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A systematic review exploring the impact of social media on breastfeeding practices Lisa J. Orchard & Wendy Nicholls 

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A systematic review exploring the impact of social media on breastfeeding practices Lisa J. Orchard & Wendy Nicholls 

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Current Psychology 41, 6107-6123 (2022) Cite this article

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Abstract

Social media has potential to promote and support positive health behaviours. This systematic review explores the influence of social media on breastfeeding decision-making, promotion and support. For the purpose of the review, social media was defined as social networking sites and blogs; M-technology and apps were only considered if they included an interactive element, such as a 'share' function, or one-to-many communication. Searches were conducted on EBSCO across seven databases (limited to 2007-2019). Of the 1261 papers initially identified, 22 met the inclusion criteria for the current review. Results are mixed, but there is evidence that social media can be used to improve breastfeeding awareness and attitudes. Breastfeeding mothers value pro-breastfeeding online communities. However, the success of such social media groups may be dependent on specific content shared, individual contributors, and group dynamics. Key considerations for practitioners are offered regarding how social media can augment services offered to support breastfeeding. Research in this field is still very much in its infancy. Further investigation of specific social media content is needed, alongside the viewpoints of those who have ceased breastfeeding against their wishes.

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Data Availability

The datasets generated during and/or analysed during the current study are available in the PsyArXiv repository https://psyarxiv.com/bxrf7/.

Notes

Social media does not have a definitive definition, making the inclusion of technologies subjective. Although social networking sites, such as Facebook, Twitter and Instagram, are easily recognised as a form of social media, there is ambiguity surrounding other forms of technology, such as WhatsApp. Within the current review, text messages, videos, general Internet usage, and phone calls were not classed as social media. 'Apps' were only considered a form of social media if the app itself allowed for interactivity between multiple users (specifically, facilitating communication with other non-health professionals). Blogs were considered a form of social media as they were presumed to fulfil the requirement of interactivity through commenting, 'liking', and shares. Discussion boards outside of specified social media platforms were not classed as social media given their traditional reliance on anonymity and that they are not historically classed as a web 2.0 development.

References

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Acknowledgements

The authors would like to thank Laura Shepherd, Jordan McMahon and Luke Wilsdon for helping with paper administration, including sourcing literature and proofreading.

Funding

This research was supported by funding from the Early Researchers Award Scheme from The University of Wolverhampton.

Author information

Authors and Affiliations

Institute of Human Sciences, University of Wolverhampton, Wulfruna Street, Wolverhampton, WV1 1LY, UK

Lisa J. Orchard & Wendy Nicholls

Contributions

Both authors contributed to the review conception. Literature search and data quality was performed by both authors. Data analysis and the first draft of the manuscript was written by Dr. Lisa Orchard. This was critically revised by Dr. Wendy Nicholls. Both authors read and approved the final manuscript.

Corresponding author

Correspondence to Lisa J. Orchard.

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Conflicts of Interest/Competing Interests

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Orchard, L.J., Nicholls, W. A systematic review exploring the impact of social media on breastfeeding practices. Curr Psychol 41, 6107-6123 (2022). https://doi.org/10.1007/s12144-020-01064-w
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A systematic review exploring the impact of social media on breastfeeding practices - Current Psychology

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Social media has potential to promote and support positive health behaviours. This systematic review explores the influence of social media on breastfeeding decision-making, promotion and support. For the purpose of the review, social media was defined as social networking sites and blogs; M-technology and apps were only considered if they included an interactive element, such as a 'share' function, or one-to-many communication.

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How to use others' feedback to learn and grow | Sheila Heen | TEDxAmoskeagMillyardWomen

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Using 24-Hour Weight as Reference for Weight Loss Calculation Reduces Supplementation and Promotes Exclusive Breastfeeding in Infants Born by Cesar... - PubMed - NCBI

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Guardian article

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As I type this, the clock hands are creeping towards 2.30am, and my baby daughter is slumbering beside me having had her first feed of the night. There will, unquestionably, be more. I am on hand 24/7 to meet her dietary needs, an always-open milk bar with only one thing on the menu and only one employee serving the drinks. There is very little customer feedback, though occasionally I am rewarded with a loud and strangely satisfying burp.

In my bleary-eyed state, I read that paediatricians, MPs, midwifes and other experts are calling for the "multiple barriers to breastfeeding" that exist in Britain to be broken down, and for steps to be taken so that the practice can be considered "a normal, natural part of everyday life".

It's hard to disagree. The UK has one of the lowest breastfeeding rates in the world, a shameful statistic that speaks volumes about the incoherence of our approach to child-rearing. Despite the well-documented benefits of breastfeeding, only 43% of mothers in Britain will still be doing it by the time their babies are six to eight weeks old. Only 1% of babies are exclusively breastfed to six months, as the World Health Organisation recommends. It's clear that, as a country, we have a problem.

But how to fix it? In a letter to the Guardian on Tuesday, 18 experts called for better education in schools, more practical support from healthcare services, and for the government to ensure that women aren't put off breastfeeding by workplace constraints. I would add one more strategy: don't baby mothers-to-be. Be honest with them about how tough breastfeeding can be.

During my pregnancy I, like thousands of other well-intentioned pregnant women, assiduously attended National Childbirth Trust (NCT) classes, merrily bought an electric breast pump, even watched a video on how to get your baby to latch on perfectly with no fuss. The background music was soothing. The baby sprang on. On a different video shown to us in our NCT class, the mother was shown adopting the "laidback" feeding position, lying down and letting the infant to do all the work. This was greatly encouraging. I could do laidback! I'd just let nature weave her magic!

Forewarned, as our mothers, and their mothers, and their mothers, used to tell us, is forearmed

Fast forward to 20 April, at 6.28pm, and my mewling daughter, just born, is showing a distinct lack of interest in my breast. A procession of midwives - all of them kind, all of them determined to show me just how straightforward nature can be - grapple with my baby's head and my nipple and try to bring them together in perfect harmony. It does not work. I spend my daughter's first evening on earth painstakingly squeezing out tiny droplets of colostrum into a minuscule syringe. It is only the next day that, infuriated perhaps by my increasingly cack-handed attempts, she eventually complies. And it is then that I realise: nature can be marvellous. She can also be capricious. And it is supremely bloody painful.

Compared to many women, I got off lightly. Friends speak of months of nipple shields, jelonet gauze dressings, bleeding, cracked nipples, mastitis. And those are just the physical difficulties. The psychological challenges of breastfeeding - the pressure (yes, and privilege) of being your baby's sole provider; the mindbending fatigue of early weeks spent half-comatose and half-dressed in the half-light - are just as formidable, perhaps even more so. One friend switched to formula at three months because, amid the sometimes terrifying anxiety of early motherhood, she needed to feel her body was once more her own.

We need to hear these voices, and act on them. To tell women that breastfeeding is a bringer of health benefits and wondrous bonding is to tell them only half the story. Is it really surprising that a first-time mother, told by all and sundry that it should be easy, painless and emotionally blissful, turns away from breastfeeding, feeling herself a failure, when none of these things turns out to be true? Are we so intent on infantilising women that we won't tell them the truth?

Forewarned, as our mothers, and their mothers, and their mothers, used to tell us, is forearmed. Better, no-nonsense education is needed. Women need to know of the cons of breastfeeding as well as the pros, so that they are better prepared for the potential challenges ahead. So that if in the early days they are faced with a dagger-like pain, they are not shocked. So that when they are sitting alone on the sofa at 5am, they are expecting it. So that they don't feel like failures if their bodies simply won't cooperate. So that they are less likely to give up because of a misguided belief that if they find breastfeeding hard it is their fault. So that they can stock up on nipple cream.

Some will say that this would serve only to lower the breastfeeding rate further; that fewer women than ever will do it if they have all this spelled out to them. But in my experience new mothers will walk over hot coals if they are told it will help their babies. Moreover, they have just given birth; they are not easily scared off. So tell them breastfeeding is a magical fairytale and they will, fairly quickly, call you on it. But tell them the truth and you might just be surprised. That your wailing newborn probably won't leap up your body via your linea nigra to your breast, like in the videos, but that that's really OK, and that after a while, they'll probably get the hang of it. That, yes, breastfeeding can be relentless, but if you catch yourself feeling lonely and exhausted in the middle of the night, you're one of many. That it's free. That it helps you lose weight. That cabbage leaves soothe the soreness and that, once the initial discomfort has passed, it can be easy and practical and really rather lovely.

It might not be the sexiest sell, but at least it's not setting you up for disappointment and frustration. Instead, perhaps it will leave you better-equipped, both physically and mentally, to continue breastfeeding.

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Don't infantilise pregnant women. Tell them how tough breastfeeding can be | Lizzy Davies

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As I type this, the clock hands are creeping towards 2.30am, and my baby daughter is slumbering beside me having had her first feed of the night. There will, unquestionably, be more. I am on hand 24/7 to meet her dietary needs, an always-open milk bar with only one thing on the menu and only one employee serving the drinks.

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science daily

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Mothers protect their babies and teach them habits to stay healthy and safe as they grow. A new UCLA-led study shows that beneficial bacteria from mothers do much the same thing.

The study found that 30 percent of the beneficial bacteria in a baby's intestinal tract come directly from mother's milk, and an additional 10 percent comes from skin on the mother's breast. What's more, babies who breast-feed even after they begin eating solid food continue reaping the benefits of a breast milk diet -- a growing population of beneficial bacteria associated with better health.

After birth, beneficial bacteria from the mother and environment colonize the infant's intestine, helping digest food and training the baby's immune system to recognize bacterial allies and enemies. But scientists still don't completely understand the mechanisms that help babies establish a healthy gut microbiome -- the diverse community of bacteria that inhabits the intestines.

"Breast milk is this amazing liquid that, through millions of years of evolution, has evolved to make babies healthy, particularly their immune systems," said Dr. Grace Aldrovandi, the study's senior author and a professor of pediatrics and chief of infectious diseases at UCLA Mattel Children's Hospital. "Our research identifies a new mechanism that contributes to building stronger, healthier babies."

The findings appear in the May 8 issue of the JAMA Pediatrics.

The study, which looked at 107 mother-infant pairs, is the largest to date showing the transfer of bacteria in the milk into the baby's gut, Aldrovandi said.

Earlier research has shown that a balanced bacterial community in the intestine is a key factor in people's susceptibility to immune diseases. For example, children who develop type 1 diabetes have abnormalities in their gut microbiomes; what's more, a healthy gut appears to protect against allergies, asthma and inflammatory bowel disease throughout life.

"We're appreciating more and more how these bacterial communities, particularly in the intestine, help guard against the bad guys," Aldrovandi said. "We know from animal model systems that if you get good bacteria in your gut early in life, you're more likely to be healthy."

Throughout the babies' first year of life, researchers collected samples of breast milk and infant stool, and swabs from the skin around the nipple. They analyzed the samples to assess which bacteria were shared between mothers and infants, and calculated the relative abundance of the bacteria. The origin of breast milk bacteria remains unclear; one hypothesis is that it travels to the breast from the mother's intestine.

The project did not address how babies who are fed only formula acquire heathy microbiomes.

Aldrovandi and colleagues want to expand the research to evaluate more samples in late infancy to better understand the transition to an adult microbiome. They would like to test in the lab how bacteria that are provided through breast-feeding are critical in infants' immune responses, and determine which beneficial bacteria are missing in people who have certain diseases.

Journal Reference:

Pia S. Pannaraj, Fan Li, Chiara Cerini, Jeffrey M. Bender, Shangxin Yang, Adrienne Rollie, Helty Adisetiyo, Sara Zabih, Pamela J. Lincez, Kyle Bittinger, Aubrey Bailey, Frederic D. Bushman, John W. Sleasman, Grace M. Aldrovandi. Association Between Breast Milk Bacterial Communities and Establishment and Development of the Infant Gut Microbiome. JAMA Pediatrics, 2017; DOI: 10.1001/jamapediatrics.2017.0378

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breastfeeding; infant's health; breast cancer; gastrointestinal problems; bacteria; microbes and more; microbiology; extreme survival

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Breast-feeding's role in 'seeding' infant microbiome: Nearly one-third of beneficial bacteria in baby's intestinal tract comes directly from mother's milk

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Mothers protect their babies and teach them habits to stay healthy and safe as they grow. A new UCLA-led study shows that beneficial bacteria from mothers do much the same thing. The study found that 30 percent of the beneficial bacteria in a baby's intestinal tract come directly from mother's milk, and an additional 10 percent comes from skin on the mother's breast.

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BBC audio

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Fi Glover joins mothers expressing milk for their premature babies in hospital.

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A longitudinal study from the United State of 3600 participants has found that children who experience trauma, abuse, neglect and family dysfunction are at increased risk of having heart disease in their 50s and 60s.

Those exposed to the highest levels of childhood adversity were found to be 50% more likely to have a heart attack or stroke in middle age. Even after controlling for risk factors for coronary artery disease in young adulthood, the researchers conclude that adverse childhood family environment is associated with heart disease later in life.

REFERENCE: Pierce, J.B., Kershaw, K.N., Kiefe, C.I., Jacobs, D.R., Sidney, S. et al. (2020) Association of childhood psychosocial environment with 30 year cardiovascular disease incidence and mortality in middle age. Journal of the American Heart Association. DOI: 10.1161/JAHA.119.015326
[Editor's Note: This study points yet again to the impact of the early family environment on children's lifelong wellbeing and good health. Interventions in the critical 1000 days may yield returns both for the individual across the life trajectory and for society.]

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Heart disease more likely for adults from dysfunctional family backgrounds

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A longitudinal study from the United State of 3600 participants has found that children who experience trauma, abuse, neglect and family dysfunction are at increased risk of having heart disease in their 50s and 60s. Those exposed to the highest levels of childhood adversity were found to be 50% more likely to have a heart attack or stroke in middle age.

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website for parents and health professionals

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To guide you towards happy mealtimes and healthy children.

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We are a group of academic psychologists who specialise in children's eating behaviour and parenting at mealtimes. Importantly, we are also mums.
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We had an exciting line-up of speakers for our 2014 GOLD Lactation Conference. We had a chance to sit down with some of the Speakers before the conference begins and learn a little bit more about them and what they will be presenting this year. Enjoy!
Please note, these are NOT presentations and do not count towards educational hours

Breast Crawl: from Science to Implementation
Dr. Kartikeya Prashant

Breast Crawl: from Science to Implementation
Dr. Prashant Gangal

( The Faux Tie: When is a "Tongue-tie" NOT a Tongue-tie? Tongue-tie Pack)
Dr. Alison Hazelbaker

& more to come!

# data[].attributes.attachment_link.description
We had an exciting line-up of speakers for our 2014 GOLD Lactation Conference. We had a chance to sit down with some of the Speakers before the conference begins and learn a little bit more about them and what they will be presenting this year. Enjoy!

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Cultural aspects

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2017

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Far from being an easily synthesised mixture of nutrients, breast milk contains a multitude of microbes, stem cells and biological molecules that scientists are still trying to understand. Dr Natalie Shenker MRSB explores what we do and don't know about the white stuff The Biologist 64(3) p10-13
After 70 years of cultural shift in the West towards babies being bottle-fed formula milk rather than breastfed, one of the prevailing views in the general population is that there is no difference biologically between breast milk and formula.

This view is also held by a large number of doctors and healthcare professionals, propagating myths about common breastfeeding issues as being reasons to stop and "just give formula". For example, if a medication is to be prescribed and there is no available information about the transfer of the drug or its metabolites into breast milk, women are often advised to stop breastfeeding to be on the safe side.

This is contrary to the reality that breastfed babies are at lower risk of infections, obesity and haematological malignancies[1]. In preterm and sick babies, breast milk is critically important to prevent infections and necrotising enterocolitis (NEC), a catastrophic gut condition that carries a mortality rate of 40%.

Some states in the US have taken the radical step of banning the use of formula on neonatal intensive care units.

For mothers, the benefits of breastfeeding are well established. It is classified by the World Cancer Research Fund/American Institute for Cancer Research as protective against breast and ovarian cancers[2]. Breastfeeding for even a short amount of time reduces risk by 16-24% for triple negative breast cancer, the most aggressive form of the disease[3,4].

An estimated 18% of ovarian cancers in the UK are linked to women breastfeeding each of their children for fewer than six months.5 According to several meta-analyses, ovarian cancer risk is 24-30% lower in women who have ever breastfed, versus those who have never done so[6].

The risk of both cancers is reduced even further in women with high-risk genetic mutations such as BRCA[1]. Women who breastfeed have lower chances of developing type 2 diabetes later in life[7], obesity[8] and cardiovascular disease, as well as a reduced likelihood of postnatal depression[9].

What is it about maternal milk that can explain this diverse impact on maternal and infant health?

Breast milk contains thousands of different molecules, growth factors, hormones, microorganisms and cells, which work together to provide the human baby with all the tools necessary to grow and develop normally. Many of its components have only recently been discovered - leaving the tantalising possibility that more remain - and the functions of many remain unknown.

Carl Linnaeus, the founder of taxonomy, originally used the word 'Mammalia' ('mamma' is Latin for breast) to describe animals that feed their young with milk. Evolutionary biologists estimate that the ancestor of all mammals lived 310 million years ago and oozed milk from its skin for the young to feed on after hatching from eggs. Over time, these skin glands evolved into nipples as a way to deliver the mother's immune system to newborns to protect them from infections. Food might have been a secondary benefit.

This immune protection covers the vulnerable period of early life when the immature immune system is not well developed - in humans, the immune system is thought to be fully mature only at the age of six. The breast itself is a source of specific immune cells and can, therefore, be seen as an immune organ, although it is never listed as such in medical textbooks. One hypothesis regarding the benefit of breastfeeding to mothers is that the breast also ramps up the mother's own immune system to aid postnatal recovery.
Breast milk contains a multitude of human and non-human cells as well as nutrients, hormones and other immune system-related components.
Human milk has evolved to specifically nourish human babies. Hundreds of bioactive components directly protect them from pathogens found in their environment.

Compared with other species, a higher proportion and diversity of fatty acids support the growth of the human brain (which is particularly large in comparison to that of other mammals), and an extraordinarily diverse microbiome (>800 bacterial strains on average, along with fungi, parasites and viruses) drives the healthy development of infant gut physiology. The composition of the breast milk microbiome changes over months and years, and work is ongoing to understand the impact this has on the developing gut.

Breast milk contains cells - and lots of them. In mature milk (produced approximately six weeks after birth), a single millilitre can contain millions of epithelial lactocytes, stem cells and immune cells.

Colostrum, produced within the first two to three days after birth, provides an energy-rich dose in just a few millilitres per feed, but also includes a dense cellular component made up predominantly of white blood cells. Of these, the most common cells are breast-specific macrophages, which can engulf and absorb harmful microorganisms.

These macrophages also manufacture lactoferrin and lysozyme. The former is an iron-binding protein that helps the baby to absorb and store iron. As well as being important nutritionally, this prevents the growth of harmful microorganisms such as E. coli, Staphylococcus species and yeast ( Candida), which need iron to survive.

Lysozyme is an enzyme that kills bacteria by disrupting their cell walls and also has antiviral effects. Both it and lactoferrin increase in concentration in breast milk over time as babies become mobile and start to explore their environment.

The World Health Organization recommends that babies should be exclusively breastfed until approximately six months of age, with the introduction of complementary foods thereafter and weaning from breastfeeding after the age of two years. This has been widely interpreted as breast milk having no benefits (or even nutritional value) over the six-month cut-off. However, breast milk not only continues to provide increased immune protection to the child, but the calorie value per feed increases as the child grows, and so they need feeding less frequently[1].

Evolutionarily, the age of natural term weaning is likely to range from between two and seven years - hence the term 'milk teeth', which start falling out when children are around six or seven.

Antibodies produced by the mother, which are transferred into milk as well as to cells in breast milk, are highly targeted against infectious agents in her environment.

When a mother ingests or inhales pathogens, lymph nodes in the lungs and small intestine manufacture specially sensitised lymphocytes, which then migrate to the breasts and create tailor-made secretory antibodies against that pathogen.

These mucosal pathogens are a major killer of children below the age of five years, causing more than 14 million deaths annually. Diarrhoeal disease alone kills five million children each year in the developing world; the risk of dying from diarrhoea is reduced by approximately 20-fold in breastfed children.

Breast milk also contains more than 200 types of sugars known as oligosaccharides. Although most oligosaccharides have unknown functions, some help to block bacterial antigens from sticking to the wall of the gastrointestinal tract. This blocking mechanism is particularly effective against Pneumococcus, an extremely 'sticky' bacterium that can cause pneumonia and systemic sepsis. Twenty oligosaccharides in milk can't be digested by humans, but are there instead to feed the 'helpful' bacteria found in breast milk and the infant gut.

These bacteria will help the baby to form its own normal microbiome, to the exclusion of harmful pathogens. Scientists and doctors are starting to understand how the microbiome has a huge role in helping the gut to develop, digest food and support the immune system of the baby as it grows.

Indeed, the microbiome of maternal milk may be critical to helping the immature gut of a very premature baby to seal, preventing colonisation by pathogenic bacteria and reducing the likelihood of the development of NEC.

As new research begins to understand lactation, more surprising findings are emerging. Multipotent stem cells were discovered in breast milk in 2007, having the potential to form an entire functioning breast ductal system that can produce milk. Stem cells are carried into the infant stomach, where they potentially can survive the acidic environment.

Animal studies have shown maternally derived stem cells to be present in the brain and kidneys of infants, creating chimeras between the mothers and their offspring. In humans, we don't know yet whether these cells are simply by-products of the 10-fold increase in ductal stem cell cycling during pregnancy or have a specific function.

Mothers and babies are known to communicate with each other through breastfeeding in multiple ways - hormonally through surges of oxytocin (the 'hug' hormone) that create feelings of wellbeing and relaxation in the mother and stimulate the milk let-down reflex, through skin-to-skin exposure, and directly through components in the milk.

Babies are born without diurnal cortisol rhythms, which develop in the first few months of life. Breastfed babies have five-fold higher levels of cortisol receptors than formula-fed babies, reflecting the transfer of cortisol through milk, although the function of cortisol in this context is unknown - it is likely to be an important mediator of metabolism and establishing normal cortisol functioning, and sleep cycles, in infants.

It has also been shown that early initiation of breastfeeding - that is, within an hour of birth - can have significant long-term effects, and work is ongoing to understand how breastfeed can modulate the infant's genes.

Finally, and most speculatively, ultrasound studies in Australia have shown that infant saliva can be sucked back into the nipple through the vacuum effect created by the mouth. Although only a hypothesis at present, babies may just be sending information into the breast about any infections to which they have been exposed. They may even be ordering what they need in their next meal through microRNAs, tiny genetic messages in their saliva.

Breast milk contains hundreds of bioactive components, including one of the most complex microbiomes in the human body. The normal physiology of how each individual component functions, let alone the complexity of the interactions within human milk and between the mother and child, leaves a broadly under-researched field open for investigation.

With the advent of novel funders internationally, independent of food industry involvement, there is hope that the seeds of a new field of biology - human lactology - are being planted. Our own work at the Hearts Milk Bank, to establish a large bioresource of breast milk samples, will facilitate a wide range of studies into infant and maternal health, a small part of a huge body of work that lies ahead.
This rich fluid may hold many clues about human health during childhood and how illnesses that start in adulthood may be patterned in our earliest days.
Breast v bottle

Public health messaging over the last 20 years has been focused around the catchy phrase 'Breast is Best', now shorthand for the debate over how our children are fed.

However, the UK has among the lowest rates of breastfeeding in the world and although this message has increased breastfeeding initiation rates to over 85%, only 40% of babies are receiving any breast milk at six weeks, and fewer than 20% at six months.

The Lancet Series on Breastfeeding[1] indicated that optimising breastfeeding globally could save more than 800,000 babies each year, and prevent 20,000 maternal deaths from cancer.

Given that most health impacts of breastfeeding for both the mother and child are time-dependent, the fact that only one in 200 women breastfeed for one year in the UK demonstrates the need for greater public education on the science of infant feeding.

Natalie Shenker MRSB is an Oxford-trained doctor with a PhD in breast cancer epigenetic risk markers from Imperial College. She is the co-founder of the Hearts Milk Bank, which aims to remove the NHS postcode lottery for screened donor milk.

References
1) Victora, C. G. et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet 387(10017), 475-490 (2016).
2) World Cancer Research Fund/American Institute for Cancer Research. Continuous Update Project Findings & Reports. Accessed October 2016.
3) Parkin, D. M. et al. The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. Summary and conclusions. Br. J. Cancer 105 (S2):S77-S81 (2011).
4) Chowdhury, R. et al. Breastfeeding and maternal health outcomes: a systematic review and meta-analysis. Acta. Paediatr. 104(467), 96-113 (2015).
5) Li, D. P. et al. Breastfeeding and ovarian cancer risk: a systematic review and meta-analysis of 40 epidemiological studies (link is external). Asian. Pac. J. Cancer Prev. 15(12), 4829-4837 (2014).
6) Luan, N. N. et al. Breastfeeding and ovarian cancer risk: a meta-analysis of epidemiologic studies. Am. J .Clin. Nutr. 98(4), 1020-1031 (2013).
7) Aune, D. et al. Breastfeeding and the maternal risk of type 2 diabetes: a systematic review and dose-response meta-analysis of cohort studies. Nutr. Metab. Cardiovasc. Dis. 24, 107-115 (2014).
8) Bobrow, K. L. et al. Persistent effects of women's parity and breastfeeding patterns on their body mass index: results from the Million Women Study. Int. J. Obes. (Lond) 37, 712-717 (2013).
9) Dias C. C. & Figueiredo, B. Breastfeeding and depression: a systematic review of the literature. J. Affect. Disord. 171, 142-154 (2015).

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Far from being an easily synthesised mixture of nutrients, breast milk contains a multitude of microbes, stem cells and biological molecules that scientists are still trying to understand.

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UNICEF

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Antenatal education

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I did Nct to make friends too. It was been useful In that respect and I still see them every 1-2 weeks. However I don't think any will become life long friends.
The actual course was rubbish!! The teacher we had was awful though. She was very vague and didn't even cover some major topics such as pain relief!
I also did an nhs antenatal class which I found much more useful from a learning point of view. I didn't make any friends in my nhs class but I know it's still possible.

Featured Discussions

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I did Nct to make friends too. It was been useful In that respect and I still see them every 1-2 weeks. However I don't think any will become life long friends. The actual course was rubbish!! The teacher we had was awful though.

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Review effectiveness of breastfeeding support

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Review effectiveness of breastfeeding support

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Cochrane

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Support for healthy breastfeeding mothers with healthy term babies. - PubMed - NCBI

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Cochrane Database Syst Rev. 2017 Feb 28;2:CD001141. doi: 10.1002/14651858.CD001141.pub5. Meta-Analysis; Research Support, Non-U.S. Gov't; Review

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The Atlantic article

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Also see:

Video: "Mother's Milk"
Hanna Rosin and three friends discuss the science and culture of breastfeeding

One afternoon at the playground last summer, shortly after the birth of my third child, I made the mistake of idly musing about breast-feeding to a group of new mothers I'd just met. This time around, I said, I was considering cutting it off after a month or so. At this remark, the air of insta-friendship we had established cooled into an icy politeness, and the mothers shortly wandered away to chase little Emma or Liam onto the slide. Just to be perverse, over the next few weeks I tried this experiment again several more times. The reaction was always the same: circles were redrawn such that I ended up in the class of mom who, in a pinch, might feed her baby mashed-up Chicken McNuggets.

In my playground set, the urban moms in their tight jeans and oversize sunglasses size each other up using a whole range of signifiers: organic content of snacks, sleekness of stroller, ratio of tasteful wooden toys to plastic. But breast-feeding is the real ticket into the club. My mother friends love to exchange stories about subversive ways they used to sneak frozen breast milk through airline security (it's now legal), or about the random brutes on the street who don't approve of breast-feeding in public. When Angelina Jolie wanted to secure her status as America's ur-mother, she posed on the cover of W magazine nursing one of her twins. Alt-rocker Pete Wentz recently admitted that he tasted his wife, Ashlee Simpson's, breast milk ("soury" and "weird"), after bragging that they have a lot of sex-both of which must have seemed to him markers of a cool domestic existence.

From the moment a new mother enters the obstetrician's waiting room, she is subjected to the upper-class parents' jingle: "Breast Is Best." Parenting magazines offer "23 Great Nursing Tips," warnings on "Nursing Roadblocks," and advice on how to find your local lactation consultant (note to the childless: yes, this is an actual profession, and it's thriving). Many of the stories are accompanied by suggestions from the ubiquitous parenting guru Dr. William Sears, whose Web site hosts a comprehensive list of the benefits of mother's milk. "Brighter Brains" sits at the top: "I.Q. scores averaging seven to ten points higher!" (Sears knows his audience well.) The list then moves on to the dangers averted, from infancy on up: fewer ear infections, allergies, stomach illnesses; lower rates of obesity, diabetes, heart disease. Then it adds, for good measure, stool with a "buttermilk-like odor" and "nicer skin"-benefits, in short, "more far-reaching than researchers have even dared to imagine."

In 2005, Babytalk magazine won a National Magazine Award for an article called "You Can Breastfeed." Given the prestige of the award, I had hoped the article might provide some respite from the relentlessly cheerful tip culture of the parenting magazines, and fill mothers in on the real problems with nursing. Indeed, the article opens with a promisingly realistic vignette, featuring a theoretical "You" cracking under the strain of having to breast-feed around the clock, suffering "crying jags" and cursing at your husband. But fear not, You. The root of the problem is not the sudden realization that your ideal of an equal marriage, with two parents happily taking turns working and raising children, now seems like a farce. It turns out to be quite simple: You just haven't quite figured out how to fit "Part A into Part B." Try the "C-hold" with your baby and some "rapid arm movement," the story suggests. Even Dr. Sears pitches in: "Think 'fish lips,'" he offers.

In the days after my first child was born, I welcomed such practical advice. I remember the midwife coming to my hospital bed and shifting my arm here, and the baby's head there, and then everything falling into place. But after three children and 28 months of breast-feeding (and counting), the insistent cheerleading has begun to grate. Buttermilk-like odor? Now Dr. Sears is selling me too hard. I may have put in fewer parenting years than he has, but I do have some perspective. And when I look around my daughter's second-grade class, I can't seem to pick out the unfortunate ones: "Oh, poor little Sophie, whose mother couldn't breast-feed. What dim eyes she has. What a sickly pallor. And already sprouting acne!"

I dutifully breast-fed each of my first two children for the full year that the American Academy of Pediatrics recommends. I have experienced what the Babytalk story calls breast-feeding-induced "maternal nirvana." This time around, nirvana did not describe my state of mind; I was launching a new Web site and I had two other children to care for, and a husband I would occasionally like to talk to. Being stuck at home breast-feeding as he walked out the door for work just made me unreasonably furious, at him and everyone else.

In Betty Friedan's day, feminists felt shackled to domesticity by the unreasonably high bar for housework, the endless dusting and shopping and pushing the Hoover around-a vacuum cleaner being the obligatory prop for the "happy housewife heroine," as Friedan sardonically called her. When I looked at the picture on the cover of Sears's Breastfeeding Book-a lady lying down, gently smiling at her baby and still in her robe, although the sun is well up-the scales fell from my eyes: it was not the vacuum that was keeping me and my 21st-century sisters down, but another sucking sound.

Still, despite my stint as the postpartum playground crank, I could not bring myself to stop breast-feeding-too many years of Sears's conditioning, too many playground spies. So I was left feeling trapped, like many women before me, in the middle-class mother's prison of vague discontent: surly but too privileged for pity, breast-feeding with one hand while answering the cell phone with the other, and barking at my older kids to get their own organic, 100 percent juice-the modern, multitasking mother's version of Friedan's "problem that has no name."

