British people are cool

About six months ago, when I was seeking experts to interview for my book, I considered contacting a well-known British researcher by the name of Alan Lucas. Problem was, I couldn’t tell where he stood on things. It’s not that I only wanted to talk to folks who agreed with everything I thought – it was simply that at this particular point in the process, I was attempting to speak with researchers who’d strayed from the party line, to see if they’d essentially been “silenced” by bad press and accusations of being in bed with Big Formula. But I wasn’t sure if Lucas was the right guy to talk to; while I found some of his research really interesting and potentially controversial (for example, he worked on one study that suggested our Western diets may not be well-suited to breastfeeding), he was also one of the first people to support the breastfeeding-leads-to-higher-IQ argument, and his work is cited by a plethora of lactivist literature. (For example, in one article about a study he did on breastfeeding and later heart disease, he said “It is quite possible that hundreds of thousands of deaths in the west are prevented by breastfeeding and many more would be prevented if the uptake of breastfeeding were greater.” Ironically, he also authored a different study warning that prolonged breastfeeding could cause hardening of the arteries. Not sure what the message is here – breastfeed, but not for too long…??)  So while a small section of his CV may have been controversial, it seemed that he was still relatively beloved by breastfeeding advocates.

In hindsight, he probably would’ve been a fascinating guy to talk to, for just this reason. Here was someone who managed to ask some potentially damning questions and remain unscathed – perhaps because he’d paid his dues by providing ample research supporting breastfeeding?

Anyway. I was thinking about Lucas a lot today, since his name was on the list of authors for this “Analysis” from the British Medical Journal which has been causing quite a stir. Entitled “Six months of exclusive breastfeeding: how good is the evidence?”, the piece is basically a review of what know, to date, about breastfeeding duration/exclusivity, delayed introduction of solids, and the risk for allergies and celiac disease (obesity is also briefly mentioned). The authors contend that WHO recommendations (6 months exclusive breastfeeding) may not necessarily be appropriate for those in developed countries. Speaking of the adoption of WHO recommendations, they suggest that “…the evidence base supporting a major, population-wide change in public health policy underwent surprisingly little scrutiny” in the first place, and that a “reappraisal of the evidence is timely in view of new data.”

The most interesting point that these authors make is that since delaying solids – especially ones with high risk for allergy- has become common practice, the incidence of food allergies and celiac’s disease have risen. Other than that, there’s really nothing all that controversial in the paper, which is why I find it amusing that it’s pissed so many people off . There was a veritable media shitstorm that occurred in the last 24 hours surrounding this paper, mostly from the breastfeeding advocacy front, who took it as a direct attack on breastfeeding. But the authors actually make a point to say that they are advocating an earlier introduction of solids (4 months versus 6 months), not formula; they are simply questioning if breastmilk alone is the ideal diet for those in developed countries after a certain point. In other words, they are still saying that women should breastfeed rather than formula feed, but that it might be advisable to offer foods along with breastmilk after four months. Not a huge deal, one would think.

One would be wrong, apparently. Within hours of the media coverage surrounding this analysis, not only were the blogs and Twitter were abuzz, reputable organizations like Baby Milk Action were freaking out, accusing the authors of being funded by baby food companies (apparently it’s not just formula makers who are out to undermine breastfeeding, but the makers of blended chicken and carrots, too. Personally, I think there is something inherently evil about blended chicken and carrots, but I doubt it’s the same kind of evil these folks are talking about).

