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Tuesday, September 18, 2012

Bullshitometer: Food before one is just for fun


Poster A: I’ve been doing baby led weaning for the past few months, but I’m starting to get discouraged. DD is 10mo and eats basically nothing. She plays with pieces of food, gums them and drops them on the floor. Occasionally a bit of food will actually make it into her. She has plenty of breastmilk and seems okay, but my health visitor is starting to get on my case about it, saying she’s going to become anemic because my milk isn’t enough! I don’t know who to believe any more. 
Poster B: Just keep repeating to yourself: Food before one is just for fun. Your LO is doing fine—playing with food is all they actually NEED to be doing at this stage. 
Poster C: Your HV doesn’t know what she’s talking about. Breastmilk is a good source of iron, because it’s so bioavailable (see Kellymom). Anyway, it doesn't make any evolutionary sense that babies would need anything other than BM before they are able to feed themselves--what did tribal babies do before pureed babyfood and iron supplements? Keep on doing what you are doing, mama! 
Poster D: Babies eat when they are ready. If she isn’t willing and able to self-feed, that means her gut isn’t mature enough. Trust your instincts and remember that food is just for fun until they’re one. 
"Food before one is just for fun" has become a common phrase heard on the ‘net in recent years, probably due to the popularity of lactivism and baby led weaning (BLW). Lactivism tends to assert that breastmilk is the perfect food—the more breastfeeding the better, pretty much. BLW (in its true form, I mean, not as a newfangled term for finger foods alongside mashed food) is a philosophy asserting that babies should self-feed all foods right from the start, and that the development of the motor skills needed for self-feeding—sitting unassisted, picking things up, chewing and so forth—are actually signs that your child needs food for the first time. In parts of the parenting universe where BLW and “natural” childrearing methods are popular, therefore, it’s not uncommon to hear of babies who are seven, nine, 12, 15 months or even older and still virtually exclusively breastfed, while their relationships with solids amount to little more than playing with food before chucking it on the floor.

When mothers express anxiety at this state of affairs, the responses given tend to be more or less as given in the above exchange, and “Food before one is just for fun” is much heard. But how true is this? Breastmilk is a wonderful food, but do babies really have no need at all for solids in their first year?

A metallic problem
As I discussed in a previous post, in terms of calories, most mothers—assuming their supply is decent and they are prepared to do some night feeds—are probably capable of meeting the calorific needs of a baby through breastmilk alone until at least the age of 12 months. Breastmilk is a highly nutritious, digestible and well-absorbed food that really does contain most of the things a body needs—there is certainly nothing to be gained from crowding it out of the diet too quickly. And yet there are a couple of exceptions which keep coming up again and again in the literature; basically, iron and zinc. Because breastmilk isn't a very good source of either of these. And both iron and zinc are very important for a child’s developing brain.

What the World Health Organization says
The WHO's views on the role of solids for 6-12mo babies are set out comprehensively in its Guiding Principles for Complementary Feeding of the Breastfeed Child (2004, most recent edition). I don't know where the "food before one..." meme came from, but it's not from the WHO. After reiterating its support for delaying solid foods for six months, the WHO goes on to stress (repeatedly and explicitly) the importance of complementary solids from the middle of the first year onwards:
"Breast milk can make a substantial contribution to the total nutrient intake of chil- dren between 6 and 24 months of age, particularly for protein and many of the vitamins. However, breast milk is relatively low in several minerals such as iron and zinc, even after accounting for bioavailability. At 9-11 months of age, for example, the proportion of the Recommended Nutrient Intake that needs to be supplied by complementary foods is 97% for iron, 86% for zinc, 81% for phosphorus, 76% for magnesium, 73% for sodium and 72% for calcium (Dewey, 2001)." 
"...the Expert Consultation concluded that the potential health benefits of waiting until six months to introduce other foods outweigh any potential risks. After six months of age, however, it becomes increasingly difficult for breastfed infants to meet their nutrient needs from human milk alone (WHO/UNICEF, 1998)." 
"Average iron intakes of breastfed infants in industrialized countries would fall well short of the recommended intake if iron-fortified products were not available (WHO/UNICEF, 1998)" 
Iron- and zinc-fortified foods are encouraged on the grounds that without fortified foods or meat, it is difficult to meet babies' micronutrient needs. (Yikes, "solids are important" AND the dreaded rice cereal... no wonder none of the crunchy sites post links to the Complementary Feeding guidelines.) Incidentally, I quoted the WHO not because I think they are the top authority on everything (their recommendations do often tilt towards the developing world), but because the WHO is really, really, really pro-breastfeeding. If even they are stating explicitly that breastmilk is generally not enough to meet babies' micronutrient needs for much beyond six months, I think we should probably sit up and listen.