And in this prison I would have stayed, if not for a chance sighting. One day, while nursing my baby in my pediatrician's office, I noticed a 2001 issue of the Journal of the American Medical Association open to an article about breast-feeding: "Conclusions: There are inconsistent associations among breastfeeding, its duration, and the risk of being overweight in young children." Inconsistent? There I was, sitting half-naked in public for the tenth time that day, the hundredth time that month, the millionth time in my life-and the associations were inconsistent? The seed was planted. That night, I did what any sleep-deprived, slightly paranoid mother of a newborn would do. I called my doctor friend for her password to an online medical library, and then sat up and read dozens of studies examining breast-feeding's association with allergies, obesity, leukemia, mother-infant bonding, intelligence, and all the Dr. Sears highlights.

After a couple of hours, the basic pattern became obvious: the medical literature looks nothing like the popular literature. It shows that breast-feeding is probably, maybe, a little better; but it is far from the stampede of evidence that Sears describes. More like tiny, unsure baby steps: two forward, two back, with much meandering and bumping into walls. A couple of studies will show fewer allergies, and then the next one will turn up no difference. Same with mother-infant bonding, IQ, leukemia, cholesterol, diabetes. Even where consensus is mounting, the meta studies-reviews of existing studies-consistently complain about biases, missing evidence, and other major flaws in study design. "The studies do not demonstrate a universal phenomenon, in which one method is superior to another in all instances," concluded one of the first, and still one of the broadest, meta studies, in a 1984 issue of Pediatrics, "and they do not support making a mother feel that she is doing psychological harm to her child if she is unable or unwilling to breastfeed." Twenty-five years later, the picture hasn't changed all that much. So how is it that every mother I know has become a breast-feeding fascist?

* * *

Like many babies of my generation, I was never breast-fed. My parents were working-class Israelis, living in Tel Aviv in the '70s and aspiring to be modern. In the U.S., people were already souring on formula and passing out No NestlÉ buttons, but in Israel, Nestlé formula was the latest thing. My mother had already ditched her fussy Turkish coffee for Nescafé (just mix with water), and her younger sister would soon be addicted to NesQuik. Transforming soft, sandy grains from solid to magic liquid must have seemed like the forward thing to do. Plus, my mom believed her pediatrician when he said that it was important to precisely measure a baby's food intake and stick to a schedule. (To this day she pesters me about whether I'm sure my breast-fed babies are getting enough to eat; the parenting magazines would classify her as "unsupportive" and warn me to stay away.)

Formula grew out of a late-19th-century effort to combat atrocious rates of infant mortality by turning infant feeding into a controlled science. Pediatrics was then a newly minted profession, and for the next century, the men who dominated it would constantly try to get mothers to welcome "enlightenment from the laboratory," writes Ann Hulbert in Raising America. But now and again, mothers would fight back. In the U.S., the rebellion against formula began in the late '50s, when a group of moms from the Chicago suburbs got together to form a breast-feeding support group they called La Leche League. They were Catholic mothers, influenced by the Christian Family Movement, who spoke of breast-feeding as "God's plan for mothers and babies." Their role model was the biblical Eve ("Her baby came. The milk came. She nursed her baby," they wrote in their first, pamphlet edition of The Womanly Art of Breastfeeding, published in 1958).

They took their league's name, La Leche, from a shrine to the Madonna near Jacksonville, Florida, called Nuestra Señora de La Leche y Buen Parto, which loosely translates into "Our Lady of Happy Delivery and Plentiful Milk." A more forthright name was deemed inappropriate: "You didn't mention breast in print unless you were talking about Jean Harlow," said co-founder Edwina Froehlich. In their photos, the women of La Leche wear practical pumps and high-neck housewife dresses, buttoned to the top. They saw themselves as a group of women who were "kind of thinking crazy," said co-founder Mary Ann Cahill. "Everything we did was radical."

La Leche League mothers rebelled against the notion of mother as lab assistant, mixing formula for the specimen under her care. Instead, they aimed to "bring mother and baby together again." An illustration in the second edition shows a woman named Eve-looking not unlike Jean Harlow-exposed to the waist and caressing her baby, with no doctor hovering nearby. Over time the group adopted a feminist edge. A 1972 publication rallies mothers to have "confidence in themselves and their sisters rather than passively following the advice of licensed professionals." As one woman wrote in another league publication, "Yes, I want to be liberated! I want to be free! I want to be free to be a woman!"

In 1971, the Boston Women's Health Book Collective published Our Bodies, Ourselves, launching a branch of feminism known as the women's-health movement. The authors were more groovy types than the La Leche League moms; they wore slouchy jeans, clogs, and bandanas holding back waist-length hair. But the two movements had something in common; Our Bodies also grew out of "frustration and anger" with a medical establishment that was "condescending, paternalistic, judgmental and non-informative." Teaching women about their own bodies would make them "more self-confident, more autonomous, stronger," the authors wrote. Breasts were not things for men to whistle and wink at; they were made for women to feed their babies in a way that was "sensual and fulfilling." The book also noted, in passing, that breast-feeding could "strengthen the infant's resistance to infection and disease"-an early hint of what would soon become the national obsession with breast milk as liquid vaccine.

Pediatricians have been scrutinizing breast milk since the late 1800s. But the public didn't pay much attention until an international scandal in the '70s over "killer baby bottles." Studies in South America and Africa showed that babies who were fed formula instead of breast milk were more likely to die. The mothers, it turned out, were using contaminated water or rationing formula because it was so expensive. Still, in the U.S., the whole episode turned breast-feeding advocates and formula makers into Crips and Bloods, and introduced the take-no-prisoners turf war between them that continues to this day.

Some of the magical thinking about breast-feeding stems from a common misconception. Even many doctors believe that breast milk is full of maternal antibodies that get absorbed into the baby's bloodstream, says Sydney Spiesel, a clinical professor of pediatrics at Yale University's School of Medicine. That is how it works for most mammals. But in humans, the process is more pedestrian, and less powerful. A human baby is born with antibodies already in place, having absorbed them from the placenta. Breast milk dumps another layer of antibodies, primarily secretory IgA, directly into the baby's gastrointestinal tract. As the baby is nursing, these extra antibodies provide some added protection against infection, but they never get into the blood.

Since the identification of sIgA, in 1961, labs have hunted for other marvels. Could the oligosaccharides in milk prevent diarrhea? Do the fatty acids boost brain development? The past few decades have turned up many promising leads, hypotheses, and theories, all suggestive and nifty but never confirmed in the lab. Instead, most of the claims about breast-feeding's benefits lean on research conducted outside the lab: comparing one group of infants being breast-fed against another being breast-fed less, or not at all. Thousands of such studies have been published, linking breast-feeding with healthier, happier, smarter children. But they all share one glaring flaw.

An ideal study would randomly divide a group of mothers, tell one half to breast-feed and the other not to, and then measure the outcomes. But researchers cannot ethically tell mothers what to feed their babies. Instead they have to settle for "observational" studies. These simply look for differences in two populations, one breast-fed and one not. The problem is, breast-fed infants are typically brought up in very different families from those raised on the bottle. In the U.S., breast-feeding is on the rise-69 percent of mothers initiate the practice at the hospital, and 17 percent nurse exclusively for at least six months. But the numbers are much higher among women who are white, older, and educated; a woman who attended college, for instance, is roughly twice as likely to nurse for six months. Researchers try to factor out all these "confounding variables" that might affect the babies' health and development. But they still can't know if they've missed some critical factor. "Studies about the benefits of breast-feeding are extremely difficult and complex because of who breast-feeds and who doesn't," says Michael Kramer, a highly respected researcher at McGill University. "There have been claims that it prevents everything-cancer, diabetes. A reasonable person would be cautious about every new amazing discovery."

The study about obesity I saw in my pediatrician's office that morning is a good example of the complexity of breast-feeding research-and of the pitfalls it contains. Some studies have found a link between nursing and slimmer kids, but they haven't proved that one causes the other. This study surveyed 2,685 children between the ages of 3 and 5. After adjusting for race, parental education, maternal smoking, and other factors-all of which are thought to affect a child's risk of obesity-the study found little correlation between breast-feeding and weight. Instead, the strongest predictor of the child's weight was the mother's. Whether obese mothers nursed or used formula, their children were more likely to be heavy. The breast-feeding advocates' dream-that something in the milk somehow reprograms appetite-is still a long shot.

In the past decade, researchers have come up with ever more elaborate ways to tease out the truth. One 2005 paper focused on 523 sibling pairs who were fed differently, and its results put a big question mark over all the previous research. The economists Eirik Evenhouse and Siobhan Reilly compared rates of diabetes, asthma, and allergies; childhood weight; various measures of mother-child bonding; and levels of intelligence. Almost all the differences turned out to be statistically insignificant. For the most part, the "long-term effects of breast feeding have been overstated," they wrote.

Nearly all the researchers I talked to pointed me to a series of studies designed by Kramer, published starting in 2001. Kramer followed 17,000 infants born in Belarus throughout their childhoods. He came up with a clever way to randomize his study, at least somewhat, without doing anything unethical. He took mothers who had already started nursing, and then subjected half of them to an intervention strongly encouraging them to nurse exclusively for several months. The intervention worked: many women nursed longer as a result. And extended breast-feeding did reduce the risk of a gastrointestinal infection by 40 percent. This result seems to be consistent with the protection that sIgA provides; in real life, it adds up to about four out of 100 babies having one less incident of diarrhea or vomiting. Kramer also noted some reduction in infant rashes. Otherwise, his studies found very few significant differences: none, for instance, in weight, blood pressure, ear infections, or allergies-some of the most commonly cited benefits in the breast-feeding literature.

Both the Kramer study and the sibling study did turn up one interesting finding: a bump in "cognitive ability" among breast-fed children. But intelligence is tricky to measure, because it's subjective and affected by so many factors. Other recent studies, particularly those that have factored out the mother's IQ, have found no difference at all between breast-fed and formula-fed babies. In Kramer's study, the mean scores varied widely and mysteriously from clinic to clinic. What's more, the connection he found "could be banal," he told me-simply the result of "breast-feeding mothers' interacting more with their babies, rather than of anything in the milk."

The IQ studies run into the central problem of breast-feeding research: it is impossible to separate a mother's decision to breast-feed-and everything that goes along with it-from the breast-feeding itself. Even sibling studies can't get around this problem. With her first child, for instance, a mother may be extra cautious, keeping the neighbor's germy brats away and slapping the nurse who gives out the free formula sample. By her third child, she may no longer breast-feed-giving researchers the sibling comparison that they crave-but many other things may have changed as well. Maybe she is now using day care, exposing the baby to more illnesses. Surely she is not noticing that kid No.2 has the baby's pacifier in his mouth, or that the cat is sleeping in the crib (trust me on this one). She is also not staring lovingly into the baby's eyes all day, singing songs, reading book after infant book, because she has to make sure that the other two kids are not drowning each other in the tub. On paper, the three siblings are equivalent, but their experiences are not.

What does all the evidence add up to? We have clear indications that breast-feeding helps prevent an extra incident of gastrointestinal illness in some kids-an unpleasant few days of diarrhea or vomiting, but rarely life-threatening in developed countries. We have murky correlations with a whole bunch of long-term conditions. The evidence on IQs is intriguing but not all that compelling, and at best suggests a small advantage, perhaps five points; an individual kid's IQ score can vary that much from test to test or day to day. If a child is disadvantaged in other ways, this bump might make a difference. But for the kids in my playground set, the ones whose mothers obsess about breast-feeding, it gets lost in a wash of Baby Einstein videos, piano lessons, and the rest. And in any case, if a breast-feeding mother is miserable, or stressed out, or alienated by nursing, as many women are, if her marriage is under stress and breast-feeding is making things worse, surely that can have a greater effect on a kid's future success than a few IQ points.

So overall, yes, breast is probably best. But not so much better that formula deserves the label of "public health menace," alongside smoking. Given what we know so far, it seems reasonable to put breast-feeding's health benefits on the plus side of the ledger and other things-modesty, independence, career, sanity-on the minus side, and then tally them up and make a decision. But in this risk-averse age of parenting, that's not how it's done.

In the early '90s, a group of researchers got together to revise the American Academy of Pediatrics' policy statement on breast-feeding. They were of the generation that had fought the formula wars, and had lived through the days when maternity wards automatically gave women hormone shots to stop the flow of breast milk. The academy had long encouraged mothers to make "every effort" to nurse their newborns, but the researchers felt the medical evidence justified a stronger statement. Released in 1997, the new policy recommended exclusive breast-feeding for six months, followed by six more months of partial breast-feeding, supplemented with other foods. The National Organization for Women complained that this would tax working mothers, but to no avail. "The fact that the major pediatric group in the country was taking a definitive stance made all the difference," recalls Lawrence Gartner, a pediatrician and neonatologist at the University of Chicago, and the head of the committee that made the change. "After that, every major organization turned the corner, and the popular media changed radically."

In 2004, the Department of Health and Human Services launched the National Breastfeeding Awareness Campaign. The ads came out just after my second child was born, and were so odious that they nearly caused me to wean him on the spot. One television ad shows two hugely pregnant women in a logrolling contest, with an audience egging them on. "You wouldn't take risks before your baby is born," reads the caption. "Why start after?" The screen then flashes: "Breastfeed exclusively for 6 months." A second spot shows a pregnant woman-this time African American-riding a mechanical bull in a bar while trying to hold on to her huge belly. She falls off the bull and the crowd moans.

To convey the idea that failing to breast-feed is harmful to a baby's health, the print ads show ordinary objects arranged to look like breasts: two dandelions (respiratory illness), two scoops of ice cream with cherries on top (obesity), two otoscopes (ear infections). Plans were made to do another ad showing rubber nipples on top of insulin syringes (suggesting that bottle-feeding causes diabetes), but then someone thought better of it. The whole campaign is so knowing, so dripping with sexual innuendo and condescension, that it brings to mind nothing so much as an episode of Mad Men, where Don Draper and the boys break out the whiskey at day's end to toast another victory over the enemy sex.

What's most amazing is how, 50 years after La Leche League's founding, "enlightenment from the laboratory"-judgmental and absolutist-has triumphed again. The seventh edition of The Womanly Art, published in 2004, has ballooned to more than 400 pages, and is filled with photographs in place of the original hand drawings. But what's most noticeable is the shift in attitude. Each edition of the book contains new expert testimony about breast milk as an "arsenal against illness." "The resistance to disease that human milk affords a baby cannot be duplicated in any other way," the authors scold. The experience of reading the 1958 edition is like talking with your bossy but charming neighbor, who has some motherly advice to share. Reading the latest edition is like being trapped in the office of a doctor who's haranguing you about the choices you make.

In her critique of the awareness campaign, Joan Wolf, a women's-studies professor at Texas A&M University, chalks up the overzealous ads to a new ethic of "total motherhood." Mothers these days are expected to "optimize every dimension of children's lives," she writes. Choices are often presented as the mother's selfish desires versus the baby's needs. As an example, Wolf quotes What to Expect When You're Expecting, from a section called the "Best-Odds Diet," which I remember quite well: "Every bite counts. You've got only nine months of meals and snacks with which to give your baby the best possible start in life ... Before you close your mouth on a forkful of food, consider, 'Is this the best bite I can give my baby?' If it will benefit your baby, chew away. If it'll only benefit your sweet tooth or appease your appetite put your fork down." To which any self-respecting pregnant woman should respond: "I am carrying 35 extra pounds and my ankles have swelled to the size of a life raft, and now I would like to eat some coconut-cream pie. So you know what you can do with this damned fork."

* * *

About seven years ago, I met a woman from Montreal, the sister-in-law of a friend, who was young and healthy and normal in every way, except that she refused to breast-feed her children. She wasn't working at the time. She just felt that breast-feeding would set up an unequal dynamic in her marriage-one in which the mother, who was responsible for the very sustenance of the infant, would naturally become responsible for everything else as well. At the time, I had only one young child, so I thought she was a kooky Canadian-and selfish and irresponsible. But of course now I know she was right. I recalled her with sisterly love a few months ago, at three in the morning, when I was propped up in bed for the second time that night with my new baby (note the my). My husband acknowledged the ripple in the nighttime peace with a grunt, and that's about it. And why should he do more? There's no use in both of us being a wreck in the morning. Nonetheless, it's hard not to seethe.

The Bitch in the House, published in 2002, reframed The Feminine Mystique for my generation of mothers. We were raised to expect that co-parenting was an attainable goal. But who were we kidding? Even in the best of marriages, the domestic burden shifts, in incremental, mostly unacknowledged ways, onto the woman. Breast-feeding plays a central role in the shift. In my set, no husband tells his wife that it is her womanly duty to stay home and nurse the child. Instead, both parents together weigh the evidence and then make a rational, informed decision that she should do so. Then other, logical decisions follow: she alone fed the child, so she naturally knows better how to comfort the child, so she is the better judge to pick a school for the child and the better nurse when the child is sick, and so on. Recently, my husband and I noticed that we had reached the age at which friends from high school and college now hold positions of serious power. When we went down the list, we had to work hard to find any women. Where had all our female friends strayed? Why had they disappeared during the years they'd had small children?

The debate about breast-feeding takes place without any reference to its actual context in women's lives. Breast-feeding exclusively is not like taking a prenatal vitamin. It is a serious time commitment that pretty much guarantees that you will not work in any meaningful way. Let's say a baby feeds seven times a day and then a couple more times at night. That's nine times for about a half hour each, which adds up to more than half of a working day, every day, for at least six months. This is why, when people say that breast-feeding is "free," I want to hit them with a two-by-four. It's only free if a woman's time is worth nothing.

That brings us to the subject of pumping. Explain to your employer that while you're away from your baby, "you will need to take breaks throughout the day to pump your milk," suggest the materials from the awareness campaign. Demand a "clean, quiet place" to pump, and a place to store the milk. A clean, quiet place. So peaceful, so spa-like. Leave aside the preposterousness of this advice if you are, say, a waitress or a bus driver. Say you are a newspaper reporter, like I used to be, and deadline is approaching. Your choices are (a) leave your story to go down to the dingy nurse's office and relieve yourself; or (b) grow increasingly panicked and sweaty as your body continues on its merry, milk-factory way, even though the plant shouldn't be operating today and the pump is about to explode. And then one day, the inevitable will happen. You will be talking to a male colleague and saying to yourself, "Don't think of the baby. Please don't think of the baby." And then the pump will explode, and the stigmata will spread down your shirt as you rush into the ladies' room.

This year alone I had two friends whose babies could not breast-feed for one reason or another, so they mostly had to pump. They were both first-time mothers who had written themselves dreamy birth plans involving hot baths followed by hours of intimate nursing. When that didn't work out, they panicked about their babies' missing out on the milky elixir. One of them sat on my couch the other day hooked up to tubes and suctions and a giant deconstructed bra, looking like some fetish ad, or a footnote from the Josef Mengele years. Looking as far as humanly possible from Eve in her natural, feminine state.

In his study on breast-feeding and cognitive development, Michael Kramer mentions research on the long-term effects of mother rats' licking and grooming their pups. Maybe, he writes, it's "the physical and/or emotional act of breastfeeding" that might lead to benefits. This is the theory he prefers, he told me, because "it would suggest something the formula companies can't reproduce." No offense to Kramer, who seems like a great guy, but this gets under my skin. If the researchers just want us to lick and groom our pups, why don't they say so? We can find our own way to do that. In fact, by insisting that milk is some kind of vaccine, they make it less likely that we'll experience nursing primarily as a loving maternal act-"pleasant and relaxing," in the words of Our Bodies, Ourselves and more likely that we'll view it as, well, dispensing medicine.

I continue to breast-feed my new son some of the time-but I don't do it slavishly. When I am out for the day working, or out with friends at night, he can have all the formula he wants, and I won't give it a second thought. I'm not really sure why I don't stop entirely. I know it has nothing to do with the science; I have no grandiose illusions that I'm making him lean and healthy and smart with my milk. Nursing is certainly not pure pleasure, either; often I'm tapping my foot impatiently, waiting for him to finish. I do it partly because I can get away with breast-feeding part-time. I work at home and don't punch a clock, which is not the situation of most women. Had I been more closely tied to a workplace, I would have breast-fed during my maternity leave and then given him formula exclusively, with no guilt.

My best guess is something I can't quite articulate. Breast-feeding does not belong in the realm of facts and hard numbers; it is much too intimate and elemental. It contains all of my awe about motherhood, and also my ambivalence. Right now, even part-time, it's a strain. But I also know that this is probably my last chance to feel warm baby skin up against mine, and one day I will miss it.

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In certain overachieving circles, breast-feeding is no longer a choice-it's a no-exceptions requirement, the ultimate badge of responsible parenting. Yet the actual health benefits of breast-feeding are surprisingly thin, far thinner than most popular literature indicates. Is breast-feeding right for every family? Or is it this generation's vacuum cleaner-an instrument of misery that mostly just keeps women down?

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Every Feed Matters: Developmentally Supportive Feeding on the NICU  Rachel Evans, Senior Speech and Language Therapist  & Alexandra Connolly, Senior Speech and Language Therapist   Birmingham Women’s and Children’s NHS Foundation Trust  Barts Health NHS Foundation trust  

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Every Feed Matters: Developmentally Supportive Feeding on the NICU  Rachel Evans, Senior Speech and Language Therapist  & Alexandra Connolly, Senior Speech and Language Therapist   Birmingham Women’s and Children’s NHS Foundation Trust  Barts Health NHS Foundation trust  

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Celeb mothers talk about the realities of breastfeeding

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Celeb mothers talk about the realities of breastfeeding

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Breast is Best - The Graham Norton Show - Preview - BBC One

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http://www.bbc.co.uk/bbcone More on this programme: http://www.bbc.co.uk/programmes/b00s5ytk Graham Norton talks to Toni Collette, Billie Piper and Shappi Khorsandi about their breast feeding habits.

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Help for students with analysis

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Take the test with BBC Taster: Test Your Argument
Professor Chris Reed, of Dundee's 'Centre for Argument Technology' says: "Machines that can argue would be able to inform public debate on everything from tackling crime to improving public health. They would help us to avoid unconscious biases, weak evidence and poorly thought-through arguments." But Arg-tech, as it's called for short, is also producing advice that all of us can use, whether we're debating issues in a high-powered meeting or arguing with mates down the pub.

Now the team want to get the listeners involved, with a BBC Taster website called Test Your Argument. The idea is to help you work out your best debating strategy and then rate your skill. To kick off the experiment, the team are doing a detailed analysis of the special edition of Moral Maze on the 50th anniversary of the Abortion Act.

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Radio 4 in Four - Moral Maze: Eight ways to win an argument - BBC Radio 4

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Take the test with BBC Taster: Test Your Argument Professor Chris Reed, of Dundee's 'Centre for Argument Technology' says: "Machines that can argue would be able to inform public debate on everything from tackling crime to improving public health. They would help us to avoid unconscious biases, weak evidence and poorly thought-through arguments."

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Health-seeking behaviours occur within a cultural context, even in a country like Australia. The cultural context determines whether a person seeks advice from a parent or friend, a complementary medicine practitioner or their GP. Kleinman's framework of explanatory models of disease and illness enables the comparison of healthcare systems in any cultural context. Kleinman proposes that the healthcare system is a cultural system with three sectors: the popular sector (shaped by individual, family and community beliefs); the folk sector (represented by non-professional healing specialists); and professional (represented by Western medical professional or professionalised indigenous healing traditions) (Kleinman, 1978).

Within such a framework, topical application of breastmilk for various conditions (eg conjunctivitis and umbilical cord care) currently sits in the popular and folk sectors and not the professional sector, particularly in developed countries. However, recent encouraging results from randomised clinical trials may change this.

In the early 1990s, a team of researchers and eye-care providers were studying eye problems in Malawi when it became apparent that there were some key pieces of the puzzle missing in their investigation.

'Traditional healers were in every village and, as a group, were providing more eye care services to the population than the ophthalmic medical assistants or ophthalmologists... Indeed, for every person being treated by a physician, a total of 35 were being treated by traditional healers.'

The application of breastmilk was one of the traditional eye medicines chosen in Malawi (Gagnon, 2000).

In Zambia, the application of breastmilk is used at various stages of umbilical cord care. A recent qualitative study looked at local perceptions, cultural beliefs and practices that shape umbilical cord care in Southern Province, Zambia by interviewing a range of stakeholders including: breastfeeding mothers; grandmothers; traditional healers; religious leaders; midwives; and health professionals (Herlihy et al, 2013).

Umbilical cord care practices and beliefs were diverse. There were multiple indications for cord application of breastmilk. Some interviewees reported its use to prevent infection; others to treat an infection that is present; and some reported that it is used as a lubricating agent to soften the cord.

If a mother is breastfeeding her baby, then breastmilk would be the most accessible treatment with no associated cost and a mother could readily treat her own baby.

So, is there high-quality evidence that shows that the topical application of breastmilk is a viable alternative to medications?

The evidence from randomised clinical trials is being collected and the results are promising. Five randomised clinical trials have been published since 2012, the most recent in 2015, comparing breastmilk application with standard care for four infant conditions: atopic eczema; nappy dermatitis; umbilical cord separation, neonatal conjunctivitis (Table 1).

In all cases, breastmilk application was as effective as standard care and in the case of umbilical cord care breastmilk application was more effective than standard care.

Table 1. Summary of recent randomised clinical trials of the effectiveness of breastmilk to treat various infant conditions: atopic eczema; diaper dermatitis; umbilical cord separation, neonatal conjunctivitis

References

Aghamohammadi, A., Zafari, M., & Moslemi, L. (2012). Comparing the effect of topical application of human milk and dry cord care on umbilical cord separation time in healthy newborn infants. Iranian Journal of Pediatrics, 22(2), 158.

Baynham, J. T., Moorman, M. A., Donnellan, C., Cevallos, V., & Keenan, J. D. (2013). Antibacterial effect of human milk for common causes of paediatric conjunctivitis. British Journal of Ophthalmology, 97(3), 377-379.

Berents, T. L., Rønnevig, J., Søyland, E., Gaustad, P., Nylander, G., & Løland, B. F. (2015). Topical treatment with fresh human milk versus emollient on atopic eczema spots in young children: a small, randomized, split body, controlled, blinded pilot study. BMC Dermatology, 15(1), 7.

Farahani, L. A., Ghobadzadeh, M., & Yousefi, P. (2013). Comparison of the effect of human milk and topical hydrocortisone 1% on diaper dermatitis. Pediatric Dermatology, 30(6), 725-729.

Gagnon, L. (2000). Investigating traditional eye medicines in Malawi. Retrieved from the IDRC website http://web.idrc.ca/en/ev-5273-201-1-DO_TOPIC.html

Ghaemi, S., Navaei, P., Rahimirad, S., Behjati, M., & Kelishadi, R. (2014). Evaluation of preventive effects of colostrum against neonatal conjunctivitis: A randomized clinical trial. Journal of Education and Health Promotion, 3.

Golshan, M., & Hossein, N. (2013). Impact of ethanol, dry care and human milk on the time for umbilical cord separation. JPMA. The Journal of the Pakistan Medical Association, 63(9), 1117-1119.

Herlihy, J. M., Shaikh, A., Mazimba, A., Gagne, N., Grogan, C., Mpamba, C., ... & Hamer, D. H. (2013). Local perceptions, cultural beliefs and practices that shape umbilical cord care: A qualitative study in Southern Province, Zambia. PLOS one, doi: 10.1371/journal.pone.0079191

Ibhanesebhor, S. E., & Otobo, E. S. (1996). In vitro activity of human milk against the causative organisms of ophthalmia neonatorum in Benin City, Nigeria. Journal of Tropical Pediatrics, 42(6), 327-329.

Kasrae, H., Amiri Farahani, L., & Yousefi, P. (2015). Efficacy of topical application of human breast milk on atopic eczema healing among infants: a randomized clinical trial. International Journal of Dermatology.

Kleinman, A. (1978). Concepts and a model for the comparison of medical systems as cultural systems. Social Science & Medicine. Part B: Medical Anthropology, 12, 85-93.

Mahrous, E. S., Darwish, M. M., Dabash, S. A., Marie, I., & Abdelwahab, S. F. (2012). Topical application of human milk reduces umbilical cord separation time and bacterial colonization compared to ethanol in newborns. Translational Biomedicine, 3(1).

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Topical treatment with breastmilk: randomised trials

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Health-seeking behaviours occur within a cultural context, even in a country like Australia. The cultural context determines whether a person seeks advice from a parent or friend, a complementary medicine practitioner or their GP. Kleinman's framework of explanatory models of disease and illness enables the comparison of healthcare systems in any cultural context.

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British Association of Perinatal Medicine

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Identification and Management of Neonatal Hypoglycaemia in the Full Term Infant - A Framework for Practice (2017)

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In 2016 NHS Improvement and British Association of Perinatal Medicine (BAPM) convened a working group to develop a Framework for Practice (FfP) to: address variation in practices in the identification, management and admission thresholds of babies admitted to neonatal units for hypoglycaemia; and

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Aptaclub formula guidelines

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Scoop by scoop

Summary

Knowing how much to feed your baby can be difficult to gauge, especially in the early stages. A guide to the quantity and frequency of feeds is shown in our baby feeding chart. Generally, from the age of 2 weeks to 6 months you can expect your bottlefeeding routine to consist of around 5 or 6 feeds a day.

Every baby is different and their appetites vary massively. The table below provides a general guide to how often and how much you should feed your baby, relative to their age.

Your baby's feeding habits may not match these guidelines precisely, and rarely will they wake exactly three hours after the previous feed is finished. As long as they are feeding well and gaining weight normally, they are probably getting the amount they need.

If your baby is premature or of a low birth weight, their feeding requirements will be different. Your midwife will be able to advise you about your baby's unique needs.

Feeding guide 0-12 months

Your baby may need more or less than the amounts shown in the table below - this is simply a guide. Never leave your baby alone during feeding.

Important

To ensure your baby's milk is mixed to the right proportions, always use the scoop provided. Please note, the colour of the scoop may change from time to time.

How to time feeds

Feeds should be timed from the moment they start. In the early days, feeding can take as long as an hour and they'll need around 6 feeds per day. Once your baby becomes more efficient at feeding, they're likely to get quicker.

To measure the time between feeds, start from the beginning of one feed until the beginning of the next. For example, if you begin feeding your baby at 11am, then you would probably expect them to be hungry again at about 2pm.

Last reviewed: 3rd December 2015

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Bottle feeding routine - Baby feeding chart - Aptaclub

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Scoop by scoop Knowing how much to feed your baby can be difficult to gauge, especially in the early stages. A guide to the quantity and frequency of feeds is shown in our baby feeding chart. Generally, from the age of 2 weeks to 6 months you can expect your bottlefeeding routine to consist of around 5 or 6 feeds a day.

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Profit before science

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A new international investigation has revealed a shocking lack of science behind the infant formula ranges sold by baby milk companies - and some questionable marketing practices as well.

Exclusive breastfeeding for the first 6 months of life - a practice recommended by every health organisation in the world - provides a baby with everything it needs to grow and thrive. Not just nutrition, but hundreds of non-nutrient factors which cannot be synthesised in the lab and which help protect against illness and promote optimal growth.

For those women who don't or can't breastfeed, being able to trust that infant formula is providing the best possible nutrition is very important.

But a new report, , from the non-profit, UK-based Changing Markets Foundation notes that while there is a single global standard for what ingredients should be in infant formula, the top 4 manufacturers, Nestlé, Danone, Mead Johnson Nutrition (recently acquired by Reckitt Benckiser), and Abbott sell a mind-boggling number - more than 400 individual products - between them globally.

Too often, according to the report, manufacturers add unnecessary ingredients with no proven benefits - so that they can charge a premium price for their products. This isn't illegal but it is unethical and in breach of a voluntary World Health Organization code on the marketing of breastmilk substitutes.

Added fats, pre- and pro-biotics and certain nutrients, may make more plausable manufacturers' claims to make formula which is closer to breastmilk, represents the latest developments in nutritional science, or satisfies hungrier babies, to promote better digestion, or to aid sleep.

But, says the report: "There is little nutritional science and few beneficial health considerations behind their extensive product ranges."
Paying a premium
These premium products do not cater to mothers' or babies' needs but instead exist to create a market that capitalises on mother's anxiety around feeding their children, and their willingness to pay a premium for what they think is scientific certainty.