But Lucas, and my new hero, Mary Fewtrell, who seems like the coolest cucumber ever, are taking this all in stride. And their attitudes are what I’m really excited about. Sure, the analysis is cool; I think there’s probably some truth to the assertion that earlier introduction of solids is better for us in the long run, but they aren’t the first to bring this up. It’s what’s between the lines of this analysis – and what its authors have said in the press – which really gets the FFF in me all riled up. Read the BMJ piece for yourself; it’s available for free here. Other than that, I want to submit the following as evidence for why I have good reason to think these authors are, as the kids like to say, “da bomb”:

1. They question WHO’s infant feeding recommendations, which is Simply. Not. Done.

2. They make reference to the fact that studies regarding breastfeeding are inherently flawed: “Apart from two randomised trials in Honduras, the studies were observational, precluding proof of causation for the outcomes examined, since residual or unidentified confounding may remain even after adjusting for potential confounders…”

3. They say this: “It can be argued that, from a biological perspective, the point when breast milk ceases to be an adequate sole source of nutrition would not be expected to be fixed, but to vary according to the infant’s size, activity, growth rate, and sex, and the quality and volume of the breast milk supply,” to which I say YESYESYESYESYES.

4. In interviews regarding the study, Alan Lucas explained that  “The WHO recommendation is very sensible for developing countries…But in the UK, it’s important we take a balanced look at the evidence.” Fewtrell told the Guardian that “she supported the WHO recommendation, but… that it needed to be interpreted differently in different countries. Exclusive breastfeeding protects against infections, which is critical in developing countries, but less important in the UK where hygiene and sanitation are better. ‘There’s only one piece of evidence relevant to babies in the UK – a slightly decreased risk of gastroenteritis,'” She also wrote off the criticism the study has received because she and some of the other study authors had worked with commercial baby food companies within the past three years (a conflict openly divulged in BMJ, incidentally), saying “This is not an attempt to promote commercial weaning foods…We are a university and Medical Research Council-funded group”, member of whom had “advised babyfood manufacturers because they were specialists in child nutrition”.

5. Fewtrell also provided my absolute favorite quote of the day, earning her a permanent place in the FFF Hall of Heroes: “Some organisations are all too happy to quote our data when it supports breastfeeding,” she said. “They are choosy in what they will allow.”

Word to your mom. Or actually, word to all moms. The truth is out there; we just need some more kick-ass women like Fewtrell to help us find it.

Suzanne Barston is a blogger and author of BOTTLED UP. Fearless Formula Feeder is a blog – and community – dedicated to infant feeding choice, and committed to providing non-judgmental support for all new parents. It exists to protect women from misleading or misrepresented “facts”; essentialist ideals about what mothers should think, feel, or do; government and health authorities who form policy statements based on ambivalent research; and the insidious beast known as Internetus Trolliamus, Mommy Blog Varietal.

Suzanne Barston – who has written posts on Fearless Formula Feeder.

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13 thoughts on “British people are cool

  1. I've read other research over the last couple years that said the same thing — moving back the ideal introducing of solids to “between four to six months” rather than “only after six months.” I really think that's where the consensus of evidence is leading.

    Mine all started solids around five months, because they insisted on eating what I was eating.

  2. Goodness, breast milk is like some perfect, cure all, worshipped food or something. How dare someone mention some research that shows even a slight downside to extended feeding and delayed sold introduction. I can only imagine the beef he's gotten for that. After all the lady that wrote “Is Breast Really the Best” got some horrible insults and accusations.

  3. I don't see what solid foods has to do with breastfeeding at all? No one just stops giving breastmilk or formula cold turkey in favor of…cold turkey or whatever. The cereals can be mixed with breastmilk and eating pureed fruits, veggies, etc (which can be made at home so as not to support the evil baby food companies)doesn't undermine that.

    I was reading another blog recently, where the discussion went off on a tangent about women who wish to keep their babies babies forever. People were talking about friends/neighbors/family members who would cry when the baby reached another milestone, and refuse to offer solid foods until well after 6mos because they wanted the baby to nurse only. Obviously, women who behave like that must be a tiny minority, but I could see how that mindset would lead to: solid food undermines breastfeeding! Those damn baby food companies are trying to dry us up!

    At any rate, my boys were offered solids around 5mos, and they did fine. We haven't noticed any food allergies so far…and with the pediatrician winking and looking the other way, we offered peanut butter at 16mos. They love peanut butter and eat it by the spoonful. Good thing, because they are tiny and they need healthy protein and fat in their diet.