That Kellymom page
The evidence most often cited in support of the "babies-under-12-months-don’t-need-solids-or-additional-iron" idea is the Kellymom page on iron. The message that is often taken home from this page is that (a) Breastmilk is an awesome source of iron because it is so bioavailable to the infant; and (b) In any case, babies are born with enough iron to last them for their first year of life.

Now, breastmilk iron is unusually bioavailable (which means, roughly, that a high proportion of its iron is actually usable by the baby); but the amount of iron found in breastmilk in the first place is so low that even with a high absorption rate, the absolute amount available to the infant is still not very high--as Science of Mom discusses here in her excellent post, even with breastmilk's unusually bioavailability a baby aged 6-12 months would need to drink 4-13 liters of breastmilk a day to get enough iron. Most babies don't drink much more than a liter a day.

As for babies’ iron stores… the Kellymom page doesn’t actually say that babies are born with a year’s worth of iron inside them. It actually says that babies are born with enough iron for “at least the first six months” provided that they are (1) born at term; (2) at least 3000g/6.5lb at birth; and (c) born to mothers without gestational diabetes. It goes on to say that babies will certainly need to have additional iron from somewhere-or-other “toward the end of the first year”; so even Kellymom is not actually saying that babies need no food whatsoever for the first year.  Also, check the dates on the sources given towards the end of the page. There is a 1999 American Association of Pediatrics report, but not the Association's well-publicized 2010 Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0-3 Years of Age), which emphasizes iron for breastfed infants much more strongly (Seattle Mama Doc has an excellent summary of the report--see Further Reading below). Basically, the conclusions of the AAP committee regarding breastfed infants are that breastfeeding exclusively past four months—not six—creates an increased risk of iron deficiency, and that therefore babies older than this should ideally be either supplemented with iron or given iron-rich complementary foods. It also states explicitly that “Exclusive breastfeeding for more than 6 months has been associated with increased risk of IDA [iron deficiency anemia] at 9 months of age.”

By the way, I think the Kellymom people could do with updating their entire list of sources—it has at least one broken link and a lot of old/tiny studies which in many cases appear to be cherry-picked or misunderstood. For example, the Kellymom page states rather vaguely that babies “have been shown” to maintain normal iron stores and hemoglobin levels up to nine months… but the only evidence it gives in support of this turns out to be a single very small (30 infants) study that took place in Honduras back in 1995. (I am, of course, being flippant: of course Kellymom is not going to update their source page, because the people at Kellymom have already decided that iron supplementation and encouraging baby to eat enough solids are generally Bad Things, so they are not going to link to any paper which seems to contradict these ideas—even though the AAP's conclusions are up-to-date and based on a review of 77 studies.)

It’s difficult to find actual studies of babies in whom solids have been delayed for long periods of time simply because we are talking about a non-conventional parenting style. However, the fact that a significant minority of exclusively breastfed babies are already iron deficient at the six-month mark makes it hard to believe that there are not potential issues with waiting much longer for solids/supplementation (Even the World Health Organization admits that exclusive breastfeeding to six months can lead to iron deficiency in susceptible infants, but asserts that nevertheless, this disadvantage is outweighed by the fact that exclusive nursing for six months in developing countries is associated with lower rates of diarrheal disease and later return of fertility in mothers—both facts which are a lot less relevant for those of us in the developed world).