In analysing the retail prices that companies around the world charge for infant formula, the report found that manufacturers charge whatever they can get away in individual markets - a fact underscored by the wildly different prices that the same brands sell for in different parts of the world.

The most expensive products, for instance, were found in China and Hong Kong, where families can spend US $286 and US $304 per month to feed a 2-3-month old baby, respectively, based on using the most expensive product in those markets.

In 2008 infant formula made in China was found to be contaminated with toxic melamine, deliberately added to some formulas to make them appear as if they contained more protein than they did. Many infants were made ill and some died from drinking the adulterated formula.

Today Chinese mothers still seek big Western brands believing that they are better, or purer, than Chinese brands. The big brands capitalise on this fear by charging exorbitant prices for their products.

As a result, parents in China can spend up to 40 percent of their average salary on infant formula. In comparison, the most expensive formula in European countries will only cost 1-3 percent of an average salary.
Trusted friends?
The report also highlighted the extent to which formula companies listen in on mothers' social media posts in order to learn about their hopes, fears and desires - and then tailor their marketing outreach around that.

Manufacturers use internet platforms such as Facebook, as well as online mother and baby clubs (often financed by formula manufacturers themselves), to collect vital information on mothers, and to portray themselves as trusted 'friends' on the 'mother's journey' in order to sell their products.

"Our report found that instead of nutritional science, companies are basing their selling strategies on market research and consumer preferences," said Nusa Urbancic from Changing Markets Foundation.

"Product differentials are carefully and deliberately designed to appeal to the tastes and lifestyle preferences of parents, or their natural desire to give their babies the best possible start in life. As such, manufacturers can package these products in 'premium' ranges and charge high prices accordingly."
Better regulation and legislation required
The report calls for a comprehensive overhaul of global infant milk products and the introduction of stricter regulation, so that only those products based on unequivocal scientific advice, and with the highest quality of nutritional ingredients, are sold.

It also calls on governments to introduce and enforce national legislation that fully implements the WHO marketing Code and to ensure that the safety and nutritional quality and completeness of products is regularly verified.

To coincide with the report Sum of Us, the global online campaigning platform, launched a petition on November 1 calling for Nestlé to make sure their infant milks are safe, nutritionally complete and based on science. It gained nearly 60,000 signature son its first day.
This Author
Pat Thomas is a The petition can be journalist, author and campaigner and former editor of the Ecologist. signed and shared at this link. The fully referenced report, Milking it, along with its executive summary, can be downloaded here.

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Infant formula companies put profit before science

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A new international investigation has revealed a shocking lack of science behind the infant formula ranges sold by baby milk companies - and some questionable marketing practices as well. Exclusive breastfeeding for the first 6 months of life - a practice recommended by every health organisation in the world - provides a baby with everything it needs to grow and thrive.

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11 of the most talked about breastfeeding pictures in the world

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Breastfeeding is a fraught topic, with many women feeling shamed, either by the 'brestapo' - for being unable or unwilling to breastfeed - or for feeding in public.

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Toddler milk is waste of money, says Which? | Parents and parenting | The Guardian

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Cows' milk has less sugar and more calcium, but almost half of mothers use more expensive formulas

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Information and resources for action including national policies, the GIRFEC approach, and data around supporting children's wellbeing.

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Breastfeeding duration and early parenting behaviour

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Breastfeeding duration and early parenting behaviour

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Amy Brown et al

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Amy Brown,

Bronia Arnott

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Abstract

Background

Popular parenting literature promotes different approaches to caring for infants, based around variations in the use of parent-led routines and promoting infant independence. However, there is little empirical evidence of how these early behaviours affect wider parenting choices such as infant feeding. Breastfeeding often requires an infant-led approach, feeding on demand and allowing the infant to regulate intake whilst conversely formula feeding is open to greater caregiver manipulation. The infant-led style associated with breastfeeding may therefore be at odds with philosophies that encourage strict use of routine and independence. The aim of this study was to explore the association between early parenting behaviours and breastfeeding duration.

Methods

Five hundred and eight mothers with an infant aged 0-12 months completed a questionnaire examining breastfeeding duration, attitudes and behaviours surrounding early parenting (e.g. anxiety, use of routine, involvement, nurturance and discipline). Participants were attendees at baby groups or participants of online parenting forums based in the UK.

Results

Formula use at birth or short breastfeeding duration were significantly associated with low levels of nurturance, high levels of reported anxiety and increased maternal use of Parent-led routines. Conversely an infant-led approach characterised by responding to and following infant cues was associated with longer breastfeeding duration.

Discussion

Maternal desire to follow a structured parenting approach which purports use of Parent-led routines and early demands for infant independence may have a negative impact upon breastfeeding duration. Increased maternal anxiety may further influence this relationship. The findings have important implications for Health Professionals supporting new mothers during pregnancy and the postpartum period.

Citation: Brown A, Arnott B (2014) Breastfeeding Duration and Early Parenting Behaviour: The Importance of an Infant-Led, Responsive Style. PLoS ONE9(2): e83893. https://doi.org/10.1371/journal.pone.0083893

Editor: Andrea S. Wiley, Indiana University, United States of America

Received: November 17, 2012; Accepted: November 17, 2013; Published: February 12, 2014

Copyright: © 2014 Brown, Arnott. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: AB was supported by a postdoctoral fellowship from the Economic and Social Research Council. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The importance of breastfeeding for infant and maternal health is well established. Infants who are formula fed are at increased risk of gastrointestinal and respiratory disorders, allergies and obesity [1], [2]. Despite this, levels of breastfeeding in the UK are low [3]. Although physiological contraindications to breastfeeding do exist [4], social and psychological variables are known to play a large role in affecting breastfeeding duration [5]. Beliefs that breastfeeding is inconvenient and difficult or that formula-fed infants are more content impact on how a mother adapts to breastfeeding [6]. Physical difficulties and lack of support can exacerbate difficulties [5], [7]. Moreover, low confidence, poor self efficacy and anxiety can also lead to formula use [8], as well as concerns for infant health, growth and development [9], [10].

However, little empirical evidence exists in relation to how early infant feeding fits within wider parenting behaviours and contexts. Previous research exploring the conceptualisation and influence of parenting styles for older children typically categorised behaviour along two dimensions of warmth and control [11]. Authoritative parents typically respond in a warm and responsive way to their child's signals but also exert an appropriate amount of age appropriate control over their child's behaviour. Conversely, authoritarian parents exhibit high levels of control combined with a low level of nurturance. Finally, permissive parents combine low levels of control with high warmth [12]. In general, an authoritative approach has been associated with desired outcomes including positive child conduct [13], enhanced cognitive development [14], and healthier nutritional intake and weight-gain trajectories [15]. How these elements of parenting older children might apply to parenting an infant and their impact upon the infant are however unclear.

One central question appears to be how aspects of parenting styles, particularly around control and nurturance might affect or drive decision to breast or formula feed. To be successful, breastfeeding often has to be baby-led, following the infants cues of hunger and satiety to promote milk supply [16]. Breastfed infants typically feed more frequently and irregularly than formula fed infants as breast milk is easily digested and varies in energy density over the course of the day [17]. On demand, unrestricted breastfeeding is associated with an earlier onset of milk production [18], faster regain of birth weight [19] and a reduced occurrence of issues related to breastfeeding discontinuation such as nipple soreness and engorgement [20]. Conversely formula feeding can be open to greater caregiver manipulation as it is easier to perform to a parent-led schedule [18]. The baby-led nature of breastfeeding can however evoke maternal anxiety regarding infant consumption or clash with maternal desire for control and predictability [10]. Essentially, breastfeeding may 'conflict' with overall approach to care giving.

In an initial study we characterised variations in parenting style during infancy exploring developed concepts of nurturance and control but applying them to infant care. For example, issues such as use of parent-led routine and encouraging the infant to self-settle were explored [21]. Here we examine the association between these early parenting behaviours and breastfeeding duration.

Methodology

Participants

All aspects of this study were performed in accordance with the ethical standards set out in the 1964 Declaration of Helsinki. Ethics approval was granted by Swansea University (UK) Department of Psychology Research Ethics Committee.

Five hundred and eight mothers with an infant aged between 0 and 12 months (mean age 27.47 weeks) (SD: 15.02) completed a self report questionnaire. Participants were recruited from local mother and baby groups in Swansea and Durham and through online parenting forums based in the UK. The groups were located in areas of varying deprivation as measured by the Welsh and English Indices of Multiple Deprivation. Groups were both privately run or based in Children's Centres or Family and Community Centres, encouraging a wide range of participation in terms of demographic background. For the groups, contact was made with group leaders who distributed questionnaires to group members. Questionnaires were returned to the leader in a sealed envelope or via post to the researcher. Questionnaires had information letters attached with details of how to contact the researcher if further information was required.

Study adverts were also placed on specific research request boards on online message boards on parenting forums based in the UK (e.g. www.mumsnet.com; www.bounty.com) with an online link to complete the questionnaire via survey monkey. All participants were based in the UK and this was verified by provision of UK postcode. Details were given as above for how to contact the researcher if needed. Questionnaire completion via either method implied consent.

Participants completing the questionnaire via paper or online copy were given a written debrief at the end of the questionnaire and given researcher details to contact if they wanted further information. All participants were given instruction to contact their relevant health professional if completing the questionnaire had raised any questions or issues with regard to caring for their baby.

Measures

The self report questionnaire explored maternal demographic background (age, education, parity), infant details (age, gender, birth weight) and details regarding breastfeeding initiation, duration and exclusivity. Participants indicated whether they breast or formula fed at birth, duration of breastfeeding if they had stopped and timing of introduction to use of formula and complementary foods if appropriate.

Participants also responded to a series of items examining their approach to parenting their infant (Infancy Parenting Styles Questionnaire (IPSQ) [21]. Items examined maternal involvement, responsiveness, sensitivity and discipline which are similar to those found in literature relating to parenting older children alongside more age specific behaviours of maternal anxiety and concern for her infant and maternal involvement in infant development such as concern for weight gain, sleep and early development ( Table 1). The IPSQ uses a five point likert scale for response (strongly agree to strongly disagree) with a a higher score on each factor indicating stronger agreement.

Data analysis

Distribution of breastfeeding duration was non-normal (Kolmogorov-Smirnov = .278 = .001) with a high proportion of mothers ceasing breastfeeding in the first few days and weeks or breastfeeding for a longer duration [as reflected in many studies such as the UK Infant Feeding Survey [3]. Therefore breastfeeding duration data was transformed and the natural logarithms computed used in order to correct for the skewed distribution. Mean scores for each factor were computed for the IPSQ [21].

Factor scores were compared using MANCOVA for infant feeding method at birth [breast/formula] and any breast milk at two, six, twelve and twenty six weeks. Maternal factors (age, education, parity, return to work), infant factors (infant age, birth weight) and birth experience (gestation, mode (section versus vaginal birth) were controlled for.

Results

The mean age of the respondents was 30.72 (SD: 5.12) years, (range from 17 to 44) and the mean number of years in education was 14.61 (SD: 2.53) (range from 12 to 20 years). Infant age ranged from 0 and 12 months (mean age 27.47 weeks (SD: 15.02). 29.4% of mothers were primiparous with the majority (54.1%) multiparas with two children. No significant difference was seen in mean age, years in education, marital status, breastfeeding duration or parenting behaviours between mothers who completed a paper or online version of the questionnaire. Exclusion criteria included multiple birth, low birth weight (<2500 g) or premature birth (<37 weeks). Demographic spread can be found in Table 2.

Parenting style

Significant associations were found between parenting style and maternal and infant characteristics ( Table 3). Mothers who were older and more educated were significantly more likely to report higher levels of anxiety and routine whilst reporting lower levels of nurturance, whilst older mothers were also significantly more likely to use a parent-led routine. Age of infant was also significantly associated with increased use of a parent-led routine and discipline and also lower levels of nurturance. Finally, birth weight was significantly inversely associated with anxiety and positively associated with greater use of parent-led routine and discipline. As noted above these variables were controlled for throughout the analyses.

Mode of feeding at birth and parenting style

Mothers indicated whether they breastfed (n = 400), gave expressed milk (n = 30) or formula fed (n = 78) at birth. A significant difference on the parent led routine factor (F (1, 505) = 4.888, p = 0.008) was found for feeding method at birth. Post hoc Bonferroni tests showed that mothers who breastfed or expressed breast milk at birth later reported using significantly lower levels of parent-led routine than mothers who formula fed. No significant difference was found between those who breastfed directly or gave expressed milk.

Significant differences in infant feeding were also found for the anxiety factor (F (1, 505) = 2.180, p = .006). Mothers who breastfed at birth scored significantly lower on this factor compared to mothers who fed expressed milk or formula fed. No significant difference was found between those who fed expressed milk or gave formula.

Scores on the nurturance factor also varied significantly for method of feeding at birth (F (1, 505) = 4.537, p = .011). Mothers who breastfed or expressed breast milk at birth later reported significantly higher scores on this factor compared to mothers who formula fed.

No significant difference was found in method of feeding at birth and scores on discipline or Involvement factors.

Breastfeeding duration and parenting style

The association between breastfeeding duration and parenting styles was also examined. The five parenting factors were compared for infants who were receiving any breast milk (or no breast milk) at two, six, twelve and twenty six weeks ( Table 4). As infants in the sample were aged 0-12 months, at each stage the sample was reduced in size to infants that age or older.

Breastfeeding duration was also significantly associated with parenting styles. Mothers who were giving any breast milk at two weeks scored significantly lower on parent-led routine (F (1, 472) = 9.813, p = .002) and anxiety (F (1, 472) = 6.632, p = .010) and significantly higher on nurturance (F (1, 472) = 10.779, p = .001) compared to mothers who were giving no breast milk.

Similarly for any breastfeeding at six weeks, mothers who were giving any breast milk scored significantly lower on parent-led routine (F (1, 409) = 10.552, p = .001) and anxiety (F (1, 409) = 5.476, p = .020) and significantly higher on nurturance (F (1, 409) = 12.415, p = .000) compared to mothers who were giving no breast milk.

Differences in parent-led routine remained significant for any breastfeeding at twelve (F (1, 359) = 5.122, p = .024) and twenty six weeks (F (1, 359) = 5.263, p = .022). However significant differences were no longer found for anxiety or nurturance.

No significant difference was found at any stage for discipline or involvement for milk feeding group.

Discussion

This paper examined the association between variations in approaches to parenting in early infancy and breastfeeding initiation and duration. Overall, parenting approaches that were higher in parent-led routine and anxiety and lower in nurturance were associated with a decreased likelihood that the infant was breastfed at birth and an increased likelihood that formula was introduced within the first six weeks postpartum. Given the importance of breastfeeding for infant and maternal health [1], understanding the impact and interaction of parenting styles upon breastfeeding is an important element in understanding maternal motivation to initiate and barriers to continuation.

Mothers who reported that they used high levels of parent-led routine day to day for their infant were less likely to initiate or continue breastfeeding. This relationship could be bidirectional. Mothers may adapt their use of routine to their chosen feeding method. Breastfeeding typically needs to baby-led and on demand to establish milk supply [18] whereas formula feeding can encourage a stricter feeding schedule and routine [6]. Moreover as breastfed infants often feed more frequently and irregularly compared to formula fed infants, a parent-led routine can be more difficult to establish [10]. Potentially mothers who breastfeed learn to, or have to, adopt a baby-led feeding pattern to continue breastfeeding whereas mothers who formula feed learn to, or choose to, follow a stricter parent-led routine. Alternatively, maternal desire for routine may drive infant feeding choice. Mothers who wish to have a strict routine may choose to formula feed for this reason. Indeed the perceived irregularity, commitment and hassle of breastfeeding are commonly cited by pregnant women for deciding not to breastfeed or to stop after a short duration of time [5]. Either way, a strict parent-led routine for infant feeding may not be beneficial to infant health, either through discouraging breastfeeding or because encouraging a baby to feed to a parent-led routine rather than its own natural patterns may promote obesity [6].

Breastfeeding initiation and continuation in the early weeks were associated with higher scores on the Nurturing factor, which included behaviours such as keeping the infant as close as possible. Nurturing behaviour is associated with improved breastfeeding outcomes; keeping the infant close, including skin-to-skin contact as soon after the birth is believed to play a critical role in breastfeeding initiation and duration [22]. Responding promptly to the infants signals of hunger encourages prolactin production which is essential to milk production [23] which is more likely if the infant is kept in close proximity including behaviour such as room sharing [24]. Again this relationship may be bidirectional - breastfeeding may encourage the mother to keep her infant close to her whereas perhaps formula feeding, where feeds are less frequent, may promote greater independence. Conversely, desire for nurturance may drive feeding choice; Mothers may choose to formula feed as they wish to have greater independence from their infant, allowing others to feed the infant or through the need to balance other responsibilities [5], [8]. Formula milk is perceived to promote infant sleep and encourage the infant to settle [10], potentially due to the increased time it takes to digest feeds [17]. An independent infant can often be viewed as a measured of parenting success e.g. 'a good baby' [25]. Thus for those who desire independence, breastfeeding may be incompatible.

Finally, greater maternal anxiety factor scores were associated with using formula from birth or stopping breastfeeding within the first six weeks. Mothers scoring high on this factor reported greater anxiety regarding their infants' development and greater tendency to seek advice from others [21]. The association between maternal anxiety and formula use has been well established. Mothers who report low self-efficacy and confidence are more likely to choose to formula feed [7]. Specific anxieties related to poor weight gain [9], concern regarding milk production [8], or that the infant is not receiving enough milk [10] are all linked to a shorter breastfeeding duration; often shorter than the mother desired. Formula feeding may provide reassurance for a mother with higher anxiety as intake is far more measurable; the amount consumed is visible, nutrient content listed on the tin and direct instructions about quantities to offer [18]. Conversely, it is possible that a negative experience of breastfeeding, leading to formula use, may increase overall maternal anxiety for their infant.

One potential insight into the development of parenting styles across this time is the sub sample of mother who gave expressed milk rather than breastfeeding directly at birth. In the UK mothers are entitled to up to nine months of paid maternity leave [26] which gives them opportunity to breastfeed for a number of months before they return to work. Low numbers of mothers in the UK choose to exclusively express milk for their infant rather than directly breastfeed [3]. This is in contrast to countries such as the USA where mothers often return to work soon after the birth, leading to greater numbers of mothers choosing to express milk for their infants for this reason. In the UK, when mothers choose to express, it is usually due to complications surrounding the birth such as infant or maternal health difficulties and/or low infant birth weight lead to the infant being given expressed milk rather than fed directly [27]. However, a negative birth experience can have a major impact on a new mother. It can increase maternal anxiety for her infant [28] that can last into childhood [29]. Concerns regarding growth and milk supply are especially strong [30]. Here, mothers who expressed breast milk at birth reported the highest levels of anxiety regarding their infant suggesting that early parenting styles may be affected by significant experiences surrounding the birth and first year. Again, further research is needed to ascertain how parenting styles form and develop.

A key question is the potential impact of the findings for those working to support breastfeeding mothers. There is a clear message emerging from the data that maternal beliefs and behaviours regarding wider parenting approach during infancy are associated with, and may be affecting, milk feeding choice. In the UK there is a very profitable market of baby care books aimed at parents of young infants [31]. These books often promote specific approaches to caring for an infant, typically focussed around how the parent should respond to the infant and use of parent led routines for sleep and feeding. Generally these books fall into two categories; those proposing a parent-led approach whereby strict sleep and feeding routines are imposed and those which are more baby-led encouraging the parent to respond to and follow infant cues and rhythms [32]. However, these books are typically not evidence based due to the lack of research exploring outcomes in this area. Given the popularity of parenting manuals that might promote structured methods of interaction and approach to the infant [21], [32], greater awareness needs to be raised as to how these books may be influencing maternal behaviour and choices, especially due to the lack of underpinning empirical evidence.

Moreover awareness should also be given by Health Professionals as to the influences beliefs about infant care approaches might have upon breastfeeding duration. Beliefs regarding routine and interaction with their infant or misconceived ideas about what normal infant sleep or feeding behaviour should be like might affect their parenting choices. Although the data presented here is correlational, given the association between infant feeding choice at birth and parenting style, perhaps the discussion of these antenatally may be important.

One specific application for health professionals could be the notable differences in both anxiety and nurturance between breast and formula groups up to six weeks postpartum but that were not significant after this time. Breastfeeding in the early days can be demanding but it is often viewed as established and easier after the infant reaches six weeks old [33], [34]. Health professionals might consider this with mothers who are feeling anxious about breastfeeding or concerned at how close they will need to remain to the infant at all times after the birth. High numbers of mothers initiate breastfeeding at birth but there is a high drop of rate in continuation, often before the mother was planning to stop breastfeeding [3]. Discussing with mothers how breastfeeding may change and become easier and less consuming after the first few weeks might encourage initiation or duration rates.

Despite the potential impact of a parent-led style upon breastfeeding duration, wider consideration does need to be given to the overall parenting experience. Sleep deprivation [35] and infant crying [36] are associated with increased risk of postnatal depression and maternal feelings of loss of control or identity [37]. An infant-led approach has been linked to night wakings for longer [38] whilst parent-led sleep training was related to reduced incidence of postnatal depression [39]. At an individual level a parent-led style and bottle feeding may have benefits that overall contribute to a more positive outcome for the family [40]. However, given the considerable importance of breastfeeding for both infant and maternal health [3], [4], more emphasis should be placed on offering increased maternal practical and emotional support and boosting confidence to enable her to breastfeed [41], [42]. Educating partners, grandparents and the wider public to the importance of following infant cues may play a key role here as might increased funding for breastfeeding peer supporters or family support workers.

There are limitations to the study. Firstly, as discussed above the data are correlational, and cannot imply cause and effect. It is possible that parenting styles influence feeding choices. On the other hand, it is possible that infant feeding choices shape parenting style. Alternatively it may be that the relationship between the variables is additive. Further although this exploratory study did include a wide range of potentially mediating variables it may be that there are other, as yet untested variables, which could explain the association. A longitudinal study exploring how attitudes and behaviors develop and change over time would address these issues. Related to this, research could consider whether these attitudes are malleable and whether interventions to promote an infant-led parenting approach may increase breastfeeding initiation and duration.

Secondly, the sample was self selecting with a slightly higher than average number of women who initiated breastfeeding at birth. Although responses were received from a variety of demographic backgrounds, the sample was older with a higher level of education than the UK average [43] with 92% of the sample of White British Origin limiting the generalisability of the findings. This was an exploratory study and further research is needed to test the findings in a population based sample to examine whether the structure and reliability of the questionnaire remains for a wider demographic. Moreover, potentially mothers with a higher level of education are more likely to research and read about their parenting choices which may affect their exposure to early parenting books and thus attitudes and behaviors e.g. decision to use a parent-led routine. Mothers with a more deprived background however are more likely to seek the guidance and support of family, particularly their mother, who may have generational ideas about how infants should be cared for [44]. Future research could ask parents to report sources of information that they have consulted regarding parenting behaviors and attitudes.

Thirdly, seventy two per cent of the responses were collected via the online survey link which could be considered a limitation [45]. However, the internet is now widely used, especially amongst pregnant and new mothers [46] and this was seen in the demographic spread of those completing online. Online recruitment methods are now increasing in popularity in health research [47], [48], [49]. No significant differences were seen in responses collected online or via paper copy. For an initial exploration of this under researched area, utilising internet recruitment methods allowed this new data to be collected. Further research should however now use more widely accessible methods in population based samples.

In conclusion, the findings raise pertinent questions in relation to the impact of parenting styles during early infancy upon breastfeeding initiation and duration. The main tenet that maternal desire for Parent-led routine and infant independence, and mothers' anxiety can impact negatively upon breastfeeding is an important consideration for those working to support pregnant and new mothers in the postnatal period. Moreover, given the popularity of specific approaches to early parenting in the popular literature, further research is needed to examine how these might be impacting upon infant health and development. Awareness needs to be raised about how the promotion of parent-led parenting styles might impede breastfeeding initiation and duration.

Author Contributions

Conceived and designed the experiments: AB BA. Performed the experiments: AB BA. Analyzed the data: AB BA. Contributed reagents/materials/analysis tools: AB BA. Wrote the paper: AB BA.

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Breastfeeding Duration and Early Parenting Behaviour: The Importance of an Infant-Led, Responsive Style

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Background Popular parenting literature promotes different approaches to caring for infants, based around variations in the use of parent-led routines and promoting infant independence. However, there is little empirical evidence of how these early behaviours affect wider parenting choices such as infant feeding.

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How do we know how many are breastfeeding

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How do we know how many are breastfeeding

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WBTi page

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Indicator 10 of any World Breastfeeding Trends Initiative report is about that country's monitoring and evaluation systems. It may not seem an exciting topic but it's essential to collect robust data on infant feeding to know what the breastfeeding rates are and how mothers are experiencing services. Without having monitoring data how can services be evaluated and then improvements planned?

For small projects, feedback from mothers may be the most effective evaluation but for larger projects and sizeable areas, the percentages of babies being breastfed (called prevalence) at particular ages help to monitor what is happening. Figures don't capture the ripple effect of support, though, such as a mother who's been helped on her breastfeeding journey then supporting friends or being more likely to breastfeed a subsequent baby or deciding to train as a peer supporter.

The WBTi UK report in 2016 found that data collection and analysis had reduced considerably since the ending of the 5-yearly infant feeding survey. There is variation between the four nations with England collecting the least data.

Changing systems in England

In England, record level data on infant feeding is currently submitted by service providers to NHS Digital as part of the Maternity Services Dataset (initiation/first milk feed) and the Children and Young People's Health Services Dataset (6-8 weeks). Whilst these new datasets are reaching full maturity, NHS England and Public Health England are publishing official statistics on an interim basis for breastfeeding initiation and breastfeeding at 6-8 weeks respectively. Both sets of data are assembled from aggregate data submitted on a voluntary basis by service commissioners. These two breastfeeding indicators are included in the Health Improvement part of the Public Health Outcomes Framework ( https://fingertips.phe.org.uk/profile/public-health-outcomes-framework).

Data on infant feeding at birth are submitted by maternity units. Babies were previously counted as breastfeeding if they went to the breast at least once in the first 48 hours. However, this is now changing to a record of the baby's first milk feed. This is captured as part of the Maternity Services Dataset and NHS Digital publishes monthly reports on the statistics of all the indicators in the data set: as well as annual data.

Local authorities have responsibility for ensuring that their commissioned providers of the universal health visiting service submit infant feeding data for babies aged 6-8 weeks as part of the Children and Young People's Health Services Dataset (which is about to be renamed the Community Services Dataset). As this data collection is not yet mature, aggregate infant feeding data is submitted to PHE on a quarterly basis. Official statistics are produced annually and quarterly

The Early Years part of PHOF, including these indicators, is maintained by the National Child and Maternal Health Intelligence Network.

In theory, the information at 6-8 weeks provides a picture of what is happening for the whole population but, disappointingly, there are quite a number of gaps. In most cases the local authority submits data to PHE but it cannot always be published as official statistics as a result of validation failures. This is most often due to too many records of 'unknown' breastfeeding status.
In one area, the health visiting service has found a solution to this by including a mandatory field on infant feeding in the electronic record of the questions about maternal mood at 6-8 weeks.
There needs to be information on at least 95% of the eligible population of babies (called coverage) to be valid and thus included. This results in some gaps in the published statistics even though the underlying data is available.

Try it yourself!

There is now a facility to compare different sets of the annual data, such as comparing gastrointestinal or respiratory infection rates with breastfeeding rates. §If there is sufficient correlation between two datasets, a red line appears. It doesn't prove there's a causal link though. You can try this for yourself here:
You select the Region, Area and Indicator you are interested in and then another Indicator for the Y-axis. You need to tick 'add regression line' to see if there is a correlation.

Using data to advocate for services

However, even if a service is well-evaluated, that does not guarantee its continued existence, as occurred with the Blackpool peer support Star Buddies programme, although this can be a useful tool in challenging actual or proposed cuts. Zoe Walsh, in her speech to Blackpool council (at 4mins 30s in the recording) in September 2017 used data as part of her clear explanation of why the service needs to be reinstated.
Data collection counts!
Cover photo credit: Paul Carter

Patricia Wise is an NCT breastfeeding counsellor and a member of the WBTi Steering Group.

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Data matters: How do we know what's happening with breastfeeding?

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Indicator 10 of any World Breastfeeding Trends Initiative report is about that country's monitoring and evaluation systems. It may not seem an exciting topic but it's essential to collect robust data on infant feeding to know what the breastfeeding rates are and how mothers are experiencing services.

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Mary Ann Liebert 2017

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An Error Occurred Setting Your User Cookie

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In general, only the information that you provide, or the choices you make while visiting a web site, can be stored in a cookie. For example, the site cannot determine your email name unless you choose to type it.

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Nancy Morhbacher blog

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A: You are not doing anything wrong. And in this case, more is not necessarily better. Formula-fed babies typically consume much more milk at each feeding than breastfed babies, but they are also more likely to grow into overweight children and adults.1,2One large study (16,755 babies in Belarus) compared feeding volumes in formula-fed and breastfed babies and found that the formula-fed babies consumed 49% more milk at 1 month, 57% at 3 months, and 71% at 5 months.3Australian research found that between 1 and 6 months of age breastfed babies consistently take on average around 3 ounces (90mL) at a feeding. (Younger babies with smaller tummies take less milk.)

Breastfed babies' milk intake doesn't increase from months 1 to 6 because their growth rate slows.4As growth slows, breastfed babies continue to get bigger and heavier on about the same daily milk intake, averaging about 25 ounces (750 mL) per 24 hours.

Why do formula-fed babies drink so much more milk? There are several reasons:

The bottle flows more consistently. During the first 3 to 4 months of life, after swallowing, an inborn reflex automatically triggers suckling.5 Milk flows more consistently from the bottle than the breast (which has a natural ebb and flow due to milk ejections, or let-downs), so babies tend to consume more milk from the bottle at a feeding. Before this reflexive suckling is outgrown, babies fed by bottle are at greater risk of overfeeding.

Breastfeeding gives babies more control over milk intake. Not seeing how much milk is in the breast makes a breastfeeding mother less likely to coax her baby to continue after he's full.3,6As the breastfed baby grows and thrives, his mother learns to trust her baby to take what he needs from both breast and bottle and also solid foods when they are introduced later. One U.K. study found that between 6 and 12 months of age breastfeeding mothers put less pressure on their babies to eat solid foods and were more sensitive to their babies' cues.7

More milk in the bottle means more milk consumed. In the Belarus study mentioned before, babies took more formula at feedings when their mothers offered bottles containing more than 6 ounces (180 mL).3

Mother's milk and formula are metabolized differently. Formula-fed babies use the nutrients in formula less efficiently,8 so they may need more milk to meet their nutritional needs. Formula is also missing hormones, such as leptin and adiponectin, which help babies regulate appetite and energy metabolism.9,10 Even babies' sleep metabolism is affected, with formula-fed babies burning more calories during sleep than breastfed babies.11

Q: If my baby takes more milk from the bottle than I can express at one sitting, does that mean my milk production is low?
A: See the previous answer. Babies commonly take more milk from the bottle than they do from the breast. The fast, consistent milk flow of the bottle makes overfeeding more likely. So if your baby takes more milk from the bottle than you express, by itself this is not an indicator of low milk production.

To reduce the amount of expressed milk needed and to decrease the risk of overfeeding, take steps to slow milk flow during bottle-feeding:

Use the slowest flow nipple/teat the baby will accept.

Suggest the feeder try holding the baby in a more upright position with the bottle horizontal to slow flow and help the baby feel full on less milk.

Short breaks during bottle-feeding can also help baby "realize" he's full before he takes more milk than needed.

For details you can share, see my handout, For the Caregiver of a Breastfed Baby HERE.

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Breast Versus Bottle: How Much Milk Should Baby Take?

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Q: Why does my breastfed baby take at most 4 ounces (120 mL) from the bottle when my neighbor's formula-fed baby takes 7 or 8 ounces (210-240 mL)? Am I doing something wrong? A: You are not doing anything wrong. And in this case, more is not necessarily better.

