Essential oils aren’t within the remit of an IBCLC and so would never be suggested in the UK (unless presumably the practitioner is also a certified and insured aromatherapist). Any parent needs to drink normal amounts of water and consume normal calories - drinking and eating excessive amounts doesn’t link to milk supply, so again this is a rather bizarre statement from someone who has supposedly undertaken rigorous training.

There are good and bad in any profession, I saw an appalling GP for an emergency appointment for a relative recently - not that I’m sure the Guardian would be interested in that though.

What’s worse here, is we internationally certified lactation consultants get the flack for anyone and everyone who ever helps with breastfeeding! In the absence of knowing the title of the person that actually helped, lactation consultant is used.

I’m not sure whether this article originated in the UK as the guardian doesn’t specify - but I’m sure many parents can relate to unskilled support lacking appropriate counselling skills they often find themselves left with.

I won’t hold my breath for a guardian article that follows from a mother with a polar opposite experience, I suspect I’d be quickly turning blue.