What does “natural” mean, anyway?
Now I'll be honest; whenever I hear someone talk about "readiness" for anything in a child-development context, I tend to reach for my skepticism; has anyone ever actually proven that the ability to sit up unassisted or reach out and grab things has any particular relationship with babies' ability to digest food or their nutritional requirements for it? And if we accept the "babies need additional iron and zinc" thing already discussed, the idea that babies only start to need solids once they reach certain development stages becomes a bit problematic. Like... okay, are we all supposed to believe that children who are slower than average to sit up are the ones who are handily born with larger-than-average iron stores in their bodies, while the ones born with less iron conveniently start sitting up earlier, or something? It doesn't really make a lot of sense to me, and as it happens the only evidence that I’m aware of on this topic seems to suggest the exact opposite—we know that in fact, iron stores tend to be lower in babies who were born small and/or premature, and these babies are also slower to reach milestones, on average.

Why would human babies and human mothers have evolved in such a way that significant numbers of babies need either iron supplementation or foods from six months at the latest (when many babies are incapable of self-feeding significant amounts of food) to avoid iron deficiency? The Science of Mom article discusses this very point.

It’s possible that breastmilk’s iron levels are low because of a good old evolutionary trade-off. Lower iron levels in the baby's GI tract reduce the risk of infections. Those cave-babies living eons ago were at high risk of gastro infections which were frequently lethal--better to risk developing a slight iron deficiency than to wind up dead from diarrhea. For those of us living in cleaner environments today, breastmilk's iron level may not be optimal and perhaps supplementation may have its merits. Furthermore, the environments where human beings evolved were also places where where (a) babies may have acquired extra iron from eating dirt off the cave floor, and (b) cord clamping was probably delayed.

Another possibility raised by a commenter on the above post is that both mothers’ and babies’ bodies evolved based on the “assumption” that babies would in fact be supplemented with easy-to-eat iron-rich food sources by the middle of the first year if not earlier. Pre-chewing of foods—especially meat—and feeding them to infants from about the middle of the first year is the norm among hunter-gatherer societies, as suggested by this intriguing paper here which floats the possibility that pre-mastication may have developed in humans as a way of providing babies with iron and other micronutrients. As I suggested in my previous post on BLW, this reality is another reason why I would question the “naturalness” of a strictly baby-led, self-feeding-only approach to solids; I think a more “natural” approach to solids might, rather, involve feeding different foods in a variety of ways, including—when necessary—mashing certain foods and helping the baby get them into his/her mouth. After all, if it’s good enough for orangutans….?

Oh the iron-y
Iron deficiency is popularly associated with pallor and general languidity; the truth is a bit more worrying than that. You can’t generally see moderate iron deficiency and it doesn’t necessarily result in your child showing any obvious signs of anemia. But that doesn’t stop it having negative and permanent effects on your child’s growing brain. Iron deficiency really does matter.

There has for a long time been a well-established body of robust evidence (see here, here and here) showing that iron deficiency in infants is associated with delayed milestones, in terms of both motor skills (walking, sitting and so on) and speech/social development. Worryingly, problems appear to persist even after the iron deficiency is caught early and corrected, suggesting that there are “window periods” when sufficient iron is needed for the normal development of particular cognitive functions: when infants who have previously been diagnosed as iron deficient are followed-up years later, they show higher rates of learning-related problems such as inattention, clumsiness and shyness, are more likely to repeat a grade and score lower on IQ tests, even after controlling for other factors such as maternal IQ and lead levels. These correlations are both robust across numerous studies and statistically significant.

Can you imagine the reaction we would see in the parenting blogosphere if a study were to come out which found comparable neurological/behavioral differences between—say—children who had been formula fed and those who had been breastfed? I just don't understand why so many breastfeeding advocates are so cavalier about iron and zinc. These things are important. Of course, an older baby eating very little is a lot less concerning if supplementary iron is given; however, a lot of the crunchy mothers tend to resist the idea of giving supplements, perhaps because they have bought so strongly into the idea that breastmilk is always a complete diet right into toddlerhood etc.; giving a supplement would be tantamount to admitting that that may not always be the case.