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WBTi

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The newest update of the has just been published by the international Infant Feeding in Emergencies Core Group, which brings together leading humanitarian organisations and experts working in this field.

Planning for the protection of infants in emergencies in the UK

Banner illustration:
Created by Michelle Pensa Branco for Safely Fed UK: Infant and Young Child Feeding in Emergencies Facebook page

Helen Gray IBCLC is Joint Coordinator of the World Breastfeeding Trends Initiative (WBTi) UK Working Group. She is on the national committee of Lactation Consultants of Great Britain, and is also an accredited La Leche League Leader. She represents LLLGB on the UK Baby Feeding Law Group, and serves on the La Leche League International special committee on the International Code.

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Protecting all infants in emergencies: Indicator 9 in the WBTi report

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The newest update of the has just been published by the international Infant Feeding in Emergencies Core Group, which brings together leading humanitarian organisations and experts working in this field.

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Breastfeeding duration and Early Parenting behaviour

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Breastfeeding duration and Early Parenting behaviour

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Amy Brown

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Amy Brown,

Bronia Arnott

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Abstract

Background

Popular parenting literature promotes different approaches to caring for infants, based around variations in the use of parent-led routines and promoting infant independence. However, there is little empirical evidence of how these early behaviours affect wider parenting choices such as infant feeding. Breastfeeding often requires an infant-led approach, feeding on demand and allowing the infant to regulate intake whilst conversely formula feeding is open to greater caregiver manipulation. The infant-led style associated with breastfeeding may therefore be at odds with philosophies that encourage strict use of routine and independence. The aim of this study was to explore the association between early parenting behaviours and breastfeeding duration.

Methods

Five hundred and eight mothers with an infant aged 0-12 months completed a questionnaire examining breastfeeding duration, attitudes and behaviours surrounding early parenting (e.g. anxiety, use of routine, involvement, nurturance and discipline). Participants were attendees at baby groups or participants of online parenting forums based in the UK.

Results

Formula use at birth or short breastfeeding duration were significantly associated with low levels of nurturance, high levels of reported anxiety and increased maternal use of Parent-led routines. Conversely an infant-led approach characterised by responding to and following infant cues was associated with longer breastfeeding duration.

Discussion

Maternal desire to follow a structured parenting approach which purports use of Parent-led routines and early demands for infant independence may have a negative impact upon breastfeeding duration. Increased maternal anxiety may further influence this relationship. The findings have important implications for Health Professionals supporting new mothers during pregnancy and the postpartum period.

Citation: Brown A, Arnott B (2014) Breastfeeding Duration and Early Parenting Behaviour: The Importance of an Infant-Led, Responsive Style. PLoS ONE9(2): e83893. https://doi.org/10.1371/journal.pone.0083893

Editor: Andrea S. Wiley, Indiana University, United States of America

Received: November 17, 2012; Accepted: November 17, 2013; Published: February 12, 2014

Copyright: © 2014 Brown, Arnott. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: AB was supported by a postdoctoral fellowship from the Economic and Social Research Council. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The importance of breastfeeding for infant and maternal health is well established. Infants who are formula fed are at increased risk of gastrointestinal and respiratory disorders, allergies and obesity [1], [2]. Despite this, levels of breastfeeding in the UK are low [3]. Although physiological contraindications to breastfeeding do exist [4], social and psychological variables are known to play a large role in affecting breastfeeding duration [5]. Beliefs that breastfeeding is inconvenient and difficult or that formula-fed infants are more content impact on how a mother adapts to breastfeeding [6]. Physical difficulties and lack of support can exacerbate difficulties [5], [7]. Moreover, low confidence, poor self efficacy and anxiety can also lead to formula use [8], as well as concerns for infant health, growth and development [9], [10].

However, little empirical evidence exists in relation to how early infant feeding fits within wider parenting behaviours and contexts. Previous research exploring the conceptualisation and influence of parenting styles for older children typically categorised behaviour along two dimensions of warmth and control [11]. Authoritative parents typically respond in a warm and responsive way to their child's signals but also exert an appropriate amount of age appropriate control over their child's behaviour. Conversely, authoritarian parents exhibit high levels of control combined with a low level of nurturance. Finally, permissive parents combine low levels of control with high warmth [12]. In general, an authoritative approach has been associated with desired outcomes including positive child conduct [13], enhanced cognitive development [14], and healthier nutritional intake and weight-gain trajectories [15]. How these elements of parenting older children might apply to parenting an infant and their impact upon the infant are however unclear.

One central question appears to be how aspects of parenting styles, particularly around control and nurturance might affect or drive decision to breast or formula feed. To be successful, breastfeeding often has to be baby-led, following the infants cues of hunger and satiety to promote milk supply [16]. Breastfed infants typically feed more frequently and irregularly than formula fed infants as breast milk is easily digested and varies in energy density over the course of the day [17]. On demand, unrestricted breastfeeding is associated with an earlier onset of milk production [18], faster regain of birth weight [19] and a reduced occurrence of issues related to breastfeeding discontinuation such as nipple soreness and engorgement [20]. Conversely formula feeding can be open to greater caregiver manipulation as it is easier to perform to a parent-led schedule [18]. The baby-led nature of breastfeeding can however evoke maternal anxiety regarding infant consumption or clash with maternal desire for control and predictability [10]. Essentially, breastfeeding may 'conflict' with overall approach to care giving.

In an initial study we characterised variations in parenting style during infancy exploring developed concepts of nurturance and control but applying them to infant care. For example, issues such as use of parent-led routine and encouraging the infant to self-settle were explored [21]. Here we examine the association between these early parenting behaviours and breastfeeding duration.

Methodology

Participants

All aspects of this study were performed in accordance with the ethical standards set out in the 1964 Declaration of Helsinki. Ethics approval was granted by Swansea University (UK) Department of Psychology Research Ethics Committee.

Five hundred and eight mothers with an infant aged between 0 and 12 months (mean age 27.47 weeks) (SD: 15.02) completed a self report questionnaire. Participants were recruited from local mother and baby groups in Swansea and Durham and through online parenting forums based in the UK. The groups were located in areas of varying deprivation as measured by the Welsh and English Indices of Multiple Deprivation. Groups were both privately run or based in Children's Centres or Family and Community Centres, encouraging a wide range of participation in terms of demographic background. For the groups, contact was made with group leaders who distributed questionnaires to group members. Questionnaires were returned to the leader in a sealed envelope or via post to the researcher. Questionnaires had information letters attached with details of how to contact the researcher if further information was required.

Study adverts were also placed on specific research request boards on online message boards on parenting forums based in the UK (e.g. www.mumsnet.com; www.bounty.com) with an online link to complete the questionnaire via survey monkey. All participants were based in the UK and this was verified by provision of UK postcode. Details were given as above for how to contact the researcher if needed. Questionnaire completion via either method implied consent.

Participants completing the questionnaire via paper or online copy were given a written debrief at the end of the questionnaire and given researcher details to contact if they wanted further information. All participants were given instruction to contact their relevant health professional if completing the questionnaire had raised any questions or issues with regard to caring for their baby.

Measures

The self report questionnaire explored maternal demographic background (age, education, parity), infant details (age, gender, birth weight) and details regarding breastfeeding initiation, duration and exclusivity. Participants indicated whether they breast or formula fed at birth, duration of breastfeeding if they had stopped and timing of introduction to use of formula and complementary foods if appropriate.

Participants also responded to a series of items examining their approach to parenting their infant (Infancy Parenting Styles Questionnaire (IPSQ) [21]. Items examined maternal involvement, responsiveness, sensitivity and discipline which are similar to those found in literature relating to parenting older children alongside more age specific behaviours of maternal anxiety and concern for her infant and maternal involvement in infant development such as concern for weight gain, sleep and early development ( Table 1). The IPSQ uses a five point likert scale for response (strongly agree to strongly disagree) with a a higher score on each factor indicating stronger agreement.

Data analysis

Distribution of breastfeeding duration was non-normal (Kolmogorov-Smirnov = .278 = .001) with a high proportion of mothers ceasing breastfeeding in the first few days and weeks or breastfeeding for a longer duration [as reflected in many studies such as the UK Infant Feeding Survey [3]. Therefore breastfeeding duration data was transformed and the natural logarithms computed used in order to correct for the skewed distribution. Mean scores for each factor were computed for the IPSQ [21].

Factor scores were compared using MANCOVA for infant feeding method at birth [breast/formula] and any breast milk at two, six, twelve and twenty six weeks. Maternal factors (age, education, parity, return to work), infant factors (infant age, birth weight) and birth experience (gestation, mode (section versus vaginal birth) were controlled for.

Results

The mean age of the respondents was 30.72 (SD: 5.12) years, (range from 17 to 44) and the mean number of years in education was 14.61 (SD: 2.53) (range from 12 to 20 years). Infant age ranged from 0 and 12 months (mean age 27.47 weeks (SD: 15.02). 29.4% of mothers were primiparous with the majority (54.1%) multiparas with two children. No significant difference was seen in mean age, years in education, marital status, breastfeeding duration or parenting behaviours between mothers who completed a paper or online version of the questionnaire. Exclusion criteria included multiple birth, low birth weight (<2500 g) or premature birth (<37 weeks). Demographic spread can be found in Table 2.

Parenting style

Significant associations were found between parenting style and maternal and infant characteristics ( Table 3). Mothers who were older and more educated were significantly more likely to report higher levels of anxiety and routine whilst reporting lower levels of nurturance, whilst older mothers were also significantly more likely to use a parent-led routine. Age of infant was also significantly associated with increased use of a parent-led routine and discipline and also lower levels of nurturance. Finally, birth weight was significantly inversely associated with anxiety and positively associated with greater use of parent-led routine and discipline. As noted above these variables were controlled for throughout the analyses.

Mode of feeding at birth and parenting style

Mothers indicated whether they breastfed (n = 400), gave expressed milk (n = 30) or formula fed (n = 78) at birth. A significant difference on the parent led routine factor (F (1, 505) = 4.888, p = 0.008) was found for feeding method at birth. Post hoc Bonferroni tests showed that mothers who breastfed or expressed breast milk at birth later reported using significantly lower levels of parent-led routine than mothers who formula fed. No significant difference was found between those who breastfed directly or gave expressed milk.

Significant differences in infant feeding were also found for the anxiety factor (F (1, 505) = 2.180, p = .006). Mothers who breastfed at birth scored significantly lower on this factor compared to mothers who fed expressed milk or formula fed. No significant difference was found between those who fed expressed milk or gave formula.

Scores on the nurturance factor also varied significantly for method of feeding at birth (F (1, 505) = 4.537, p = .011). Mothers who breastfed or expressed breast milk at birth later reported significantly higher scores on this factor compared to mothers who formula fed.

No significant difference was found in method of feeding at birth and scores on discipline or Involvement factors.

Breastfeeding duration and parenting style

The association between breastfeeding duration and parenting styles was also examined. The five parenting factors were compared for infants who were receiving any breast milk (or no breast milk) at two, six, twelve and twenty six weeks ( Table 4). As infants in the sample were aged 0-12 months, at each stage the sample was reduced in size to infants that age or older.

Breastfeeding duration was also significantly associated with parenting styles. Mothers who were giving any breast milk at two weeks scored significantly lower on parent-led routine (F (1, 472) = 9.813, p = .002) and anxiety (F (1, 472) = 6.632, p = .010) and significantly higher on nurturance (F (1, 472) = 10.779, p = .001) compared to mothers who were giving no breast milk.

Similarly for any breastfeeding at six weeks, mothers who were giving any breast milk scored significantly lower on parent-led routine (F (1, 409) = 10.552, p = .001) and anxiety (F (1, 409) = 5.476, p = .020) and significantly higher on nurturance (F (1, 409) = 12.415, p = .000) compared to mothers who were giving no breast milk.

Differences in parent-led routine remained significant for any breastfeeding at twelve (F (1, 359) = 5.122, p = .024) and twenty six weeks (F (1, 359) = 5.263, p = .022). However significant differences were no longer found for anxiety or nurturance.

No significant difference was found at any stage for discipline or involvement for milk feeding group.

Discussion

This paper examined the association between variations in approaches to parenting in early infancy and breastfeeding initiation and duration. Overall, parenting approaches that were higher in parent-led routine and anxiety and lower in nurturance were associated with a decreased likelihood that the infant was breastfed at birth and an increased likelihood that formula was introduced within the first six weeks postpartum. Given the importance of breastfeeding for infant and maternal health [1], understanding the impact and interaction of parenting styles upon breastfeeding is an important element in understanding maternal motivation to initiate and barriers to continuation.

Mothers who reported that they used high levels of parent-led routine day to day for their infant were less likely to initiate or continue breastfeeding. This relationship could be bidirectional. Mothers may adapt their use of routine to their chosen feeding method. Breastfeeding typically needs to baby-led and on demand to establish milk supply [18] whereas formula feeding can encourage a stricter feeding schedule and routine [6]. Moreover as breastfed infants often feed more frequently and irregularly compared to formula fed infants, a parent-led routine can be more difficult to establish [10]. Potentially mothers who breastfeed learn to, or have to, adopt a baby-led feeding pattern to continue breastfeeding whereas mothers who formula feed learn to, or choose to, follow a stricter parent-led routine. Alternatively, maternal desire for routine may drive infant feeding choice. Mothers who wish to have a strict routine may choose to formula feed for this reason. Indeed the perceived irregularity, commitment and hassle of breastfeeding are commonly cited by pregnant women for deciding not to breastfeed or to stop after a short duration of time [5]. Either way, a strict parent-led routine for infant feeding may not be beneficial to infant health, either through discouraging breastfeeding or because encouraging a baby to feed to a parent-led routine rather than its own natural patterns may promote obesity [6].

Breastfeeding initiation and continuation in the early weeks were associated with higher scores on the Nurturing factor, which included behaviours such as keeping the infant as close as possible. Nurturing behaviour is associated with improved breastfeeding outcomes; keeping the infant close, including skin-to-skin contact as soon after the birth is believed to play a critical role in breastfeeding initiation and duration [22]. Responding promptly to the infants signals of hunger encourages prolactin production which is essential to milk production [23] which is more likely if the infant is kept in close proximity including behaviour such as room sharing [24]. Again this relationship may be bidirectional - breastfeeding may encourage the mother to keep her infant close to her whereas perhaps formula feeding, where feeds are less frequent, may promote greater independence. Conversely, desire for nurturance may drive feeding choice; Mothers may choose to formula feed as they wish to have greater independence from their infant, allowing others to feed the infant or through the need to balance other responsibilities [5], [8]. Formula milk is perceived to promote infant sleep and encourage the infant to settle [10], potentially due to the increased time it takes to digest feeds [17]. An independent infant can often be viewed as a measured of parenting success e.g. 'a good baby' [25]. Thus for those who desire independence, breastfeeding may be incompatible.

Finally, greater maternal anxiety factor scores were associated with using formula from birth or stopping breastfeeding within the first six weeks. Mothers scoring high on this factor reported greater anxiety regarding their infants' development and greater tendency to seek advice from others [21]. The association between maternal anxiety and formula use has been well established. Mothers who report low self-efficacy and confidence are more likely to choose to formula feed [7]. Specific anxieties related to poor weight gain [9], concern regarding milk production [8], or that the infant is not receiving enough milk [10] are all linked to a shorter breastfeeding duration; often shorter than the mother desired. Formula feeding may provide reassurance for a mother with higher anxiety as intake is far more measurable; the amount consumed is visible, nutrient content listed on the tin and direct instructions about quantities to offer [18]. Conversely, it is possible that a negative experience of breastfeeding, leading to formula use, may increase overall maternal anxiety for their infant.

One potential insight into the development of parenting styles across this time is the sub sample of mother who gave expressed milk rather than breastfeeding directly at birth. In the UK mothers are entitled to up to nine months of paid maternity leave [26] which gives them opportunity to breastfeed for a number of months before they return to work. Low numbers of mothers in the UK choose to exclusively express milk for their infant rather than directly breastfeed [3]. This is in contrast to countries such as the USA where mothers often return to work soon after the birth, leading to greater numbers of mothers choosing to express milk for their infants for this reason. In the UK, when mothers choose to express, it is usually due to complications surrounding the birth such as infant or maternal health difficulties and/or low infant birth weight lead to the infant being given expressed milk rather than fed directly [27]. However, a negative birth experience can have a major impact on a new mother. It can increase maternal anxiety for her infant [28] that can last into childhood [29]. Concerns regarding growth and milk supply are especially strong [30]. Here, mothers who expressed breast milk at birth reported the highest levels of anxiety regarding their infant suggesting that early parenting styles may be affected by significant experiences surrounding the birth and first year. Again, further research is needed to ascertain how parenting styles form and develop.

A key question is the potential impact of the findings for those working to support breastfeeding mothers. There is a clear message emerging from the data that maternal beliefs and behaviours regarding wider parenting approach during infancy are associated with, and may be affecting, milk feeding choice. In the UK there is a very profitable market of baby care books aimed at parents of young infants [31]. These books often promote specific approaches to caring for an infant, typically focussed around how the parent should respond to the infant and use of parent led routines for sleep and feeding. Generally these books fall into two categories; those proposing a parent-led approach whereby strict sleep and feeding routines are imposed and those which are more baby-led encouraging the parent to respond to and follow infant cues and rhythms [32]. However, these books are typically not evidence based due to the lack of research exploring outcomes in this area. Given the popularity of parenting manuals that might promote structured methods of interaction and approach to the infant [21], [32], greater awareness needs to be raised as to how these books may be influencing maternal behaviour and choices, especially due to the lack of underpinning empirical evidence.

Moreover awareness should also be given by Health Professionals as to the influences beliefs about infant care approaches might have upon breastfeeding duration. Beliefs regarding routine and interaction with their infant or misconceived ideas about what normal infant sleep or feeding behaviour should be like might affect their parenting choices. Although the data presented here is correlational, given the association between infant feeding choice at birth and parenting style, perhaps the discussion of these antenatally may be important.

One specific application for health professionals could be the notable differences in both anxiety and nurturance between breast and formula groups up to six weeks postpartum but that were not significant after this time. Breastfeeding in the early days can be demanding but it is often viewed as established and easier after the infant reaches six weeks old [33], [34]. Health professionals might consider this with mothers who are feeling anxious about breastfeeding or concerned at how close they will need to remain to the infant at all times after the birth. High numbers of mothers initiate breastfeeding at birth but there is a high drop of rate in continuation, often before the mother was planning to stop breastfeeding [3]. Discussing with mothers how breastfeeding may change and become easier and less consuming after the first few weeks might encourage initiation or duration rates.

Despite the potential impact of a parent-led style upon breastfeeding duration, wider consideration does need to be given to the overall parenting experience. Sleep deprivation [35] and infant crying [36] are associated with increased risk of postnatal depression and maternal feelings of loss of control or identity [37]. An infant-led approach has been linked to night wakings for longer [38] whilst parent-led sleep training was related to reduced incidence of postnatal depression [39]. At an individual level a parent-led style and bottle feeding may have benefits that overall contribute to a more positive outcome for the family [40]. However, given the considerable importance of breastfeeding for both infant and maternal health [3], [4], more emphasis should be placed on offering increased maternal practical and emotional support and boosting confidence to enable her to breastfeed [41], [42]. Educating partners, grandparents and the wider public to the importance of following infant cues may play a key role here as might increased funding for breastfeeding peer supporters or family support workers.

There are limitations to the study. Firstly, as discussed above the data are correlational, and cannot imply cause and effect. It is possible that parenting styles influence feeding choices. On the other hand, it is possible that infant feeding choices shape parenting style. Alternatively it may be that the relationship between the variables is additive. Further although this exploratory study did include a wide range of potentially mediating variables it may be that there are other, as yet untested variables, which could explain the association. A longitudinal study exploring how attitudes and behaviors develop and change over time would address these issues. Related to this, research could consider whether these attitudes are malleable and whether interventions to promote an infant-led parenting approach may increase breastfeeding initiation and duration.

Secondly, the sample was self selecting with a slightly higher than average number of women who initiated breastfeeding at birth. Although responses were received from a variety of demographic backgrounds, the sample was older with a higher level of education than the UK average [43] with 92% of the sample of White British Origin limiting the generalisability of the findings. This was an exploratory study and further research is needed to test the findings in a population based sample to examine whether the structure and reliability of the questionnaire remains for a wider demographic. Moreover, potentially mothers with a higher level of education are more likely to research and read about their parenting choices which may affect their exposure to early parenting books and thus attitudes and behaviors e.g. decision to use a parent-led routine. Mothers with a more deprived background however are more likely to seek the guidance and support of family, particularly their mother, who may have generational ideas about how infants should be cared for [44]. Future research could ask parents to report sources of information that they have consulted regarding parenting behaviors and attitudes.

Thirdly, seventy two per cent of the responses were collected via the online survey link which could be considered a limitation [45]. However, the internet is now widely used, especially amongst pregnant and new mothers [46] and this was seen in the demographic spread of those completing online. Online recruitment methods are now increasing in popularity in health research [47], [48], [49]. No significant differences were seen in responses collected online or via paper copy. For an initial exploration of this under researched area, utilising internet recruitment methods allowed this new data to be collected. Further research should however now use more widely accessible methods in population based samples.

In conclusion, the findings raise pertinent questions in relation to the impact of parenting styles during early infancy upon breastfeeding initiation and duration. The main tenet that maternal desire for Parent-led routine and infant independence, and mothers' anxiety can impact negatively upon breastfeeding is an important consideration for those working to support pregnant and new mothers in the postnatal period. Moreover, given the popularity of specific approaches to early parenting in the popular literature, further research is needed to examine how these might be impacting upon infant health and development. Awareness needs to be raised about how the promotion of parent-led parenting styles might impede breastfeeding initiation and duration.

Author Contributions

Conceived and designed the experiments: AB BA. Performed the experiments: AB BA. Analyzed the data: AB BA. Contributed reagents/materials/analysis tools: AB BA. Wrote the paper: AB BA.

# data[].attributes.attachment_link.title
Breastfeeding Duration and Early Parenting Behaviour: The Importance of an Infant-Led, Responsive Style

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Background Popular parenting literature promotes different approaches to caring for infants, based around variations in the use of parent-led routines and promoting infant independence. However, there is little empirical evidence of how these early behaviours affect wider parenting choices such as infant feeding.

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Breastfeeding rates up but North/South gap widens

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Breastfeeding rates in Ireland are increasing steadily, but the gap between North and South is getting wider.

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Adding mothers milk to donor milk reinstates live properties

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Adding mothers milk to donor milk reinstates live properties

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Abstract

The American Academy of Pediatrics recommends that extremely preterm infants receive mother's own milk (MOM) when available or pasteurized donor breast milk (DBM) when MOM is unavailable. The goal of this study was to determine whether DBM could be inoculated with MOM from mothers of preterm infants to restore the live microbiota (RM). Culture dependent and culture independent methods were used to analyze the fluctuations in the overall population and microbiome, respectively, of DBM, MOM, and RM samples over time. Using MOM at time = 0 (T0) as the target for the restoration process, this level was reached in the 10% (RM-10) and 30% (RM-30) mixtures after 4 h of incubation at 37°C, whereas, the larger dilutions of 1% (RM-1) and 5% (RM-5) after 8 h. The diversity indexes were similar between MOM and DBM samples, however, different genera were prevalent in each group. Interestingly, 40% of the bacterial families were able to expand in DBM after 4 h of incubation indicating that a large percentage of the bacterial load present in MOM can grow when transferred to DBM, however, no core microbiome was identified. In summary, the microbiome analyses indicated that each mother has a unique microbiota and that live microbial reestablishment of DBM may provide these microbes to individual mothers' infants. The agreement between the results obtained from the viable bacterial counts and the microbiome analyses indicate that DBM incubated with 10-30% v/v of the MOM for 4 h is a reasonable restoration strategy.

Keywords: mother's own milk, restoration, personalization, donor breast milk, bacterial load, human milk microbiome

Introduction

The benefits of human milk for preterm infants include immune and nutritional protection against infection, decreased necrotizing enterocolitis (NEC), and other morbidities ( Wight, 2001). In the absence of mother's own milk (MOM), the American Academy of Pediatrics recommends using DBM over formula in very preterm infants ( Moretti, 2012). Thus, the current practice at the University of Florida, UF Health Neonatal Intensive Care Unit (NICU), is to provide premature infants of gestational age less than 30 weeks with DBM if the MOM supply is low or not available.

Numerous components of human milk are thought to be beneficial for the infant ( Newburg et al., 2005). Accumulating data suggests that microbes that are indigenous to human milk may not be contaminants and play a beneficial role for the infant ( Jeurink et al., 2013). Up to 200 different bacterial species have been found in human milk. Hunt et al. (2011) studied milk samples from 16 healthy women collected at three different time points. A common group of nine bacterial genera was present in all samples, but in different concentrations among the subjects. Each individual demonstrated a unique milk microbiome that was stable over time ( Hunt et al., 2011). Collectively, these data highlight a personalized collection of milk microbes from each mother that is optimized for the health of her own infant.

Donor breast milk used in most NICUs is pasteurized due to safety concerns ( Landers and Updegrove, 2010). Pasteurization of DBM kills 99% of bacteria and may also inactivate a large proportion of the bioactive components. Since DBM is pooled and pasteurized, it lacks the unique live maternal milk microbiome, which may be of benefit to the infant (for a review see Jost et al., 2015). The majority of mothers of very preterm infants are able to express small amounts of their own milk and although it may be of insufficient volume to meet the daily nutritrional requirements of their infant, it can still provide lasting health benefits. Our objective was to encourage the NICU mothers to continue pumping and use a small amount of MOM to inoculate the pasteurized DBM to add back the potentially beneficial naturally occurring microbes. We hypothesized that fresh MOM can be mixed with DBM to improve the quality of DBM by cultivating the beneficial milk microbiome to reflect MOM. Studies were performed to determine optimal dilutions and incubation times to obtain a microbial content most similar to that of the MOM.

Materials and Methods

Subjects

The study cohort consisted of twelve mothers who provided a breast milk sample between December 2014 and February 2016. Mothers had delivered an infant at less than 32 weeks gestation, weighing less than 1500 g at birth, and who were expressing over 100 mL of breast milk per day and producing at least 45 mL with each expression session. This pilot study was approved by the Institutional Review Board (IRB201400527) at the University of Florida and mothers provided written informed consent. Exclusion criteria included mothers who had delivered an infant with a chromosomal abnormality or who was severely ill and mothers who were currently taking antibiotics. Data collected included gender, gestational age at birth, gestational age at breast milk collection, birth weight, race, maternal age, parity, mode of delivery, maternal BMI, maternal infections, maternal medications, maternal antibiotics, and Medicaid eligibility. Baseline demographics are summarized in .

Table 1

Milk Collection

Each mother pumped one sample of 45 mL of breast milk (MOM) into a sterile container using a new breast pump kit (Symphony Breast Pump Kit, Medela LLC, McHenry, IL, United States) and hospital grade electric breast pump (Symphony Breast Pump, Medela LLC, McHenry, IL, United States). Prior to sample collection, mothers were provided the verbal instructions regarding hand hygiene during milk expression and techniques for breast pump cleaning per NICU protocol. Immediately following collection, the samples were placed on ice and delivered to the laboratory for processing. The pasteurized DBM was obtained frozen from the Human Milk Banking Association of North America (HMBANA) milk bank (see http://rmchildren.org/mothers-milk-bank/donate-milk/collection-and-storage/ for details on the collection guidelines for donors) and were thawed immediatly prior to each restoration process.

Restoration of the Live Microbiome of DBM

The restoration strategy was to add increasing amounts of MOM (1, 5, 10, and 30% v/v) into pasteurized DBM. As controls, pure DBM and MOM were included. Once blended, the milk mixtures were incubated at 37°C. Samples were taken at time 0, 4, and 8 h. For viable bacterial counts, samples were analyzed immediately. For microbiome analyses, 2 mL were centrifuged at 12,000 rpm for 5 min at 4°C, the supernatant removed, and pellets stored at -80°C until the DNA was extracted. The pH and physical appearance of the samples at each time point was also recorded.

Culture Dependent Bacterial Analysis

Viable cell counts were determined by plating serial dilutions of each sample on selective and non-selective agar plates at time 0, 4, and 8 h (T0, T4, and T8, respectively). Based on the most common groups of bacteria cultivated from human milk ( Wight, 2001; Martín et al., 2003; Reviriego et al., 2005; Jost et al., 2013; Menon and Williams, 2013), the following media were used: acidified Man, Rogosa and Sharp (MRS) agar for lactic acid bacteria (Fisher Scientific Company), Berens agar (BSM agar) for Bifidobacterium (Sigma-Aldrich) amended with BSM supplement Mupirocin Lithium Antibiotic (Fisher Scientific Company), Mannitol salt agar (MSA) for Staphylococcus (Fisher Scientific Company), Nutrient rich agar for facultative aerobes including Streptococcus (Sigma-Aldrich), and MacConkey agar for enterobacteria (Fisher Scientific Company). All plates were incubated at 37°C for 48-72 h. MRS and BSM agar plates were incubated in jars enclosing a burning candle to create a reduced oxygen environment while MacConkey and Nutrient agar plates remained incubated aerobically.

DNA Isolation, Library Construction and Sequencing

DNA was extracted from milk samples and preserved at -80°C using the PowerFecal ® DNA isolation kit (MoBio Lab, Inc. United States) with the following modification: the pellet was homogenized in 750 μL of bead solution, then 100 μL of Protease from Streptomyces griseus 20 mg/mL (Sigma-Aldrich, Steinheim, Germany) was added ( Marcial et al., 2017) The mixture was incubated at 37°C for 15 min, then the samples were processed according to the manufacturer's protocol. In the elution step, the DNA was collected in 70 μL of water and quantified. The DNA concentration was standardized to 1 ng/μL before the amplification of the V4 region using primers 515F/806R barcoded for Illumina HiSeq platform ( Caporaso et al., 2012). To reduce variability and potential bias from potential sources of DNA contamination, all samples were processed with the same batch of DNA extraction kits as well as PCR reagents.

Bioinformatics and Statistical Analysis

Clustering of Operational Taxonomic Units (OTUs) at 97% similarity was performed with the subsampled open-reference OTU picking method ( Rideout et al., 2014) with no removal of singletons. The Greengenes reference dataset version 13.8 ( DeSantis et al., 2006) was used as the reference for OTU picking and for taxonomy assignment with uclust ( Edgar, 2010). OTUs identified as mitochondrial DNA or as chloroplasts were removed from further analyses using R studio.

Community structure was analyzed in R with phyloseq ( McMurdie and Holmes, 2013) and plotted with ggplot2 ( Wickham, 2009). Differences in taxonomic profiles were analyzed by Welch's t-test (for two groups) or by ANOVA (for multiple groups) with Tukey-Kramer post hoc tests with STAMP ( Parks et al., 2014) and PAST ( Hammer et al., 2001).

Results

Mother's Own Milk Shows a High Variability in the Number of Culturable Bacteria

At baseline t = 0, the amount of four bacterial populations were quantified in MOM and used as the target goal for each individual mother. It was found that the amount of bacteria in MRS plates (lactic acid bacteria including Lactobacillus) were between 10 ³ and 10 ⁵ CFU/mL with most of them being at 10 ⁴ CFU/mL (). The bacterial load in MSA and nutrient broth were between 10 ³ and 10 ⁶ CFU/mL with an equal distribution in concentrations among the MOMs (). Only four MOM samples (30% of samples) grew on MacConkey agar at concentrations between 10 ¹ and 10 ² CFU/mL (data not shown). Bifidobacterium colonies were not recovered on Berens agar under our experimental conditions. The viable counts were also determined in DBM. Around 10 ² CFU/mL were counted in nutrient broth for half of the DBM samples ().

Restoration of the Live Microbiome of DBM with Mother's Own Milk

As described in the methods section, each of the twelve samples of MOM were inoculated in DBM at 1% (RM-1), 5% (RM-5), 10% (RM-10) and 30% (RM-30). Samples, including incubated DBM and MOM, were taken across three time points. The goal of this experiment was to determine the cultivable bacterial load of each sample to establish the minimum time and dilution required to reach the initial bacterial concentration found in MOM.