  4. Yes, we Brits kick ass 😉

    On a more serious note, another fantastic blog. I was wondering if you would comment on this study!

    I think the biggest problem (at least in the UK) is journalism. Or rather, atrocious journalism. The mis-reporting around this study has been phenomenal. The first I heard of the article was on the BBC radio news, which opened with the strapline “Breastfeeding is no longer considered best for babies past 6 months…” I mean, what? Did the “journalist” even read the study?!

    So with “journalism” like that, people were picking up the wrong ends of about 50 different sticks, and running to the Internet with it to scream about the evil Anti-BF scientists who are in league with Formula Companies and the Devil.

    I will admit to having laughed at the latter.

    We need more researchers like this group, for sure 🙂

  5. Lynne–Journalists in America are no better. Well, maybe some, but we have the same sensationalist crap here. Shoddy research, and insistence on spinning the information to hype somebody's agenda.

    Our media tends to be either liberal or conservative (and by media I mean all media, not just tv news programs) and stories will be reported to reflect the party line.

  6. Writing from Baby Milk Action, it is important to base health recommendations on sound science. While the authors of the comment piece in the BMJ were calling for a review of the WHO recommendations, they are already kept under review – a systematic review was published by the Cochrane Library in 2009. We link to the paper from our blog. It found no new evidence that warranted a change to the recommendations.

    Setting a time of 4 months for introducing complementary foods – as effectively happens with baby food companies label products for use from this age – could be criticised for setting a fixed time, as much as any other age. Interestingly, the World Health Assembly Resolution specifically relating to the introduction of complementary foods (WHA 47.5) adopted in 1994, says complementary feeding should be fostered from 'about 6 months', with continued breastfeeding. There are issues around whether the same recommendations should apply to babies fed on formula, which I am happy to explore.

    It is important to understand why there has been such strong action on many fronts from the baby food industry over this 4 month/6 month difference. Introducing foods at 4 months, generally means purees and paps, which parents are less likely to home prepare, and so become consumers. Wait to 6 months – or follow a baby-led weaning approach, which also tends to see other foods being consumed at 6 months – and babies can eat appropriately prepared family foods. The puree and pap phase can be missed completely.

    The baby food industry does not like this. A marketing director for Cow & Gate once advised: “We suggest milk is merchandised on the left hand side of the fixture, followed closely by an early weaning block – jars and packet foods from 4 months – to stop mums drifting into home-made foods.”

    When multi-million pound profits are involved, it is necessary to keep a very clear focus on what is best for mothers and babies – and that is what Baby Milk Action attempts to do. Our slogan is: “Protecting breastfeeding – Protecting babies fed on formula”.

    There is a lot more to say on this topic. I recently answered questions from members of the Mumsnet forum about our work in support of mothers who use formula and the questions and answers can be found on our website.

    I hope this is a useful comment. It is intended to be.

  7. From what I understand, they weren't discussing new discoveries: they just had a pragmatic review of why the recommendations were what they were.

    Here was something I observed when I had my daughter back in 2006. Health Canada I think had pushed the age of solids up to 6 months a few years prior. Anyway, the recommendation was a blanket 6 months without much discussion as to why: the only reason to delay as per the Health Canada site was an increase risk of Gastroenteritis just like those scientists suggested.

    Now does that mean I think all babies should start the day they turn 4 months? No, of course not, but perhaps some useful guidelines could be produced by Public Health organizations to suggest which babies would be good candidates (excellent head control, babies that were full-term plus (the reality being my daughter who was born at 41.5 weeks had the same recommendation from the her date of delivery as those born at 37 weeks), babies that are close to sitting on their own etc).

    I don't think it's wrong for people to wonder where and why the 6 month guideline is what it is. A friend of mine's doctor told her that there were many pediatricians out there who don't agree with it at all. Does WHO have to make the same recommendation for every infant?