Bullshitometer verdict
I think the phrase “Food before one is just for fun” needs to go die a merciful death, to be honest. In all likelihood, the phrase itself was invented by some well-meaning person who wanted to encourage a more relaxed approach to solids among anxious mothers who were engaging in weird little mompetitions with other mothers about who could cram the most “jars” inside their child--and in the process, harmfully crowding breastmilk/formula out of the baby's diet.

But it’s looking increasingly as though this phrase has begun to be interpreted as meaning that solid foods play no nutritional role at all before one year of age—and that therefore, it’s completely fine and not an issue if months and months go by while your older baby eats basically no foods at all and does not receive any micronutrient supplementation either. And the evidence suggests strongly that this is just not true.

Obviously, you can hardly force-feed a child who doesn't want solids, but there is such a thing as being flexible--trying different things (purees, finger foods, spoon feeding, whatever) and seeing what the baby takes to, rather than insisting that a baby who won't self-feed is "not ready" for solid foods and therefore should not have them. And if a baby or toddler is refusing solids in any shape or form, an iron and zinc supplement is a wise idea. Rice-cereal-phobes can take heart, by the way—it’s looking increasingly as though iron is actually absorbed better from natural sources such as ground meat (which also provides much-needed zinc to babies).

Finally, it’s good to see that delayed cord clamping seems to be becoming mainstream, as routine DCC could prevent a fair bit of iron deficiency. When all's said and done, though, DCC appears to improve infants' iron store levels up to six months of age; even if this became standard practice from tomorrow onwards, babies wouldn't be getting a years' worth of iron pumped into them.

I do understand that there is a lot of resistance to the idea that most breastfed babies probably need some solids (or supplements) by six months or so, because so many people are powerfully attached to the idea of breastmilk as being the perfect food. But perhaps, as Science of Mom suggests, “This should not be taken as a deficiency of breast milk but rather as an indicator that it is important and natural for babies to start consuming solid foods around 6 months.” Breastfeeding is best; but we should also be focusing on the nutritional quality of the complementary foods that we offer babies, and in doing what we can to help them eat enough of them.


Further reading
Guiding Principles for Complementary Feeding of the Breastfeed Child: Good background reading, but like all WHO stuff should probably be taken as a very rough guide--trying to make sure your child gets XXX number of solid-food calories a day sounds like a guide for how to give yourself a nervous breakdown
 Guiding Principles for Feeding Non-Breastfed Children 6-24 MonthsFor you bottle feeders; I haven't had a chance to look through it, though!
Why is breastmilk so low in iron: A great post from a real nutritionist (and extended breastfeeding mother!)
Baby Led Weaning (or starting solids) book review and nutritionist weighs in (with her 7 month old daughter!) Another blog post by someone who knows about nutrition
Iron for babies & toddlers: I love Seattle Mama Doc; she is always so reassuring and kind.

14 comments:

  1. I love the logic in this post. And all the research supporting it. I've had more than one 'crunchy' mom tell me that people that choose differently than them (about BLW, vaccines, whatever) just aren't as well educated about it. Love that this post completely debunks that :).

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  2. Yes, the "educated" thing gets a bit old sometimes...;)

    By the way, Science of Mom, I noticed a post from you in my email box, but for some reason it has disappeared! I assume you didn't delete it yourself? I'll just put it back while I try to find out if something has gone wrong with my spam filter (if you did want to delete it, let me know and I will delete this one;)):

    Science of Mom wrote: "Great post! This is one of those crunchy things that I just don't get. Food is totally natural! And guess what? It is fun, too! And nutritious! And really, most babies I know want to put everything in their mouths, especially things they see you eating. Make it whole grain, organic, grass-fed, whatever, but let the kids eat! Iron deficiency is real and you'd think that the whole neurodevelopment thing would be convincing..."

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  3. Re the above: I think the thing is that this is very much about turning breastfeeding into a competition: who breastfeeds the longest and the most exclusively, wins (or something). Because I have noticed that some people who strongly support doing solids very slowly as long as they assume that the baby is exclusively breastfed, tend to change their argument and support more solids earlier if the baby is formula fed/combo fed--Jack Newman, for example, says that if you are working and thinking about formula supplementation, you could just get the daycare worker to spoonfeed plenty of solids instead...