For each growth media, the concentration of bacteria was determined and ratios were calculated using MOM concentration at time 0 as the target concentration (represented as 1) (). On average, all RM samples increased in bacterial concentration over time (). A good correlation was found between the size of the inoculum and the amount of bacterial growth while the initial concentration of bacteria did not affect the outcome.

For MSA media, which targets mostly Staphylococcus, after 4 h of incubation at 37°C, 75% of the RM-10 reached a ratio of 0.6 compared to the MOM original bacterial load while all RM-30 reached a ratio of 1. For MRS media, which targets mostly lactic acid bacteria, 33% of the RM-10 reached a ratio of 1 compared to MOM while 58% of RM-30 reached the same ratio after 4 h. In Nutrient agar, which is a general purpose media targeting non-fastidious organisms, after 4 h of incubation 42% of samples in RM-10 reached a ratio of 1 compared to MOM while 83% reached a ratio of 1 in the RM-30 samples. After 8 h of incubation the bacterial load in all growth media tested (MSA, MRS, and Nutrient agar) for RM-10 and RM-30 went over the initial concentration of MOM (). In contrast, the two highest milk dilution ratios (RM-1 and RM-5) were less than 0.5 at 4 h of incubation and then at 8 h of incubation reached a ratio > 1, exceeding the MOM bacterial load ().

Since microbial growth may result in changes in pH as well as physical changes to the milk, the overall appearance (i.e., phase separation and curdling) and pH was monitored throughout the incubation period. Visual inspection of the milk samples did not reveal changes during the incubation period. Analysis of pH indicated that MOM samples were more alkaline (pH 7.5 ± 0.11) than pasteurized DBM (pH 6.5 ± 0.15) at T0. The incubation of MOM milk for 8 h resulted in a significant decrease ( p = 0.047) in pH to 7 ± 0.5 while no significant changes were observed in DBM samples or RM samples over time.

Donor Milk versus Mother's Own Milk Have a Similar Diversity Index

Illumina sequencing of the V4 region of the bacterial 16S rRNA was performed on all milk samples. After quality control, a total of 15,575,142 sequences were obtained with a mean of 75,976 sequences per sample. The rationale of this microbiome analyses was to have an unbiased view of the changes in the microbial community during the restoration process.

First, we compared the community structure of DBM and MOM at T0. The alpha diversity expressed as Chao1 and Shannon index was similar between the two sets of samples (). It cannot be concluded, however, that due to the similarity in alpha diversity between DBM and MOM that the bacterial load is the same since DBM is pasteurized. The relative abundance of genera was compared between the two samples (). Acinetobacter, Staphylococcus, Halomonas, Bacillus, Stenotrophomonas, unclassified Enterobacteriaceae genus, Streptococcus, Shewanella, Pseudomonas, Serratia, Enterococcus, unclassified Enterobacteriaceae genus, unclassified Methylobacteriaceae genus, unclassified Pseudomonadaceae genus, unclassified Xanthomonadaceae genus and Bacteroides constituted 85% of the sequences found in DBM. In MOM the most abundant genus were Halomonas, Staphylococcus, Shewanella, Corynebacterium, Enterobacteriaceae genus, Acinetobacter, unclassified Methylobacteriaceae genus, unclassified Enterobacteriaceae genus, Bacteroides, Stenotrophomonas and Lactobacillus. The statistical analyses showed that Halomonas ( p < 0.01) and Shewanella ( p < 0.01) were more abundant in MOM than in DBM samples. Similarly, Staphylococcus, Corynebacterium, and Lactobacillus were more abundant in MOM, yet did not reach statistical significance ( p < 0.1) when compared to that of DBM. On the contrary, Acinetobacter, an unclassified Enterobacteriaceae genus, and Serratia, showed a significantly higher relative abundance ( p < 0.05) in DBM.

Fluctuations in the Alpha Diversity of RM Samples during Microbial Restoration

Next, the fluctuations in the microbial community as a result of the restoration process was determined. As described earlier, the working hypothesis is that the restoration process will result in the expansion of the microbial population without loss of diversity. The expansion of MOM was used as a positive control to determine microbial populations that will be able to expand in vitro. The Shannon index was utilized to determine the species richness across time between DBM, MOM, and the RM samples (). It was found that after 4 h of incubation the MOM samples had a significant decrease ( p < 0.01) in alpha diversity only when compared to DBM and RM-1. In contrast, after 8 h of incubation, there is a significant decrease ( p < 0.001) in diversity when comparing MOM to all other samples (DBM and RM). However, even when a decrease in diversity was observed in RM-10 and RM-30, they did not reach statistical significance ( p = 0.07 and p = 0.14, respectively). The change in diversity of MOM and RM-10 or RM-30 suggests the differential growth of few bacterial species.

The analysis of the bacterial richness of the RM allowed for the assessment of the expanding microbiome to determine if the RM samples, over time, become similar to MOM at T0. A multidimensional scaling (MDS) plot was generated to visualize the variability of the microbial community in each MOM and their derived RM samples (). It was expected that the DBM samples of each individual set should remain clustered together since DBM is pasteurized and should have negative to little bacterial growth. In most cases, the DBM samples remained clustered together, such as MOM sample 4, 5, 6, 7, 8, 10, 11, and 12 (shown as circles in ) whereas, in DBM used for MOM samples 2 and 9 has a small difference in bacterial richness over time. Overall, these MDS plots allowed the visualization of fluctuations of the microbial population in the different RM samples over time. In some mothers, it was observed that the different RM samples migrated toward MOM at T0, suggesting that the RM sample became more similar to MOM at T0 (). However, some exceptions were observed. For example, all samples derived from MOM 3 cluster together, indicative that the restoration process was not successful. Mothers 11 and 12 show migration of all the dilutions moving away from MOM at all time-points and toward DBM instead. Mothers 11 and 12 shared the same sample of DBM so it is possible that live bacteria still found within this DBM sample are hindering the expansion of MOM-derived microbiota.

RM Samples Do Not Share a Common Expanding Microbiome

Next, we determined if a core microbiome was expanding in all the RM samples. Based on the culture dependent results where the target bacterial load (of the culturable population) was reached after 4 h and a decrease in diversity was observed in the microbiome after 8 h of incubation, the next series of analyses were performed on all the samples (DBM, RM, and MOM) only after 4 h of incubation.

For these analyses the relative abundance of each bacterial family was obtained. To identify families that increase in abundance after 4 h, the bacterial load from T0 was subtracted from the bacterial load from T4 across all samples. If a family increased in concentration within the negative control (DBM), it was excluded in the results. It was found that out of the 120 ± 40 families identified within MOM samples, an average of 37 ± 12 were able to increase concentration after 4 h of incubation. Interestingly, in all RM samples, 23-38% of the families were able to increase in concentration ().

All bacterial genera within the families that increased in concentration after 4 h of incubation were analyzed. Some genera showed some statistical trends like Gemella, unclassified Gemellales genus, Salinicoccus, Gallionella, unclassified Proteobacteria genus 1, unclassified Proteobacteria genus 2, Shewanella, Alicyclobacillus, Pediococcus, and Lactobacillus, however, no significant differences ( p < 0.2) were observed (data not shown). In contrast, Staphylococcus showed a significant increase in concentrations ( p < 0.01) (data not shown). In summary, a common core of microbes that expand in RM samples was not identified, with the exception of Staphylococcus.

Mother's Own Milk Samples Cluster by the Birth Mode of Delivery

Unable to determine a common expanding microbiome among RM samples, the data was stratified and analyzed considering the birth mode of delivery. The principal component analysis using MOM samples at T0, clustered into c-section and vaginal delivery with the exceptions of mothers 6 and 7 ( Supplementary Figure S1). The distribution of the 15 most abundant genera among samples is shown in Supplementary Figure S2.

The microbiome of MOM samples divided by mode of delivery (c-section n = 5 and vaginal n = 7) were analyzed using a Welch's t-test (Supplementary Table S1). It was found that Erwinia ( p = 0.03) and Pseudomonas ( p = 0.03) were more prevalent among c-section samples while Halomonas ( p = 0.02), Lactobacillus ( p = 0.04), Prevotella ( p = 0.04), Ruminococcus ( p = 0.04), unclassified Clostridiaceae genus ( p = 0.03), and unclassified Enterococcaceae genus ( p = 0.02) were found at higher concentrations in vaginal delivery samples (Supplementary Table S1). Other genera that had p-values greater than 0.05 and less than 0.13 were also taken into consideration for further analyses. These results indicate that the differences in genera observed between the mode of delivery of MOM might explain the inability to identify a core microbiome that expand in RM samples.

The data from RM samples was stratified by mode of delivery and the genera that were differentially found between c-section and vaginal delivery were analyzed (Supplementary Table S1). The relative increase in abundace after 4 h of incubation was tested using ANOVA and Tukey's post hoc tests. It was found that most genera did not change significantly. Agrobacter showed a significant difference ( p < 0.05) between vaginal RM-10 and c-section RM-10. Interestingly, 3 unclassified genera (unclassified Clostridiaceae genus, unclassified Enterococcaceae genus 2, and unclassified Methylophilaceae genus) increased in relative abundace in all c-section RM samples but not in vaginal delivery birth RM samples (data not shown). These results suggest that each MOM has a unique diverse bacterial load, having no core microbes.

Discussion

In this work we show that by using a small amount of MOM to inoculate pasteurized DBM, it is possible to reestablish the potentially beneficial naturally occurring microbes. MOM contains irreplaceable immune modulating factors including commensal bacteria ( Wold and Adlerberth, 2002; Jost et al., 2013). Feeding preterm infants MOM has been shown to decrease NEC and sepsis with even small amounts of MOM providing some protection ( Furman et al., 2003; Schanler, 2005; Meinzen-Derr et al., 2009; Corpeleijn et al., 2012, 2016; Abrams et al., 2014; Chowning et al., 2016). The microbiome found in MOM may provide short term and long term benefits to infants including preventing colonization by pathogens, stimulating production of cross-reactive antibiodies, and possibly establishing a healthy intestinal microbiome which may prevent long term morbidities including obesity, type 2 diabetes, chronic intestinal inflammation, autoimmune disorders, allergy, irritable bowel syndrome, and allergic gastroenteritis ( Goulet, 2015; Lemas et al., 2016; Wallace et al., 2016). Unfortunately, many mothers of preterm infants are unable to produce sufficient amounts of breast milk to sustain 100% of their infant's nutritional needs ( Smith et al., 2003; Lee and Gould, 2009). The RM may offer a personalized and beneficial alternative to DBM when MOM is limited. Since MOM contains a unique and unchanging microbiome ( Hunt et al., 2011; Cacho and Neu, 2014), providing infants their own mother's milk may be beneficial, especially for infants born preterm, at risk for infection and other premature specific morbidities.

Our culture dependent approach indicated that the main bacterial groups that were tested, namely Staphylococcus, lactic acid bacteria (and other that can grow in MRS agar), along with other facultative aerobes (including Streptococcus), can be propagated into DBM, however, a large variability in bacterial load was observed between mothers. Previous studies examining bacteria present in breast milk have required aseptic sample collection of milk by mothers to limit skin flora and potential contaminants ( Martín et al., 2003, 2007; Collado et al., 2009; Hunt et al., 2011; Jost et al., 2013; Khodayar-Pardo et al., 2014). In contrast, we aimed to examine the typical microbes that the preterm babies consistently received from their mother's milk during routine NICU expression practices and therefore, mothers performed routine NICU protocols for hand hygiene techniques and equipment cleaning. Consistent with Heikkilä and Saris (2003) and Martín et al. (2003), our results reveal that Staphylococcus, facultative aerobes, lactic acid bacteria, and few Gram negatives can be cultured from breast milk. We were not able to isolate Bifidobacterium in culture which may be due to the sensitive anaerobic nature of Bifidobacterium, having not provided the proper anaerobic environment or handling techniques to facilitate growth. In addition, it is possible that Bifidobaceterium is negligible in breast milk from mothers delivering preterm infants as indicated from the study by Khodayar-Pardo et al. (2014), which showed less Bifidobacterium compared to milk from mothers of term infants. Small numbers of Gram negative bacteria grew on MacConkey agar (results not shown), which is consistent with previous research indicating that approximately 30-70% of breast milk samples contained Gram negative bacteria ( Botsford et al., 1986; Landers and Updegrove, 2010; Keim et al., 2013). Small amounts of Gram negative bacteria in breast milk may be important in preparing the immune system to utilize toll-like receptor mediated tolerizing mechanisms to prevent an exaggerated response to future Gram negative bacteria ( Madara, 2004).

Interestingly, pasteurized DBM obtained from HMBANA showed that 10 ² CFU/mL of bacteria were still present in nutrient broth (facultative anaerobes including Staphylococcus and Streptococcus) in 44% of the DBM samples. This is consistent with previous studies describing the presence of staphylococcal species in DBM as well as spore forming bacteria such as Bacillus cereus ( Crielly et al., 1994; Landers and Updegrove, 2010; Decousser et al., 2013; Akindolire et al., 2015; Dewitte et al., 2015). Although microbial diversity indexes were similar between DBM and MOM, the most abundant genera differed. The most prevalent genera in MOM were Halomonas, Shewanella, Corynebacterium, Staphylococcus, and Lactobacillus, while the most common genera in DBM were Acinetobacter, unclassified Enterobacteriaceae, and Serratia. These differences may reflect variances in the mothers who provided breast milk samples and the sanitation or method used for collection. DBM is typically obtained from mothers who are breastfeeding term infants who are often more than 6 months old. In contrast, the MOM in this study was obtained from mothers of preterm, hospitalized infants who because of their infant's prematurity, were unable to breastfeed and were thus dependent on mechanical breast milk expression to obtain milk for their infants.

We found that Halomonas was present in greater abundance than Staphylococcus in comparison with other studies in MOM. Although Halomonas has not been previously described in breast milk from mothers delivering preterm, Staphylococcus is a well-known predominant phyla in breast milk ( Hunt et al., 2011; Urbaniak et al., 2012, 2016; Jost et al., 2013). We also found Shewanellaceae was high in MOM ( p < 0.05) compared to DBM. The main genera found to be of great abundance in MOM across different studies are Staphylococcus, Streptococcus, Proteobacteria groups, and Propionibacteria ( Hunt et al., 2011; Kumar et al., 2016). However, Bifidobacterium, Bacteroides, Parabacteroides and Clostridia groups have also been identified to be a part of the breast milk microbiota ( Sinkiewicz and Ljunggren, 2008; Kumar et al., 2016). Although Bifidobacterium was identified from our sequencing results, it was not shown to be prevalent. These differences in the predominant genera being Halomonas and Shewanellaceae as opposed to Staphylococcus and Streptococcus may be due to the fact that (except for rare occasions in three patients) mothers in our study did not breastfeed their infants. They were dependent on mechanical breast pumps for milk removal, thus the mother's breasts were not routinely exposed to oral microbes from the infant's mouth. Other reasons for these variations may be attributed to younger gestational age at delivery, stage of lactation, milk collection strategies and geographic variations in our study compared to others. In DBM, the most abundant genera were Acinetobacter, unclassified Enterobacteriaceae genus, and Serratia.

Results of this study suggest that the optimal restoration strategy to reach a microbial content most similar to MOM was a mixture of RM-10 incubated for 4 h. Using the bacterial load and microbial content of MOM at T0 as the target, we were able to successfully restore the microbiome in the RM-10 and RM-30 mixtures after 4 h of incubation, whereas larger dilutions of RM-1 and RM-5 reached the target level after 8 h. Although it did not reach the microbial content of MOM, RM-10 was able to reach 60% of the bacterial load of MOM. In contrast, RM-30 exceeded the target goal of MOM in the majority of incubated samples. This may be clinically undesireable since potentially pathogenic bacterial strains may grow to possibly harmful levels. Overall, our results demonstrate that inoculation with an amount of MOM as small as 1% can populate DBM with the mother's potentially beneficial bacteria.

The alpha diversity of MOM and the larger dilutions of RM (RM-10 and RM-30) decreased as incubation time increased. In contrast, the diversity of DBM and smaller dilutions of RM (RM-1 and RM-5) remained similar to their original levels as incubation time increased. This trend of MOM toward decreased diversity suggests replication of only a few microbial species. Breast milk studies show that microbial diversity is associated with a healthy lactating milk microbiome as opposed to the milk microbiome of a mother with mastitis where Staphylococcus or Streptococcus species predominate ( Delgado et al., 2008). This decreased diversity indicates that in order to preserve microbial diversity similar to that found in MOM, a 4 h incubation time compared to an 8 h incubation time may be optimal, which confirms the culture based results favoring a 4 h incubation time over 8 h for the RM.

Birth mode of delivery has been shown to affect the microbiota of breast milk in the majority of studies, suggesting a difference in the milk microbiome between infants born via c-section and those born vaginally ( Azad et al., 2013; Gregory et al., 2015; Liu et al., 2015; Brumbaugh et al., 2016; Dominguez-Bello et al., 2016; Lee et al., 2016; Nagpal et al., 2016; Rutayisire et al., 2016). In our study, we observed a differential clustering of microbiomes from the breast milk of c-sections versus vaginally delivering mothers. Although it is clear each individual mother's milk microbiota has bacterial variability, c-section and vaginal deliveries cluster with one another. Further analysis illustrated that bacterial genera most prevalent in breast milk from vaginal deliveries were Halomonas, Lactobacillus, Prevotella, unclassified Clostridiaceae genus, Clostridium, Comamonas, and Dorea. Those genera most prevalent in breast milk from cesarean deliveries were Erwinia, Pseudomonas, Ruminococcus, unclassified Enterococcaceae genus, Agrobacterium, Citrobacter, Enterococcus, Klebsiella, unclassified Bacilli genus, unclassified Bradyrhizobiaceae genus, and unclassified Methylophilaceae genus. Further statistical analysis does not show a common microbiota across breast milk regardless of c-section or vaginal delivery, concluding that the microbiota of breast milk is variable between each mother.

Based on our results, restoration of the live microbiome of DBM with MOM appears to be a promising and innovative method to provide preterm infants with beneficial breast milk bacteria. It is well known that breast milk changes over time to meet specific needs of infants which are attributed to stages of lactation, gestational age, infant feeding, and the health status of the breastfeeding dyad ( Daly et al., 1996; Kent, 2006; Hassiotou et al., 2013). If mothers of preterm infants are able to express even minimal amounts of breast milk, restoration of the microbiome in DBM may allow their infants to receive milk more specific to their individual needs based on the stage of lactation and gestational age, thereby potentially improving their overall health. We used non-culture based techniques to take a snapshot of the full range of bacteria present in fresh preterm milk and pasteurized donor milk. The main limitation of our study is its small sample size and the use of antibiotics during the peripartum period. Nevertheless, it addresses the concept that the live microbiota donor human milk can be effectively restablished by MOM. In addition, mothers were not required to clean their breasts prior to breast milk sampling so their samples may have contained a higher level of skin colonizing microbes. Another limitation of the study is that safety parameters were not assessed. Future studies will need to include the analyses of potential pathogenic bacterial groups that may proliferate in the RM samples in the NICU environment.

In summary, we have shown that each mother has a unique milk microbiota and that the live microbiome in DBM can be restored with these unique bacteria using small amounts of MOM. This is a novel approach to possibly improving the bioactivity of DBM by adding specific MOM microbes in small quantities to personalize her own infant's milk. Personalizing DBM may benefit the mother-infant dyad and contribute to a more robust infant intestinal microbiome. The agreement between the results obtained from the viable bacterial counts and the microbiome analyses indicate that DBM incubated with 10 percent of the MOM for 4 h is a reasonable restoration strategy. Future studies should include larger samples sizes, activity of the microbes in RM in comparison to DBM and MOM samples, and clinical evaluation of the safety and efficacy.

Ethics Statement

This pilot study was carried out in accordance with the recommendations of the Institutional Review Board (# 201400527) at the University of Florida with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the Institutional Review Board at University of Florida.

Author Contributions

The authors' responsibilities were as follows: NC, LP, JN, and GL designed the research; NC, NH, KP, GM, LC, and NL performed the research; DL contributed new reagents/analytic tools; NC, NH, LC, LP, and GL analyzed the data; NC, NH, LP, JN, and GL evaluated the data; NC, NH, LP, JN, and GL wrote the manuscript; NC, NH, LP, JN, and GL had primary responsibility for the final content; All authors read and approved the final manuscript. Medela, AG was not involved in the implementation, data collection, statistical analysis, interpretation of date, or manuscript preparation and writing.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

The authors would like to thank the mothers who generously provided milk samples for the study. We acknowledge our dedicated neonatal nurses for taking excellent care our patients. We also acknowledge Christopher Gardner and Tara Miller for their technical help. Finally, we acknowledge Medela Company for supplying the new sterile pumping kits used in this study.

Abbreviations

Footnotes

Funding. Funding for this study was provided by Medela, AG.

Supplementary Material

The Supplementary Material for this article can be found online at: http://journal.frontiersin.org/article/10.3389/fmicb.2017.01470/full#supplementary-material

FIGURE S1

This is a principal component analysis (PCA) of the microbiota of MOM samples at T0. The circles represent moms that delivered through C-Section and the squares are those that delivered through vaginal births.

FIGURE S2

Heatmap showing the top 15 genera of each DBM sample, with the exception of replicates DBM 1, 2 and 11 (DBM 1 and 2 being a replicates of 3 and DBM 11 being a replicate of 12), and each MOM sample.

References

Akindolire M., Babalola O., Ateba C. (2015). Detection of antibiotic resistant [Staphylococcus aureus from milk: a public health implication.Int. J. Environ. Res. Public Health 12 10254-10275. 10.3390/ijerph120910254PMC free article]

Gregory K. E., LaPlante R. D., Shan G., Kumar D. V., Gregas M. (2015). Mode of birth influences preterm infant intestinal colonization with [Bacteroides over the early neonatal period.Adv. Neonatal Care 15 386-393. 10.1097/ANC.0000000000000237PMC free article]

Hammer Ø., Harper D. A. T., Ryan P. D. (2001). PAST: paleontological statistics software package for education and data analysis. Palaeontol. Electron 4 1-9. 10.1016/j.bcp.2008.05.025

Lee H. C., Gould J. B. (2009). Factors influencing breast milk versus formula feeding at discharge for very low birth weight infants in California. 155 657.e-662.e 10.1016/j.jpeds.2009.04.064

Marcial G. E., Ford A. L., Haller M. J., Gezan S. A., Harrison N. A., Cai D., et al. (2017). [Lactobacillus johnsonii N6.2 modulates the host immune responses: a double-blind, randomized trial in healthy adults.Front. Immunol. 8:655 10.3389/fimmu.2017.00655PMC free article]

Sinkiewicz G., Ljunggren L. (2008). Occurrence of Lactobacillus reuteri in human breast milk.Microb. Ecol. Health Dis. 20 122-126. 10.1080/08910600802341007

Wickham H. (2009). ggplot2: Elegant Graphics for Data Analysis. New York, NY: Springer. 10.1007/978-0-387-98141-3

Wold A. E., Adlerberth I. (2002). "Breast feeding and the intestinal microflora of the infant - implications for protection against infectious diseases," in Short and Long Term Effects of Breast Feeding on Child Health eds Koletzko B., Michaelsen K. F., Hernell O., editors. (Boston, MA: Kluwer Academic Publishers; ) 77-93. 10.1007/0-306-46830-1_7

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Personalization of the Microbiota of Donor Human Milk with Mother's Own Milk

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The American Academy of Pediatrics recommends that extremely preterm infants receive mother's own milk (MOM) when available or pasteurized donor breast milk (DBM) when MOM is unavailable. The goal of this study was to determine whether DBM could be inoculated with MOM from mothers of preterm infants to restore the live microbiota (RM).

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Seeking advice. A and I Kruk/Shutterstock

Becoming a new parent certainly ranks up there in the exhaustion and anxiety stakes. Countless parents find themselves questioning at 3am whether their baby is feeding too much, if they should be sleeping through the night by now, and wondering if there is anything else they should be doing differently. Social media posts often boast of sleeping, contented babies while in reality many parents feel unable to put their baby down. Some want a miracle solution - and quickly.

Ever since the publication of Dr Benjamin Spock's multi-million selling baby and childcare title, the Common Sense Book of Baby and Child Care, countless self-proclaimed experts have purported incredible solutions for infant sleep, feeding and care. Generations of parents have turned to books such as Dr Spock's for advice over the years, but the thing is - beyond anecdotal evidence - we don't actually know whether these books work.

The elephant in the room with many of these books is that actually, despite their popularity, they are not based on evidence. Some of them actually go against what we know about promoting positive, healthy infant attachment, well-being and health. In fact our recent research has suggested that some books' impact on maternal well-being is not good, and that there is a link between their use and an increased likelihood of symptoms of depression and anxiety.

Oksana Kuzmina/Shutterstock

The problem is that these there is a potential mismatch between expectations of what the books offer and the reality of being a parent. Our research found that mothers' experience of following books' advice played an important part in their well-being. If they found the books useful, the mothers' well-being was not affected, but if they didn't find them useful, they were at a higher risk of depression and anxiety. Unfortunately only around a fifth of mothers in the study found them useful - 22% reported feeling more in control - while over 50% found them harmful in some way, and 53% felt more anxious).

Only one in ten of the participants felt that the advice in the books made them less tired, while one in six actually reported feeling like a failure because of them. The promised nights of sleep did not emerge. Given that mothers who are already feeling anxious and miserable might be drawn to these books as a solution, the potential for things to be made worse is concerning.

Unhelpful advice

So why don't these books seem to work for most parents? Most likely because the suggestion that you can encourage a baby into a parent-led routine goes against a lot of what we know about young babies' needs. Babies need to feed often because their tummy is small. Breast milk in particular is really easily digested so they need to feed lots - which also helps build a good milk supply.

Waking at night is normal too. After all, lots of adults wake up at night but can attend to their own needs such as pulling a cover back over them or getting a drink. Babies need help doing this. Finally, human infants are really quite vulnerable compared to many other mammals. They can't even hold their heads up let alone walk and feed themselves shortly after birth. This means that they are programmed to want to keep their caregiver close.

Trying to persuade babies that they want to feed less often, sleep through the night and lie contentedly on their own flies in the face of normal developmental infant needs. Although some parents may be lucky enough to find it works for them, many others will find it instead creates other issues. For example, trying to limit how much a baby feeds can reduce milk supply, making them distressed, and increasing the likelihood of breastfeeding difficulties. Not responding to an infant's cries at night is stressful for their developing brains too. Meanwhile, sleeping close to their mother at night promotes a steadier temperature, heart rate and breathing.

Miracle cure

Saying all of this, you can fully understand why parents are drawn to books that promise that routines will work. Motherhood is exhausting and many new mothers are now isolated from family, which can increase the risk of depression. Many may need to return to work while still dealing with sleepless nights.

It's normal for parents to worry about whether they are doing it "right". But they should remember that a baby having frequent needs and wanting to be kept close is normal. In fact, responding to babies' needs helps the new-born to learn that the world is a good place.

Books and "expert" advice may seem like a good idea but the fact of the matter is that little ones respond to biology, and haven't been reading the same advice as mum or dad.

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Are baby advice books making mothers depressed and anxious?

# data[].attributes.attachment_link.description
Becoming a new parent certainly ranks up there in the exhaustion and anxiety stakes. Countless parents find themselves questioning at 3am whether their baby is feeding too much, if they should be sleeping through the night by now, and wondering if there is anything else they should be doing differently.

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V Harries and Amy Brown

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The transition to motherhood can be challenging. The baby book market has taken advantage of this, publishing a range of books that suggest adopting strict routines for infant sleep, feeding, and general care. Despite their multi-million sales, their impact has not been established. The aim of this study was to explore the maternal experience of using these books, and the association with maternal well-being. Three hundred and fifty-four mothers with an infant aged 0-12 months reported use of infant parenting books that promote strict routines, experience of using them, and measures of postnatal depression, maternal self-efficacy and parenting stress. Use of the books was associated with increased depressive symptoms and stress, alongside lower self-efficacy, although experience of using the books predicted this. Although those who found the books useful had greater well-being, the majority did not find them useful, which was associated with lower well-being.

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The association between use of infant parenting books that promote strict routines, and maternal depression, self-efficacy, and parenting confidence

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The transition to motherhood can be challenging. The baby book market has taken advantage of this, publishing a range of books that suggest adopting strict routines for infant sleep, feeding, and general care. Despite their multi-million sales, their impact has not been established.

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Michael Rosen BBC Radio 4

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Taking Turns in Conversation, Word of Mouth - BBC Radio 4

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Michael Rosen and Laura Wright discuss how we take it in turns to talk, in conversation.

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Overview of research from neuroscience

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Early life experiences set the stage for physical health in later life. Reducing early toxic stress is key to preventing disease in adults ( Shonkoff, 2016).

Breastfeeding is one important way to decrease early toxic stress. Recent studies have shown that breastfeeding increases babies' physical and mental well-being, and these effects go well beyond the composition of the milk. Maternal responsiveness is key to understanding these long-term effects. When mothers consistently respond to their babies' cues, they set the stage for lifelong resiliency in their offspring. And responsiveness is built into the breastfeeding relationship. We see this reflected in children's mental health.

In one study of 2,900 mother-infant pairs, breastfeeding for one year was associated with better child mental health at every age up to age 14 ( ). Longer duration of breastfeeding was associated with better child mental health at every assessment point.

Maternal depression

Maternal depression has a well-documented negative effect on babies and children. It is harmful because it impairs mothers' ability to be responsive to their babies. Depressed mothers tend to disengage from their babies, and fail to respond to their cues. Babies experience this as highly stressful, and there can be lifelong effects from being raised by a chronically depressed mother or father ( Field, Diego, & Hernandez-Reif, 2009 ; Kendall-Tackett, 2002 , 2010 ; Weissman, 2006 ).

Edward Tronick 's 'Still-Face Mother' experiments are an analog of what happens with maternal depression. You can see the effects of not responding in these compelling videos.

These effects are long lasting. A 20-year follow-up of children of depressed parents compared them with a matched group of adult children whose parents had no psychiatric illness. The adult children of depressed parents had three times the rate of major depression, anxiety disorders, and substance abuse compared to adult children of non-depressed parents.

For many years, feeding method was not included in studies of maternal depression. In fact, for years, professionals who specialized in perinatal mental health believed that breastfeeding was actually a risk factor for postpartum depression. Fortunately, we now have evidence that indicates that exclusively breastfeeding mothers are at lower risk for depression. Indeed, breastfeeding is protective of maternal mental health ( Dennis & McQueen, 2009 ; Groer & Davis, 2006 ; Kendall-Tackett, Cong, & Hale, 2011 ).

Sleep

One reason why breastfeeding lowers depression risk is its impact on sleep. On every parameter of sleep, exclusively breastfeeding mothers fare better than their mixed- or formula-feeding counterparts:

Our study of 6,410 mothers indicated that exclusively breastfeeding mothers were significantly better on every sleep measure compared to their mixed- and formula-feeding counterparts. Surprisingly, there was no significant difference between the mixed- and formula-feeding mothers ( Kendall-Tackett et al., 2011 ). In other words, exclusive breastfeeding is a different physiological experience than mixed feeding. When mothers supplement with formula, they lose the physiological benefit of breastfeeding on their sleep.

Protection and responsivity

One study also found that breastfeeding protects babies when their mothers are depressed. This study compared four groups of mothers: mothers who were either depressed (breast or formula-feeding) or non-depressed (breast or formula-feeding). The measure was the babies' EEG (electroencephalogram) patterns (abnormal patterns were a symptom of depression in the infants). The babies of depressed, breastfeeding mothers had normal EEG patterns compared to the babies of depressed, formula-feeding mothers ( Jones, McFall, & Diego, 2004 ). In other words, breastfeeding protected the babies from the harmful effects of their mothers' depression. The reason for this finding comes down to maternal responsivity. The researchers discovered that the depressed, breastfeeding mothers did not disengage from their babies. They couldn't. The breastfeeding mothers looked at, touched, and made eye contact with their babies more than the mothers who were not breastfeeding. And that was enough to make a difference.