    That said, I personally wasn't huge on the puree phase either (actually my daughter wasn't), but many parents I know made their own baby food at home (granted I am in a country with generous mat leave).

    FFF – Yes, the British are great, not that I am biased (and have a British Passport and Citizenship).

  8. I think the most important discussion around this is a shift in thought that exclusive BM for AT LEAST 6 months is being brought to light. I know many mothers that struggled to exclusively BF until six months, not introducing solids, under the presumption that it will reduce their child's likelihood of allergies (and in one case celiac disease specifically, which didn’t work, in addition to other food allergies). It was delayed even when their child showed signs of readiness and interest, which is not following baby lead weaning, and they were having trouble meeting the babies' supply needs as well.

    If the AAP and WHO's recommendations to exclusively BF for AT LEAST 6mos were followed by the following (WHO's statement to this analysis) I am sure it would help mothers make and educated decision for their child without enduring undue stress:

    The systematic review's findings suggest that exclusive breastfeeding of infants with only breast milk, and no other foods or liquids, for six months has several advantages over exclusive breastfeeding for 3-4 months followed by mixed breastfeeding.

    “These advantages include a lower risk of gastrointestinal infection for the baby, more rapid maternal weight loss after birth, and delayed return of menstrual periods. No reduced risks of other infections or of allergic diseases have been demonstrated. No adverse effects on growth have been documented with exclusive breastfeeding for six months. But a reduced level of iron has been observed in some developing country settings.”

    I would, as mother, like to evaluate what is more of a potential risk for my child, allergies vs. getting a stomach bug and me losing weight or getting my period sooner. Just stating exclusive 6 mos breast feeding is best, is not necessarily the best. That is the point of this analysis and I LOVE IT!

    In response to the marketing of baby food being a conspiracy to undermine BF. I don't know. Just like the marketing of formula is supposedly doing that as well, this train of thought really presumes mothers are mindless idiots that cannot make a decision for their child. I think witholding/spinning data like many lactavists do are even more guilty of that than baby food companies!

  9. Thankfully I have a pediatrician who can think for herself and recommended starting solids at 4 months because of K's reflux in addition to his developmental readiness. He had neck control at birth and rolled over at 2 weeks. As a previous commenter noted, looking at these things over chronological age is far more important and why doctor discretion is usually the best course!

  10. I always disliked dogmatic “one size fits all” recommendations, such as “6 months”, although I have loads of problems with the Lucas, Fewtrell et. al.'s recommendations, which I don't have the time to go into here. However, I always liked the La Leche League recommendation of “around the middle of the first year”, as well as the suggestion of watching the baby for signs of readiness and not the calendar . My babies started eating solids between 6 and 8 months and I had a friend, who was an LLL leader, whose babies started at 5 months. You couldn't get solid food down my children before 6-7 months (and believe me I tried, especially with the eldest) and you couldn't keep her babies from eating food at 5 months.

  11. Oh for god's sake. Now there's some kind of baby food conspiracy? Really? I'm starting to think folks have lost their minds. My doctor always, ALWAYS said between 4 and 6 months, and her main question was whether the individual baby was ready. As in, does the formula/breastmilk seem to satisfy? Or is the baby always hungry and getting worse? Do they watch you eat? Do they mimic the motions of eating? I made my decision based on each kid. My first was over 4 months, and mostly formula fed. My second was almost exclusively breastfed until she was 5 months, but started eating a little before she was 4 months, because said child was clearly starving. And she LOVED her food.

    And in what world DON'T babies start with purees? I made all of my oldest daughter's food, and for several months it was all pureed, because that's what she could eat, and not choke on. I started making my second daughter's food as well, and she hated it. She has some occupational/texture issues, so jarred food is better for her, and we're slowly breaking into table foods now at 7 months. Again, needs of the individual child trump.

    We all want what's best for our kids, but really, I'm starting to think people are losing their minds, talking about conspiracy theories with food companies. I know plenty of people who breastfed a long time and still used jarred foods. Yes, the companies want you to buy their food but is that evil? Calm down people, calm down!