    The other inconsistency I have noticed is that many of the same people who are very into applying the letter of the law when it comes to the WHO's no-solids-before-six-months thing, are either not aware of the WHO's policies on complementary foods or are ignoring them. According to the WHO guidelines, a BF baby in a developed country needs about 130 calories a day from complementary foods from 6-8 months, about 310 calories from 9-11 months and 580 calories in the second year (which seems quite a lot even to me, but there you go).http://whqlibdoc.who.int/paho/2003/a85622.pdf

    Of course, I don't think the WHO's guidelines should be taken as law, but I just thought this was interesting.

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  4. Excellent post! I just discovered this blog and look forward to reading more.

    I think a lot of the "food before one is just for fun" mantra arises because it's not uncommon at all for pediatricians to insist that a child of 6-7 months NEEDS to be eating 3 square meals of baby food, plus rice cereal a day. Where other countries recognize that solid food introduction should be gradual, include a variety of flavors, and should include food that the rest of the family is eating, American doctors are much more resistant and many recommend only purees in too large a quantity. And the purees typically fed to infants as "first foods" are not good sources of iron anyways, which has just exacerbated the need for rice cereal to swoop in and "make up the difference".

    I also think that truly following baby-led weaning involves offering your child a variety of foods, and not just withholding or ignoring solids in the name of "food being just for fun". It's not common for an infant to go to 12 months and eat no/close to no solids at all.

    Here is an interesting critique of the AAP recommendations, published in "Pediatrics" itself:

    http://pediatrics.aappublications.org/content/127/4/e1098.full

    Another study published just a few months ago in Pediatrics found that while longer durations of exclusive breastfeeding were associated with lower levels of serum ferritin, it did not meet clinical significance, and therefore warranted more investigation.

    http://pediatrics.aappublications.org/content/131/5/e1530.abstract

    The International Breastfeeding Journal has also published their own "prospective study of iron status in exclusively breastfed term infants up to 6 months of age" in 2008

    http://www.internationalbreastfeedingjournal.com/content/3/1/3

    "We found that(i) Babies of non-anemic and anemic mothers who were exclusively breastfed until six months age did not develop iron deficiency anemia or iron deficiency; (ii) The iron status of the babies had no relation with the breast milk iron and lactoferrin concentration at any particular time; (iii) The declining haemoglobin and serum ferritin of babies of non-anemic and anemic mothers significantly correlated with the declining breast milk iron and lactoferrin concentration."

    The UK's Journal of Maternal and Child Health published a survey study about infant development and solid food readiness in 2011. They used data from 923 infants about when they first began to reach for food, and when they began eating and how much. They concluded that for a majority of infants, baby-led weaning is completely feasible, but poses some risks for babies who are developmentally delayed.

    http://onlinelibrary.wiley.com/doi/10.1111/j.1740-8709.2010.00274.x/full

    A controlling method of infant feeding is also linked to adverse affects, mostly higher risk of obesity and eating disorders, so I think that finding a middle ground is probably the best. Parents should watch their infants for signs of readiness, but also look at other developmental milestones for signs of delay. They can feed their infant using either purees or finger foods, but should be mindful of the amounts, and infants at risk for developing iron-deficiency anemia (preterm, SGA, immediate cord clamped, not eating many/any solids, etc) should follow up with their doctor and have iron levels tested earlier than the routine 12 month checkup.

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  5. Good points and interesting links, thanks. I must have a thorough read through all them when I next have a moment.

    I think that overall, the WHO Complementary Feeding guidelines are very sensible--they talk a little bit about a concept they call "responsive feeding"--not force feeding, but definitely being very encouraging and also physically helping children get food in their mouths if they cannot do so by themselves, by spoonfeeding as and when necessary. Although the WHO is very, very pro-breastfeeding, even to the point of being a bit over-the-top at times, these guidelines are actually very clear that breastmilk alone does not provide enough of certain nutrients like iron or zinc once the baby gets much past 6mo, and that therefore solid food does play an important complementary role as well. The only thing in the guidelines I would disagree on is the no-solids-before-6mo thing--I think that in developed countries, starting a little food from 4mo or 5mo is okay as long as the emphasis is on little tastes and not sailing in with the jars.