Cycle of violence

Mothers with a history of childhood abuse often feel as though they do not have the tools they need to parent their own children successfully. They may wonder whether they will perpetuate the cycle of violence.

Impaired sleep can be an important trigger to the intergenerational transmission of abuse. Babies of mothers with depression or PTSD are more likely to have sleep difficulties, possibly because of their exposure in utero to their mothers' elevated stress hormones ( Field, Diego, & Hernandez-Reif, 2006 ; Field et al., 2007 ). And a recent study found that for women with PTSD and a history of childhood abuse, infant sleep difficulties and maternal depression impaired mother-infant bonding and increased the risk of intergenerational transmission of trauma ( Hairston et al., 2011 ). But there's a different picture if the mother breastfeeds.

In Strathearn et al's ( 2009 ) 15-year longitudinal study of 7,223 Australian mother-infant pairs, breastfeeding substantially lowered the risk of maternal-perpetrated child maltreatment. Non-breastfeeding mothers were 2.6 times more likely to be physically abusive, and 3.8 times more likely to neglect their children compared to breastfeeding mothers.

The results of our 2013 study may help explain why this is so. In our sample of 6,410 new mothers, 994 women reported previous sexual assault. As predicted, sexual assault had a pervasive, negative effect on mothers' sleep, physical well-being, and mental health. The sexually assaulted mothers' sleep was poor, they were more tired, they were more anxious and angry, and had more depression. But when we added feeding method to our analyses, we found that breastfeeding attenuated the effects of sexual assault and downregulated the stress response. This effect was only for exclusively breastfeeding women ( Kendall-Tackett, Cong, & Hale, 2013 ). Anger, in particular, was lessened and this might explain Strathearn's findings cited above. Also, lower rates of depression improve maternal responsiveness, which is protective.

Attachment and long-term health

We can also examine the impact of security of mother-infant attachment and its effects on long-term health. In an article written shortly before the end of their lives, attachment pioneers Mary Ainsworth and John Bowlby noted that maternal (or caregiver) responsivity was key to creating a secure attachment in infants. Ainsworth developed the primary measure of attachment in infants: The Strange Situation.

The Strange Situation has been used in thousands of studies all over the world. Secure attachment on this measure is a great predictor of child mental and physical health. And responsiveness is key. When babies are not responded to consistently, they develop insecure attachments, and that has long-term implications for health, as a recent 32-year longitudinal study of 163 people found ( Puig, Englund, Simpson, & Collins, 2013 ). Participants in this study were followed from birth to age 32. At 12 to 18 months, they were assessed via the Strange Situation. Those with insecure attachments had significantly more inflammation-based illnesses at age 32 than those who had secure attachments. These findings are likely due to the chronic activation of the inflammatory response system in those with insecure attachments.

In summary, the results from these studies demonstrate that breastfeeding has a much larger role to play in maintaining physical and mental health than we have previously believed.

Because breastfeeding increases maternal responsivity, it makes the day-to-day experience of mothering more tolerable. And it increases the chances that the babies will be securely attached. Breastfeeding is so much more than just a method of feeding. It's a way of caring for a baby that will provide a lifetime's worth of good health because it provides a way for mothers to connect with their babies-even if they did not experience that kind of care themselves.

In short, breastfeeding can make the world a happier and healthier place, one mother and baby at a time. It's not just the milk.

References

Shonkoff, J. P., Boyce, W. T., & McEwen, B. S. (2009). Neuroscience, molecular biology, and the childhood roots of health disparities: building a new framework for health promotion and disease prevention. (21), 2252-2259. doi: 301/21/2252 [pii] 10.1001/jama.2009.754

Shonkoff, J.P. (2016). Capitalizing on Advances in Science to Reduce the Health Consequences of Early Childhood Adversity. JAMA Pediatr, 170(10),1003-1007. doi:10.1001/jamapediatrics.2016.1559.

Strathearn, L., Mamun, A. A., Najman, J. M., & O'Callaghan, M. J. (2009). Does breastfeeding protect against substantiated child abuse and neglect? A 15-year cohort study. Pediatrics, 123 (2), 483-493. doi: 123/2/483 [pii] 10.1542/peds.2007-3546.
Kathleen Kendall-Tackett, PhD, IBCLC, FAPA
Dr. Kendall-Tackett is a health psychologist and International Board Certified Lactation Consultant, and the owner and Editor-in-Chief of Praeclarus Press , a small press specializing in women's health. She is Editor-in-Chief of two peer-reviewed journals: Clinical Lactation and Psychological Trauma. She is Fellow of the American Psychological Association in Health and Trauma Psychology, Past President of the APA Division of Trauma Psychology, and a member of the Board for the Advancement of Psychology in the Public Interest. Dr. Kendall-Tackett specializes in women's-health research including breastfeeding, depression, trauma, and health psychology, and has won many awards for her work including the 2016 Outstanding Service to the Field of Trauma Psychology from the American Psychological Association's Division 56.

Dr. Kendall-Tackett has authored more than 400 articles or chapters, and is currently completing her 35th book, The Phantom of the Opera: A Social History of the World's Most Popular Musical. Her most recent books include: Depression in New Mothers, 3 rd Edition (2016, Routledge UK, in press), Women's Mental Health Across the Lifespan (2016, Routledge US, in press, with Lesia Ruglass), Psychology of Trauma 101 (2015, Springer, with Lesia Ruglass) and The Science of Mother-Infant Sleep (2014, Praeclarus, with Wendy Middlemiss). Her websites are:
Google Scholar
Now available in Spanish too: Crianza Natural

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Neuroscience Shows Breastfeeding Is Not Just Milk

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Early life experiences set the stage for physical health in later life. Reducing early toxic stress is key to preventing disease in adults ( Shonkoff, 2016). Breastfeeding is one important way to decrease early toxic stress. Recent studies have shown that breastfeeding increases babies' physical and mental well-being, and these effects go well beyond the composition of the milk.

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Useful for discussing PND
Prepare the viewer as can be distressing to watch

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Risk of Bottle feeding for rapid weight gain

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Risk of Bottle feeding for rapid weight gain

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Li et al 2012

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Objective To better understand the mechanisms behind breastfeeding and childhood obesity, we assessed the association of weight gain with the mode of milk delivery aside from the type of milk given to infants.

Design A longitudinal study of infants followed up from birth to age 1 year. Multilevel analyses were conducted to estimate infant weight gain by type of milk and feeding mode.

Setting Pregnant women were recruited from a consumer mail panel throughout the United States between May 2005 and June 2007.

Participants One thousand eight hundred ninety nine infants with at least 3 weight measurements reported during the first year.

Main Exposures Six mutually exclusive feeding categories and proportions of milk feedings given as breastmilk or by bottle.

Main Outcome Measures Weight measurements reported on 3-, 5-, 7-, and 12-month surveys.

Results Compared with infants fed at the breast, infants fed only by bottle gained 71 or 89 g more per month when fed nonhuman milk only ( P < .001) or human milk only ( P = .02), respectively. Weight gain was negatively associated with proportion of breastmilk feedings, but it was positively associated with proportion of bottle-feedings among those who received mostly breastmilk. Among infants fed only breastmilk, monthly weight gain increased from 729 g when few feedings were by bottle to 780 g when most feedings were by bottle.

Conclusions Infant weight gain might be associated not only with type of milk consumed but also with mode of milk delivery. Regardless of milk type in the bottle, bottle-feeding might be distinct from feeding at the breast in its effect on infants' weight gain.

The estimated percentage of US children aged 2 to 5 years and 6 to 11 years classified as overweight increased from 5.0% and 6.5% in 1980 to 10.4% and 19.6%, respectively, in 2007-2008. The increase in childhood obesity was also observed among those aged 6 to 23 months, from 7.2% in 1980 to 11.6% in 2000. Given the numerous health risks related to childhood obesity, its prevention is becoming a public health priority. It has been reported that feeding practices affect growth and body composition in the first year of life, with breastfed infants gaining less rapidly than formula-fed infants. There is also evidence that breastfed infants continue to have a low risk for later childhood obesity.

There are multiple hypotheses for the mechanisms behind breastfeeding and childhood obesity and one of them pertains to the poor self-regulation of energy intake among formula-fed infants. In contrast to infants fed at the breast who may need to actively suckle, formula-fed infants are more likely to be passive in the feeding process, and caregivers' control might undermine infants' capability for self-regulation to balance energy intake against internal cues of hunger and satiety. Theoretically, feeding babies with expressed breastmilk could increase infant weight gain because it is fed by bottle. So far, only one pilot study has examined early growth patterns of babies fed breastmilk by breast vs by bottle. The purpose of this study was to compare infant weight gain by both milk type (human vs nonhuman milk) and feeding mode (breast vs bottle) and examine whether bottle-fed infants gain weight more rapidly than those fed at the breast during the first year. The study had 2 specific hypothesis: (1) Infant weight gain is not only affected by type of milk but also by mode of milk delivery and (2) Regardless of the type of milk in the bottle, bottle-feeding might put infants on a faster track of weight gain.

The Infant Feeding Practices Study II is a longitudinal study of new mothers and their infants conducted by the Food and Drug Administration and the Centers for Disease Control and Prevention from May 2005 to June 2007. Women were recruited in their third trimester of pregnancy from a consumer opinion panel of approximately 500 000 households throughout the United States. Eligibility criteria included mothers aged 18 years or older and infants born after 35 weeks' gestation with a birth weight of at least 2.25 kg. About 3000 infants were followed up from birth for 1 year, with 10 postnatal questionnaires mailed at approximately monthly intervals. The response rates for each postpartum survey varied from 63% to 83%. All data collection procedures were approved by the Food and Drug Administration institutional review board. The details of overall Infant Feeding Practices Study II design and response rates were presented elsewhere.

The outcome measures were 4 weight measurements reported on the 3-, 5-, 7-, and 12-month surveys. Mothers were asked at each of these surveys what was their infant's weight measured at the most recent doctor's visit and visit date. Because weights reported on each survey were measured at different times across infants, age at weight measurement varied from infant to infant. To limit reporting errors, we calculated the z score of weight for age using the Centers for Disease Control and Prevention's reference and considered z scores of 5 or greater or −5 or less as biologically implausible.

Because infant weight is a cumulative function of previous feedings over time, we first identified the time interval between 2 consecutive weight measurements and then aggregated all the feeding data available within each interval to tie each weight outcome to its corresponding feeding exposures. The 3 main exposure variables from each interval were milk feeding category, percentage of milk feedings given as breastmilk, and percentage of milk feedings given by bottle.

At each postpartum survey (about 1, 2, 3, 4, 5, 6, 7, 9, 10, and 12 months of age), mothers were asked how often they breastfed or fed pumped breastmilk as well as how often they fed formula and other types of milk in the past 7 days, which was used to categorize infants by whether they were fed at the breast, by expressed milk, or by formula and other types of milk. Aggregating all the feeding data within the same weight measurement interval, each infant was classified into 1 of the 6 mutually exclusive overall milk feeding categories: (1) Breastfed only; (2) Breastfed and human milk by bottle; (3) Breastfed and nonhuman milk by bottle; (4) Human milk by bottle only; (5) Human and nonhuman milk by bottle; and (6) Nonhuman milk by bottle only.

For the percentage of milk feedings given as breastmilk or by bottle, we first calculated the percentage of total milk feedings that were of the breast (BF%); expressed breastmilk (EBM%); or nonhuman milk (NHM%) including formula, cow's, or other milk at each survey (BF% + EBM% + NHM% = 100%). We then calculated the mean proportion of milk feedings as breastmilk (BF% + EBM%) or by bottle (EBM% + NHM%) during each interval. Both breastmilk and bottle-feeding proportions were further classified as less than 33%, 33% to 66%, and greater than 66% to represent low, medium, or high frequency of milk feedings as breastmilk or given by bottle.

To control for potentially confounding effects, we adjusted for the following factors in our multilevel analysis: maternal age; race/ethnicity; maternal education; percentage of poverty; marital status; parity; postpartum participation in the Special Supplemental Nutrition Program for Women, Infants, and Children program; prepregnancy body mass index (calculated as weight in kilograms divided by height in meters squared); infant sex; gestational age; age at solid food introduction; average number of sweet drinks consumed per day during the first half year (including juice drinks, soft drinks, soda, sweet tea, Kool-Aid, etc); and birth weight. Percentage of poverty was defined as a ratio of household income to the poverty threshold by household size. Prepregnancy body mass index was based on maternal recall during the prenatal survey. Age at solid food introduction was defined as the infant's age when any solid food was first reported on any of the monthly surveys. Birth weight was obtained from a short telephone interview with prenatal respondents within a week after birth. Except for gestational age, age at solid food introduction, sweet drinks consumption, and birth weight, all other confounding factors were adjusted using categorical variables as shown in Table 1.

Table 1. Characteristics of Analytical Sample of 1899 Mother-infant Pairs

Table 1. Characteristics of Analytical Sample of 1899 Mother-infant Pairs

Neonatal questionnaires were available from 3033 mothers. Of these, 13% (n = 392) did not complete the 3-, 5-, 7-, and 12-month surveys; 6% (n = 184) reported fewer than 3 out of 5 possible weight measurements; 1% (n = 41) reported biologically implausible weight; 2% (n = 75) had an invalid visit date for the weight measurement; 4% (n = 126) reported smaller weight in the subsequent survey; 1% (n = 38) had missing data on feeding exposures; and 9% (n = 278) had missing data on covariates. This yielded a final sample of 1899 mother-infant pairs with a total of 5719 observations from 4 weight measurement intervals.

Individual growth curve models were developed for multilevel analysis and specifically designed for exploring longitudinal data on individual changes over time. Using this approach, we applied the MIXED procedure in SAS (SAS Institute) to account for the random effects of repeated measurements. To specify the correct model for our individual growth curves, we compared a series of MIXED models by evaluating the difference in deviance between nested models. Both fixed quadratic and cubic MIXED models fit our data well, but we selected the fixed quadratic MIXED model because the addition of a cubic time term was not statistically significant based on a log-likelihood ratio test. We first modeled infant weight as a function of corresponding milk feeding categories. This model estimated linear slopes of weight gain for each feeding category with final estimates adjusted for the potential confounding factors listed previously. Infant age at weight measurement was the time variable, and age squared was the quadratic term included in the model. Because milk feeding categories varied from time to time, we entered them into the model as a time-varying covariate to allow the linear effect of milk feedings to vary with age. As such, the model accommodates infants who were fed in one category for one period but another category for a different period.

We then modeled infant weight as a function of proportions of milk feedings given as breastmilk or by bottle with both terms entered simultaneously into the model as continuous variables. Because the association of weight gain with proportion of bottle-feedings might vary by proportion of breastmilk feedings, we added a product term between these 2 continuous variables in the model to test the significance of its interaction. We also categorized these 2 proportions into 3 groups (<33%, 33%-66%, and >66%) and conducted a log-likelihood ratio test for the nested models with and without all 2-way interactions between them. Because both interaction tests suggested a significant interaction between type of milk and feeding mode ( P < .001), we conducted stratified analysis to examine the association of weight gain with proportion of milk feedings either as breastmilk or by bottle separately. Specifically, for each level of bottle-feedings proportion, we examined monthly weight gain by 10% increments in breastmilk-feedings proportion; for each level of breastmilk feedings proportion, we examined monthly weight gain by 10% increments in bottle-feedings proportion. To further separate the effects of bottle use from type of milk, we also estimated the monthly weight gain by proportion of bottle-feedings among infants fed only breastmilk as well as monthly weight gain by proportion of breastmilk feedings among infants fed only by bottle. All the data analyses for this study were conducted using SAS software version 9.2 (SAS Institute Inc).

Most of the study sample was aged 25 to 34 years, white, married, and had education beyond high school ( Table 1). Approximately half were overweight or obese prior to pregnancy and one-third was participating in the Special Supplemental Nutrition Program for Women, Infants, and Children program. Although infant weight was reported at 3, 5, 7, and 12 months, it was measured at an average of 10, 18, 28, and 52 weeks, respectively.

Table 2 shows weight gain by corresponding feeding categories from the same interval. Not counting groups 4 and 5, which had very small sample sizes, infants fed with nonhuman milk by bottle only (group 6) had the largest weight gains at 3 to 5 months, >5 to 7 months, and >7 to 12 months. Infants who were breastfed and fed nonhuman milk (group 3) had rates of weight gain intermediate between those who were breastfed only (group 1) and those who were only fed nonhuman milk (group 6) in each of these age ranges.

Table 2. Crude Gain in Weight (g/mo) by Corresponding Feeding Categories at Each Weight Measurement Interval for 1899 Infants

Table 2. Crude Gain in Weight (g/mo) by Corresponding Feeding Categories at Each Weight Measurement Interval for 1899 Infants

To summarize the estimates for fixed-effect parameters from the MIXED modeling in an easy way to interpret, we present linear monthly weight gain for each feeding category compared with infants fed at the breast only ( Table 3). Compared with infants fed at the breast only, infants fed only by bottle gained 71 or 89 g more per month when fed nonhuman milk only ( P < .001) or expressed human milk only ( P = .02), but they gained only 37 g more per month when fed both expressed human milk and nonhuman milk ( P = .08). Infants fed both at the breast and by bottles of expressed human milk gained similar to infants fed at the breast only, whereas infants fed both at the breast and by bottles of nonhuman milk gained 45 g more per month ( P < .001).

Table 3. Multilevel Analyses of Linear Monthly Weight Gain for Each Feeding Category Compared With Infants Fed at Breast Only for 1899 Infants a

Table 3. Multilevel Analyses of Linear Monthly Weight Gain for Each Feeding Category Compared With Infants Fed at Breast Only for 1899 Infants a

The results from a main-effects model with both breastmilk-feedings proportion and bottle-feedings proportion considered as primary exposure variables indicated that a 10% increase in the proportion of breastmilk feedings was associated with a 3.6-g decrease in weight gain per month ( P = .07), whereas a 10% increase in proportion of bottle-feedings was associated with a 4.1-g increase in weight gain per month ( P = .05). Because of the significant interactions between feeding mode and type of milk, we stratified the analysis by examining their effects separately ( Table 4). Among those with more than 66% of feedings by bottle, a 10% increment in the proportion that were of breastmilk was associated with a 5.9-g decrease in monthly weight gain. In contrast, infants gained 8 g more per month for each 10% increment in the proportion of bottle-feedings among those who received at least two-thirds of their feedings with breastmilk.

Table 4. Multilevel Analyses of Associations of Weight Gain With Increment in Proportion of Milk Feedings Either as Breastmilk or by Bottle for 1899 Infants a

Table 4. Multilevel Analyses of Associations of Weight Gain With Increment in Proportion of Milk Feedings Either as Breastmilk or by Bottle for 1899 Infants a

Because type of milk and feeding mode were confounded by each other, examining bottle effects among infants fed by breastmilk only and examining breastmilk effects among infants fed by bottle only would be useful to tease out this confounding effect ( Figure). Among infants fed by breastmilk only, weight gain increased from 729 g per month at low bottle-feedings to 780 g per month at high bottle-feedings. However, the relationship between weight gain and percentage of breastmilk feedings among infants fed by bottle only was U-shaped.

Our study suggests that bottle-feeding, aside from the type of milk used, might be an independent factor associated with infant weight gain. Regardless of milk type in the bottle, bottle-feeding might be distinct from feeding at the breast in its effect on infants' weight gain.

The mechanisms behind breastfeeding and childhood obesity are unclear. In addition to the biological mechanism of unique properties of breastmilk, such as leptin and adiponectin found in human milk, the ability of breastfed infants to self-regulate their energy intake might be another possibility. Infants might play a more active role in determining their intake when feeding at the breast. Mothers who breastfeed might also develop a feeding style that is less controlling. On the contrary, the duration and amount of bottle-feeding more likely depend on the caregivers' decisions, which are often based on visual observations of the remaining milk in the bottle with encouragement to finish the bottle. In addition, the variations in the taste and nutrient content within each breastfeeding episode (much higher fat content toward the end) might also serve as a physiological signal for babies to stop suckling. This variation does not occur with bottle-feeding. Thus, infants frequently fed by bottles may gradually lose their ability to self-regulate and ultimately gain weight more rapidly than those fed at the breast.

Giving expressed breastmilk provides benefits when direct breastfeeding is impossible, but breastfeeding and breastmilk feeding might be fundamentally different. In addition to caregivers' control of feeding expressed breastmilk, some of the immune components, vitamins, and fat might be lost during the storage and handling. Nevertheless, feeding expressed breastmilk is certainly as close to breastfeeding as one can get when breastfeeding is infeasible. We found that infants categorized as "breastfed and human milk by bottle" grew similarly to those fed only at the breast, but infants categorized as "breastfed and nonhuman milk by bottle" grew more rapidly ( Table 3). This suggests that supplementing breastfeeding with expressed breastmilk would be preferable to supplementing breastfeeding with nonhuman milk. Thus, breastfeeding mothers who need to feed their infant by bottle should be supported for expressing breastmilk.

Infants categorized as consuming "human milk by bottle only" and "nonhuman milk by bottle only" gained more weight than infants fed at the breast only, but there was no such bottle effect observed among infants categorized as consuming "human and nonhuman milk by bottle." This might be owing to the fact that infants in this mixed feeding category were more likely fed at the breast previously than the other 2 groups (data not shown). Our previous study suggests that infants fed at the breast develop a better self-regulation of milk intake, which may be carried over even after feeding is transitioned from breast to bottle. Similarly, mothers who previously breastfed might better recognize infants' cues of hunger and satiety, which may last even after they stop breastfeeding.

Stratified analysis allowed us to examine the effects of bottle use and breastmilk feeding separately. While weight gain was negatively associated with breastmilk feeding, it was positively associated with bottle-feeding when the proportion of breastmilk feedings was high ( Table 4). The dose-response relations between weight gain and bottle use among infants fed only breastmilk further implies a potential risk of bottle-feeding for rapid weight gain during infancy ( Figure).

There are several limitations of this study. First, because black and Hispanic mothers were underrepresented in the study population, our results may not be applicable to the entire US population. Second, because both weight measurement and feeding practice were reported by mothers, reporting errors may have occurred. However, the recall period was relatively short and it is unlikely that the misclassification of feeding exposures depended on weight outcomes given the longitudinal design of this study. For nondifferential misclassification, the reporting errors would bias the results toward the null value. Third, the final analytical sample excluded 278 cases owing to missing data on covariates. However, our sensitivity analysis based on the full sample without controlling for these covariates in the models indicated similar results. Fourth, despite our statistical efforts to minimize the confounding effects, we may not have completely separated out the effects of bottle use from the type of milk because of the complexity of infant feeding and observational nature of this study. Lastly, a large number of infants were fed completely at the breast or completely with nonhuman milk, so the continuous results presented in Table 4 could be driven by patterns in these extreme groups. However, we eliminated these infants to limit the contribution of extreme values to the estimates but observed similar findings.

The strengths of this study include that the Infant Feeding Practices Study II was the largest longitudinal study on infant feeding practices in the United States, the reporting bias for the feeding variables was minimized by a short 7-day retrospective recall at a monthly interval, and the residual effects of other variables were limited by controlling a wide range of potentially confounding variables in the multilevel analysis. Of the many advantages of multilevel analyses, individual growth modeling accounts for correlated data from repeated weight measurements as well as the changes in feeding categories from time to time on an individual basis.

In conclusion, regardless of milk type in the bottle, bottle-feeding might be distinct from breastfeeding in its effect on infant weight gain. Feeding at the breast needs to be the first feeding choice for babies. When feeding at the breast is not always feasible, supplementing breastfeeding with expressed breastmilk is a good alternative, but special attention is needed for infants' internal feeding cues while bottle-feeding.

Correspondence: Ruowei Li, MD, PhD, Centers for Disease Control and Prevention; National Center for Chronic Disease Prevention and Health Promotion; Division of Nutrition, Physical Activity, and Obesity, 4770 Buford Highway, MS K25, Atlanta, GA 30341 ( ril6@cdc.gov).

Accepted for Publication: November 19, 2011.

Author Contributions: Dr Li had full access to all the data in the study and takes full responsibility for the integrity of the data and the accuracy of the analysis. Study concept and design: Li, Fein, and Grummer-Strawn. Acquisition of data: Li, Fein, and Grummer-Strawn. Analysis and interpretation of data: Li, Magadia, Fein, and Grummer-Strawn. Drafting of the manuscript: Li and Magadia. Critical revision of the manuscript for important intellectual content: Li, Fein, and Grummer-Strawn. Statistical analysis: Li, Magadia, and Grummer-Strawn. Obtained funding: Grummer-Strawn. Administrative, technical, and material support: Li, Fein, and Grummer-Strawn. Study supervision: Grummer-Strawn.

Financial Disclosure: None reported.

Funding/Support: The Infant Feeding Practices Study II was funded by the Food and Drug Administration, Centers for Disease Control and Prevention, Office of Women's Health, National Institutes of Health, and Maternal and Child Health Bureau in the US Department of Health and Human Services.

Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the Food and Drug Administration.

Online-Only Material:An author podcast about this article is available here.

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Risk of Bottle-feeding for Rapid Weight Gain During the First Year of Life

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In a longitudinal study of infants followed from birth to age 1 year, Li and colleagues conducted multilevel analyses to estimate infant weight gain by type of milk and feeding mode. The study involved 1899 infants with at least 3 weight measurements reported during the first year.

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Poem by Holly McNish

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'Embarrassed // poem by Hollie McNish // directed by @dypka // @holliepoetry' on ViewPure

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This poem is taken from my book Nobody Told Me: a journey from pregnancy to pre-school in poetry and prose: http://www.blackfriarsbooks.com/book/nobody-told-me/\n\n\

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You are probably a bit of a blamer - most of us are. But why should we give it up? In this witty sequel to our most watched RSA Short, inspirational thinker Brené Brown considers why we blame others, how it sabotages our relationships, and why we desperately need to move beyond this toxic behaviour.

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The power of vulnerability

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'The power of vulnerability | Brené Brown' on ViewPure

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http://www.ted.com Brené Brown studies human connection -- our ability to empathize, belong, love. In a poignant, funny talk at TEDxHouston, she shares a deep insight from her research, one that sent her on a personal quest to know herself as well as to understand humanity.

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Radio 4 programme

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Claudia Hammond explores Carl Rogers's revolutionary approach to psychotherapy, led by the client and not the therapist. His influence can be seen throughout the field today.

Claudia Hammond presents the history of psychology series which examines the work of the people who have changed our understanding of the human mind. This week she explores Carl Rogers' revolutionary approach to psychotherapy, led by the client and not the therapist. His influence can be seen throughout the field today.

Claudia meets Rogers' daughter, Natalie Rogers, who has followed in her father's footsteps and developed Expressive Arts Person-Centred Therapy, and hears more about the man from Maureen O'Hara of the National University at La Jolla, who worked with him. Richard McNally of Harvard University and Shirley Reynolds of Surrey University explain how far Rogers' influence extends today, and Claudia sees this for herself in a consulting room in downtown San Francisco, where she meets Person-Centred psychotherapist, Nina Utigaard.

Producer: Marya Burgess

Three Approaches to Psychotherapy (1965): film clips courtesy of Sharon K. Shostrom, Psychological & Educational Films.

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BBC Radio 4 - Mind Changers, Carl Rogers and the Person-Centred Approach

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Claudia Hammond explores Carl Rogers's revolutionary approach to psychotherapy, led by the client and not the therapist. His influence can be seen throughout the field today. Claudia Hammond presents the history of psychology series which examines the work of the people who have changed our understanding of the human mind.

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A mothers article about breastfeeding her 4 year old child

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In December 2004, I wrote in these pages about how I found myself "still breastfeeding" a 14-month-old, when previously I had viewed "extended breastfeeders" as a bit odd, needy and, frankly, freaky. When I first became a mother, I had envisaged myself as a mother with a clipboard, with me in charge, not the baby. I never expected to be the sort of mother I am now, breastfeeding a four-year-old on demand. I thought I knew myself, but motherhood introduced me to a self I never even knew was lurking.

To pick up where I left off three years ago: at just over a year old, my daughter seemed to be losing interest in breastfeeding. But as it turned out, that was the lull before the storm. Just as she started walking, at 18 months, she started to feed intensively. This is normal: as babies reach major developmental stages, they need to feed more. Whereas she had never been able to tell me when she was hungry as a baby, now she beat her chest with her fists - like Tarzan's Cheetah - to tell me that she wanted milk. And she wanted milk a lot. I'd be lying if I said there weren't times when I wished I'd weaned her. I found it hard, but I was lucky. Far from being isolated, I co-run a pro-breastfeeding website that has lots of long-term breastfeeders as members. I wasn't going through anything others hadn't previously.

From the age of two, my daughter started to switch breasts - that is to say, she would no longer feed on one breast, then sedately take the other. She would switch, sometimes manically, between the two, because she had learnt that the let-down (the flow of milk) is faster if you stimulate the breasts in this way. It was also about this time that she started a habit I find extremely annoying to this day: twiddling. While she fed off one breast she would twiddle the other nipple, as if trying to tune in to a short wave radio station. Again, this was to stimulate the milk so that when she did latch on to the second breast, it was all ready to go.

I found feeding between the ages of two and four quite hard at times. She needed to feed a lot, sometimes 50 feeds a day, although they were quick. When we moved house, her feeding became almost frenzied, as if she thought I would leave her. Docking on to the "mothership" became vitally important. I'm not sure how I would have met her needs so quickly during this time without breastfeeding. And I'm not sure I could have parented during the terrible twos without it: it was like having an entire cavalry at your beck and call. Breasts are a powerful parenting tool.

Despite this, breastfeeding is often blamed for many childhood malaises. Your baby is hungry/ sleepy/won't sleep/colicky/you're tired? Give up breastfeeding! The very thing that can make life easier is jettisoned, purely out of ignorance. Imagine if every time you said you found parenting a little bit hard, someone said, "Put your child up for adoption." It'd be ridiculous, wouldn't it?

No matter how hard I found breastfeeding, however, I couldn't stop, for two reasons. The more knowledgeable I became, the more vital I knew sustained breastfeeding to be. And, second, because it is obvious how much breastfeeding means to my daughter. There's the beauty in feeding an older child: there is no second guessing - she tells me just how important my milk is to her, how it "makes everything better". When she gets a cold, she tells me that she needs my milk to "kill the cough". One night, she started to run a desperately high fever (104) and I had no medicine or way of getting any. I fed her all night; she injected her germs into me while my body made the antibodies she needed and fed them back to her. We both worked through the night and, by morning, she was better, as if the fever had never happened. Knowing that you have the wherewithal to comfort and cure your child within your own body is hugely magical and empowering. The bonuses that breastfeeding gifts you make the not-so-easy times fade into nothing.

Because we don't have a habit of feeding walking, talking children in this country, I stopped feeding my child in public when she got to be about two. I didn't want anyone else's ignorance to negate something she found so comforting. Now, there's a word: comfort. I remember, pre-motherhood, challenging a friend of mine who was breastfeeding her 18-month-old child. "But isn't it just for comfort?" I said. "What's wrong with wanting to comfort my child?" she said. Now, this is what I tell people, too. We - or rather, not me; not any longer - seem to be terribly afraid of comforting children. Sometimes it seems as if the more hands-off you are as a parent, the more of a success you are deemed to be.

Breastfeeding is about comfort, but it's also about nutrition, and that continues for as long as you breastfeed your child, whatever age they are. My milk is a living fluid - full of enzymes, macronutrients, minerals, vitamins, essential fatty acids, T-cells and at least 200 types of immunoglobin. And that's just what's known - there are ingredients in breast milk that we don't even know about yet. My milk changes, hour by hour, to meet the needs of my child. It isn't like any other woman's milk, anywhere on the planet, because my daughter isn't like any other child in the world.

In September, just as my child was about to turn four, I went to Italy with her. I'd been the year before and had encountered gentle curiosity about us still feeding. This time was different. "It's a tragedy," said one aged cousin, "that she's still feeding." "Who," I asked, "is it a tragedy for? Not me and not my daughter."