  12. Replying to Mike Brady’s comment on behalf of Baby Milk Action, above:

    Mike: The review of the evidence by the WHO doesn’t actually assess the Chantry et al paper that found an increased risk of iron deficiency with later introduction of other foods. I have no idea whether the study in question is any good as I don’t have the full text, but it seems to me that it’s an important point that should indeed be addressed. It’s not ‘sound science’ to assume that because a topic has previously been reviewed then we can dismiss the need to consider any new evidence in its own right.

    And, despite all the hoo-hah about how terrible it is that the authors are questioning the WHO recommendations, based on review of over 3000 studies, found several benefits from prolonging exclusive breastfeeding, blah, blah… well, how strong is the evidence in favour of delaying solids, at the end of the day? I’ve read the WHO recommendations (both the original and the updated version), and what practically all of the available evidence actually says is that, in the developed world, there doesn’t seem to be any significant difference in outcomes between breastfed babies who wait until six months before starting anything else and breastfed babies who don’t. The only difference the WHO review found in outcomes for developed-world babies was in the Kramer study that found a 1 in 40 increased chance of gastrointestinal infections in babies who started substances other than breastmilk between 4 and 6 months compared to babies exclusively breastfed for 4 months. The Cohen and Dewey RCTs, on the other hand, didn’t find any difference in gastrointestinal infection rates associated with introduction of solids at four months in breastfed babies compared to six months. Since then, we’ve had the Chantry et al paper on respiratory tract infections showing that introducing other nutrition between 4 and 6 months is associated with a small increase in rates of respiratory infection (again, as far as I could calculate from the figures given it’s around a 1 in 40 risk) and a small increase in risk of frequent ear infections.

    So, we’ve got some evidence for a small increase in risk of chest infections and some contradictory evidence for a possible small increase in risk of GI infections with early introduction of solids, and, as far as outcome for babies in the developed world go, that’s it. Frankly, I don’t see that as such an unassailable mountain of evidence as to be beyond reconsideration as new evidence comes in, and I don’t think it merits the degree of pushing of the no-solids-before-six-months dogma that we as parents get. Like Darcie, I’d have much preferred being told about the available evidence so that I could weigh it up for myself, rather than simply being told that I should breastfeed exclusively for six months, end of. It sure as hell wasn’t worth the amount of worry and guilt I went through when I realised that my milk supply wasn’t going to hold out for exclusive BF after I went back to work at four months. Going through that was *not* best for my health. I’m all in favour of seeing more questioning of these blanket recommendations.

  13. “It is important to understand why there has been such strong action on many fronts from the baby food industry over this 4 month/6 month difference. Introducing foods at 4 months, generally means purees and paps, which parents are less likely to home prepare, and so become consumers. Wait to 6 months – or follow a baby-led weaning approach, which also tends to see other foods being consumed at 6 months – and babies can eat appropriately prepared family foods. The puree and pap phase can be missed completely.”

    I strongly disagree with this. Every parent I know made or makes their own baby food, so I'm not sure on what data you base this statement. Of course, that doesn't mean *every parent* makes their baby food, but I don't see how broadening the recommendation from “6 months+” to “4-6 months” would encourage parents to buy ready-made purees. Also, my son would gag on anything that was very thinned pureed at first, so I don't believe “baby-led weaning” to be appropriate for every baby.

    I think that revising this recommendation is a very good thing. I've heard a few stories where the mothers were so gung-ho on “EBF for 6 months” that they completely ingored their babies' needs. The babies would cry and cry and cry, but the mothers would not feed them solids and blame it on other things. Funny how the poor babies stopped crying when they finally started cereal and purees! I remember my son's pedi's recommendation to be very reasonable, to start solids “when he starts waking up unusuallly frequently to feed, OR 6 months”. My son stopped STTN at 5½ months and we started cereal then.

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