    Needless to say, the WHO Complementary Feeding guidelines get basically no attention at all on the lactivist/crunchy sites, because these guidelines have the nerve to point out that breastmilk alone is often not enough for older babies, and that foods do actually matter too, even before 12mo.

    http://www.who.int/nutrition/publications/guiding_principles_compfeeding_breastfed.pdf

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  6. Hi - I'm a first time mom trying to decide when to start solids with my baby. There is sooo much (conflicting) information online that it's driving me crazy. I'm not here to judge anyone's opinion. I need some guidance and it is obvious to me that you know much more about this subject than I do. If you could share your opinion with me I would really appreciate it.

    I found a 2012 AAP publication which talks about the benefits of doing exclusive BF for a minimum of 6 months vs 4-6 months:
    http://pediatrics.aappublications.org/content/129/3/e827.full.pdf

    I thought the benefits were considerable so I had decided on the 6 months mark. I also read that Kellymom page about the baby's gut not being mature until somewhere between 6-8 months. So I was wondering, maybe stretch it to 7 months and then switch to formula+solids gradually? And now after reading after iron deficiency I am back to square one with no idea on what to do.

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  7. "I need some guidance and it is obvious to me that you know much more about this subject than I do." Oooh, gosh.... I am not sure how true this is, but I will take it as a compliment, thank you!

    Solids and when to start them are a complicated subject it is true, and there is no really solid (ha ha) evidence on the best age to start. If you are feeling confused, I would recommend maybe having a read through some of the stuff I put on the No-BS Breastfeeding Resource page, http://breastfeedingwithoutbs.blogspot.com/p/no-bs-breastfeeding-resources.html and in particular, I would recommend reading the Rana Conway book, "Weaning Made Easy." Conway talks a little bit about the 4-6mo issue. As she says, you can make a case for starting at either 4, 5 or 6mo; the important thing is to bear in mind that while milk provides the bulk of baby's nutrition, solids do play an important role too and are not JUST for fun.

    As for Kellymom... I like Kellymom as a resource for stuff like "how to cup-feed a baby who will not take a bottle" or "how to get rid of clogged ducts" etc. etc. but as for the research on that site, my own personal stance is that I would take it with a big pinch of salt. A lot of it seems to be agenda-driven or is based on very small/old studies etc....

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  8. I bought the Kindle version of the book you recommend and it's wonderful!! I can't thank you enough for helping me with my research.

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  9. I don't think of food before 1 as not introducing until then. I think of it as follow your babys cues and to not get worked up if baby doesn't eat much as well don't go over board they still need bm or formula

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  10. I don't think of food before 1 as not introducing until then. I think of it as follow your babys cues and to not get worked up if baby doesn't eat much as well don't go over board they still need bm or formula

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  11. absolutely fantastic post! I asked my doc about BLW at our six month check up, and he said no, and tbh I was kind of questioning his judgement...Then someone posted this link on a similar question to breast is best on FB. THANK YOU so much for taking the time to write and research all this for us!!

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  12. I just found this blog and I'm so happy to read it. As a nurse I really appreciate your scientific sources. I have had several lactivists insist that I'm causing harm by giving my 9 month old 3 solid meals a day on top of nursing. I knew i wasn't he loves his food and I knew about the risk for iron deficiency anemia in ebf older babies. I did learn a lot too. Thanks so much. Have you wrote about nursing on demand vs. a schedule. I'd love your take on that. We have been on a somewhat flexible schedule since 2 months and I find it makes our lives much easier.

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  13. Another irony: Follow baby's cues but never offer solids before 6 months. If my baby is grabbing food out of my hands at 5 months, I must be misreading social cues as developmental ones. SMH

    Thanks for this post.

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  14. Love your site. I have read different breastfeeding forums and sites and some of the info out there is such crap. I also have dug further into the Kellymom sources and found that some of their studies were done in the early 1900s! While it has some good advice, I find it ridiculous how the lactivists spew the same BAD info over and over again.

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