I smiled and offered tea, but she wasn't able to answer. Breastfeeding is an emotive subject - the most emotive I've written about. It brings up all sorts of stuff in people; even friends that have hitherto been supportive probably think I'm in freak territory now, even though I'm just doing what Mother Nature intended - humans are the only mammals that don't let their offspring feed to term. I can't deny that I like to normalise breastfeeding in a world that sees it as increasingly alien, and I'm also aware that some women don't have the support network I do and feel they need to feed in secret or enforce weaning when they don't really want to, because family and friends put pressure on them.

Naomi Stadlen, a psychotherapist, breastfeeding counsellor and author of What Mothers Do, Especially When it Looks Like Nothing, once told me that she thought people might feel threatened by the intimacy between a mother and her breastfeeding child. An uncomplicated response to the information "Yes, I'm still breastfeeding", might be curiosity; any stronger reaction was likely to be the other person projecting their problem on to you. It was a useful piece of information.

My child turned four at the end of September; her need to breastfeed seems to have dramatically declined, although, yet again, this may change. Feeding her is a wonderful time we have together and no matter how busy I think I am, it makes me sit down and be with her. She has lots of skin-to-skin contact with me, which I now know is important for neurological development. I've learnt that the natural age of weaning is closer to six years - when the first permanent molars appear - than six months. If I have another baby, my daughter may wean during pregnancy as milk supply can dip at that time. But if she continues to feed during pregnancy and beyond - called tandem feeding and perfectly possible - or if I don't have another baby, then she's in charge. She will wean when she is, uniquely to her, developmentally and immunologically ready (a child's immune system doesn't mature until they are about seven); she will then lose the ability to suckle. I'm interested to see where this goes and how much more I can surprise myself. All I know is that I'm glad I've got this far.

Annalisa Barbieri is co-founder of www.iwantmymum.com
Further reading: www.artofchange.co.uk, www.kathydettwyler.org, www.llli.org.

Why mother's milk is best

* No scientific study has ever been carried out in the UK on breastmilk or breastfeeding beyond two years of age, despite strong anecdotal evidence of its benefits.

* Jack Newman, a paediatrician and world authority on breastfeeding, has this to say about breastfeeding an older child: "Possibly the most important aspect of nursing a toddler is not the nutritional or immunologic benefits, important as they are. I believe the most important aspect of nursing a toddler is the special relationship between child and mother. Breastfeeding is a life-affirming act of love. This continues when the baby becomes a toddler. Anyone without prejudices, who has ever observed an older baby or toddler nursing, can testify that there is something almost magical, something special, something far beyond food going on."

* The World Health Organisation recommends breastfeeding for at least two years.

* Breast milk has 70kcal per millilitre.

* Beyond 18 months, breast milk can provide as much as 31 per cent of calories and 38 per cent of all dietary protein.

* The iron in breastmilk is much more readily absorbed - a child may get as much as 50 per cent of its iron from his or her mother's milk.

* By the 20th month of lactation, levels of igG and igA (two immunoglobulins) are still as high as in the second week.

* "Independence, not dependence, is one outstanding trait that breastfed children who self-wean have in common," one study found (Ferguson, 1987).

* Last week, new research was published that showed breastfeeding protected against heart disease and high cholesterol. Children with a particular gene who were also breastfed were shown in the majority of cases to have a higher IQ.

* Breastfeeding has already been shown to protect both mother and baby against diabetes and certain cancers.

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Why I still breastfeed my four year old. The Independent.

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In December 2004, I wrote in these pages about how I found myself "still breastfeeding" a 14-month-old, when previously I had viewed "extended breastfeeders" as a bit odd, needy and, frankly, freaky. When I first became a mother, I had envisaged myself as a mother with a clipboard, with me in charge, not the baby....

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There is a smart drug- called breastmilk

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There is a smart drug- called breastmilk

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Opinion piece in Independent 2008

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Imagine if today, scientists discovered a drug that could save 13 per cent of all the babies who currently die. Now imagine that drug also made your baby cleverer - and dramatically slashed her chances of developing heart disease, diabetes, leukaemia, asthma or obesity as an adult. Oh: and imagine it was free.

The "drug" exists. It is called breast milk. Yet in the developed world, we often stigmatise women who give it to their babies as "creepy". In the developing world, we allow corporations to tug babies from their mother's nipple, and put them on to powders that bring more profit - and more death.

I come at this from a strange perspective. My mother breastfed me until I was nearly three; she only stopped the day I wrote her a note saying I expected to be breastfed that afternoon. Today, whenever I have a success, she clutches her breasts and exclaims: "It's thanks to these!" Whenever my bottle-fed brother and sister have a failing in life, she howls: "Think what you could have been if I'd given you the tit." (Whenever she gets a bit too self-congratulatory, I remind her she also smoked 40 cigarettes a day. "Ach," she says, "it's stressful having a little bastard suckin' at you all the time.")

It's the best thing you can do for your baby - without it I'd be even fatter and more disease-ridden. It's good for you too, significantly reducing a mother's risk of osteoporosis and cancer of the ovary. Yet my mum was made to feel like a flasher. She was glared at in public places, and asked to leave restaurants, parks and even buses. Unsurprisingly, Britain today has the worst record on breastfeeding in the developed world, after Belgium. Some 24 per cent of our babies never taste breast milk at all - and by six weeks, a majority have shifted entirely to formula.

Why? Why do we hobble our babies, and our country? Let's rule out some of the more glib explanations. The number of women who physically can't breastfeed with the right support is negligibly small: the World Health Organisation (WHO) puts it at 1 per cent. Nor is it because women prefer the "liberation" of the bottle. A Department of Health study found that 90 per cent of mothers who stopped feeding at six weeks said they wanted to carry on, while 40 per cent of those who stopped at six months felt the same.

The most primal reason belongs to an old, old story: women are conditioned to find their own bodies disgusting, except when they can be used to entice men. A get-your-tits-out-for-the-lads culture doesn't want you to get your tits out for your baby: they're for titillation, not nurture. This week, one of the Government's best ministers - Harriet Harman - has succeeded in peeling this back, by including the legal right to breastfeed your baby in public into the new Equalities Bill.

But the biggest reason most women give for reluctantly pushing their baby on to the bottle is their need to return to work. How do we change that? For clues, look at the country where breastfeeding rates are still 90 per cent at six months: Norway. They give mothers a year off with 80 per cent pay, and give state employees breastfeeding breaks when they do come back. Yes, this costs businesses some money up front - but it saves a fortune further down the line, because you have a cleverer workforce that pays more tax and puts less pressure on the health service. If British babies were breastfed at Norwegian rates for just three months, the NHS would save £50m annually in the treatment of one disease alone - gastroenteritis.

That leaves another dark explanation for the fall-off: the role of unchecked corporate power. There is no profit to be made from a mother's milk, so at the turn of the last century corporations tried to find a way to divert babies from nestling at their mother's breast to Nestlé-ing at the corporate teat. They invented "baby formula" and marketed it as the classier, cleaner alternative. Cow & Gate powder was sold with a crown on the tin, bragging the Windsor children used it. (Look how that turned out.)

Gradually, in the democratic world, the corporations were restrained from making the most blatantly bogus claims about breast milk - but they keep slipping the leash. In Britain, they are banned from marketing baby formula to those younger than six months old. But instead they market "follow-up formulas" for older kids with exactly the same logo, covered with claims that it is "closer than ever to breast milk".

This has produced a situation of startling public ignorance, where a third of mums think baby formula is "as good" or even "better" than breast milk. The poorest women know least and shift to formula first - adding another milky layer of inequality to our island. This dodgy marketing needs to be banned today.

But this breast-con swells to a 52DD scandal in the developing world. I recently visited Bangladesh, where mothers are routinely told to abandon their healthy breast milk and spend great swaths of their income on formula. I think of all the dead and dying babies I saw, and wonder how many could have been saved by a substance that was there, free, all along. WHO calculates that 1.3 million babies die every year because they are not breastfed. That's a World Trade Centre-full a day.

Nestlé are still the most notorious offenders, controlling a near-majority of the world market. In Botswana, Nestlé has distributed a pamphlet claiming if you give your baby its "acidified" formula, "diarrhoea and its side effects are counteracted". In reality, babies who use this rather than breast milk are more likely to contract diarrhoea - and die. Public health campaigns can hardly fight back: the corporation's annual marketing budget is bigger than the entire annual budget of the world's 28 poorest countries.

Nestlé says they consistently promote breastfeeding as the first, best option - but in 1999, a British Advertising Standards Authority studied the evidence and ruled they had to remove from their advertising the claim they sold their formula "ethically and responsibly". It is only tight, binding international regulation - here, and abroad - that will tame corporations from milking the poorest with misinformation. To join the campaign to make it happen, visit www.babymilkaction.org.

And yet, for all the evidence, it still seems like an implausible story. Can a powder mix of misogyny and unregulated corporate power really induce women against their will to harm their own children? It does, baby, every day. These are still shockingly powerful forces. Now suck on that - or fight back.

j.hari@independent.co.uk

Reuse content

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Johann Hari: There is a smart drug - it's called breast milk

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Imagine if today, scientists discovered a drug that could save 13 per cent of all the babies who currently die. Now imagine that drug also made your baby cleverer - and dramatically slashed her chances of developing heart disease, diabetes, leukaemia, asthma or obesity as an adult. Oh: and imagine it was free.

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breastfeeding in the UK Aug 17

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State of infant feeding services in the UK

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State of infant feeding services in the UK

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Special Collection - Enabling breastfeeding for mothers and babies | Cochrane Library

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Enabling women to breastfeed is a public health intervention with wide-reaching global implications. Not only is breastfeeding a fundamentally important human behaviour that strengthens attachment and psychological outcomes, but the use of breastmilk substitutes - either exclusively or partially - has substantive short, medium and long-term impact on survival, health and wellbeing for babies and women.

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Social attitudes that deter women from breastfeeding for more than a few weeks in the UK need to change in the interests of babies' health, experts say.

The UK has one of the lowest rates of breastfeeding in the world, even though the medical evidence shows it protects babies from infection and improves their mental and physical development.

Prof Neena Modi, president of the Royal College of Paediatrics and Child Health, one of the signatories to a letter sent to the Guardian calling for a change in attitudes, said she was disturbed that their research had found children thought breastfeeding was "yukky" and added that "society is ambivalent about women's bodies".

Some women who have just given birth say their partners would not be happy if they breastfeed, she said. "Perhaps many men feel discomforted because they grow up to regard the breast as a sexual object," she told the Guardian. "In which case I suggest that they should put these attitudes well and truly behind them."

Women who choose to breastfeed in public occasionally find themselves in the headlines. Louise Burns, 35, protested in 2014 over a request by staff at Claridge's hotel in London that she should cover herself and the baby while breastfeeding in the tearoom.

Some prominent women in other countries have deliberately chosen to break the mould, making headlines around the world. Senator Larissa Waters became the first politician to feed her baby during a vote in Australia's parliament in May.

Aliya Shagieva, youngest daughter of the Kyrgyz president, posted a photograph on social media in April of herself feeding her baby in her underwear with the caption: "I will feed my child whenever and wherever he needs to be fed." In the ensuing furore and acknowledging the disapproval of her parents, she took the post down.

Modi said there is an assumption that breastfeeding is not important in a developed nation like the UK. Yet it will benefit the children of the affluent just as much as the least well-off, from protecting them from obesity to potentially improving their performance in the classroom.

"If someone was selling rich middle class parents some wonderful new whatever to improve their children's intellectual ability, it would probably sell like hot cakes. And breast milk is absolutely just that," she said. "Society is riddled with contradictions and muddled thinking about breastfeeding."

In the letter, the presidents of five royal colleges and heads of expert organisations call for the "multiple barriers" to breastfeeding in the UK to be overturned. "Though some women are unable to breastfeed and some choose not to, with the right support, the vast majority of women are able to breastfeed successfully," it says.

Although nearly three-quarters of new mothers begin to breast feed, within two months less than half are still doing it, in spite of the many benefits to the growing baby. By six months, only a third (34%) of UK babies are receiving any breast milk, compared with 49% in the United States and 71% in Norway. Only 1% are exclusively breastfed to six months, as the World Health Organization recommends.

Some women feel they are being criticised by the pro-breastfeeding lobby. Modi says that healthcare professionals should be careful not to make them feel this is something that is hard to learn and do properly. "Haranguing women and being overly dogmatic is not the way forward," she said. "We'd like women going into this anticipating that it will be a wonderful, joyous thing, rather than what seems to be happening in some cases, with women slightly worried and fearful that they are going to be failures."

Schools should teach children that breastfeeding is natural and healthcare services should give practical support, say the signatories, who include Alison Thewlis MP, chair of the all-party parliamentary group on infant feeding and health inequalities, Sue Ashmore, of Unicef UK's Baby Friendly Initiative and Justine Roberts, founder of Mumsnet.

"Above all, social attitudes towards breastfeeding must improve," they write. "Women, their partners and families must feel comfortable about breastfeeding as a normal natural part of everyday life. In short, the solutions lie with all of us."

Their letter comes as Unicef and the WHO publish a new report warning that thousands of babies are dying across the world and economies losing billions of dollars for want of breastfeeding.

No country in the world meets the standards promoted by the WHO, they say. Worldwide, only 40% of babies are breastfed exclusively for six months. Only 23 countries out of 194 have achieved six months' exclusive breastfeeding for at least 60% of babies.

Breastfeeding "offers children unparalleled health and brain-building benefits. It has the power to save the lives of women and children throughout the world, and the power to help national economies grow through lower healthcare costs and smarter workforces. Yet many societies are failing to adequately support women to breastfeed," says the report.

The report spells out the human and economic cost to countries that fail to support breastfeeding. In five of the world's largest emerging economies - China, India, Indonesia, Mexico and Nigeria - the lack of investment in breastfeeding results in an estimated 236,000 child deaths per year and US$119bn (£90.3bn) in economic losses, it says.

Increasing the proportion of babies globally that are breastfed exclusively for six months to 50% by 2025 could save the lives of 520,000 children under the age of five and potentially generate US$300bn in economic gains over 10 years by reducing illness and healthcare costs and increasing productivity, says the report.

"Breastfeeding is one of the most effective - and cost effective - investments nations can make in the health of their youngest members and the future health of their economies and societies," said Unicef's executive director, Anthony Lake. "By failing to invest in breastfeeding, we are failing mothers and their babies - and paying a double price: in lost lives and in lost opportunity."

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UK attitudes to breastfeeding must change, say experts

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Social attitudes that deter women from breastfeeding for more than a few weeks in the UK need to change in the interests of babies' health, experts say. The UK has one of the lowest rates of breastfeeding in the world, even though the medical evidence shows it protects babies from infection and improves their mental and physical development.

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Links to a padlet on resources for counselling skills

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Links to a padlet on resources for counselling skills

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Celeste Headlee: 10 ways to have a better conversation | TED Talk

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When your job hinges on how well you talk to people, you learn a lot about how to have conversations -- and that most of us don’t converse very well. Celeste Headlee has worked as a radio host for decades, and she knows the ingredients of a great conversation: Honesty, brevity, clarity and a healthy amount of listening. In this insightful talk, she shares 10 useful rules for having better conversations. “Go out, talk to people, listen to people,” she says. “And, most importantly, be prepared to be amazed.”

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Does spoon feeding make babies overweight

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Does spoon feeding make babies overweight

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Amy Brown

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Assessing a tasty treat. Simon Wheatley/Flickr, CC BY-SA

Deciding when and how to introduce babies to solid foods can be overwhelming for parents. But aside from timing and amount, could how babies are introduced to solid foods also make a difference to their health?

Until the early 20th century, babies were simply given foods that the rest of the family ate, towards the end of their first year. This was before the dawn of the baby food industry led to the majority of babies in Western countries being weaned onto solid foods using specially prepared, pureed infant foods that are spoon-fed.

However, since government recommendations in 2003 changed to introduce solid foods at six months, increasing numbers of parents have been returning to letting their baby eat the same food as the rest of the family, by following baby-led weaning. Evidence suggests that delaying introduction of solids until six months may protect against babies becoming overweight. So spoons and purees are being forgone to let infants eat at their own pace - which they are typically developmentally able to do at six-months-old.

Research has found that parents are choosing baby-led weaning because they feel it makes for less stressful and easier (albeit messier) mealtimes. But growing numbers of parents also choose to follow the method because of suggestions that it may help their baby develop better eating habits and a healthier weight - but is this true?

The evidence so far

Limited research on baby-led weaning suggests that, to some extent, yes, it can help children develop better eating habits. Preschool children who followed baby-led weaning are less likely to be overweight than those who were spoon-fed. Similarly, toddlers who had followed the approach were less likely to be fussy eaters, less likely to overeat and were less likely to be overweight.

But is it really as simple as saying that spoons and purees are potentially putting babies at greater risk of being overweight and developing picky eating habits? In a nutshell, no.

A more balanced explanation is that baby-led weaning promotes a number of behaviours that positively shape an infant's appetite and weight development. The baby-led approach naturally encourages parents to let their baby go at their own pace when eating. Research with older children shows that when parents are too controlling over what and how much their child eats, the child is more likely to go on to develop weight problems and be a fussy eater. Babies and young children are good at regulating their intake of food according to energy needs but parents encouraging them to finish all the food on their plate, or withdrawing certain foods so they crave them, can break this down.

The baby-led approach, on the other hand, allows infants to be in control, rather than parents. Although spoon-feeding parents may be responsive, the baby may accept more food than it would eat when self feeding.

We also know that adults who eat slowly are less likely to be overweight. The same could very well apply with infants: naturally, it takes more time for an infant to self-feed and chew whole foods than it does to be spoon-fed purees.

Potentially, the way food is presented to infants who are following baby-led weaning may promote a wider variety of intake too. Food in its whole form may not only be more appealing than puree, but self-feeding also allows infants to explore how foods feel. We know that this is an important part of how children learn: when older children are allowed to play with food they are more likely to eat it.

The importance of context

It could be that the healthy food attitudes gained through baby-led weaning are due to factors unrelated to the experience, however. Baby-led weaning has often been linked with breastfeeding as a natural follow on. Breastfeeding mothers are more used to their baby being in control of feeding - although bottle fed babies do follow baby-led weaning too. On average, breastfed babies are less likely to be overweight or fussy eaters and this might explain the difference, rather than weaning approach.

Healthy attitudes might also be developed because of the type of parent who chooses to baby-led wean. Babies who have a more difficult temperament are typically weaned earlier, before the recommend six months point, meaning they are likely to be spoon-fed. Mothers who are more anxious about their baby are also more likely to spoon feed too. This anxiety is linked to non-responsive feeding, which can increase the risk of the child being overweight.

Overall, it's not a clear answer but current research does suggest that infants who follow a baby-led weaning approach may go on to be better eaters and have a healthier weight - but more studies are needed to confirm this.

However, this doesn't mean that parents who choose to spoon-feed should worry. Babies' food attitudes are unlikely to be anything specifically to do with spoons, but rather positive feeding interactions. Giving purees within a mixed diet is unlikely to have a negative impact; what is important is variation, chance to explore and, most importantly, a laid-back parenting approach.

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Does spoon-feeding really make babies overweight?

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Deciding when and how to introduce babies to solid foods can be overwhelming for parents. But aside from timing and amount, could how babies are introduced to solid foods also make a difference to their health? Until the early 20th century, babies were simply given foods that the rest of the family ate, towards the end of their first year.

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Community practitioner

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The practice of a mother feeding her child in the most natural way now makes regular headlines - and often for the wrong reasons. Just last month, a senator breastfeeding her child in Australian parliament was deemed shocking enough for the world's media to report on it (see page 12-13), with images flooding social networks to predictably polarising reactions. 'It's frankly ridiculous, really, that feeding one's baby is international news,' said the senator at the time.

Back home, Northern Ireland has 'among the world's worst' breastfeeding rates, the media fairly reported in May (Northern Ireland Assembly, 2017). Also reported was data showing almost half of mothers who gave birth after 2012 left hospital 'without attempting to breastfeed' (Detail Data, 2017). These findings together with the senator hitting the headlines, help to reveal where western culture stands on breastfeeding.

Nationwide issues

Headlines aside, Northern Ireland's low uptake is causing concern, as is the rest of the UK as a whole: it has recently been shown to have among the lowest breastfeeding rates in Europe (WBTi, 2016).

And last November, the World Breastfeeding Trends Initiative (WBTi) published a report with worrying results for the UK: on national policy for instance, the UK scored just one out of 10 for having 'no established UK-wide infant-feeding group for sharing good practice' (WBTi, 2016).

The problem appears not to be with initiation - aside from the recent findings from Northern Ireland, the UK as a whole scores highly on breastfeeding babies within an hour of birth (WBTi, 2016) - but with continuation. In England, for example, less than half of women are still breastfeeding two months after giving birth, according to a recent Public Health England (PHE) (2017) poll. And this is in spite of the WHO's widely publicised and accepted recommendation of exclusive breastfeeding for the first six months of life (WHO, 2016).

A lack of support

So what's going wrong? The WHO's Dr Nigel Rollins blames a fundamental lack of support. Nigel co-authored the significant breastfeeding series in The Lancet last year, claiming that more than 800,000 child deaths per year could be prevented by breastfeeding (Rollins et al, 2016). 'The success or failure of breastfeeding should not be seen solely as the responsibility of the woman,' he says. 'Her ability to breastfeed is very much shaped by the support and the environment in which she lives. There is a broader responsibility of governments and society to support women through policies and programmes in the community.'

There's already a wealth of research highlighting the health benefits of breastfeeding to mother and baby, and clear public health and long-term economical motivations for driving up the UK's rates. We also know that financial investment is required from the next government so that healthcare professionals can support all women who want to breastfeed beyond that crucial two-month point.

But it's the societal and cultural factors influencing the nation's perceptions of breastfeeding that need deeper investigation. It's vital to look beneath the surface at why women are reluctant to breastfeed, why those who start are abandoning it, and what can be done to better support them.

Public shaming

A recent news story shows the kind of reactions women may face when breastfeeding in public: it was reported that a young mother was asked to stop publicly nursing her son in the Royal Liverpool Hospital by a nurse who implied it was 'sexual' and would make others 'uncomfortable'. Little wonder women feel wary of breastfeeding in public.

'Something is wrong if you can't figure out that parts of the body can have more than one role and adapt your thoughts accordingly,' says Dr Amy Brown, programme director for child public health at Swansea University and author of Breastfeeding Uncovered. 'Mouths can be used in a sexual way, yet we don't criticise people for eating in front of others, do we?' It is perhaps for this reason that bottle, not breast imagery is used for baby clothes, changing room doors and children's dolls, says Amy. 'Bottles are so symbolic of motherhood and that is blindly accepted,' she adds.

Bernadette Wood, a health visitor and infant-feeding trainer based in Suffolk, agrees. 'Children's playthings continue to present formula feeding as the norm,' she says. 'And I think the idea of babies as parasites, along with the sexualisation of the female body, has led to girls thinking of breastfeeding as disgusting or just plain wrong.'

Mixed messages?

Dr Tim Kurz, senior lecturer in psychology at the University of Bath, has carried out research analysing how various public health materials deal with the topic of infant feeding, as well as how mothers engage with and feel about the messages. 'We have identified a paradoxical situation in which mothers are given a clear directive that breastfeeding is the optimal way to feed their infant, but at the same time are told that they shouldn't "feel guilty" or "let anyone make them feel guilty" if, for whatever reason, they use formula,' he says.

'Furthermore, it is often suggested in advice materials that mothers who formula feed must not let themselves feel guilty, because this will have negative effects on the child.

'While well intentioned, these mixed messages place an unfair psychological burden on mothers,' Tim adds. The result, he suggests, is a sense of guilt that could cause women to feel inadequate as mothers. We need to be careful about language when communicating with them, he says.

'Either women genuinely have the "right to choose", in which case they should be told that they are not guilty, rather than that they should not feel guilty.' Or public health materials should accept their advice makes women who don't breastfeed feel guilty, rather than blame women for feeling that way, he says.

It could well be that breastfeeding promotion would benefit from a slightly different approach. Charlotte Faircloth, senior lecturer in social sciences at the University of Roehampton, observes that the public health perspective 'fails to take into account that breastfeeding is an embodied practice, and that mothers and babies are part of a social network'.

'A focus on the mother-child dyad can often screen out the other pulls on a woman's time that might make breastfeeding difficult or unrealistic, such as other children and work commitments,' she says, adding that a sense of responsibility could extend far beyond infant feeding.

'I worry that one of the effects of this culture of instructing women as to how best feed their babies plays into the idea that it is mothers who are responsible for wider health inequalities or similar. In fact, the broader structural systems in society - class, for example - are more of a determinant of how babies turn out, not the practices of individual mothers.'

The Unicef Baby Friendly call to action

Unicef's Baby Friendly Initiative is calling on UK and devolved governments to implement four key actions to create a supportive, enabling environment for women who want to breastfeed:

1. Develop a national infant-feeding strategy board in each of the four nations, including members from all relevant government departments and tasked with developing a comprehensive national infant-feeding strategy and implementation plan

2. Include actions to promote, protect and support breastfeeding in all policy areas where breastfeeding has an impact

3. Implement evidence-based initiatives that support breastfeeding, including the Unicef UK Baby Friendly Initiative, across all maternity, health visiting, neonatal and children's centre services

4. Adopt, in full, the International Code of Marketing Breastmilk Substitutes.

For more on the UK's engagement with the initiative, see Last word (page 48-49), and to view the call to action in full, go to bit.ly/Unicef_BFI_call

Social standing

Like it or not, there is an association between breastfeeding and social class. While women in poorer countries tend to breastfeed for longer than those in higher-income countries, in the highly developed UK, the better health and social outcomes linked to breastfeeding have in some ways caused it to be perceived as a middle-class practice.

Yet this is more likely based on correlation than causation, says Charlotte. 'Breastfed children tend to be healthier, but middle-class women tend to breastfeed,' she observes. 'Is it the breastfeeding? Breastmilk? A general middle-class orientation to parenting? We don't really know, because even in those studies that say they control for it, the "choice" to breastfeed or formula feed isn't always a choice.'

What is surely needed is better education for everyone about breastfeeding, starting from childhood. 'As a society we have lost knowledge around what breastfeeding is really like,' explains Amy. 'The fewer women who breastfeed, the fewer people will see it, and the fewer will understand how to support it. 'Children should be taught about breastfeeding, the breast and how breastmilk works, as young as possible, so that the next generations of mothers feel more prepared. This would also enable them to learn about it in a context that is separate from being parents themselves: they can think about it without feeling pressured or overwhelmed,' Amy adds.

This ties in with the recommendation from the WBTi 2016 report that all professionals who could affect women's decision to breastfeed and continue breastfeeding, including childcare workers and GPs, should receive high-quality training (WBTi, 2016).

A new way forward

Ultimately, does UK culture need to undergo a shift in order to better accommodate breastfeeding and better equip women to adhere to the six- month exclusive recommendation? The response seems to be a resounding 'yes'.

'There is a lot of pressure on new mothers to get their lives back - whether that means losing weight, regaining their social life or going back to work as quickly as possible,' says Amy. 'But [life] before [your baby] has gone: you have a brand new person to care for and we should have systems in place that make that easier: better maternity leave, better support for new mothers and simply better value for the mothering role.'

Amy adds that much can be learned from the countries that score highly in breastfeeding uptake and duration. '[These countries] tend to view breastfeeding as normal, but more widely they support their new parents better,' she says. 'Longer, better paid maternity leave and extended paternity leave for fathers is common in Scandinavia, where breastfeeding rates are high. This would help in instilling the value of what mothers and families do.'

Charlotte suggests that a shift in conversation could be needed from health benefits to 'reproductive rights and women's autonomy'.

'The regulation of women's behaviours in the reproductive years is getting tighter and tighter,' she observes. 'We are now meant to regulate our diets before we even think about having a baby. I see this as an extension backwards of a broader parenting culture, in which fierce debate about women's reproductive choice reigns.'

But how can cultural change come about? Sociologists have previously claimed that new customs and practices are likely to be more readily adopted under two conditions: if they represent what is viewed as socially desirable and useful; and if they do not clash with existing and still-valued customs and practices.

'Of course it is going to take time,' concedes Amy. 'We need to reverse a generation or more of formula being the norm. I think we need to take a wider approach to supporting new families better.'

Maybe we could start by listening to women. 'Culture change happens from both the top down - for example, policy - and the bottom up, with people's experiences,' says Charlotte. 'The top-down approach hasn't worked so far on the infant-feeding front, and we have a huge gap between the two. Perhaps starting from women's experiences and what they say they actually want might help build a more supportive culture.' (See below for two women's views).

Listening to mothers - Two women have their say...
'The phrase "breast is best" is unhelpful' Lyndsey from Barnsley says:
'I think the UK has low breastfeeding rates for various reasons.

'I was fortunate to live in a health authority that had invested money in providing breastfeeding information, education and support in the community. This isn't universally available and I think if it were, more first-time mums might try it.

'I also think there's still a taboo about breastfeeding in public; either mums don't feel comfortable breastfeeding their baby in public or they find other people's reactions and attitudes to it unsettling or off-putting. It might be a generational thing - more people may choose to breastfeed if they themselves were breastfed.

'I think the phrase "breast is best" is really unhelpful and negative. It puts pressure on mothers to breastfeed by inferring that if they use formula milk they clearly don't want what is best for their children. Breastfeeding can easily work for some people and it can be a rewarding and positive experience, but it can equally be incredibly difficult, if not impossible for others, and be a stressful and negative experience.

'To resolve the taboo around breastfeeding in public, there are simple things that could be done. Signs in shops and cafés supporting breastfeeding are helpful. And creating a separate, comfortable room with seating would provide privacy for any mums anxious about breastfeeding in public, and without them having to resort to feeding their child in a toilet cubicle.'
'It's about convenience' Debbie from London says:
'Breastfeeding never appealed to me, and I knew the second I fell pregnant that I would not be swayed. I wanted to share every second of my son with my husband as I had carried my son for nine months and wanted to make sure that once he was born, looking after him was equal.

'Secondly, as I did not take maternity leave it meant I was able to have the help of other people feeding my son while I worked, without me having to 'cluster feed' and be tied to my baby. Thirdly, since I was born, formula milk has advanced and my son so far has an immune system on a par, if not better, than some breastfed babies.

'I also think it's [the culture in the UK] about convenience. Formula milk is available everywhere and means you can confidently feed your child in public without being shamed. I know you can express into a bottle but again this can be painful and not as convenient. It also means you can quickly return to your busy life of eating and drinking as normal, plus lots of new mums go back to work straight away so breastfeeding simply wouldn't work for them.'

As we approach yet another general election at the time of going to press, the next government needs to recognise that well-supported healthcare professionals who are not exhausted or under pressure will be able to invest more time in promoting the healthiest choices to women.

Bernadette refers to an encouraging survey in her local press, which found most mothers try to breastfeed 'because their midwife or health visitor recommends it'. The same survey suggested health benefits are lowest on the list of reasons, below cost and convenience.

Perhaps the smartest way forward, in addition to implementing better national policy and education around breastfeeding, is simply to listen and learn.

References

Betts J, Russell R. (2017) Breastfeeding: attitudes and policies. See: niassembly.gov.uk/globalassets/documents/raise/publications/2016-2021/2017/health/0917.pdf (accessed 25 May 2017).

Detail Data. (2017) Breastfeeding status of infants. See: data.nicva.org/dataset/breastfeeding-status-infants (accessed 25 May 2017).

PHE. (2017) New survey of mums reveals perceived barriers to breastfeeding. See: gov.uk/government/news/new-survey-of-mums-reveals-perceived-barriers-to-breastfeeding (accessed 25 May 2017).

PHE. (2015) New mothers are anxious about breastfeeding in public. See: gov.uk/government/news/new-mothers-are-anxious-about-breastfeeding-in-public (accessed 25 May 2017).

Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, Piwoz EG, Richter LM, The Lancet Breastfeeding Series Group. (2016 ) Why invest, and what it will take to improve breastfeeding practices? The Lancet 387: 491-504.

WBTi. (2016) WBTi UK report 2016. See: worldbreastfeedingtrends.org/GenerateReports/report/WBTi-UK-2016.pdf (accessed 25 May 2017).

WHO. (2016) Infant and young child feeding. See: who.int/mediacentre/factsheets/fs342/en (accessed 24 May 2017).

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The practice of a mother feeding her child in the most natural way now makes regular headlines - and often for the wrong reasons. Just last month, a senator breastfeeding her child in Australian parliament was deemed shocking enough for the world's media to report on it (see page 12-13), with images flooding social networks to predictably polarising reactions.

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Far from being an easily synthesised mixture of nutrients, breast milk contains a multitude of microbes, stem cells and biological molecules that scientists are still trying to understand. Dr Natalie Shenker MRSB explores what we do and don't know about the white stuff The Biologist 64(3) p10-13
After 70 years of cultural shift in the West towards babies being bottle-fed formula milk rather than breastfed, one of the prevailing views in the general population is that there is no difference biologically between breast milk and formula.

This view is also held by a large number of doctors and healthcare professionals, propagating myths about common breastfeeding issues as being reasons to stop and "just give formula". For example, if a medication is to be prescribed and there is no available information about the transfer of the drug or its metabolites into breast milk, women are often advised to stop breastfeeding to be on the safe side.

This is contrary to the reality that breastfed babies are at lower risk of infections, obesity and haematological malignancies[1]. In preterm and sick babies, breast milk is critically important to prevent infections and necrotising enterocolitis (NEC), a catastrophic gut condition that carries a mortality rate of 40%.

Some states in the US have taken the radical step of banning the use of formula on neonatal intensive care units.

For mothers, the benefits of breastfeeding are well established. It is classified by the World Cancer Research Fund/American Institute for Cancer Research as protective against breast and ovarian cancers[2]. Breastfeeding for even a short amount of time reduces risk by 16-24% for triple negative breast cancer, the most aggressive form of the disease[3,4].

An estimated 18% of ovarian cancers in the UK are linked to women breastfeeding each of their children for fewer than six months.5 According to several meta-analyses, ovarian cancer risk is 24-30% lower in women who have ever breastfed, versus those who have never done so[6].

The risk of both cancers is reduced even further in women with high-risk genetic mutations such as BRCA[1]. Women who breastfeed have lower chances of developing type 2 diabetes later in life[7], obesity[8] and cardiovascular disease, as well as a reduced likelihood of postnatal depression[9].

What is it about maternal milk that can explain this diverse impact on maternal and infant health?

Breast milk contains thousands of different molecules, growth factors, hormones, microorganisms and cells, which work together to provide the human baby with all the tools necessary to grow and develop normally. Many of its components have only recently been discovered - leaving the tantalising possibility that more remain - and the functions of many remain unknown.

Carl Linnaeus, the founder of taxonomy, originally used the word 'Mammalia' ('mamma' is Latin for breast) to describe animals that feed their young with milk. Evolutionary biologists estimate that the ancestor of all mammals lived 310 million years ago and oozed milk from its skin for the young to feed on after hatching from eggs. Over time, these skin glands evolved into nipples as a way to deliver the mother's immune system to newborns to protect them from infections. Food might have been a secondary benefit.

This immune protection covers the vulnerable period of early life when the immature immune system is not well developed - in humans, the immune system is thought to be fully mature only at the age of six. The breast itself is a source of specific immune cells and can, therefore, be seen as an immune organ, although it is never listed as such in medical textbooks. One hypothesis regarding the benefit of breastfeeding to mothers is that the breast also ramps up the mother's own immune system to aid postnatal recovery.
Breast milk contains a multitude of human and non-human cells as well as nutrients, hormones and other immune system-related components.
Human milk has evolved to specifically nourish human babies. Hundreds of bioactive components directly protect them from pathogens found in their environment.

Compared with other species, a higher proportion and diversity of fatty acids support the growth of the human brain (which is particularly large in comparison to that of other mammals), and an extraordinarily diverse microbiome (>800 bacterial strains on average, along with fungi, parasites and viruses) drives the healthy development of infant gut physiology. The composition of the breast milk microbiome changes over months and years, and work is ongoing to understand the impact this has on the developing gut.

Breast milk contains cells - and lots of them. In mature milk (produced approximately six weeks after birth), a single millilitre can contain millions of epithelial lactocytes, stem cells and immune cells.

Colostrum, produced within the first two to three days after birth, provides an energy-rich dose in just a few millilitres per feed, but also includes a dense cellular component made up predominantly of white blood cells. Of these, the most common cells are breast-specific macrophages, which can engulf and absorb harmful microorganisms.

These macrophages also manufacture lactoferrin and lysozyme. The former is an iron-binding protein that helps the baby to absorb and store iron. As well as being important nutritionally, this prevents the growth of harmful microorganisms such as E. coli, Staphylococcus species and yeast ( Candida), which need iron to survive.

Lysozyme is an enzyme that kills bacteria by disrupting their cell walls and also has antiviral effects. Both it and lactoferrin increase in concentration in breast milk over time as babies become mobile and start to explore their environment.

The World Health Organization recommends that babies should be exclusively breastfed until approximately six months of age, with the introduction of complementary foods thereafter and weaning from breastfeeding after the age of two years. This has been widely interpreted as breast milk having no benefits (or even nutritional value) over the six-month cut-off. However, breast milk not only continues to provide increased immune protection to the child, but the calorie value per feed increases as the child grows, and so they need feeding less frequently[1].

Evolutionarily, the age of natural term weaning is likely to range from between two and seven years - hence the term 'milk teeth', which start falling out when children are around six or seven.

Antibodies produced by the mother, which are transferred into milk as well as to cells in breast milk, are highly targeted against infectious agents in her environment.

When a mother ingests or inhales pathogens, lymph nodes in the lungs and small intestine manufacture specially sensitised lymphocytes, which then migrate to the breasts and create tailor-made secretory antibodies against that pathogen.

These mucosal pathogens are a major killer of children below the age of five years, causing more than 14 million deaths annually. Diarrhoeal disease alone kills five million children each year in the developing world; the risk of dying from diarrhoea is reduced by approximately 20-fold in breastfed children.

Breast milk also contains more than 200 types of sugars known as oligosaccharides. Although most oligosaccharides have unknown functions, some help to block bacterial antigens from sticking to the wall of the gastrointestinal tract. This blocking mechanism is particularly effective against Pneumococcus, an extremely 'sticky' bacterium that can cause pneumonia and systemic sepsis. Twenty oligosaccharides in milk can't be digested by humans, but are there instead to feed the 'helpful' bacteria found in breast milk and the infant gut.

These bacteria will help the baby to form its own normal microbiome, to the exclusion of harmful pathogens. Scientists and doctors are starting to understand how the microbiome has a huge role in helping the gut to develop, digest food and support the immune system of the baby as it grows.

Indeed, the microbiome of maternal milk may be critical to helping the immature gut of a very premature baby to seal, preventing colonisation by pathogenic bacteria and reducing the likelihood of the development of NEC.

As new research begins to understand lactation, more surprising findings are emerging. Multipotent stem cells were discovered in breast milk in 2007, having the potential to form an entire functioning breast ductal system that can produce milk. Stem cells are carried into the infant stomach, where they potentially can survive the acidic environment.

Animal studies have shown maternally derived stem cells to be present in the brain and kidneys of infants, creating chimeras between the mothers and their offspring. In humans, we don't know yet whether these cells are simply by-products of the 10-fold increase in ductal stem cell cycling during pregnancy or have a specific function.

Mothers and babies are known to communicate with each other through breastfeeding in multiple ways - hormonally through surges of oxytocin (the 'hug' hormone) that create feelings of wellbeing and relaxation in the mother and stimulate the milk let-down reflex, through skin-to-skin exposure, and directly through components in the milk.

Babies are born without diurnal cortisol rhythms, which develop in the first few months of life. Breastfed babies have five-fold higher levels of cortisol receptors than formula-fed babies, reflecting the transfer of cortisol through milk, although the function of cortisol in this context is unknown - it is likely to be an important mediator of metabolism and establishing normal cortisol functioning, and sleep cycles, in infants.

It has also been shown that early initiation of breastfeeding - that is, within an hour of birth - can have significant long-term effects, and work is ongoing to understand how breastfeed can modulate the infant's genes.

Finally, and most speculatively, ultrasound studies in Australia have shown that infant saliva can be sucked back into the nipple through the vacuum effect created by the mouth. Although only a hypothesis at present, babies may just be sending information into the breast about any infections to which they have been exposed. They may even be ordering what they need in their next meal through microRNAs, tiny genetic messages in their saliva.

Breast milk contains hundreds of bioactive components, including one of the most complex microbiomes in the human body. The normal physiology of how each individual component functions, let alone the complexity of the interactions within human milk and between the mother and child, leaves a broadly under-researched field open for investigation.

With the advent of novel funders internationally, independent of food industry involvement, there is hope that the seeds of a new field of biology - human lactology - are being planted. Our own work at the Hearts Milk Bank, to establish a large bioresource of breast milk samples, will facilitate a wide range of studies into infant and maternal health, a small part of a huge body of work that lies ahead.
This rich fluid may hold many clues about human health during childhood and how illnesses that start in adulthood may be patterned in our earliest days.
Breast v bottle

Public health messaging over the last 20 years has been focused around the catchy phrase 'Breast is Best', now shorthand for the debate over how our children are fed.

However, the UK has among the lowest rates of breastfeeding in the world and although this message has increased breastfeeding initiation rates to over 85%, only 40% of babies are receiving any breast milk at six weeks, and fewer than 20% at six months.

The Lancet Series on Breastfeeding[1] indicated that optimising breastfeeding globally could save more than 800,000 babies each year, and prevent 20,000 maternal deaths from cancer.

Given that most health impacts of breastfeeding for both the mother and child are time-dependent, the fact that only one in 200 women breastfeed for one year in the UK demonstrates the need for greater public education on the science of infant feeding.

Natalie Shenker MRSB is an Oxford-trained doctor with a PhD in breast cancer epigenetic risk markers from Imperial College. She is the co-founder of the Hearts Milk Bank, which aims to remove the NHS postcode lottery for screened donor milk.

References
1) Victora, C. G. et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet 387(10017), 475-490 (2016).
2) World Cancer Research Fund/American Institute for Cancer Research. Continuous Update Project Findings & Reports. Accessed October 2016.
3) Parkin, D. M. et al. The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. Summary and conclusions. Br. J. Cancer 105 (S2):S77-S81 (2011).
4) Chowdhury, R. et al. Breastfeeding and maternal health outcomes: a systematic review and meta-analysis. Acta. Paediatr. 104(467), 96-113 (2015).
5) Li, D. P. et al. Breastfeeding and ovarian cancer risk: a systematic review and meta-analysis of 40 epidemiological studies (link is external). Asian. Pac. J. Cancer Prev. 15(12), 4829-4837 (2014).
6) Luan, N. N. et al. Breastfeeding and ovarian cancer risk: a meta-analysis of epidemiologic studies. Am. J .Clin. Nutr. 98(4), 1020-1031 (2013).
7) Aune, D. et al. Breastfeeding and the maternal risk of type 2 diabetes: a systematic review and dose-response meta-analysis of cohort studies. Nutr. Metab. Cardiovasc. Dis. 24, 107-115 (2014).
8) Bobrow, K. L. et al. Persistent effects of women's parity and breastfeeding patterns on their body mass index: results from the Million Women Study. Int. J. Obes. (Lond) 37, 712-717 (2013).
9) Dias C. C. & Figueiredo, B. Breastfeeding and depression: a systematic review of the literature. J. Affect. Disord. 171, 142-154 (2015).

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Far from being an easily synthesised mixture of nutrients, breast milk contains a multitude of microbes, stem cells and biological molecules that scientists are still trying to understand.

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Twins and triplets information including transitioning to the breast and dropping top ups

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Many parents worry how they can get their co-sleeping older babies into their own room and into their own cots. However, there's another way which can be much easier, much more gentle and less stressful for everyone. The floor bed!

The difficulty of using a cot is having to settle them into it. Contrary to popular belief, many children under the age of 2 do not lie down and go to sleep happily on their own. Many still need a feed or a cuddle to d o this. But getting them to go into the cot after feeding or cuddling to sleep can be difficult. As soon as you lower them down and let go, they're awake again, either almost straight away or at the end of the first sleep cycle.

A floor bed can remedy a lot of the problems. Either just a mattress on the floor, or on a low slatted bed base, or on conjunction with a cot (or two) with the side taken off.

Here are some of the positives:

* Baby is settled to sleep in the bed they are expected to sleep in. Often a baby falls asleep in its parent's arms or bed as this is the easiest way to get them to sleep. Then when the baby wakes up, they find themselves in their cot, sometimes in a different room. This can be very disorienting as any adult who has awoken somewhere different to where they fell asleep can testify!

* If the baby wakes in the night, the parent can settle them back to sleep in the baby's own bed easily with a feed or a cuddle. No need to move them out of their environment.

* The fact it is on the floor means it is safe if they roll out or get up and wander in the night. And they will not try to climb out of the cot! Ensure furniture is screwed to the walls for safety and nothing can be pulled on top of them. Parents can also use a baby monitor.

* Parents can co-sleep part of the night in baby's bed if necessary ensuring a good night sleep for all. This also means that the other parent can remain in the parental bed. The co-sleeping parent can sneak back to their own bed if they are still awake once baby has settled.

* It is a very gentle way to encourage a baby to move into their own room or in with their sibling whenever the parents think this is the correct time for their family.

* Later on the parent can gradually retreat by lying next to the child, lying a bit further away, popping out for a minute, until eventually they are happy with a story, a kiss and a cuddle and then sleep.

So for parents wanting a gentle way to transition a child to sleeping on their own space, this can be an ideal solution.

Photos courtesy of Gentle Parenting Twins and Triplets UK & Ireland facebook group.

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Many parents worry how they can get their co-sleeping older babies into their own room and into their own cots. However, there's another way which can be much easier, much more gentle and less stressful for everyone. The floor bed! The difficulty of using a cot is having to settle them into it.

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Upper lip tie discussion

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These pictures below show you normal infant placement. Infant upper lip frena are supposed to be "low sitting".

SOME EXAMPLES OF NORMAL UPPER LIPS.

These babies had no feeding problems, reflux, wind or any other issues.

The confusion as to why everyone at the moment thinks these are ties, is I believe is explained well here. It's because they can see the low sitting frenum. As I discuss in this piece 93.4% of babies do, as the frenum attaches to the gum or palate.

Why?

People are concerned their child has a gap in their teeth, and yet this is exactly as it should be.

Here we can see a normal ADULT MOUTH:

In contrast let's look at the ideal INFANT MOUTH:

See how different it looks? And note the low sitting frenulum. Glenn Carty Orthodontist tells us:

"Did you know that Adult front teeth are 2-3 mm wider than baby front teeth? Adult front teeth therefore occupy more space than baby front teeth. A young child's smile should appear very different to that of an adult's. The smile should resemble a picket fence. The baby front teeth should be spaced. While this might not look pretty, the extra space is needed for proper alignment of the adult front teeth"

The frenulum moves up the gum-line in the first 10 years of life, until it sits in the adult position. The gap closes as second teeth align - as per the photo below.

This spacing also makes teeth easier to keep clean. A
2011 paper states:

The superior labial frenum is triangular in shape and attaches the lip to the alveolar mucosa and/or gingiva. It extends over the alveolar process in infants and forms a raphe that reaches the palatal papilla. Through the growth of alveolar process as the teeth erupt, this attachment generally changes to assume the adult configuration. [1] Taylor has observed that a midline diastema is normal in about 98% children between six and seven years of age, but the incidence decreases to only 7% in persons 12-18 yrs old. [2] But in some instances, the infantile arrangement is retained.

So normally they regress but sometimes this doesn't happen and the frenulum remains lower on the gum. Sometimes a gap (or a diastema) can be seen. A very famous example of this being of course, Madonna:

Diastema is heavily prevalent in some cultures - for example Nigeria has incredibly high rates. In turn it's considered extremely attractive and surgery exists to create the gap. In contrast it's very uncommon in other areas such as china.

What criteria are we using to diagnose tied versus normal? How was this established and is it reliable?

When it comes to tongues we look at what normal presentation and function is, and we establish (or we should) how far away from that each baby is.

It's not just as simple as the skin you can see...

Initially it was assumed the frenulum caused the gap, it seems obvious - we can see a thick meaty piece of skin between the teeth, thus it was assumed that the frenulum not regressing at the expected age, was the root cause of a persistent gap into adulthood. I nterestingly as researchers began exploring further, they discovered it wasn't quite so clear cut.
Some concluded that when the normal regression of the frenulum didn't happen, it wasn't the frenulum causing the gap, but the gap that resulted in the frenulum remaining low. Another study found a cleft in the bone was associated with some gaps, and others found removing the frenulum did not alone, appear to make a difference to the gap compared to those that remained untreated;10 years later there was no identifiable differences between he two groups. Some theorised certain types of frenulum could cause a gap, but researchers decided ultimately this wasn't so. They noted gaps with frenula and frenula without gaps. They also noted wide variance in the normal frenulum in terms of visual presentation - thickness and so on.

A 2012 review outlines the evidence concerning the cause of a persistent gap, and the possibility of closing it by removing the frenulum:

"At the beginning it was thought that the labial fraenum interfered with the closure of the midline diastema. This belief resulted in misdiagnosis and unnecessary surgical intervention of the fraenum 13,14.

They then outline all the papers and their findings - I've linked below if you want to look in more detail.
They continue:

"Since there is no evidence concerning the fact that the maxillary labial fraenum is the main causative factor for a midline diastema, some orthodontists propose the following therapeutic methodology 37,45: Initially, it is necessary for the dentist to make a diagnostic trial, in order to find out whether the fraenum is implicated in the pathogenecity of the diastema.

1. Positive "blanch test" of the incisal papilla, when pulling the lips forward. By pulling the upper lip and exerting pressure on the fraenum, if there is a blanching, it is safe to predict that the fraenum will unfavourably influence the development of the anterior occlusion;

It is important to emphasize the fact that frenectomy has clinical validity only after the eruption of all 6 permanent teeth if it failed to close the diastema, and then only in conjunction with orthodontic treatment. So after the eruption of all 6 permanent teeth, 9,14,16,20,34,36,37 orthodontic appliances are used to close the diastema. A frenectomy is carried out, so as the scar tissue will hold the teeth together 16,20,27,33,37,39,48 . During the primary dentition phase, surgical intervention of the labial fraenum is not recommended7."

This clarifies blanch tests etc are a tool that may be useful as a diagnostic tool once 6 permanent teeth are in. They weren't designed for, nor tested in terms of accuracy or reliability, in babies and young infants who are expected to have a low sitting frenulum.

The above paper continues to explain the different opinions held by dentists and oral surgeons. Surgeons tend to prefer removing the frenum and following immediately with orthodontics (so they have good, clear access to the tissue), some dentists agree;
other dentists feel a better result is obtained by pushing the teeth together first with orthodontics, and then removing the frenulum, or only removing it if the teeth "drift" back apart again - so any resulting scar tissue holds the teeth together. The last group don't feel there are any benefits to frenectomy.
What all seem to agree on, is the risk of removing tissue from the gum when there are no teeth to push together, suggesting that this may at times result in scar tissue on the gum that makes it impossible to completely close the gap. They continue:

"In the orthodontic community there is unanimity on this issue 37. Orthodontists support that the fraenum should be maintained until the age of the eruption of all 6 permanent anterior teeth. After that, and only if the diastema remains the same, a frenectomy is indicated, with subsequent orthodontic closure of the diastema 9,16 "

"Oral surgeons suggest that in case of a maxillary midline diastema, a small intervention of the fraenum is useful. In this way, the closure of the diastema is facilitated and the orthodontic treatment is not affected 9,2 "

So the "unanimous" view is that 6 permanent teeth should be in before the frenulum is removed - ie this is the optimal time for removal along with orthodontics.

What are the risks and benefits therefore to removing it earlier than this, or b efore the top teeth have even appeared?

I couldn't turn up any studies exploring this.

Here we can see the progression of teeth following lip tie removal in a child who should still have a low sitting frenum, as they do in the first picture:

We can see the child has typical spacing in the first picture, similar to that we saw above. These pictures have been shared as evidence removing a tie removes a gap - and in this instance it seems clear that removal indeed rapidly resulted in adult dentition and lack of spacing between the teeth.
However we know already this is what happens in the majority of people with time, so what benefits and risks of hastening this process? How will this impact on adult teeth spacing long-term?
Interestingly we can note the top lip still looks thin and pinched. There also appears to be slight yellowing between the teeth on the last photo, although I'm not sure whether that is just this particular photo and the light.

One mum has expressed concern her child's top teeth have come in crossed following his upper tie removal (he had no teeth at the time of the procedure):

Will this self correct as other teeth align and a correctly functioning tongue exerts appropriate pressure? Is this linked with premature removal of the frenulum and something parents need to factor their decision making process?
Without studies we're working from anecdote, which is non-transparent and unreliable.

Mr Sheehan (ENT) Manchester, proposes that as part of the role of the upper lip frenum is to stabilise the top lip, removal of the upper lip tie may also allow over extension when smiling in some people, perhaps those with naturally longer gums.

Helen Marshall (IBCLC) shares similar concerns:

"I had my upper tie removed at around 10 or 11 years old because of a gap in my teeth. My lip pulls higher up and exposes more of the gum when smiling, and which started post-revision. You can see where it attached to my lip and gum, and my smile would not be the same if it hadn't been cut - --my lips wouldn't be able to ride up and uncover my gums"

Assessing an infant for lip tie.

Even if we were to establish the blanch test above may accurately determine the lip is tight, does that mean we can assume the cause is the length of the frenulum? We talk about assessing function not appearance, but even this isn't straightforward.

Tongue ties can cause tension through the lips that makes them tight:

The above baby had incredible tension pulled through his mouth by his tongue tie. When we "flipped his lip", it didn't flip at all - instead it blanched and felt incredibly tight. His parents commented they didn't know where he got his mouth shape as they both had full, plump lips. After the tongue was released and baby turned to his parents, the first thing they both noted was the phenomenal difference in his lips and mouth shape.

The little girl below didn't just have her lips bound down by her tongue tie, her whole chin and jaw was pulled back too. We saw her chin move forward when feeding immediately post revision, and function was completely changed.

Something as simple as being hungry can cause a baby to tighten their lips. When we assess hungry infants post feed and note tightness, this often presents different when baby is full and relaxed. Therefore in order to accurately hope to assess function, don't we need to release the tongue first?

What people also often don't understand is that if baby is in a shallow latch on the breast or bottle, the top lip can sometimes curl under when feeding, appearing as though it can't do anything but - to try and compensate. This is extremely common in tongue tied babies

as this post demonstrates. However as anyone who fully understands the mechanics of milk transfer and has observed thousands of dyads will know - it is not desirable for the top lip to flange outwards when feeding either - it should be neutral as the post above highlights (and the image below shows), flange suggests anything from slightly shallower to very shallow latch.

Below is the same breastfed baby as above with the curled under top lip, immediately after tongue tie release:

If we just treat the lip, do we sometimes just allow for more or better compensation?

"The added ability to fully flange the top lip will allow a baby to compensate for continued poor positioning or tongue function issues. But of course this is treating a symptom and not the underlying cause. Improving positioning, tongue -tie division, tongue exercises and suck training to promote effective tongue mobility would be more appropriate. "(Oakley 2016)"

One mum on Facebook explained how her journey developed.

Her son had a tongue tie, he had learnt to feed gripping extra hard with his top lip - just like the babies above. However they were unable to find anyone who would release the tongue and so only the lip was treated.

Following this, he was no longer able to adequately grip with the excess force he had been doing to compensate, and was no longer able to breastfeed.

This proved an extremely traumatic time for all involved and mum feels more studies are needed.

At the moment Lack of Guidance
We have no NICE guidance pertaining to lip tie, nor recommendations from any other recognised authority.
Nobody has (in any official capacity), questioned whether the procedure is beneficial to infant feeding, or for the prevention of diastema; whether it has the desired outcome or when the best time for treatment is. Whether the area needs numbing and if pain relief afterwards is required. Whether both tongue and lip should be released together, given not only the change in presentation post tongue tie release, but because of the difficult or discomfort baby may have feeding with two sore areas in the mouth.
This paper different practitioners use different lasers (some use heat to cauterise the area, others use intense water jets to vapourise tissue). discusses that scarring can occur, and describes a surgical technique combining the frenectomy with a "laterally positioned pedicle graft", to give the best aesthetically pleasing response- are infant frenectomies different? Which method is safest, most effective?

Best practice should surely be based on best for baby, not "we've travelled a long way so may as well just do both..."
Perhaps most importantly, nobody seems to have explored whether there could be any unintended risks associated with the procedure. Some argue those who treat would have observed problems should that be the case - however long-term risks can be very difficult to identify in practice rather than research, especially if we're approaching with a bias, and we're not clarifying what "normal" is.

Abnormal lip frena of course exist, and whilst those promoting removal of the ULT claim we in the UK are "behind" and "ignorant" when it comes to diagnosis and treatment, I'm not entirely convinced. I've found when there is truly abnormal presentation (such as a excessively wide, tight frena that have bound down the lip) the NHS
have treated.
Interestingly they tend to release the tissue up where it is attached to the lip, not touching tissue on the gum margin. In the private sector I have seen both methods used, suggesting we also need assessment and standardisation of this area too.
However, when presented with normal low sitting frena being called a tie, the NHS (as evidence supports), recommend reassessing again age 8-10 and treating if appropriate.

This is why controlled studies are key.

We need to start asking questions, so that we continue to push for studies and evidence to support guidance for practice. Simply acceptin g the word of those performing the procedure is not enough.

Some charge as much as £500 for a consult and release lasting around 15 minutes, enabling them to see 4 per hour. A 7 hour day that's potentially £14,000, or £70k per week, 280k per month, and so on. Further charges may be applied for feeding support, which many parents report is often needed.
That's of course not to say there aren't situations where removal may be beneficial - lack of evidence isn't lack of efficacy, but we need to know more!
Parents need facts on which to base a decision, as do those supporting infant feeding.

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Upper Lip Tie Treatment in Infants - Informed Choice, Risks & Efficacy

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These pictures below show you normal infant placement. Infant upper lip frena are supposed to be "low sitting". SOME EXAMPLES OF NORMAL UPPER LIPS. These babies had no feeding problems, reflux, wind or any other issues. The confusion as to why everyone at the moment thinks these are ties, is I believe is explained well here.

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A painting of a weary but happy mother feeding her eight-month-old daughter has won this year's BP Portrait Award, netting its artist - the subject's husband - the £30,000 top prize.

Judges at the National Portrait Gallery were moved by Benjamin Sullivan's work Breech!, whose title hints at the trauma of baby Edith's birth. It was painted in his Suffolk studio over a period of weeks "when Edith's cooperation was forthcoming", Sullivan says, and reflected a time when a "sense of calm descended" on the new parents.

The broadcaster Kirsty Wark, who was on the judging panel, said: "The woman is tired. She is in love. Her life has changed for ever. We know her."

Breech! is Sullivan's 13th work to be shortlisted for the gallery's portrait prize exhibition, a record for any artist. In 2008 he was commissioned by the gallery to paint the scientist Sir Martin Rees, and part of his prize this year is another commission.

Second prize went to the French artist Thomas Ehretsmann for Double Portrait. The title alludes to the fact that while the painting shows only the head and shoulders of his wife, Caroline, she was eight months pregnant.

Third prize went to Antony Williams, whose work has made the exhibition on seven previous occasions.

The competition attracted 2,580 entries this year from 87 countries. The free exhibition opens at the National Portrait Gallery in central London on 22 June until 24 September, when it will travel to Exeter, Edinburgh and Sunderland.

The gallery has faced strong criticism from the campaign group Culture Unstained for its decision to accept sponsorship from BP for the 28th year. The group claims the oil company's ties to regimes linked to human rights abuses does not follow the gallery's ethical fundraising policy.

A spokesman for the gallery said a complaint had not been received. "When we do, we will review and respond in accordance with the gallery's complaints policy."

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Painting of nursing mother wins BP Portrait Award 2017

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A painting of a weary but happy mother feeding her eight-month-old daughter has won this year's BP Portrait Award, netting its artist - the subject's husband - the £30,000 top prize. Judges at the National Portrait Gallery were moved by Benjamin Sullivan's work Breech!, whose title hints at the trauma of baby Edith's birth.

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Breast milk grows babies’ bodies, fuels neurodevelopment, provides essential immunofactors and safeguards against famine and disease -- why, then, does science know more about tomatoes than mother’s milk? Katie Hinde shares insights into this complex, life-giving substance and discusses the major gaps scientific research still needs to fill so we can better understand it.

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including microbiome

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These studies explore the links between breastfeeding and gastrointestinal illness, gut health, and diarrhoea.
Impact of breastmilk on neonatal enteral feeding outcomes
This study found that exclusive breastfeeding had a positive impact on premature babies with gastrointestinal disorders. Babies who were exclusively breastfed had shorter parenteral nutrition courses, achieved earlier full enteral feeds and were discharged from hospital significantly sooner than those who received formula.
Shinnick, J et al (2016), Effects of a Breast Milk Diet on Enteral Feeding Outcomes of Neonates with Gastrointestinal Disorders, Breastfeeding Medicine, doi:10.1089/bfm.2016.0002 Breastfeeding reduces the risk of infectious diseases in infancy
This study of 4,164 infants in Holland found that exclusive breastfeeding for four months and partially thereafter reduced the risk of infections in the upper respiratory, lower respiratory and gastrointestinal tracts.
Duijts L, Jaddoe VWV, Hofman A et al (2010) Prolonged and Exclusive Breastfeeding Reduces the Risk of Infectious Diseases in Infancy. Pediatrics; 126: e18-e25 Breastfeeding protection against diarrhoea and lower respiratory tract infection
This study of 18,819 infants found that exclusive breastfeeding protects against hospitalisation for diarrhoea and lower respiratory tract infection. The effect of partial breastfeeding is weaker. The findings suggest that an estimated 53% of diarrhoea hospitalisations could have been prevented each month by exclusive breastfeeding and 31% by partial breastfeeding. Similarly, 27% of hospitalisations for lower respiratory tract infection could have been prevented each month by exclusive breastfeeding and 25% by partial breastfeeding.
Quigley M.A., Kelly Y.J., Sacker A.S. (2007) Breastfeeding and Hospitalization for Diarrheal and Respiratory Infection in the United Kingdom Millennium Cohort Study. Pediatrics; 119; e837- e842 Breastfeeding and Crohn's/Ulcerative Colitis
This meta-analysis supports the hypothesis that breastfeeding is associated with lower risks of Crohn's disease and ulcerative colitis. However, the authors call for further research as only a few studies were graded to be of high quality.
Klement E et al (2004). Breastfeeding and risk of inflammatory bowel disease: a systematic review with meta-analysis. Am J Clin Nutr 80: 1342-52.

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Gastro-Intestinal Illness - Baby Friendly Initiative

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Impact of breastmilk on neonatal enteral feeding outcomes This study found that exclusive breastfeeding had a positive impact on premature babies with gastrointestinal disorders. Babies who were exclusively breastfed had shorter parenteral nutrition courses, achieved earlier full enteral feeds and were discharged from hospital significantly sooner than those who received formula.

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'Human Milk: The Breastfeeding Advert' on ViewPure

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Human Milk, Tailor-Made for Tiny Humans' is a major independent public health initiative to support breastfeeding parents and tiny humans in the UK and beyond, by informing everyone of the little known phenomenal composition and workings of our own milk.\n\nThe Human Milk advert and website will detail and explain the composition and workings of our milk; human milk.

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Formula milk production
Radio 4 2016

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The Secret Formula, Food Programme - BBC Radio 4

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Sheila Dillon lifts the lid on powdered baby milk.

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Radio 4 July 2017

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Infant Formula, Series 1, 50 Things That Made the Modern Economy - BBC Radio 4

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For many new mothers who want, or need, to get back to work, infant formula is a godsend.

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Formula milk video

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Adam Ruins Everything - Why Baby Formula Isn't Poison | truTV